Forum: Research Questions

Discussing: Closed head trama

Closed head trama

I have read the wonderful material that has been presented in the research articles and have supplimented it with my own knowledge (personal experience - yep, that is why she is so wierd!) and questions to a friend of mine who is a nurse. I have a few more specific questions concerning a fic I am writing.

First of all, would simple drilling of a hole in the skull be considered 'trepanning'? Would it be effective to reduce pressure on the brain?

For closed head trama, I was under the impression that it was not bleeding that was the problem but brain swelling from the point of impact (or possibly both) that was the issue when dealing with concussion injury. Today, they use medicines that quickly reduce swelling, anti inflammatories and diuretics, to keep the pressure on the brain down and thereby reduce the damage that that might cause. I have gotten a few herbal remedies that might have been available at the time (I also am very careful about using european native species - glad someone noticed that) but I don't know which would have been the most commonly used for this injury, or what would have been the most commonly used treatment for it.

Any ideas would be appreciated to get me over this hump in my story.

Ariel

 

 

Re: Closed head trama

Okay, now, I'm no expert on this, and I'm going on memory here.

Yes, that is trepanning (or trephining - means the same). Yes, it would (or at least, could) relieve pressure on the brain.

I believe you are correct that at least some of the time it is swelling against the skull that causes the problem, but one can also have internal bleeding even if the skull is not broken as well. Trepanning would presumably allow this internal bleeding to be dealt with, although I don't know how much it would do for swelling of brain tissues - trepanning holes are typically not large.

It was a surgery that was successfully carried out in pre-modern medicine, not all the time but there have been many discoveries of skulls with trepanning holes that show bone growth, i.e. healing, around the edges of the hole. I'm under the impression that it was done in the Americas (Inca society? maybe Aztecs?), and possibly in Egypt? Don't know to what extent it was practiced in pre-modern Europe, to be honest. I have at least one book on medicine in that period, but it's at home and I'm at work. I'll try to remember to look it up tonight, if I have time.

Celandine

 

 

Re: Closed head trama

Cel, you are correct that trepanning or trephination will reduce pressure in head trauma ONLY if the pressure comes from a collection of blood which can drain out of the hole.

The swelling itself can cause a problem, which trepanning would not help. However head trauma is much more likely to cause serious problems because of bleeding rather than simple swelling, although it can happen. If the problem was a blood collection, drilling a hole would be the main therapy available in Middle-earth.
Concussion is the term used when there is no blood collection, and concussions rarely are life-threatening, although they can leave neurologic damage.

Interestingly, steroids which were considered a mainstay of treatment of head trauma for years, are no longer recommended. Diuretics in general are not used, but one specific one that is called an osmotic diuretic (mannitol) is used when someone is seriously deteriorating, usually not from a concussion. I don't know of any herbal equivalent for this.

Current treatment recommendations for brain injury are to maintain a good blood pressure and sufficient oxygen, since abnormally low pressure or oxygen compounds the damage. Another very reasonable and easy measure is to elevate the head of the bed by 30 degrees. Low tech, no downside (sorry, bad pun), and some evidence exists that this is helpful.

I regret to say my herbal knowledge is still minimal, but since antiinflammatories are no longer recommended, that may simplify the herbal issue.

Lyllyn

 

 

Re: Closed head trama

Yes, thank you! I knew about the elevation (and have that in my story) but not about the anti inflammatories... thank you! So even willow bark tea (aspirin) would not be recommended? It thins the blood and, I believe, is supposed to dialate capillaries?

You also say, maintain good blood pressure - would this mean keeping victim from shock, where blood pressure would drop? Would you also think that keeping the room quiet, dark and warm and avoiding elevated blood pressure would also be important? I would have thought with either bleeding or pressure, that excitement, arguements would be a problem for the injury too.

Thanks for the good info!

Ariel

 

 

Re: Closed head trama

Willow bark would be good for the pain, but should avoided until the healer is sure that the patient isn't bleeding, as aspirin would inhibit clotting. A reasonable approach would to be see the patient improve for at least 24 hours before giving it.

Good on the head elevation!

It would indeed mean keeping them from shock which to a medical person may mean something different than the average reader would understand. In a situation like this in modern life it would mean keeping the blood pressure above 90 systolic (the top number), and giving fluids by IV if needed, or even blood transfusions, depending on the situation. In Middle-earth fluids could only be given by mouth, and the healer would do that only if the person wasn't likely to vomit, and could swallow well.

