Current numerical pressure ulcer classification systems (staging, grading, or categories) are problematic and misleading because they imply that pressure ulcers progress through defined stages (from I to IV).

In December 2011, a panel of experts rocked the pressure ulcer world by attacking some of the underpinnings of the current pressure ulcer classification systems (Staging, Grading, Categories). They said that some of the language creates problems from clinical, regulatory, legal and economic perspectives. The advisory panel is proposing the new Superficial Changes & Deep Pressure Ulcer Theory©. Here is one piece of what they asserted:

The current numerical pressure ulcer classification systems are intended to describe the anatomic depth of tissue damage. Stage 1 is characterized by non-blanchable erythema of intact skin that may be coupled with alterations in skin temperature and tissue consistency. Stage 2 is a superficial lesion involving the erosion of epidermis with epidermal base or an ulcer with loss of epidermis and a dermal base. Full thickness tissue damage may extend to subcutaneous tissue as in stage 3 pressure ulcers and to deeper supporting structures such as muscle, fascia, joint capsule and bone that are classified as stage 4 pressure ulcers. Evolution of pressure ulcers does not necessarily follow a predictable linear pattern from superficial to deep; from Stage 1 ulcers to Stage 2, then to Stage 3 and finally Stage 4 ulcers.

Deep tissue injury
Accumulating evidence suggests that a number of pressure ulcers (most Stage 3 and 4 ulcers) may initially originate in the deep tissue compartment and progress outward to the dermis and epidermis (inside out theory). Deep tissue injury may not be visible to naked eyes but may take hours to days before any clinical signs are evident. Once observed, deep tissue injury can deteriorate rapidly into deep craters despite stringent and optimal treatment that meets the standard of care. Deep tissue injury has the appearance of a purple or maroon bruise under intact skin that resembles and is often mistaken for a stage 1 pressure ulcer. Donnelly documented that 10% of pressure ulcers were initially diagnosed as stage 1 by visual inspection and evolved to stage 3/4 within days. It is possible that a proportion of the stage 1 ulcers in this study were misclassified and that they were really deep tissue injuries given how quickly these ulcers evolved over time. Other skin lesions with color change may reflect different dermatological diagnoses including; moisture associated dermatitis, fungal or yeast intertrigo or other dermatological conditions.

By eliminating the current numerical classification system and documenting the partial thickness and full thickness depth along with the appropriate physical findings (location, size, base, exudate, and margins), healthcare providers may prevent misleading communication.

Modified with permission from Dr. Diane Krasner, one of the authors of the Shifting the Original Paradigm article published in Advances in Skin and Wound Care December 2011.

This is only one of the controversial areas covered by this article. Get in on the shifting thinking about pressure sores by learning from one of the authors of this landmark statement. Dr. Krasner explores these and other controversies in an all new multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here. Early bird pricing ends February 13.

The second category, a maintenance wound, is when the patient refuses the treatment of the cause (eg, will not wear compression) or a health system error or barrier (no plantar pressure redistribution is provided in the form of footwear or the patient cannot afford the device). These may change, and periodic re-evaluation may be indicated.

Expected healing time for wounds
Chronic wounds are often recalcitrant to healing, and they may not follow the expected pathway that estimates a wound should be 30% smaller (surface area) at week 4 to heal in 12 weeks.

Impact of nonhealing wounds
Chronic, nonhealing wounds are disabling and constitute a significant burden on patients’ activities of daily living (ADLS) and the healthcare system. Of persons with diabetes, 2% to 3% develop a foot ulcer annually, whereas the lifetime risk of a person with diabetes developing a foot ulcer is as high as 25%.8 It is estimated that venous leg ulcers affect 1% of the adult population and 3.6% of people older than 65 years. As our society continues to age, the problem of pressure ulcers is growing. Each of these common types of chronic wounds will require accurate and concise diagnosis and appropriate treatment.

