Brain Injury & Critical Care - Frequently Asked Questions

This information applies to patients with a serious brain injury, which might have been caused by a car accident, a fall, a stroke or an infection.

Who is involved in my relative's care?

In the intensive care unit (ICU), there is a ‘neuro' team who will care for your loved one; these health professionals have extra training and experience with serious brain injuries. The ‘neuro' team includes registered nurses, respiratory therapists, dieticians, physiotherapists, pharmacists, social workers, EEG- and radiology technicians.
At Sunnybrook, the most serious injuries are treated in the top level ICU called the Critical Care Unit (CrCU on M2).
An intensivist is a specially trained doctor who is responsible for the daily medical treatment of brain-injured patients in the ICU. A neurosurgeon or a neurologist may also consult, depending on the type of injury.
Since Sunnybrook is a teaching hospital, there are many doctors (residents and fellows) receiving additional training in critical care.
Each intensivist usually manages the ICU for one week at a time. On Mondays, when care is transferred to the incoming intensivist, detailed and lengthy handover meetings are held with the entire team.

How long will it take to know the full extent of my relative's injuries?

When your loved one arrived in the emergency room, his/her injuries were assessed. The original damage to the brain is called the primary brain injury.
In the days that follow, secondary brain damage may develop (mainly caused by bleeding and swelling). These complications can be much harder to predict and visualize (even with a CT scan). Because of this, we cannot predict how long it will take to know the full extent of the injuries.
Diagnosis of injuries can be complicated by:
1. Bleeding: Sometimes a very small blood vessel may rupture; it may be so small that it may not be seen on the first CT scan. But overtime, it may create a clot that presses on the brain or blood from it may pool in the space between the brain's protective layers.
2. Swelling: After any injury, it is normal for the injured tissues to swell as extra fluid, nutrients and immune cells rush to help in healing. With an injured brain, this often happens gradually and can take up to 7 days to see the full extent. This can be especially challenging since there is a limited amount of space within the skull. This can cause an increase in pressure in the brain, which may influence brain circulation and oxygenation.
3. Diffuse axonal injury: In certain types of brain injury, there is microscopic damage to the connections between the brain cells, which can disrupt the normal functioning of the brain. This type of injury cannot always be seen on CT or MRI scans.

Will the brain repair itself?

With respect to the original brain injury, there are no specific treatments to repair the brain cells themselves. Our treatments focus on:
- Preventing further damage.
- Providing the best possible environment for the brain to get better.
To help the brain to recover, our staff regularly monitor breathing and blood pressure as well as keeping the surroundings as calm as possible.
Neuroscientists are actively working to understand if individual brain cells can recover. We know that sometimes some brain functions can be regained because of ‘brain plasticity'. This means that:
1. Healthy brain cells may compensate for the damaged ones and may perform their functions.
2. New brain connections can be made.

Why does my relative look so different?

Seeing a loved one in the ICU can be upsetting as he/she may be swollen, bruised or bandaged.
To help with recovery, the patient may be surrounded by monitors, IVs, breathing equipment and feeding tubes. The patient may have a neck brace if a spinal cord injury has not yet been ruled out. The patient may be placed on a cooling blanket to help to bring down his/her body temperature. Compression stockings may be put on to prevent blood clots.

Why do you need to examine my relative every hour?

While scans tell us about structures of the brain, neurological tests at the bedside give information about some of the brain's functions. We test:
- The reaction of the pupils.
- The movement of the arms and legs.
- The patient's response to a brief painful stimulus.
Because of the potential for further brain damage (which requires quick treatment), these tests should be done frequently.
The Glasgow Coma Scale (GCS) is one example of a neurological rating scale that is commonly used. It combines tests of eye opening, ability to follow commands and responsive movement; it gives a number from 3 to 15. It provides a baseline to assess neurological changes over time.

How can you tell if my relative is getting worse? What will you do next?

As your relative's condition changes, the doctors may decide that surgery is the best option. The decision to operate depends on the potential benefits versus the risks of surgery.
There are 3 operations commonly performed on brain-injured patients.
1. Brain monitoring- In this procedure, a small hole is made in the skull, so that wire probes can be inserted to read pressure and/or oxygen levels, to give data from within the brain itself.
2. Craniotomy - In this procedure, the neurosurgeon briefly removes a piece of the skull, in order to repair a bleeding blood vessel or to remove a blood clot. At the end of the surgery, the piece of skull is returned.
3. Decompressive craniectomy - In this procedure, the neurosurgeon creates space for the brain to swell by temporarily removing a piece of skull, which is kept sterile and frozen in a tissue bank. When the patient is stronger, the piece of skull is replaced in a second operation.

