Journal of Neuroscience Nursing:
Foreword: The Editorial in this issue has been written by Laura Mcilvoy, a member of JNN's Editorial Board. She highlights the issues and concerns that envelop traumatic brain injury, its classification and treatment, and the patients it touches.
V. Susan Carroll, MS, RN, CNE
March has been designated Brain Injury Awareness Month, so it's a good time to consider some facts about brain injury. The term brain injury has a lot of meanings. Acquired brain injury is frequently used to indicate any type of injury to the brain after birth, such as traumatic brain injury (TBI) or stroke, but it is primarily used in the literature and online in discussing TBI. There is no consistent definition of TBI. The Centers for Disease Control (CDC) has one, the National Institutes of Health has another, and the TBI Act of 2008 has another. It's not that these definitions are radically different; they are in fact very similar. It's just interesting that the various governmental agencies involved in the detection and treatment of TBI can't agree on a common vocabulary in describing it.
The number of TBIs continues to grow in the United States, with an estimated 1.7 million TBIs occurring annually. This number is based on CDC data from 2002 to 2006 and does not include individuals seen in nonhospital settings or unreported incidences. Fortunately, the TBI Act of 2008 authorizes the CDC to conduct studies to determine the incidence of TBI and prevalence of TBI-related disability and to report national trends in TBI.
Although TBI definitions are inconsistent, the determination of injury severity is more structured. Initially, the Glasgow Come Scale (GCS) score was used to define injury severity, with GCS scores of 3-8 being severe, 9-12 moderate, and 13-15 mild. Currently, duration of unconsciousness and posttraumatic amnesia are also considered in determining TBI severity. Over 80% of TBIs are classified as mild severity and include the diagnosis of concussion. There are between 1.6 million and 3.8 million sports-related concussions annually in the United States (see www.biausa.org). The "signature injury" of the Iraq and Afghanistan conflicts is mild TBI. The Defense and Veterans Center reports the military incidence of TBI quarterly. The number of TBIs within the armed forces has increased to almost 30,000 a year, with approximately 80% of those classified as mild.
Each classification of severity requires specific treatment modalities. Evidence-based detection and treatment management guidelines are now available for a variety of TBIs. Both medical and nursing severe TBI treatment guidelines have been developed by the American Association of Neurological Surgeons and the American Association of Neuroscience Nurses (see www.braintrauma.org and www.aann.org). Various groups have developed classification systems and treatment recommendations for sports-related concussions. The American Academy of Neurology (AAN) published the latest recommendations in 1997. In November 2010, AAN published a position statement calling for any athlete who is suspected of having a concussion to be removed from play and evaluated. They also stated that their 1997 guidelines are currently being revised and updated. In response to the increased incidence of military TBI, in 2009 the Veterans Administration/Department of Defense Clinical Practice Guidelines for the Management of Concussion/TBI were developed and published (see www.DVBIC.org).
As the incidence of traumatic brain injury increases, so do the number of survivors experiencing physical, emotional, and cognitive problems. We need to advocate for measures that enable accurate detection of injury and evidence-based guidelines that can be used to provide quality treatment. We need to prepare ourselves to provide leadership and knowledge as we integrate injured warriors back into the population. We need to be what we are, neuroscience nurses.