Levels of Traumatic Brain Injury

By J. Thomas Anderson

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The dangerous and subtle nuances of traumatic brain injury are just emerging in the collective public, legal and medical consciousness. In the past, mild concussions were not necessarily equated with traumatic brain injury (TBI), but with increasingly sensitive medical tests and public scrutiny of news from battle fields and playing fields, the understanding of a concussed brain is being expanded to include traumatic injury in all its forms. According to the Center for Disease Control (CDC), concussion is a type of traumatic brain injury, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth. 

There are three broad classifications of TBI, mild, moderate and severe. Loss of consciousness (LOC) is the default factor for estimating severity of brain injury, but LOC is certainly not a necessary precursor for TBI. A mild traumatic brain injury (mTBI) may involve loss of consciousness for up to thirty minutes, may involve very brief loss of consciousness, possibly no more than a few seconds or minutes, and in some cases no LOC at all.  

Moderate TBI involves loss of consciousness or change in the mental status which lasts between thirty minutes and six hours. The confusion in a moderate brain injury can last from days to weeks and involve cognitive and behavioral impairments for months or years. 

Loss of consciousness exceeding six hours indicates severe TBI and may include states ranging from minimal responsiveness to coma. A fourth level exists within the severe category in which the brain is actually penetrated. Recent media attention highlighted severe TBI when a Florida teenager survived an accidental spear gun shot through the brain. He was awake, and interacting with hospital staff following his life flight. It goes without saying that severe TBI may disrupt normal function of the brain and cause substantial disability or death. Immediately following a sudden trauma, a TBI victim may appear dazed, combative, confused or incoherent, while being able to speak or walk around. Needless to say, the traumatized person may not be able to reliably evaluate their own level of consciousness. Remarkably a third of fatally injured TBI patients will obey commands and speak lucidly shortly before their deaths. The initial injury triggers a cascade of invisible internal chemical and physical events which cause further devastating damages. 

Health care providers assessment of a trauma victim will often erroneously chart "no LOC" based on the patients initial babble. Defense brain injury experts jump on that premature and inaccurate diagnosis in an attempt to dismiss or diminish TBI. Such an opinion is based upon the initial health care provider record and the answer that the victim supplied when asked "were you knocked unconscious?" The typical response is "I don't think so" or "I don't know", and so "No LOC" is wrongly charted even if the patient subsequently passes out or dies.  

It is well-understood that there is no requirement for loss of consciousness in diagnosing TBI despite some eloquent defense lawyers and experts arguments to the contrary. No one really "remembers" being unconscious. It is our task to explore altered mental status by asking questions which tease out the information: lapse in memory, witness observation, facts supporting head trauma, underlying truth in obtuse medical notations, proper tests, insightful experts, discerning friends and family observers, proper investigation, post-injury evidence, and so forth. 

The Glascow Coma Scale (GCS) is another tool the defense may use to attempt to undermine the existence of a brain injury or diminish the level of TBI. University of Glascow neurosurgeons Bryan Jennett and Graham Teasdale developed the GCS as an objective initial assessment for scoring a patient's conscious state. Although the GCS has been vetted in over 4,500 publications, as with all science, depending on your opponent, it may be questioned. The scale itself is a simple method of scoring between the numbers of 3 (awful) and 15 (preferable, from the victim's point of view). First responders often rate patients on the GCS during transportation to hospital emergency centers. The scale, which is sometimes published in EMT reports, consists of three categories of response which are scored separately and then totaled to achieve the GCS. The categories are Eye Opening Response, Verbal Response, and Motor Response. Total scores ranging between 3 and 8 are considered comatose. Scores between 9 and 12 are considered moderate and scores above 13 are considered minor.  

Please know that GCS scores of 15 can result in debilitating brain injuries. However, defendants waive GCS charts of 15 as victory flags for evidence of no TBI. According to the CDC over one and a half million TBI's occur annually in the United States. Traumatic brain injury is now listed by our government as a serious health problem resulting in a substantial number of deaths and permanent disability. 

At least fifty-six percent of traumatic brain injuries presented to emergency departments in the United States are missed completely. The types of imaging our emergency rooms commonly use, initial CAT scans and MRIs for example, often miss mTBI.  

Predicting mTBI outcome for patients has long been an inexact science. Furthermore, use of the word "mild" as an official classification of less serious types of brain injury presents an inherent problem when trying to persuade defendants and jurors to provide for the future care of one who has sustained an mTBI resulting in permanent disability. Today, with many resources and attention directed toward TBI, permanent disability from a mTBI is becoming more recognized and accepted. 

Regardless of the level of severity or source of brain injury, if TBI produces a change in the function of the brain and repair or rehabilitation is possible, that repair or rehabilitation should be accomplished. In the case of a brain injury, the cure is often a prosthetic device which addresses or compensates for the loss of normal function in the same way crutches compensate for impaired motor function. Examples include short and long term neurological cognitive therapy, life coaching, attendant care, or some combination of those therapies, among others. The long term cost for this type of rehabilitative process may be prepared by a qualified life care planner. The costs can be substantial, even in injuries involving a mild concussion with no loss of consciousness and no obvious physical injuries. We are just beginning to learn the price of a brain. After all, no brain injury would be considered mild on your own shoulders.