Forgive me if the explanations are either too simplistic or complex, you obviously have some knowledge of this.

Keeping the room dark and quiet would certainly add to the patient's comfort. Loud noise, arguments would not be dangerous, but would make the headache worse. The blood pressure would have to get awfully high, much higher than you'd expect a young person in good health to get during an argument, for it to be a problem.

You are most welcome,
Lyllyn

 

 

Re: Closed head trama

Yes, thank you! I have a BS in Biology. Helps with some things and not with others. I went on to use it in Forestry, not medicine, so my expertise is not quite refined enough for this stuff.

One last question and I will be done. I have written in that his pupils are slightly dilated and sluggish to respond. I was planning on having them get slightly more dilated during the first 24 hours as the brain pressure increases and this will be a bone of contention between the older and younger healer who are dealing with this patient (the younger one being the first on the scene and the preference of the parents - the older one being brought to the situation by the very imposing MIL).

My question is, would this kind of pupil reaction be believable with a bad concussion/brain contusion? I do intend for their to be neuromotor problems for months afterwards (story will include a very long convalescence) but nothing permanent, and I wanted to insure that my story was at least believable medically.

Ariel

 

 

Re: Closed head trama

Ariel, the pupil dilation may not work the way you need in this story. In head trauma, when both the pupils dilate due to pressure, the patient is very close to death. The typical sequence is:
1. Bleeding which causes an expanding mass pushing on the rest of the brain.
2.The brain, having nowhere else to go, pushes against the skull and the brainstem is pushed against the base of the skull. Typically one side will be damaged first, resulting in one dilated pupil.
3. As the pressure continues, the damage continues, and the other pupil will also dilate. When this happens, the healer has very little time to do something. Along with the pupils, this much pressure destroys the centers that control breathing and heartbeat.

A dilating pupil in a patient that with decreased conciousness is taken to mean an expanded blood clot. In real life that person would get an immediate CT, if a CT was unavailable due to extreme distance, a burr hole could be appropriate even in modern times.

Now, if you just want to scare the heck out of people, a head injury can cause (often temporary) damage to the nerve that controls the pupil, and the patient can have a 'blown' pupil, but be otherwise normal in every way.

If you want to present a picture of deterioration, the most important sign to go by is mental status. If you were to give your character a decreasing mental status (more confused, I can get specific if you like), especially adding in the above eye injury (traumatic mydriasis) or one somewhat dilated pupil, it would be reasonable for healers to argue. Just the increasing confusion in the patient is enough reason to argue. You could throw in some difficulty with using one arm and leg, but complete ongoing paralysis would suggest something less reversible.

Yllyn

 

 

Re: Closed head trama

You ARE a wealth of information! I had these visions of going to a physician, asking these questions and having him consider comitting me! LOL!

I had already a slightly dilated pupil, but I was going to do it in both eyes. Need to rethink that. The injury I have written occured at the back of the head, so optic nerve damage is very possible. I like the idea of the blown pupil, because I DO want to scare the heck out of people. I have already shown some deterioration. The character was injured then regained conciousness and though confused and in pain, he was responsive. I then wrote a gradual decrease in responsiveness till he reached a comatose state. It is in this comatose state that I currently have him and I am planning on having the continuation of treatment be a bone of contention between the healers.

I should learn to limit myself to subjects I actually know! But it's so much fun making a fool of yourself!

Would you have any suggestion as to what would be a treatment that the older healer would propose that would be logical but not recommended? I was planning on having him take one look at the dialated pupils and think the patient was done for (he's not known for his bedside manner but I don't want to make him an incompetent). Or perhaps you can suggest a treatment option that would be old fashioned, not out of line, but no longer recommended (like the anti-inflamatories)?

Thank you AGAIN for all this wonderful info! I am downright PARANOID about writing inaccuracies...

Ariel

 

 

Re: Closed head trama

The 'lucid interval' you mention, coupled with subsequent deterioration sounds like an expanding hematoma (blood collection, for anyone else lurking). There would be only one treatment, drilling a hole. You could have the older healer reluctant or fearful of tackling that, or feel that it's hopeless.

On the antiinflammatory issue, it was a very modern treatment, and it only applied to steroids, not any antiinflammatory.

