The program on head injuries was fascinating, but I missed the first part. In 1950, my mother, only 36 at the time, died of what was later confusedly called both an aneurysm and a possible brain tumor. She was in the hospital for only 2 weeks before she died, and had neither a CAT scan or an MRI. (Perhaps neither was available in 1950 in Montana hospitals.) Would your new method of monitoring cranial pressure be used to save patients like my mother? Or are organic injuries different from impact injuries in that they are less treatable?

Margo Warner
Modesto, CA
margo.warner@ccc-infonet.edu

In 1950 there were no CAT scans or MRIs. CAT scans were first used in 1975, before MRIs. What they may have done back in 1950 was either an angiogram (where they inject dye into the arteries and then take an x-ray) or a ventriculogram (in which they take an x-ray of the ventricles of the brain to determine if there is a brain tumor). If she had an aneurysm rupture, an angiogram probably would have picked it up. The guidelines are essentially followed with patients who have an aneurysm rupture or a brain tumor and are suspected to have high pressure inside the head.

Dr. Ghajar,
Do the Guidelines contain information which could be utilized by rural (paramedic level) prehospital E.M.S. providers, when prehospital patient care time could exceed one hour?

Jake R. Hansen
Sandy, UT
jhansen@mail.xmission.com

The first three sections of the guidelines contain information that's useful for pre-hospital EMS providers. More research has to be done on the pre-hospital care since we're finding out that the pre-hospital care in traumatic brain injury as well as stroke is crucial to getting a good outcome in patients. I think in the future we'll hopefully see much more emphasis on resuscitation, diagnosis, and appropriate treatment in the ambulance.

On 10-19-95, I was involved in a MVA. It took 6 months before I was diagnosed with a mild traumatic brain injury by a psychologist. Physicians I had seen ignored symptoms such as nausea, dizziness, fatigue, balance problems, emotional lability, sleep difficulties, depression, etc., because I didn't think I had hit my head. They seemed not to know that a concussion can happen from sudden deceleration. They also did not recognize the sequelae or didn't think anything could be done, since I am so "high functioning". Question: What is being done to educate medical professionals about mild head trauma? From reading your interview with NOVA, I see that severe head trauma is also an area needing more attention. Why should we have to wait 6 months for a diagnosis and then seek out help on our own? Is there anything that we as patients can do? I've been trying to educate the docs I see, one at a time. It could be a lifetime effort.

Mary Ann Yonki
WIlkes-Barre, PA
MAYonki@aol.com

There are 6 million head injuries every year in the United States and 2 million are seen in the emergency rooms and a half a million are admitted to the hospital. 60,000 die from severe head injuries which is a very high figure for a death rate. In fact, it's the number one cause of death and disability in young people. Minor and moderate head injury are seen much more frequently in the emergency room. Even a concussion can cause significant disruption in a person's life. Symptoms such as not being able to pay attention, short-term memory difficulties, headaches, and dizziness are frequent complaints of patients who have a minor head injury. A typical minor head injury is: you hit your head, pass out, come to very quickly, and essentially appear totally normal when seen in the emergency room. Some patients are kept overnight after having a CAT scan of their brain to make sure there are no blood clots and frequently those CAT scans are normal, the patient is discharged, but may go on afterwards to have great difficulties in day-to-day living. I think the most disabling part of head injury is short-term memory difficulty and not being able to pay attention to tasks long enough to complete them. There are sport concussion guidelines and I refer you to Dr. Jim Kelly at the Chicago Institute of Rehabilitation and his efforts in trying to educate the public on this topic.

If a person suffers a head injury—such as from a fall—and it is not possible to take them to a doctor right away, what should one do? Is it safe to allow the person to go to sleep if that is what they feel like doing, or should they be forced to stay awake?

Mary Chunko
Washington, DC
mc24a@nih.gov

The most important thing to do with anybody who is unresponsive from any cause is the ABCs: airway, breathing, and circulation. I highly recommend everyone in the public take a CPR (cardiopulmonary resuscitation) course which will teach you the basics of establishing an airway, making sure the patient is breathing, and checking on their circulation. Beyond that, it's important to get qualified medical personnel to do definitive therapy. Anybody who suffers a head injury and has a period of unconsciousness should be taken to a hospital, be seen by a physician, and get a CAT scan to make sure that there isn't a blood clot or a more serious injury.

Dr. Ghajar:
My brother was taken to a public hospital on 9/29, after being assaulted—head injury. He was combative so the doctor's treated him with Ativan, Haldol, and Narcan, I believe. He immediately went into a comatose state, violently moving only his limbs involuntarily after receiving Ativan. They say there is no pressure, swelling or bleeding in the brain and the scans and lumbar/spinal taps were negative. I recently had him transferred to a private hospital, Washington Hospital Center, where the care appears to be more comprehensive and thoughtful.

My questions are:
Should a neurosurgeon monitor intracranial pressure even if the CT scan show absolutely no problems?

Could a medicine called Ativan, then Haldol and Narcan put someone in a comatose state if given to a head trauma victim to calm him down?

One doctor mentioned that it appeared as though my brother was without oxygen for a period of time. Would this put him in a comatose state where this limbs move constantly?

Any recommendations I can give the doctors on what they might look into? They are puzzled.



Carole Sund
Washington, DC
csund@nea.org

I'm not clear from reading the medical history you've given about the brother what the events were that led to his current condition. Concerning your question, should a neurosurgeon monitor your intracranial pressure even if the CAT scan shows absolutely no problem, the guidelines recommend if the patient is in a coma from traumatic brain injury and has a normal CAT scan, there are three other things the neurosurgeon should check on. If two out of three of one of the following conditions is evident, then it is recommended that the patient have intracranial pressure monitoring: age over 40, motor posturing, or a low blood pressure. However, if the patient does not meet those criteria and has a normal scan, it would be up to the neurosurgeon to decide whether the monitoring is appropriate or not. Ativan is a valium-type of drug. Some of these medications may, in certain doses, produce a comatose state. However, I cannot give you any definitive answer because of the lack of facts in this case. Patients who have a lack of oxygen can be in a comatose state. A qualified neurologist should look at the history and the early facts to make a diagnosis and some prognosis in your brother's case.

Once the guidelines were developed were they sent to every trauma center in the U.S. or to neurosurgeons?

Karen Hansen
Downing, WI
khans@win.bright.net

The guidelines were sent to every neurosurgeon in North America in April, 1996.

Dear Dr. Ghajar,
I would like to know what journal your data was published in.

Joan Logan
Lake Villa, IL
dlogan@wwa.com

There are over 3,000 research articles reviewed for the publication of the guidelines. I would refer you to the guidelines themselves to get the original references which you can obtain either from the American Association of Neurological Surgeons or from the Aitken Foundation.