Introduction

A traumatic brain injury is an alteration Thumbnail image for Word brain photo.jpg
in brain function, or other evidence
of brain pathology, caused by
an external force.

Magnitude of problem:

The Centers for Disease Control and Prevention (CDC) estimate
that 1.7 million people in the U.S. sustain traumatic brain
injuries (TBIs) annually and at least 3.17 million children and
adults live with a permanent disability as a result of a TBI.

Motor vehicle crashes are the second leading cause of TBI after falls:
-815 deaths/year from TBI (MDH 2008)
-7500 ED visits for TBI/year (MDH 2008)

Recent trends:
Brain injuries due to car crashes have declined an impressive 25% between 1984 and 1992.(Sosin, D.M., Sniezek, J.E., Waxweiler, R.J. , 1992)

Most Common Causes and Risk Factors

Motor Vehicle and Impact:

Impact of head against the windshield/ejection from vehicle.
Impact of head against the steering wheel.(Ruan J.S., Prasad P., 1995)
Impact of head against the side window.(Morris A., Ahamedali H., Murray M., Hill J., 1995)

Traumatic Brain Injury, Motor Vehicle Crashes and Related Factors:

Over 50% of those who sustain a brain injury have been intoxicated at the time of injury.(Coma Guide for Care Givers, 2000)

Person's aged 15 to 24 years old are at the highest risk for brain injury. Those under 5 have a moderately high risk of brain injury. TBI risk remains low in the midlife years, but then rises again as a person passes 60 years of age. This pattern is indicative of increased exposure to motor vehicle crashes in young adults and increased falling in the elderly due to their increasing physical fragility. (Kraus J.F., McArthur D.L., 1996)

28% of TBI is caused by motor vehicle crashes. When examining TBI that requires hospitalization, almost half (49%) are caused by motor vehicle crashes.(Sosin D.M., Sniezek J.E., Thurman D.J., 1991)

Motor vehicle crashes are the second leading cause of TBI and account for the largest cause of death resulting from TBI at 17.3% and 31.8% respectively among all age groups. (What are the leading causes of TBI?, 2010)

Motor vehicles are the leading cause of TBI-related hospitalizations.(Thurman, 2001)

CDC Safety Tips for driving or riding in motor vehicles:

The following tips to avoid TBI in motor vehicle accidents point to some of the common causes and risk factors for injury in car crashes:

  • Always wear a seat belt.
  • Properly secure or buckle children into child safety seats appropriate for their ages and weights every time you travel.
  • Properly secure or buckle children under 12 in the back seat to avoid air bag injuries.
  • Never drive after using alcohol or drugs.
  • Do not ride in a car with a driver who is drug- or alcohol-impaired.
  • Prevent others from driving while impaired with alcohol or drugs. (CDC, 2006)


Costs

Annually, the cost for TBI for medical care and lost wages is $60 billion.(Findelstein E., Corso P., Miller T., and Associates, 2006)

Over a severe TBI survivor's lifetime, the cost of care can reach $4 million.(National Institute of Neurological Disorders and Stroke, 1989)

The average acute rehabilitation cost for survivors of a severe TBI is $110,891, or about $1,000 per day. The average hospital and rehabilitation length of stay is about 55 days for those who are severely injured.(Whitlock J.A., Hamilton B.B., 1995)

These costs are conservative as the information found is from old estimates.

Factors That Have Limited the Reduction of Injuries

Historical Context:

Conceptualization of brain injury as sickness rather than disease in early 1900's.

Treatment followed a medical model with professionals dictating treatment for acute
rehabilitation. Post-acute programs began to develop and pushed to differentiate
this care from acute care. Post-acute rehab was non-hospital based treatment with
an interdependent model of care. Individuals were no longer referred to as patients
but called clients. Care was provided by non-professionals under the direction of a
team of professional consultants. The individual and his/her family were considered
team members. Post- acute rehab separated itself from the medical model. The
science was not strong - outcomes were not adequately tracked, therapies were not
evidence-based. Funding sources did not consider care to be beneficial and
therefore did not cover costs.

TBI was seen as an "event" - a final outcome to an
insult in an isolated body system. Once it was fixed, there would be no other effect
on the body.(Association, 2009)

New Directions:

The Brain Injury Association published a position paper in March 2009.