Chronic wounds: Medical legal assumptions
In the medical legal world there may be an assumption that most if not all wounds can be healed with proper care. In the medical world, what percentage of wounds are considered nonhealable? In a study of 173 wounds, 70% were considered healable, 25% were considered maintenance, and 5% were considered nonhealable including skin changes at life’s end.

Dr. Diane Krasner

Dr. Diane Krasner provides an intimate and detailed look at pressure ulcer causes and cures in a multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports.

When you register for the course, you will receive the full article quoted from here, plus 9 additional articles, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized critique of your report. Sign up for Pressure Sore Case Analysis and Reports.

Physiologic changes that occur as a result of the dying process (days to weeks) may affect the skin and soft tissues. These changes may manifest as observable (objective) changes in skin color, turgor, or integrity, or as subjective symptoms such as localized pain. Here is the medical legal issue: clinicians assert that these changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care.

Dr. Alois Alzheimer was on call in 1901 when a 51-year-old woman, Frau August D, was admitted to his asylum for the insane in Frankfort. Dr. Alzheimer followed this patient, studied her symptoms and presented her case to his colleagues as what came to be known as Alzheimer’s Disease. When Frau Auguste D died on April 8, 1906, her medical record listed the cause of death as “septicemia due to decubitus.” Alzheimer noted, “at the end, she was confined to bed in a fetal position, was incontinent and in spite of all the care and attention given to her, she suffered from decubitus.” So, here we have the first identified patient with Alzheimer’s Disease having developed immobility and two pressure ulcers with end stage Alzheimer’s. In our modern times, end stage Alzheimer’s Disease has become an all-too-frequent scenario with multiple complications including SCALE (Skin Changes at Life’s End).

Causes of skin changes at the end of life
When the dying process compromises the homeostatic mechanisms of the body, a number of vital organs may become compromised. The body may react by shunting blood away from the skin to these vital organs, resulting in decreased skin and soft tissue perfusion and a reduction of the normal cutaneous metabolic processes. Minor insults can lead to major complications such as skin hemorrhage, gangrene, infection, skin tears and pressure ulcers that may be markers of SCALE.

Are skin changes at the end of life preventable?
Skin changes at life’s end are a reflection of compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes). When a patient experiences SCALE, tolerance to external insults (such as pressure) decreases to such an extent that it may become clinically and logistically impossible to prevent skin breakdown and the possible invasion of the skin by microorganisms. Compromised immune response may also play an important role, especially with advanced cancer patients and with the administration of corticosteroids and other immunosuppressant agents.

Skin changes may develop at life’s end despite optimal care, as it may be impossible to protect the skin from environmental insults in its compromised state. These changes are often related to other cofactors including aging, co-existing diseases and drug adverse events. SCALE, by definition occurs at life’s end, but skin compromise may not be limited to end of life situations; it may also occur with acute or chronic illnesses, and in the context of multiple organ failure that is not limited to the end of life.

Dr. Diane Krasner

Legal perspective on skin changes at end of life
What you’ve read is the medical perspective. There are attorneys who dispute the existence of SCALE and see it as a handy way for a facility to defend the development of a pressure sore. Join the controversy on February 27 and March 5, 2012. Dr. Diane Krasner provides an intimate and detailed look at pressure ulcer causes and cures in a multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here. Early bird pricing ends February 13.

Pain Scales Use with Pressure Ulcers
Pain from pressure sores can sometimes be measured. A variety of pain scales are used to measure that which is subjective. The universally accepted measurement techniques are the utilization of visual analog scales (10-cm line with no pain at one end and worst possible pain at the other end, and the patient places an ‘‘x’’ at the appropriate point), Faces Pain Scale (various levels of happy and sad faces), or the numerical rating scale. The numerical rating scale asks if the patient has any pain on a 0- to 10-point scale with the anchors that 0 is no pain, 5 is the pain associated with a bee sting, and 10 would be the amount of pain experienced by slamming the car door on your thumb. Even in patients who cannot respond verbally, such as those with dementia, pain still needs to be assessed. There are pain scales for these patients that rely on nonverbal clues such as facial grimaces and pupil dilatation. (Assessment of pain for people with dementia can be found at www. hartfordign.org.)

