Severe TBI

Each year, TBIs contribute to a substantial number of deaths and cases of permanent disability. In fact, TBI is a contributing factor to a third (30%) of all injury-related deaths in the United States.1 In 2010, approximately 2.5 million people sustained a traumatic brain injury.2 Individuals with more severe injuries are more likely to require hospitalization.

Changes in the rates of TBI-related hospitalizations vary depending on age. For persons 44 years of age and younger, TBI-related hospitalizations decreased between the periods of 2001–2002 and 2009–2010. However, rates for age groups 45–64 years of age and 65 years and older increased between these time periods. Rates in persons 45–64 years of age increased almost 25% from 60.1 to 79.4 per 100,000. Rates of TBI-related hospitalizations in persons 65 years of age and older increased more than 50%, from 191.5 to 294.0 per 100,000 during the same period, largely due to a substantial increase (39%) between 2007–2008 and 2009–2010. In contrast, rates of TBI-related hospitalizations in youth 5–14 years of age fell from 54.5 to 23.1 per 100,000, decreasing by more than 50% during this period.1,2

A severe TBI not only impacts the life of an individual and their family, but it also has a large societal and economic toll. The estimated economic cost of TBI in 2010, including direct and indirect medical costs, is estimated to be approximately $76.5 billion. Additionally, the cost of fatal TBIs and TBIs requiring hospitalization, many of which are severe, account for approximately 90% of the total TBI medical costs.3,4

Lt. Col. Tim Maxwell’s Story

They train together. They fight together. So if wounded, why shouldn’t they go through recovery together? This was the question that Lt. Col. Tim Maxwell asked about his fellow marines being discharged from the hospital and left alone to recover from injuries of war.

TBI Classification Systems

TBI injury severity can be described using several different tools.

The Glasgow Coma Scale (GCS),5 a clinical tool designed to assess coma and impaired consciousness, is one of the most commonly used severity scoring systems. Persons with GCS scores of 3 to 8 are classified with a severe TBI, those with scores of 9 to 12 are classified with a moderate TBI, and those with scores of 13 to 15 are classified with a mild TBI.

Other classification systems include the Abbreviated Injury Scale (AIS), the Trauma Score, and the Abbreviated Trauma Score. Despite their limitations,6 these systems are crucial to understanding the clinical management and the likely outcomes of this injury as the prognosis for milder forms of TBIs is better than for moderate or severe TBIs.7-9

Potential Affects of Severe TBI

A non-fatal severe TBI may result in an extended period of unconsciousness (coma) or amnesia after the injury. For individuals hospitalized after a TBI, almost half (43%) have a related disability one year after the injury.10 A TBI may lead to a wide range of short- or long-term issues affecting:

Cognitive Function (e.g., attention and memory)
Motor function (e.g., extremity weakness, impaired coordination and balance)
Sensation (e.g., hearing, vision, impaired perception and touch)
Emotion (e.g., depression, anxiety, aggression, impulse control, personality changes)

Approximately 5.3 million Americans are living with a TBI-related disability and the consequences of severe TBI can affect all aspects of an individual’s life.11 This can include relationships with family and friends, as well as their ability to work or be employed, do household tasks, drive, and/or participate in other activities of daily living.

Fast Facts

Falls are the leading cause of TBI and recent data shows that the number of fall-related TBIs among children aged 0-4 years and in older adults aged 75 years or older is increasing.
Among all age groups, motor vehicle crashes and traffic-related incidents result in the largest percentage of TBI-related deaths (31.8%).12
People aged 65 years old and older have the highest rates of TBI-related hospitalizations and death.13
Shaken Baby Syndrome (SBS), a form of abusive head trauma (AHT) and inflicted traumatic brain injury (ITBI), is a leading cause of child maltreatment deaths in the United States.

Meeting the Challenge of Severe TBI

While there is no one size fits all solution, there are interventions that can be effective to help limit the impact of this injury. These measures include primary prevention, early management, and treatment of severe TBI.

CDC’s research and programs work to reduce severe TBI and its consequences by developing and evaluating clinical guidelines, conducting surveillance, implementing primary prevention and education strategies, and developing evidence-based interventions to save lives and reduce morbidity from this injury.