The purpose of this paper was to encourage the classification of a TBI not as an event, not as the final outcome, but rather as the beginning of a disease process. The paper presents the scientific data supporting the fact that neither an acute TBI nor a chronic TBI is a static process--that a TBI impacts multiple organ systems, is disease causative and disease accelerative, and as such, should be paid for and managed on a par with other diseases.(Association, 2009)

Poor outcomes after TBI result from shortened length of stays in both inpatient and
outpatient medical treatment settings. Payers point to a lack of sufficient evidence-
based research as a primary reason for coverage denial of medically-necessary
treatment. This occurs particularly when behavioral health services and cognitive
rehabilitation are needed.(America, 2011)

Haddon's Matrix and Strategies

Haddon's Matrix:
Thumbnail image for IMG2.jpg

Haddon's Strategies:

1) Prevent the creation of the hazard in the first place:
If we no longer had modes of transportation aside from walking, we would no longer have travel-associated TBI. We could eliminate automobiles, but TBI still likely occurred in horse and buggy crashes.

2) Reduce the amount of hazard brought into being:
Enforcing laws to reduce speeding, warning about driving during hazardous weather.

3) To prevent the release of a hazard that already exists:
This could be things that increase driver awareness and communication. One example would be the systems to alert a driver when they are falling asleep, or increasing the visibility of hazards on the roadway.

4) Modify Rate/spatial distribution of release of hazard:
Airbags, seat belts, collapse of automobile structures to reduce rate of deceleration in collision.

5) Separate in time or space the hazard and that which is to be protected:
An example of this could be the long nosed cars of the 60's and 70's. The long nose of the car provided increased separation in space between the hazard (energy from the collision) and the occupant of the vehicle

6) Separate the hazard from host by interposition of material:
Airbags, roll cage design of cars.

7) To modify the basic quality of the hazard:
This would be to reduce the speed limits or reduce the speed the vehicle is able to travel. That would modify the basic quality of the hazard.

8) To make that to be protected more resistant to damage from the hazard: This would include good nutritional status, proper amounts of CSF in the skull, increased musculature.

9) Countering the damage that has already been done:
This would include things like a cooling protocol for those people in a coma, as this reduces the amount of ongoing damage that is happening to the brain after the initial insult.

10) Stabilize, repair and rehabilitate:
These include hospital care, medical procedures to repair macroscopic damage, and then rehabilitation to regain lost abilities due to TBI.

References

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Coma Guide for Care Givers. (2000). Retrieved April 2, 2011, from Delaware Health and Social Services, Division of Services for Aging Adults with Physical Disabilities: http://www.dhss.delaware.gov/dsaapd/files/coma_guide.pdf

What are the leading causes of TBI? (2010). Retrieved March 5, 2011, from CDC: http://www.cdc.gov/TraumaticBrainInjury/causes.html

America, B. I. (2011). Join the Congressional Brain Injury Task Force. Retrieved March 5, 2011, from Brain Injury Association of America: http://www.biausa.org/literature81100/CongressionalBrainInjuryTaskForceFactSheet2011

Association, B. I. (2009). Conceptualizing Brain Injury as a Chronic Disease. Retrieved March 5, 2011, from Brain Injury Assocaiton of America: http://www.biausa.org/biaa-position-papers.html

CDC. (2006). Traumatic Brain Injury Prevention Tips. Retrieved March 5, 2011, from CDC: http://www.cdc.gov/ncipc/factsheets/tbiprevention.html

Findelstein E., Corso P., Miller T., and Associates. (2006). The Incidence and Economic Burden of Injuries in the United States. New York: Oxford University Press.

Kraus J.F., McArthur D.L. (1996). Epidemiologic Aspects of Brain Injury. Neurologic clinics, 435-450.

Morris A., Ahamedali H., Murray M., Hill J. (1995). Head Injuries in Lateral Impact Collisions. Accident Analysis and Prevention, 749-756.

National Institute of Neurological Disorders and Stroke. (1989). Interagency Head Injury Task Force Report. Bethesda, MD.

Ruan J.S., Prasad P. (1995). Coupling of a Finite Element Human Head Model with Lumped Parameter Hybrid III Dummy Model: Preliminary Results. Journal of Neurotrauma, 725-734.

Sosin D.M., Sniezek J.E., Thurman D.J. (1991). Incidence of Mild and Moderate Brain Injury in the United States. Brain Injury, 47-54.

Sosin, D.M., Sniezek, J.E., Waxweiler, R.J. . (1992). Trends in Death Associated with Traumatic Brain Injury, 1979 through 1992. Journal of the American Medical Association, 1778-1780.

Thurman, D. (2001). The epidemiology and economics of head trauma. In H. R. Miller L., Head Trauma: Basic, Preclinical, and Clinical Directions. New York: Wiley and Sons.

Whitlock J.A., Hamilton B.B. (1995). Functional Outcome After Rehabilitation for Severe Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation, 1103-1112.

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