A patient with a pressure sore
Bill is a 70 year-old-man who developed paraplegia. During his prolonged hospitalization, a stage IV pressure sore formed. One year later, it is still present and it dominates his life at home. Pressure sores may have a huge impact on the quality of a patient’s life. There is a financial impact of prolonged treatment – dressing changes, supplies, debridements, and flap surgeries. There is a medical impact of complications and risk of death from sepsis. There is a personal impact of physical restrictions, social isolation, loss of independence, and emotional problems. There is dealing with odors and limitations on the length of time one can sit. But pain is one of the biggest factors that affects the quality of the patient’s life.

Causes of Painful Pressure Ulcers
Pain levels should be recorded before dressing change, during dressing change, and after dressing reapplication. Krasner has defined wound associated pain at dressing change (intermittent and recurrent) versus incident pain from debridement or the persistent pain between dressing changes. Woo carried the Krasner concept further and demonstrated that anxiety and other patient-related factors could intensify the pain experience.
The Wound Associated Pain Model of Woo and Sibbald defines pain from the cause of the wound as often being persistent or present between dressing changes and distinguishes this pain from the pain associated with local wound care components (dressing change, debridement, infection, lack of moisture balance). All of these factors can be modified by patient-centered concerns, including previous pain experience, anxiety, depression, mobility and awareness or lack of comfort with the setting, and the procedure or treatment plan. Pain is an under-recognized and undertreated component of chronic wound care that has been demonstrated to be more important to patients than healthcare professionals. Causes of pain at dressing change include the dressing material adhering to wound base, skin stripping from strong adhesives, and aggressive trauma from cleansing technique (eg, scrubbing with gauze).

Many patients also express chronic persistent pain between dressing changes even at rest. A systematized approach should examine other systemic and disease factors that may play a role in precipitating and sustaining persistent wound-related pain. Common systemic factors are bacterial damage from superficial critical colonization or deep and surrounding compartment infections, deep structural damage (eg, acute Charcot foot in patients with diabetes), abnormal inflammatory conditions (eg, vasculitis, pyoderma gangrenosum), or periwound contact irritant skin damage from enzyme-rich wound exudate.

Impact of Pressure Ulcer Related Pain
Bill has a Morphine pump in his abdomen to deal with his pain. He takes supplemental Morphine by mouth. There are times he sleeps all day and is awake all night. The impact of chronic unrelenting pain can be devastating, eroding the individual’s quality of life and constituting a significant amount of stress. Increased levels of stress have been demonstrated to lower pain threshold and decrease tolerance. The result is a vicious cycle of pain, stress/anxiety, anticipation of pain, and worsening of pain. Increased stress also activates the hypothalamus-pituitary-adrenal axis, producing hormones that modulate the immune system compromising normal wound healing. Medications including nonnarcotic for moderate pain and narcotic analgesics for moderate to severe pain are required to treat severe pain as outlined below. A consult from a pain and symptom management team may be considered. Comprehensive management should also include careful selection of atraumatic dressing, prevention of local trauma, treatment of infection, patient empowerment, stress reduction, and patient education.

Modified by Pat Iyer with permission from Dr. Diane Krasner, coauthor of Special Considerations in Wound Bed Preparation 2011, an Update, Advances in Skin and Wound Care, September 2011

Dr. Diane Krasner

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up here for Pressure Sore Case Analysis and Reports.

The injury
The August 2011 Trial Magazine write up explains that the patient twice approached the doctor while he was employed at Virginia Beach Psychiatric Center. During the first encounter, the patient made statements to the physician before he was escorted away. In the second encounter, the patient formed his hand into the shape of a gun and pressed it against the doctor’s head and said “bang.”

