Traumatic brain injury

Traumatic brain injury (TBI) is a serious public health problem in the United States. Each year, traumatic brain injuries contribute to a substantial number of deaths and cases of permanent disability. Recent data shows that, on average, approximately 1.7 million people sustain a traumatic brain injury annually.1

A TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI may range from “mild,” i.e., a brief change in mental status or consciousness to “severe,” i.e., an extended period of unconsciousness or amnesia after the injury. The majority of TBIs that occur each year are concussions or other forms of mild TBI.2

Concussion and mild TBI
What is a concussion?
A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth.

Health care professionals may describe a concussion as a “mild” brain injury because concussions are usually not life-threatening. Even so, their effects can be serious.

Severe traumatic brain injury
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 (30.5%) of all injury-related deaths in the United States.1 On average, approximately 1.7 million people sustain a traumatic brain injury annually.1

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. 2,3

Types of severe TBI
There are two types of severe TBI, each described below by associated causes:
Closed – an injury to the brain caused by movement of the brain within the skull. Causes may include falls, motor vehicle crash, or being struck by or with an object.
Penetrating – an injury to the brain caused by a foreign object entering the skull. Causes may include firearm injuries or being struck with a sharp object.

The Glasgow Coma Scale (GCS)4, 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 limitations5, 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.6-8

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.9 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.10 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%).1
• People aged 75 years old and older have the highest rates of TBI-related hospitalizations and death.1
• 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.

References
(1) 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.
(2) 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.
(3) Coronado, McGuire, Faul, Sugerman, Pearson. The Epidemiology and Prevention of TBI (in press) 2012
(4) Teasdale, G, Jennett, B. Assessment of coma and impaired consciousness. A practical scale. Lancet 304(7872):81-84, 1974.
(5) Stein SC. Classification of head injury. In: Narayan, RK, Wilberger, Jr., JE, Povlishock, JT, eds. Neurotrauma. McGraw-Hill, 1996:31-41.
(6) 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.
(7) 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.
(8) Williams, DH, Levin, HS, Eisenberg, HM. Mild head injury classification. Neurosurgery 27(3):422-428, 1990.
(9) 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.
(10) 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.
(11) Champion HR, Holcomb JB, Young LA. Injuries from explosions. Journal of Trauma 2009;66(5):1468–1476.
(12) 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 TraumaExternal Web Site Icon. 2007 Dec;63(6):1271-8.
(13) 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.

How many people have TBI?
National TBI Estimates
• Each year, an estimated 1.7 million people sustain a TBI annually.1
• TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States.1
• About 75% of TBIs that occur each year are concussions or other forms of mild TBI.2

TBI by age (1)
• Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI.
• Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years.
• Adults aged 75 years and older have the highest rates of TBI-related hospitalization and death.

TBI by gender (1)
• In every age group, TBI rates are higher for males than for females.
• Males aged 0 to 4 years have the highest rates of TBI-related emergency department visits, hospitalizations, and deaths.

References
(1) 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.
(2) Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public 3. health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.
(3) 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.
(4) Coronado, McGuire, Faul, Sugerman, Pearson. The Epidemiology and Prevention of TBI (in press) 2012

What are the potential effects of TBI?
The severity of a TBI may range from “mild,” i.e., a brief change in mental status or consciousness, to “severe,” i.e., an extended period of unconsciousness or amnesia after the injury.

TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions.

• Thinking (i.e., memory and reasoning);
• Sensation (i.e., touch, taste, and smell);
• Language (i.e., communication, expression, and understanding); and
• Emotion (i.e., depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).1

TBI can also cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.1

About 75% of TBIs that occur each year are concussions or other forms of mild TBI.2

Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.3

General tips to help aid in recovery:
• Get lots of rest. Don't rush back to daily activities such as work or school.
• Avoid doing anything that could cause another blow or jolt to the head.
• Ask your health care professional when it's safe to drive a car, ride a bike, or use heavy equipment, because your ability to react may be slower after a brain injury.
• Take only the drugs your health care professional has approved, and don't drink alcohol until your health care professional says it's OK.
• Write things down if you have a hard time remembering.
• You may need help to re-learn skills that were lost. Your health care professional can help arrange for these services.4'

References
(1) National Institute of Neurological Disorders and Stroke. Traumatic brain injury: hope through research. Bethesda (MD): National Institutes of Health; 2002 Feb. NIH Publication No.: 02-158.
(2) Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.
(3) Centers for Disease Control and Prevention (CDC). Sports-related recurrent brain injuries—United States. MMWR 1997;46(10):224–227.
(4) Centers for Disease Control and Prevention (CDC). Facts about concussion and brain injury: Where to Get Help. 2010.

What are the leading causes of TBI?
The leading causes of TBI are:

• Falls (35.2%);
• Motor vehicle – traffic (17.3%);
• Struck by/against events (16.5%); and
• Assaults (10%).1

Falls1
Falls continued to be the leading cause of TBI (35.2%) in the United States. Falls cause half (50%) of the TBIs among children aged 0 to 14 years and 61% of all TBIs among adults aged 65 years and older.

Motor vehicle-traffic crashes1
Among all age groups, motor vehicle crashes and traffic-related incidents were the second leading cause of TBI (17.3%) and resulted in the largest percentage of TBI-related deaths (31.8%).

Struck by/against events1
Struck by/against events, which include colliding with a moving or stationary object, were the second leading cause of TBI among children aged 0 to 14 years, with 25%.

Assault1
Assaults produced 10% of TBIs in the general population; they accounted for only 2.9% in children aged 0 to 14 years and 1% in adults aged 65 years old and older.

Who is at risk?
Approximately 18% of all TBI-related emergency department visits involved children aged 0 to 4 years.
Approximately 22% of all TBI-related hospitalizations involved adults aged 75 years and older.
Males are more often diagnosed with a TBI (59%).

Blasts are a leading cause of TBI for active duty military personnel in war zones.2 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.TraumaticBrainInjuryAtoZ.org.

References
(1) 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
(2) Champion HR, Holcomb JB, Young LA. Injuries from explosions. Journal of Trauma 2009;66(5):1468–1476.

This information was developed by the Centers for Disease Control and Prevention, Injury Prevention & Control.

Centers for Disease Control and Prevention. Traumatic Brain Injury. Available at: https://www.cdc.gov/traumaticbraininjury/. Last accessed January 16, 2014.

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