Why is my relative in a medically-induced coma?

Your loved one may get different medications, including sedatives to keep him/her calm and to allow medical interventions (such as breathing tubes and brain monitoring equipment).
Sedatives can also be used to put your loved one into a medically-induced coma. Since sedatives calm the brain's activity, they may decrease brain swelling. The sedatives will be reduced as soon as they are not needed.

My relative is squeezing my hand. Does that mean he/she is going to be okay?

ICU staff frequently use simple tests involving movement for information on the brain's function. However, not all movement is directed by the brain; some is a reflex-type movement (which is controlled by the spinal cord). If he/she squeezes your hand, it may only be a reflex.
It is still a good idea to report this information, but it is important not to attach too much meaning to this gesture.
Some positive signs that the brain is slowly getting better include:
- Breathing without a machine.
- Purposeful responses when interacting with staff.

Why doesn't my relative recognize me?

Coming out of a coma is a gradual process - it is very different than the way that it is shown on television.
He/she may not make eye contact or recognize loved ones immediately. Focusing can be very difficult for an injured brain, so he/she may stare into the distance.
If your loved one regains consciousness, there may be gaps in his/her memory and abilities. An understanding, low-pressure approach to recovery is always best.

My relative is off sedation but remains unresponsive. Does that mean he/she is brain dead?

No, it does not necessarily mean that he/she is brain dead; your relative may be in a coma. A coma is a deeply unconscious state; it is a response to the brain injury. Your loved one may still recover - partially or completely.
Although coma and brain death may appear similar, there are clear medical differences. Brain death occurs when all brain activity has stopped irreversibly. There are formal tests to determine brain death and the doctor will discuss these circumstances with you if they apply to your relative.

Can you tell if my relative is suffering? Are the procedures painful?

All patients are given pain medication that has been recommended for brain injuries. As part of our pain management, nurses will regularly assess your loved one and adjust the doses as needed.
As a brain-injured patient regains consciousness, his/her first responses may involve self-protection. Frequently, a patient will tug at the IV or breathing tube because they can restrict movement. The patient may moan or become upset as staff perform routine tests. The patient is not truly aware of these actions. This behaviour is not necessarily a sign of pain; it is a normal part of recovery.

How long will it take for my relative to recover? Why can't you be more specific?

Brain injuries differ significantly and therefore giving a specific time frame is very difficult.
1. Different injuries: Certain types of brain injuries require a longer recovery time, because of their cause, location or severity.
2. Different patients: Individual patients recover at different rates. Research tells us that health history and age play important roles.
3. Different progress: Set backs and complications also extend the recovery. Prolonged swelling, infection and seizures are all factors that may extend the time frame for recovery.
In general terms, a patient can continue to improve for two years; however, much of the recovery takes place over the first 6 months.
Even estimates that are specific to your relative's condition may change. Speak to the intensivist for the most up-to-date information.
Despite every effort, some patients will not respond to treatments.
Stages that a brain-injured patient may go through as he recovers include:
1. No response: The patient remains unconscious, with few signs of awareness.
2. Emerging: The patient may open his eyes, follow simple commands and experience periods of wakefulness during the day.
3. Agitated: The patient may become easily frustrated or even aggressive. In this stage, the patient may not seem like himself.
4. Confused: The patient may be able to follow a particular command one day and then be confused by it the next day.
5. Appropriate: The patient responds appropriately to directions and can follow a daily routine.
As a patient stabilizes and his prognosis becomes clearer, he may be moved from the top level ICU (the Critical Care Unit on M2) to the B5 ICU or the D4 ICU.

Does my relative know what's going on around him/her? Can he/she hear me if I talk to him/her?

We are not certain how much an unconscious patient can hear and understand. In case the patient can hear us, our staff members will speak directly to your loved one.
We encourage you to talk to your loved one, to update him/her on visitors or family news. However, constant conversation is not necessary, as the patient needs time to rest.

Will my relative be the same as he/she was before?

Physical changes: Some patients will regain their previous physical abilities. For many, their recovery will include many months of rehabilitation and may include re-learning everyday tasks, like feeding themselves.
Mental changes: Many patients will experience some long-lasting mental changes. The most common involve short-term memory, concentration, and decision-making.
Emotional changes: Changes in temperament or personality are common, including anger or depression.

What can I do to help?

First of all, look after yourself and use your energy wisely. It can be a long journey.
The ICU can be a busy, noisy and stressful place. Family members play an important role in keeping their loved one calm. Sitting quietly by the bedside and holding your loved one's hand may be helpful.
Keep a notebook to write down your questions so they can be fully answered at an appropriate time. Also record the responses so that you can share the information with other family members accurately.