The patient approached the doctor at the nursing station, and beat him.

The standard of care issues raised in this case related to the inadequate security provided. Although violent incidents occurred every few days at the facility, it retained only one part-time security guard to patrol the parking lot.

In Shetty v. Psychiatric Solutions, Inc., the jury awarded 5.35 million. Post trial motions are pending. Case site: No. CL09-1873 (Virginia, Norfolk City Cir. Nov 22, 2010.)

Evaluation of these kinds of cases is based on determining if an event was foreseeable. Dr. Shetty’s attorneys argued that the patient had threatening behavior, a documented history of violence and was involuntarily committed to the facility. He was placed on the lowest watch level.

Standard of care
Violence against staff may take place anywhere in the hospital. Emergency and psychiatric nurses are particularly sensitized to this issue, as they are more common targets. As this case shows, the facility has an obligation to protect its staff by accurately identifying the risk of violence (to the extent possible) and providing safeguards for staff.

Med League nurses have assisted attorneys with psychiatric cases including evaluating the events in light of the standards of care, providing the relevant standards for the time frame involved, creating a chronology of events and or supplying psychiatric healthcare experts.

Pat Iyer is president of Med League. She is very glad she does not work in a psychiatric hospital.

Bladder cancer occurs in 38 out of 100,000 men and 10 out of every 100,000 women. There are several risk factors for bladder cancer; the most common one is cigarette smoking. People who have been exposed to chemicals in the dye and rubber industries are also at risk. Dry cleaners, clothing manufacturers, and coal handlers are also at risk. (1) You increase your risk of bladder cancer by eating large amounts of fried meats and animal fats.
Blood in the urine is the most common sign of bladder cancer. Some people have pain or burning during urination and a change in bladder habits, such as feeling the need to urinate more frequently. Other conditions may cause these same symptoms, making bladder cancer difficult to diagnose. Bladder cancer may be present without symptoms for a long time. (2)

Bladder cancer is diagnosed by examining the urine for blood, examining the urine for cells (urine cytology), and performing a cystoscopy and an abdominal CT scan or ultrasound. A cystoscopy is performed under anesthesia, and involves inserting a lighted instrument into the urethra to examine the bladder. The balder is filled with fluid to enlarge it. The addition of a blue or white light makes it easier to see abnormalities of the inside of the bladder. The urologist biopsies any abnormal–appearing areas.

The most common type of bladder tumor is called urothelial. It tends to be superficial and not invade the walls of the bladder. It makes up 90% of all bladder tumors. The bladder may also have squamous cell or adenocarcinoma, more aggressive types of tumors. High grade tumors are also more aggressive, as are poorly differentiated ones.

If the urologist sees a tumor, the first step is to remove it and send it for pathology. It may be difficult to cut tumors out of the bladder because of the risk of perforating the bladder wall. Uncontrolled bleeding and perforation occur in less than 5% of cases. (3)

Bladder cancer is the sixth leading cause of cancer death among Americans (4). Complete removal of the tumor is not always possible, and therefore some patients have to undergo radical surgery consisting of removal of the bladder. An artificial bladder is created with a loop of bowel. This surgery has significant quality of life issues. It is accompanied by removal of the uterus and ovaries and part of the vagina or the prostate and seminal vesicles. Urine may drain into a bag attached the abdomen or be removed several times a day with a catheter. Surgery may be used along with chemotherapy or radiation therapy to reduce spread of cancer through the lymph nodes.

Liability issues surrounding bladder cancer include:
• Delay in diagnosis of bladder cancer
• Failure to correctly interpret ultrasounds or CT scans
• Damage to the bladder and surrounding structures during biopsy or bladder tumor removal
• Delay in recognizing hemorrhage or perforation of the bladder
• Failure to correctly read pathology slides
• Treatment – related complications such as extravasation (leaking into tissues) of chemotherapy

Bladder cancer is a nasty disease. Reduce your risks by not smoking, reducing your consumption of meat, and by promptly seeking medical attention if you have any of the symptoms of bladder cancer.