Although it wouldn't be medically useful, you could have the older healer follow the erroneous line of reasoning that since liquid is building up in the brain a diuretic should be given. There are herbs that are diuretic. Mind you, modern medicine would be horrified at this for several reasons.

Or you could have them argue as to whether to drill a burr hole or not.

Lyllyn

 

 

Re: Closed head trama

You know what? You have just outlined the way I outlined the story the very first time I did this chapter! LOL! I have been gathering information and changing things in the story, but from this last post, it seems like I was on the right track from the beginning!

Again, thank you!

Ariel

 

 

Re: Closed head trama

Now, if you just want to scare the heck out of people, a head injury can cause (often temporary) damage to the nerve that controls the pupil, and the patient can have a 'blown' pupil, but be otherwise normal in every way.

Just so I know, how long would this blown pupil last? And would a blown pupil be at all reactive or would it be completely fixed?

Thanks.

Ariel

 

 

Re: Closed head trama

Just so I know, how long would this blown pupil last? And would a blown pupil be at all reactive or would it be completely fixed?

Actually, I'm sorry if I was confusing, a 'blown' pupil is medical slang for what happens with the increased pressure in the skull with bleeding when the pressure is enough to push the brainstem against the skull. The dilated pupil from the injury only to the nerve makes it look like a blown pupil.
It would not react, and can last up to several months, or even be permanent. Of course it can also resolve more quickly.

Lyllyn

 

 

Re: Closed head trama

Thank you for your prompt response! I will have to change that as I had the 'blown' pupil reacting. In the story, I had one pupil blown and the other not, and the healer getting worried when the normal pupil started to dialate. Would this be too much trama or would it be an appropriate amount for great concern, quick action but have the character still able to effect a full recovery in time?

Ariel

 

 

Re: Closed head trama

If one pupil is simply the eye itself, not a problem with bleeding inside the skull, it is not an issue. If you are adding the other pupil dilating because of pressure in the skull, someone should be doing something soon, as within less than an hour, and preferably much faster than that. And yes, if one pupil is dilated, and the damage is all from pressure, and the pressure is released rapidly, a good recovery is quite possible.

the problem with the dilated pupil from the injured nerve to the eye is that now your healer can't tell what's going on, or how fast things are deteriorating, even if he or she realizes one eye is peripheral nerve damage as opposed to inside the skull.

Getting very complicated for Middle-earth.

Lyllyn

 

 

Re: Closed head trama

Yes, I can leave out the blown pupil and simply make it dialated and slow to respond. That will make one eye dialated and slow to respond and the other eye starting to dialate before she starts her surgery - and it is within the hour of her noticing this that she does - though much happens in that hour.

Doing a bit of a rewrite on the first few chapters (because the last ones came out much more like 'me' - I must be getting back my 'groove') and figured I would fix some of the problems I had with logic and medical details before I got too far.

Ariel

 

 

Re: Closed head trama

Lyllyn - Oh fount of medical wisdom... I have taken your advice (though I still have to rewrite some of the earlier chapters to remove the dialated and blown pupils) and used it in the writing of my most recent chapter. I would appreciate it greatly if you would take a look at it... just this chapter - I don't expect you to read the whole story - but I would greatly appreciate a review of it on purely medical grounds. Did I make any blatant errors or at least if I have, do you think anyone with less than a passing familiarity with medicine would miss it?

If you don't have time, I understand too.

Fear - chapter 9

Ariel

 

 

Re: Closed head trama

I looked at 9 and a few chapters back, as well. I don't see any problems. For your own information a 'blown' pupil is just medical slang for a dilated pupil due to pressure on the brain. So if Daisy is talking to Doc Clearwater or Bob and they are speaking of it, it's reasonable to use the slang, although many would not. For non dialogue you're better off with 'dilated' just so others can understand.

Lyllyn

 

 

Re: Closed head trama

Thanks for your input, Lyllyn. I really appreciate you taking the time to look at it for me.

Ariel

 

 

Re: Closed head trama

Was wondering if Lyllyn would be willing to look at another chapter concerning the recovery of a patient with this sort of injury. The chapter is posted in beta and I would appreciate her taking a look at it to see if this is a believable situation 1 week post trauma.

Chapter 13

Thank you,

Ariel

 

 

Re: Closed head trama

Ariel, I have read your chapter. On the whole it could stand as it is, but I'll mention a few things.

