Coma After Car Accident: Key Questions and Insights

Coma due to a car accident?

The patient is 50 years old and was brought to the hospital after a car accident on Saturday (the 20th) at 11 AM.
The Glasgow Coma Scale score was 3, and the pupils were dilated.
A right subdural hematoma was diagnosed.
Due to the regional hospital's inability to provide treatment, the patient was transferred to a medical center at 2 PM.
After surgery at 7 PM, the doctor stated that the bleeding was not severe, but swelling was compressing the brainstem, leading to the coma.
A decompression surgery was performed at that time, with intracranial pressure (ICP) around 70 mmHg, and intubation was done.
The doctor mentioned that the prognosis was not very optimistic and that, based on his experience with similar patients, reducing the swelling is quite difficult.
Today (the 21st), the ICP has decreased to 30 mmHg, and the cardiopulmonary function has stabilized; however, there is still no brain response.
We were presented with a do-not-resuscitate consent form to consider signing.
1.
Does dilated pupils indicate brainstem injury? Is it irreversible?
2.
Does brain swelling mean it occurred immediately upon impact, or did it start with bleeding and then gradually swell?
3.
Does the decrease in ICP from 70 to 30 indicate that the swelling has reduced? Is the condition improving?
4.
What does it mean when there is no brain response? What actions can family members take to stimulate brain activity? Although she currently shows no response, can she still hear our voices and feel anything?
5.
Does this indicate brain death? It seems we are close to the determination process for brain death.
6.
In such cases, is there a golden period for recovery? How long should we wait to see if she will regain consciousness? Generally, is the chance of awakening low for patients like this?
7.
Does being presented with a do-not-resuscitate consent form suggest that we should prepare ourselves psychologically?
8.
Additionally, why do relatives say we must not sign the consent for tracheostomy? I have read some information indicating that the regulations have become more lenient regarding withdrawal of life support, haven't they? I understand my description may not be clear or complete, but I appreciate your answers to these many questions.
Thank you.

J, 20~29 year old female. Ask Date: 2013/07/21

Dr. Ding Xianwei reply Neurosurgery

Your information is indeed insufficient, so I will share based on experience! Generally speaking, if a patient arrives at the hospital with a Glasgow Coma Scale score of only 3 and there is not much bleeding, the prognosis is typically very poor.
If surgery is performed, it would merely prolong life, and the chances of regaining consciousness are not optimistic.
Of course, a decrease in intracranial pressure from 70 to 30 can sometimes be a positive sign, but it can also indicate a negative outcome.
However, brain death requires a series of strict assessments, so if organ donation is being considered, those evaluations must be conducted.
Currently, it should not be related to the tracheostomy consent form.
However, if a prolonged battle is anticipated, a tracheostomy may be necessary.

Reply Date: 2013/07/21

More Info

I'm sorry to hear about the situation you're facing. Understanding coma and the implications of brain injuries can be incredibly challenging and emotional. Here’s a comprehensive response to your questions based on medical knowledge and insights regarding coma and brain injuries.

1. Dilated Pupils and Brain Stem Injury: Dilated pupils can indicate several things, including potential damage to the brain stem, which is responsible for many autonomic functions, including pupil response. However, it’s not exclusively indicative of irreversible damage. The prognosis depends on the extent of the injury and the underlying cause of the dilation. In some cases, pupils can remain dilated due to medications or other factors, so it’s essential to consider the entire clinical picture.

2. Swelling of the Brain: Brain swelling (cerebral edema) can occur immediately after a traumatic injury due to the initial impact, leading to bleeding and inflammation. In some cases, swelling can develop over time as a response to the injury. The initial bleeding can cause pressure, leading to secondary injury, which can exacerbate swelling. Therefore, it’s possible that both bleeding and swelling occurred simultaneously or that swelling developed as a secondary response to the initial injury.

3. Intracranial Pressure (ICP) Changes: A decrease in ICP from 70 to 30 is a positive sign, indicating that the brain may be responding to treatment, and the swelling might be subsiding. However, while a lower ICP is generally favorable, it does not necessarily mean that the patient is out of danger. Continuous monitoring is crucial, as fluctuations can occur.

4. Lack of Brain Response: When a patient shows no response, it means they are not exhibiting signs of awareness or voluntary movement. Family members can engage in gentle stimulation, such as talking, holding hands, or playing familiar music, which may elicit a response. While the patient may not show outward signs of awareness, some studies suggest that patients in a coma can still hear and process sounds, although this varies greatly among individuals.

5. Brain Death Considerations: The absence of response does not automatically equate to brain death. Brain death is a clinical diagnosis that requires specific criteria to be met, including the absence of brainstem reflexes and the ability to breathe independently. It’s essential to follow the medical team’s guidance on this matter, as they will conduct the necessary tests to determine brain death.

6. Recovery Timeline: The "golden period" for recovery varies significantly among individuals. Generally, the first few weeks post-injury are critical for assessing recovery potential. While some patients may show signs of improvement within weeks, others may take longer. The likelihood of recovery diminishes with prolonged unconsciousness, but each case is unique, and some patients do recover after extended periods.

7. Consent for Withdrawal of Care: Being presented with a consent form for withdrawing care can be distressing and often indicates that the medical team is preparing for the possibility of a poor prognosis. It’s essential to have open discussions with the healthcare providers about the patient’s condition and what the options are moving forward.

8. Tracheostomy Concerns: Relatives may express concerns about signing a consent for a tracheostomy due to fears about the implications of long-term ventilation and the potential for a diminished quality of life. It’s crucial to understand that tracheostomy can be a means to provide long-term respiratory support, but it also raises ethical and emotional questions regarding the patient's quality of life and wishes.

In conclusion, navigating the complexities of a coma following a traumatic brain injury is incredibly challenging. It’s essential to maintain open communication with the medical team, ask questions, and seek support from counselors or support groups. Each case is unique, and while the situation may seem dire, there are instances of recovery that can occur even in the most challenging circumstances. Your concerns and questions are valid, and seeking clarity is an important step in this difficult journey.

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