Patricia Iyer is president of Med League Support Services, Inc.

(1) Malignant Neoplasms, Rakel: Textbook of Family Medicine, 8th Edition
(2) Bladder cancer, Dr. Melissa Stopper, emedicinehealth
(3) Endoscopic surgical management, Wein: Campbell-Walsh Urology, 10th edition
(4) Surgery for bladder cancer, Wein: Campbell-Walsh Urology, 10th edition

Data are critical to understanding the impact of this important public health problem. This information can help inform TBI prevention strategies, identify research and education priorities, and support the need for services among those living with a TBI.

National TBI Estimates
Each year, an estimated 1.7 million people sustain a TBI annually.1 Of them:

• 52,000 die,
• 275,000 are hospitalized, and
• 1.365 million, nearly 80%, are treated and released from an emergency department.

TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States.1 About 75% of TBIs that occur each year are concussions or other forms of mild TBI.2 *The number of people with TBI who are not seen in an emergency department or who receive no care is unknown.

• Learn about the leading causes of TBI.
• For additional tables, figures and information about TBI in the United States, see the full report Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002 – 2006.

TBI by Age 1
• Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI.
• Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years.
• Adults aged 75 years and older have the highest rates of TBI-related hospitalization and death.

TBI by Gender 1
• In every age group, TBI rates are higher for males than for females.
• Males aged 0 to 4 years have the highest rates of TBI-related emergency department visits, hospitalizations, and deaths.

TBI Estimates by State
CDC currently funds 30 states to conduct basic TBI surveillance through the CORE state Injury Program.
To find TBI-related death and hospitalization data by participating CORE states, see State Injury Indicators Web-based Query System. (http://www.cdc.gov/injury/wisqars/index.html) )Note: Not all states participate in the submission of TBI- and other injury-related data compiled in this report.)

Costs of TBI
Direct medical costs and indirect costs such as lost productivity of TBI totaled an estimated $60 billion in the United States in 2000.3

References
1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
2. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.
3. Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; 2006.

Jane Heron MBA RN is a legal nurse consultant with Med League Support Services, inc.

You are handling a case involving a patient who had a head injury, and you wonder if the standard of care was met regarding assessment. Here is a quick overview about diagnostic testing (based on Clinical Guidelines for head injury listed in the National Guideline Clearinghouse)

Adults:
1) Skull x-rays (if a CT scan is not indicated)

2) Immediate CT (Computerized Tomography) scan should be done in an adult with any of the following:
a) Eye opening only to pain or not conversing (Glasgow Coma Score 12 out of 15 or less)
b) Confusion or drowsiness (GCS 13-14/15) followed by failure to improve within one hour of clinical observation or within two hours of injury
c) Fracture of base of skull, depressed skull fracture, and/or suspected penetrating injuries
d) A deteriorating level of consciousness or new focal neurological signs
e) Full consciousness (GCS 15/15) with no fracture, but with other symptoms (e.g. severe and persistent headache or two distinct episodes of vomiting)
f) History of coagulopathy (clotting or bleeding disorder; taking blood thinners) and loss of consciousness, amnesia, or any neurological features

3) CT scan within 8 hours in an adult who is otherwise well, but has any of the following:
a) Age > 65 (with loss of consciousness)
b) Clinical evidence of a skull fracture (e.g.: boggy scalp hematoma) but no clinical features indicative of an immediate CT scan
c) Seizure activity
d) Significant retrograde amnesia (> 30 minutes)
e) Dangerous mechanism of injury (pedestrian struck by motor vehicle. Occupant ejected from motor vehicle. Significant fall from height) or significant assault (e.g.: blunt trauma with a weapon)

4) Skull x-rays should be done only if CT scan is unavailable and the person has a mild head injury

5) In adults with a GCS < 15, who have indications for a CT scan, the cervical spine (neck) should also be scanned. This should include the cervical spine to T4 (Thoracic) images.