The shunt is actually fairly modern; it's a tube running from a reservoir of fluid in the brain down into another part of the body, eg the abdomen. You could change the word to 'drain' but I don't know that they'd leave a drain in. It's a conduit for infection, and with a moderate head injury most people wouldn't need it, just the initial trephination.

If Frodo does have vertigo, any sudden movement of his head is likely to set off the symptoms. During times he has the vertigo, he is likely to be nauseated. You didn't contradict this, as I noted Drogo was careful at the end not to jostle him, very good! The one place I had questions about that was the bathing scene. He is obviously uncomfortable in the water, but I'd expect the main problem to be moving him.

Aside from that, it looks good. Extra bonus - some material that I found on recovery:

"The recovery from coma follows a set course.

1. Eyes open as brain stem recovers functions concerning wakefulness. Words may be uttered.
2. A possible period of 'cerebral irritation' - a lot of swearing and aggression!
3. A period of quiet confusion
4. End of post traumatic amnesia (*length of this period, rather than coma, can correlate with outcome)
5. Subtle abnormalities can now be seen, patient can return home, behaviour can still be erratic."

"The prognosis for speech and language is generally good, though like the rest of this field, it is controversial. The removal of haematomas and reduction of ICP accounts for some of the recovery in the first 1-3 weeks."

"They can have problems with judgement and concentration. There can be problems with complex communicative language use. In general, the main problem post TBI is one of Sustained attention - keeping engaged in a task that may not itself be intrinsically interesting (like most of work!)."

Lyllyn

 

 

Re: Closed head trama

Thank you for your prompt reply, Lyllyn!

I will change that to stitches and shunt to drain - It will be an easy enough change to make to have her removing the last of her stitches instead.

It also sounds like the course you have described for his recovery is about what I had in mind (including the agression - I seem to recall feeling VERY angry at my father when he thought it was funny that I couldn't even crawl without falling over! - was definitely going to include that!) and the issues of judgment and speech impairment were definitely on my list.

As with the bath scene, it was really being suspended over the water as Primula lowered him in that bothered Frodo rather than the water itself. I will see if I can make that clearer. I experienced that phenomenon myself and so was pretty confident about it. It is movement, yes, but you also fear situations where you don't feel secure - situations where you might fall or might be jostled. That is what I was going for in that scene and if that is unclear, I will rectify.

Again, thank you so much for taking the time to look at this for me. It is definitely above and beyond and I really appreciate it.

Ariel

 

 

Re: Closed head trama

I wanted to thank Lyllyn again for her invaluable medical advice which has helped me to keep my little fic from being both boring and inaccurate!

I have posted another chapter and used the information you provided - it was exactly what I needed - but I have two questions for you if you are able to answer them. First, how long would the posttraumatic amnesia last? Is that something that would be a permanent loss (which was my understanding) or could it return over time? Do you have any idea of the timeframe of the recovery, or is that also extremely variable? Also, how long do you think the vertigo would last? I have him still suffering mildly from it a week after the injury. Would he still have it after two weeks? Three? Would it be incredible if I stretched it out to being a gradual recovery that wasn’t complete until four weeks post trauma?

Thanks again for your help. I feel so much like I am imposing – if there is anything I can do for you, please let me know…

Ariel

 

 

Re: Closed head trama

Ariel, I was just having a poke around the internet (anyhting to avoid doing chores ;-)) and found the following info which may be of use to you.

PTA can last for hours, days or weeks depending upon the severity of the brain injury. When a child/young person is in PTA, they are unable to remember day-to-day events that have occurred, such as who came to visit them in hospital. They usually can remember up to the time of injury but have problems remembering what happened afterwards. Children/young people in PTA are often confused and disorientated which means they may not know where they are or what time of day it is. Most children/young people come out of PTA, even in the most severe cases.

Westmead Children's Hospital

Injuries are regarded as severe if post traumatic amnesia (PTA) exceeds 24 hours and very severe if the PTA exceeds one week.
tbilaw

Avon

 

 

Re: Closed head trama

First, how long would the posttraumatic amnesia last? Is that something that would be a permanent loss (which was my understanding) or could it return over time? Do you have any idea of the timeframe of the recovery, or is that also extremely variable?

