Irwin & Boesen - Denver, Colorado Trial Attorneys

After a traumatic brain injury, a person can experience a variety of symptoms but not necessarily all of the following symptoms. (This information is not intended to be a substitute for medical advice or examination). A person with a suspected brain injury should contact a physician immediately, go to the emergency room, or call 911 in the case of an emergency. Symptoms of a traumatic brain injury include, but are not limited to, any of the following:

Slow pulse
Slow breathing rate, with an increase in blood pressure
Vomiting
Lethargy (sluggish, sleepy, gets tired easily)
Headache
Confusion
Ringing in the ears, or changes in ability to hear
Difficulty with thinking skills (difficulty “thinking straight”, memory problems, poor judgment, poor attention span, a slowed thought processing speed)
Inappropriate emotional responses (irritability, easily frustrated, inappropriate crying or laughing)
Difficulty speaking, slurred speech, difficulty swallowing
Body numbness or tingling
Loss of bowel control or bladder control
Sleep disorders
Fatigue
Depression
Spinal fluid (thin water-looking liquid) coming out of the ears or nose
Loss of consciousness; however, loss of consciousness may not always occur
Dilated (the black center of the eye is large and does not get smaller in light) or unequal size of pupils
Vision changes (blurred vision or seeing double, not able to tolerate bright light, loss of eye movement, blindness)
Dizziness, balance problems
Respiratory failure (not breathing)
Coma (not alert and unable to respond to others) or semicomatose state
Paralysis, difficulty moving body parts, weakness, poor coordination

To appreciate the extent of a precipitating injury, it is helpful to understand two commonly used medical scales that may be found in medical charts involving traumatic brain injuries.

The first is the Glasgow Coma Scale which rates a patient’s ability to open his/her eyes, response to verbal commands, and verbal responses. Each level of response indicates the degree of brain injury.

Glasgow Coma Scale

Eyes	Scores
Open spontaneously Open to verbal command Open to pain No response	4 3 2 1
Best motor response to a verbal command
Obeys verbal command	6
Best motor response to painful stimulus
Localizes pain Flexion - withdrawal Flexion - abnormal Extension No response	5 4 3 2 1
Best verbal response
Oriented and converses Disoriented and converses Inappropriate words Incomprehensible sounds No response	5 4 3 2 1

The lowest score is a 3 and indicates no response from the patient. A person who is alert and oriented would be rated at 15.

Rancho Los Amigas Cognitive Scale
The Rancho Los Amigas Cognitive Scale describes levels of function and is used to assess the efficacy of treatment programs. The scale scores cover deep coma to appropriate functioning. Most patients will demonstrate characteristics from several levels at once.

Level I: no response to pain, touch, sound or sight.
Level II: generalize reflex response to pain.
Level III: localized response to pain. Blinks to strong light, turns toward or away from sound, responds to physical discomfort, inconsistent response to commands.
Level IV: confused/agitated. Alert, very active, aggressive or bizarre behaviors, performs motor activities but behavior is non-purposeful, extremely short attention span.
Level V: confused/non-agitated. Gross attention to environment, highly distractible, requires continual redirection, difficulty learning new tasks, agitated by too much stimulation. May engage in social conversation but with inappropriate verbalization.
Level VI: confused/appropriate. Inconsistent orientation to time and place, retention span/recent memory impaired, begins to recall past, consistently follows simple directions, goal-directed behavior with assistance.
Level VII: automatic/appropriate. Performs daily routine in highly familiar environment in a non- confused but automatic robot-like manner. Skills noticeably deteriorate in unfamiliar environment. Lacks realistic planning for own future.
Level VIII: purposeful/appropriate.

Explanation of Symptoms
Following traumatic brain injuries sight, sound, taste, touch and smell can suffer decreased or increased sensitivity, or a complete loss. Loss of sensation to parts of the body and hypersensitivity are also common. Double vision, loss of depth perception, and an inability to see on one side of the body can occur. Loss of proprioception (the inability to know where arms and legs are in relationship to the body) may also take place.

Fatigue is extremely common in the early stages following injury. In many cases the fatigue is profound and staying alert and awake for these patients is difficult. This can easily be confused with being unmotivated because these patients have difficulty paying attention and are often sleepy.

Speech disorders follow damage to the cranial nerve which enervates the face. Dysarthria, difficulty in pronouncing words, characterized by slurred or slow speech or loss of the ability to vocalize, results from weak muscles or reduced coordination of the muscles required to produce speech. A closely related condition, dysphagia, the inability to swallow and chew properly, can be readily observed when a patient extends his/her neck or engages in some accommodating movement when swallowing. Reports of choking or the need to soften food with water before swallowing are significant.