Children (<16 years old):
1) Immediate CT scanning for:
a) GCS <= 13 in the Emergency Department
b) Witnessed loss of consciousness > 5 minutes
c) Suspicion of open or depressed skull injury or tense fontanelle (space between bones of infant’s skull)
d) Social neurological deficits

Any sign of a basal skull fracture may also warrant an immediate CT scan.

2) CT scanning within 8 hours should be considered for the following:
a) Presence of any bruise, swelling, or laceration > 5 cm on the head
b) Post-traumatic seizure, with no history of epilepsy or reflex anoxic seizure (caused by a temporary interruption in the blood supply to the brain which can be caused by sudden unexpected stimulus, such as pain or fear)
c) Amnesia lasting > 5 minutes
d) Clinical suspicion of non-accidental head injury
e) A significant fall
f) Age < 1 year: GCS < 15 in emergency department
g) Three or more episodes of vomiting
h) Abnormal drowsiness (slowness to respond)

MRI (Magnetic Resonance Imaging) is usually only done when patients have mental status changes that are unexplained by CT scan findings. An MRI can be more sensitive than CT scans in identifying non-hemorrhagic (no bleeding) diffuse axonal lesions.

Indications for admission to the hospital

An adult should be admitted to the hospital if:
a) Level of consciousness is impaired (GCS < 15/15)
b) Patient is fully conscious (GCS 15/15) but has any indication for an immediate CT scan (if the CT scan is normal and there are no other indications for admission, the person may be considered for discharge)
c) Person has significant medical problems
d) Person has social problems and can’t be supervised by a responsible adult

Person may require neurosurgical assessment, monitoring, or other care management if:
a) Persistent coma (GCS <= 8/15) after initial resuscitation
b) Confusion persist for more than four hours
c) Deterioration in the level of consciousness after admission (a sustained drop of one point on the motor or verbal GCS scales, or two points on the eye opening scale)
d) Focal neurological signs
e) Seizure without full recovery
f) Compound depressed skull fracture
g) Definite or suspected penetrating injury
h) A cerebrospinal fluid (CSF) leak or other sign of a basal skull fracture

Jane Heron MBA RN is employed by Med League as a legal nurse consultant.

There are two broad types of traumatic brain injuries: closed or open.

A closed head injury is when there is a blow to the head or sudden, severe movement of the head which causes the brain to move about within the skull. This is the most common type of brain injury and can cause brain swelling. Although the skull is a rigid box which protects the brain, if the brain swells or there is bleeding, there is no room for additional fluids or swelling. Therefore, there can be increased pressure on the brain, and tissue compression. If this pressure is left untreated, and the brain continues to swell, it can eventually lead to pushing the brain through the base of the skull. This compresses the area that controls breathing and can eventually lead to death.

An open head injury occurs when the skull is fractured and penetrated. This can be caused by a severe blow powerful enough to break the skull. Portions of the skull can be pressed into the brain. Penetrating injuries, such as gunshots, sharp objects, and projectiles can cause foreign material, such as bone fragments, hair, dirt, and skin into the brain. The person may be more at risk for developing infections because of this. This type of injury can cause brain swelling, as well as lacerations from the skull fragments

A coup/contrecoup injury is caused when there is sudden acceleration and deceleration of the head. An example of this would be a motor vehicle accident when the person is hit from behind. This often involves a “whiplash” injury. The person’s head is thrown forward with great force, and then thrown back. The brain travels within the skull. The front area of the brain hits the inside of the skull when the person goes forward. When the person is then thrown backward, the back of the brain also hits the inside of the skull. The person sustains injuries at both areas of impact.