Developing and Evaluating Clinical Guidelines

CDC researchers conducted a study to assess the effectiveness of adopting the Brain Trauma Foundation (BTF) in-hospital guidelines for the treatment of adults with severe traumatic brain injury (TBI). This research indicated that widespread adoption of these guidelines could result in:

a 50% decrease in deaths;
a savings of approximately $288 million in medical and rehabilitation costs; and
a savings of approximately $3.8 billion—the estimated lifelong savings in annual societal costs for severely injured TBI patients.14

TBIs in the Military

Blasts are a leading cause of TBI for active duty military personnel in war zones.15 CDC estimates of TBI do not include injuries seen at U.S. Department of Defense or U.S. Veterans Health Administration Hospitals. For more information about TBI in the military including an interactive website for service members, veterans, and families and caregivers, please visit: www.dvbic.org .

CDC, in collaboration with 17 organizations, published the Field Triage Guidelines for the Injured Patient .16 These guidelines include criteria on severe head trauma and can help provide uniform standards to emergency medical service (EMS) providers and first responders, to ensure that patients with TBI are taken to hospitals that are best suited to address their particular injuries.

Conducting Surveillance

Data are critical to help inform TBI prevention strategies, identify research and education priorities, and support the need for services among those living with a TBI. CDC collects and reports both national and state-based TBI surveillance data:

CDC presents data on the incidence of TBI nationwide in its report: Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths, 2002-2006. This current report presents data on emergency department visits, hospitalizations, and deaths for the years 2002 through 2006 and includes TBI numbers by age, gender, race, and external cause.
CDC currently funds 30 states to conduct basic TBI surveillance through the CORE state Injury Program. (Note: While some un-funded states do participate in the submission of TBI- and other injury-related data compiled in this report, the report does not include data from all 50 states.)

Implementing Primary Prevention and Education Strategies

CDC has multiple education and awareness efforts to help improve primary prevention of severe TBI, as well as those that promote early identification and appropriate care.

Additional Prevention Resources

References

National Vital Statistics System (NVSS), 2006–2010. Data source is maintained by the CDC National Center for Health Statistics.
National Hospital Discharge Survey (NHDS), 2010; National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010; National Vital Statistics System (NVSS), 2010. All data sources are maintained by the CDC National Center for Health Statistics.
Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; 2006.
Coronado, McGuire, Faul, Sugerman, Pearson. The Epidemiology and Prevention of TBI (in press) 2012
Teasdale, G, Jennett, B. Assessment of coma and impaired consciousness. A practical scale. Lancet 304(7872):81-84, 1974.
Stein SC. Classification of head injury. In: Narayan, RK, Wilberger, Jr., JE, Povlishock, JT, eds. Neurotrauma. McGraw-Hill, 1996:31-41.
Coronado, VG, Thurman, DJ, Greenspan, AI, et al. Epidemiology. In: Jallo, J, Loftus, C, eds. Neurotrauma and Critical Care of the Brain. New York, Stuttgart: Thieme, 2009.
Levin, HS, Gary, HE, Eisenberg, HM, et al. Neurobehavioral outcome 1 year after severe head injury. Experience of the Traumatic Coma Data Bank. J Neurosurg 73(5):699-709, 1990.
Williams, DH, Levin, HS, Eisenberg, HM. Mild head injury classification. Neurosurgery 27(3):422-428, 1990.
Selassie AW, Zaloshnja E, Langlois JA, Miler T, Jones P, Steiner C. Incidence of Long-term disability following Traumatic Brain Injury Hospitalization, United States, 2003 J Head Trauma Rehabil 23(2):123-131,2008.
Thurman D, Alverson C, Dunn K, Guerrero J, Sniezek J. Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil 1999;14(6):602-615.
Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
National Hospital Discharge Survey (NHDS), 2006–2010; National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006–2010. All data sources are maintained by the CDC National Center for Health Statistics.
Faul M, Wald MM, Rutland-Brown W, Sullivent EE, Sattin RW. Using a cost-benefit analysis to estimate outcomes of a clinical treatment guideline: testing the Brain Trauma Foundation guidelines for the treatment of severe traumatic brain injury. J Trauma . 2007 Dec;63(6):1271-8.
Champion HR, Holcomb JB, Young LA. Injuries from explosions. Journal of Trauma 2009;66(5):1468–1476.
CDC. Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage. Morbidity and Mortality Weekly Reports Recommendations and Reports. January 23, 2009 / Vol. 58 / No. RR-1.