Sleep disorders are another area of inquiry. Total reversals of sleep patterns, the need for multiple naps and rest periods and loss of bowel and bladder control are reported.

Neurologic damage readily disrupts how a person thinks and processes information. Memory, attention, organization, planning, and perception are functions disrupted by traumatic brain injuries. Attention and concentration is something most of us do well. We pay attention and focus on a specific task and block out distractions both internal and external. Survivors of traumatic brain injuries quickly change subjects and have difficulty following through an idea or a sequence to completion. The slightest distraction causes a complete loss of concentration and results in confusion. Without attention and concentration, learning cannot occur.

Significant confusion following a head injury is so common that the primary medical inquiry is to establish if the patient is oriented. Not knowing the day, week, year, or where they are, results in the patient asking searching questions. Coping with confusion is extremely frustrating and leads to more confusion. As a defense mechanism to bring rationality to their existence, many patients will develop their own explanation or history, integrating some accurate information, into a fabric of reality and fantasy. Confabulation is not coping with reality, but it is more closely associated with denial and is a defense mechanism.

Patients have difficulty planning which is known as impaired executive function. Planning requires good memory, learning, judgment, attention and organizational skills. Difficulty in following a logical progression or focusing or getting stuck on one step, stage or activity raises frustrations. Dealing with abstract concepts as literal facts is additionally confusing. Aphorisms, such as a complimentary "you are a tough cookie," are interpreted to mean that the listener is a piece of food that is extremely hard to chew.

The most significant hurdle to learning after injury is memory loss and impairment. The mind’s capacity to receive, store, and retrieve information is affected. Short-term memory and recalling what happened yesterday is more common than the loss of recall for older information. This should not be confused with retrograde amnesia, which is the inability to recall events before injury. Anterograde amnesia is the inability to recall events that have occurred since injury.

Impaired communication skills, such as aphasia, the inability to understand or recall the simplest words, is caused by brain cell damage, not by physical inability to speak. Patients who have difficulty understanding are diagnosed with receptive aphasia. Expressive aphasia is the diagnosis for those having difficulty remembering words, naming objects or expressing ideas.

Impaired judgment may often occur. Being stimulus bound is when the brain only recognizes and reacts to objects and events in the immediate environment. Applying a task to a similar but different situation cannot be accomplished. Difficulty in interpreting the actions or inaction of others is common. Those who show concern and attention can be viewed as being angry toward the patient.

People with impaired memory may remember and retain old skills, but learning new ones require repeated instructions and extended practice. Even then they can be readily forgotten, with accompanying frustration, depression, and anger.

Frontal lobe injuries can be interpreted as causing dullness because this area of the brain controls impulses, motivation and initiation. These patients need to be reminded and prompted in simple tasks, such as daily care and living tasks. Regular encouragement and visual cues are helpful in prompting initiation.

In addition to physical consequences of traumatic brain injuries, the ability to understand feelings and the ability to control emotions are impacted. A whole range of behavioral symptoms occur with traumatic brain injuries: agitation, depression, frustration, rapid changes in emotion and severe mood changes, insensitivity to others, self-centeredness, rage tantrums, poor impulse control, loss of inhibition, decreased libido, inappropriate sexual expression and loss of self-esteem. Pre-existing conditions may also be amplified following traumatic brain injuries.

Lost motor control or weakness of one arm or leg or on one side of the body is known as hemiparesis. Poor balance, decreased endurance, loss of the ability to plan movements of arms, legs and poor coordination are evident. Patients experience spasticity or abnormal tone and muscle stiffness.

Seizures can occur immediately or may be delayed until months or even years after the initial trauma. A seizure is a burst of abnormal electrical energy in the brain. In generalized seizures, or major motor seizures, the entire body stiffens. Loss of consciousness, irregular breathing, and loss of bowel and bladder accompany severe shaking. After regaining consciousness, the patient reports soreness and confusion. A second category of seizures are known as focal motor or partial seizures which present as jerking movements or twitching. Consciousness remains intact and often is viewed as a loss of concentration. Often the patient does not know that a seizure has taken place.

Patients suffering mild to severe brain injuries may have hospital and rehabilitation care from a wide range of professionals. Knowing the role of these providers is important to appreciating the significance and magnitude of traumatic brain injuries and in formulating a courtroom presentation that explains the breadth of disability a patient must endure.