An epidural hematoma is a collection of blood caused when there is bleeding between the inside of the skull and the outer lining of the brain (the dura). Because there is very little extra space within the skull, this bleeding can quickly increase the pressure within the skull. The brain can be compressed which can compromise blood supply to the brain. It can also damage the nerve pathways, blood vessels, and brain tissue.

A subdural hematoma is a collection of blood caused when there is bleeding between the outer lining of the brain (the dura) and the brain tissue. This also quickly increases the pressure within the skull and will require surgery to drain the blood clot.

A subarachnoid hematoma is a collection of blood between the arachnoid space and the pia mater (the second and third protective layer of the brain).

Diffuse axonal injury is a very devastating injury and may involve no impact. It causes permanent damage to the nerves in the brain. Rapid acceleration of the head can cause the brain to move in the skull. This can cause shearing forces that can destroy the axons of the brain which are needed for proper brain function.

Secondary insults such as hypotension (low blood pressure) and hypoxia (low oxygen levels) are the most prominent secondary trauma-induced injuries. Both dramatically affect long term outcome and mortality rates. Low blood pressure is critical because it leads to decreased brain perfusion.

The patient’s chances of recovery will be affected by his age, other medical problems, the type and extent of the injury, and the care that he receives during the critical stages of his illness.

Jane Heron is a legal nurse consultant with Med League Support Services, Inc.

Wilma (fictitious name) suffered a frontal lobe injury when she was thrown into the windshield after her car was rear ended. Wilma got lost driving in her neighborhood, could not figure out how to operate her security alarm on her house, or to how to assemble food in the right order to follow a recipe.

The frontal lobe is behind the forehead. It controls emotion, personality, judgment, morality, language, problem solving, and impulse control.

Problems in this area of the brain may result in the following problems:
a) Recent memory deficits
b) Inattentiveness
c) Poor concentration
d) Behavioral disorders/personality changes
e) Inappropriate social and/or sexual behaviors
f) Flat affect
g) Depression
h) Expressive aphasia (the person knows what they want to say but has difficulty with communicating the words or sentences)
i) Impulsiveness
j) Psychotic disorders (abnormal thinking and perceptions; difficulty staying in touch with reality)

Roger was hit on the top of the head by an object that fell off a shelf in a store. He suffered a parietal lobe injury. The parietal lobe is under the top and back half of the skull. Roger had difficulty walking because he could not tell where his feet were in relationship to the floor. He also had trouble following conversations. The parietal lobe affects sensory function, pain, temperature, spatial relations, and proprioception (sense of body position).

Problems in this lobe can cause deficits in:
a) Ability to read, draw, or write
b) Receptive aphasia – difficulty understanding others
c) Problems with perception or awareness of one side of the body
d) Ideational apraxia – the loss of the ability to carry out purposeful movements
e) Constructional apraxia – the loss of the ability to copy objects
f) Dressing apraxia – the loss of the ability to know how to dress

Gretta had a seizure disorder. She fell backwards during a seizure and struck the back of her head. She became blind. The occipital lobe in the back of the head affects vision. Injuries to the occipital lobe may cause deficits in:
a) Receiving visual input
b) Visual interpretation
c) May cause blindness

Juan was hit in the side of the head by a baseball bat. He had a temporal lobe injury. He lost his memory of recent as well as distant events, and had a severe speech impairment. The temporal lobe is the major area for memory and affects hearing, language reception, and the sense of smell and taste.

Deficits in this area can cause:
a) Hearing problems
b) Agitation
c) Irritability
d) Receptive aphasia (difficulty understanding others)
e) Attention deficits

By understanding the locations of the functions of the brain, it is possible to understand how injuries to these areas result in deficits.

Patricia Iyer is president of Med League Support Services, Inc. Her firm has handled many cases of traumatic brain injury caused by personal injury or medical malpractice.
Jane Heron is a legal nurse consultant at Med League.