Post-traumatic amnesia (PTA) is variable. I assume you are less interested in the retrograde type which is loss of events prior to the injury, so I'll focus on the inability to form new memories that occurs after the event. Events that occur during this period are most likely permanent, as the brain can't store the information. With the retrograde type of loss some of it may come back.
PTA fluctuates from day to day. Someone is recovered when they can consistently recall day to day events. The duration of PTA varies from a few minutes to many weeks to permanent deficits. IIRC, your story has Frodo comatose for a few days. One very rough guideline I found:

Coma lasting seconds to minutes results in PTA that lasts hours to days; recovery plateau occurs over days to weeks.
Coma that lasts hours to days results in PTA lasting days to weeks; recovery plateau occurs over months.
Coma lasting weeks results in PTA that lasts months; recovery plateau occurs over months to years.

Also, how long do you think the vertigo would last? I have him still suffering mildly from it a week after the injury. Would he still have it after two weeks? Three? Would it be incredible if I stretched it out to being a gradual recovery that wasn’t complete until four weeks post trauma?

The vertigo duration is also variable, with the possibility of periodic episodes. Four weeks is certainly possible.

Thanks again for your help. I feel so much like I am imposing – if there is anything I can do for you, please let me know…

Ariel, the best payback is to do similar things for others. Answer questions, write an article, etc.

Besides, like Avon, (waves at Avon) I am managing to avoid chores and trying to write a story that is misbehaving.

Lyllyn

 

 

Re: Closed head trama

Thanks to both Avon and Lyllyn for their prompt replies! LOL I wish I had been able to provide you with something actually interesting to avoid work with, but I am afraid all I can offer is Frodo angst.

I assume you are less interested in the retrograde type which is loss of events prior to the injury, so I'll focus on the inability to form new memories that occurs after the event.

Actually, I need to have the character have retrograde amnesia for the period just before his accident too... say a few hours. I have known people who were in car accidents who lost the events of the day they had the accident, so I figured that was feasible at least. I will incorporate the inability to form new memories more than I have. I have expressed this mostly in the scattered nature of Frodo’s observations, but realize I am drawing on my own experiences here. From the perspective of years later, my memory must seem scattered because I was having difficulty making new memories and probably only recall those few moments when my brain was able to work correctly. I didn’t realize that but it makes sense. I will have to see if my readers find the scene unbelievable or not, but thank you for that insight.

As for doing work for others, I am available for betaing but my skills are not quite to the level of most of the writers at HASA. I am afraid I would not be of much help to them. I do a lot of work with young writers and people just starting out who are dealing with some of the more fundamental problems of grammar and spelling, but beyond that I don’t feel at all qualified to offer myself. Even the tree article I was going to write for this site came up against the logical realization that I am an American forester and know little to nothing about European forests other than what I have read. If you need treatises on forest fire, animal behavior, leatherworking or archery, I might be able to offer something, but even in those, (other than the forest fire stuff) I would not feel qualified enough to make definitive statements.

I am sorry to say I am probably pretty darned useless when all is said and done!

Edit: I am getting ready to produce an article on medieval forest management practices and forest law for my SCA group. Do you think that would be of any help here? Just a thought.

Ariel

 

 

Re: Closed head trama

If you need treatises on forest fire, animal behavior, leatherworking or archery, I might be able to offer something, but even in those, (other than the forest fire stuff) I would not feel qualified enough to make definitive statements.

I am sorry to say I am probably pretty darned useless when all is said and done!


Huh! That's what they all say when I threaten with them with resource!nuzgul.

Edit: I am getting ready to produce an article on medieval forest management practices and forest law for my SCA group. Do you think that would be of any help here?

I seem to remember someone writing a story and looking for forest fire information. I can see information on medieval forest management, forest fires, and political issues involving forests being quite useful. Leatherworking and archery, likewise.

Lyllyn


 

 

Re: Closed head trama

Huh! That's what they all say when I threaten with them with resource!nuzgul.

Uh oh... well with my work/home/life schedule and full stable of bunnies, I am usually immune to nuzguls - I have no time for them! but since I am writing this piece anyway, I am sure I could paste a copy here.

I seem to remember someone writing a story and looking for forest fire information.

Yes, I looked that story over for the girl. She had done her homework well, but had a very fundemental flaw in her story that really couldn't be written out. She decided, and I agreed, that since I was probably the only person who would know that this was an error, she would let it lie.

I do get involved where I can, but have no illusions as to the limits of my abilities. Maybe not completely useless, just of very limited utility.

Ariel

 

 

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