Traumatic stress from injury: Research into practice

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Traumatic stress from injury Research into
practice

• Flaura Koplin Winston, MD PhD
• Nancy Kassam-Adams, PhD
• Angela Marks, MSEd
• Center for Injury Research and Prevention
• (http//traumalink.chop.edu)
• EMSC, 2006

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Injury traumatic stress

• Life threat (self or others)
• Fear, helplessness, horror
• Symptoms
• Avoidance
• Intrusive thoughts
• Hyperarousal

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Goals

• Provide an overview of our EMSC-funded research
  base for traumatic stress in children and their
  parents after injury
• Illustrate interventions for traumatic stress
• Discuss practical application

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Stress vs. Traumatic Stress

• Many aspects of illness and injury are stressful.
• Painful / difficult to deal with
• Strain individuals familys coping resources
• Some aspects are potentially traumatic.
• Extremely frightening or horrifying
• Life-threatening
• Sudden, painful, or overwhelming

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Medical events associated with intense emotional
distress

• Serious / life-threatening illness
• (cancer, HIV, transplantation)
• Injury (fractures, burns)
• Intentional (e.g., assault)
• Unintentional (e.g., car crash)
• Painful or scary procedures
• Medical emergencies

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Experiences

• I thought I was going to die. Thought I must
  really be hurt. I was so scared because my mom
  was not there.

• I saw my son lying in the street. Bleeding,
  crying, the ambulance, everybody around him. It
  was a horrible scene. I thought I was dreaming.

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Traumatic stress symptoms

• Re-experiencing
• Thoughts feelings pop into ones mind.
• Re-living what happened - feels like its
  happening again.
• Get upset at reminders.
• Avoidance
• Try to block it out not think about it.
• Try to stay away from reminders.
• Feel numb or no emotions.

• Increased arousal
• Always afraid something bad will happen.
• More easily startled / jumpy.
• Trouble with sleep or concentration.
• Dissociation
• Things feel unreal -- like a dream.
• Trouble remembering parts of what happened.

Traumatic stress symptoms ? Posttraumatic Stress
Disorder
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Impact of traumatic stress on health
functioning

• PTSD associated with
• wide range of adverse health outcomes in children
  preschool thru adolescence
• (Graham-Bermann Seng 2005 Seng et al 2005)
• poorer treatment adherence post-transplant
• (Shemesh et al 2000 Shemesh 2004)
• lower health-related quality of life
  functional outcomes (e.g., more missed school
  days) after injury
• (Holbrook et al 2004 CHOP data)

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Traumatic stress model

• Data on medical PTSS has been reported but
  largely without a conceptual model.
• We have proposed a model with the goal of guiding
  intervention.
• The model has three phases
• Phase I. Peri-trauma
• Phase II. Early, ongoing and evolving responses
• Phase III. Longer-term PTSS

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Trajectory of response to trauma
Phase III
Phase II
distress
Phase I
PTE
time
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Treatment of response to trauma
distress
PTE
time
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Acute traumatic stress reactions are common, but
88 of injured children
83 of their parents
report at least one acute PTS symptom in the
first month after child injury
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Significant minority has persistent symptoms
16 of injured children
15 of their parents
have persistent PTS symptoms impairment 4 to 8
months after child injury
Can we identify those at risk? Can we prevent
persistent symptoms?
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Early, ongoing and evolving responsesFocus of
EMSC-funded work

• Opportunities to address current distress and
  prevent development of persistent distress
• Information
• Anticipatory guidance
• Screening

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INJURY Tip sheets for parents and kids
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Screening Tool for Early Predictors of PTSD
(STEPP)

• Predicting PTSD
• 6 months later
• Child Parent
• Sensitivity 88 96
• Specificity 48 53
• PPV 25 27
• NPV 95 99

Winston, Kassam-Adams, et al. (2003). Screening
for risk of persistent posttraumatic stress in
injured children and their parents. JAMA, 290
(5) 643-649.
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Dr. John Surgeon Department of Surgery
Childrens Hospital Lastly, an important but
often overlooked consequence of an injury is
post-traumatic stress (PTSD), which can develop
in a child or the parent of an injured child
regardless of injury severity or treatment
duration. With this letter, I have enclosed a
brochure and pocket guide on pediatric injury and
traumatic stress. These highlight signs and
symptoms to look for to identify patients and
families at greater risk for PTSD, and give
suggestions for anticipatory guidance. A parent
handout is also enclosed.
Trauma surgeons discharge letter
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Pediatric Medical Traumatic Stress Toolkit for
Health Care Providers
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Pocket cards
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Pocket cards
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Pocket cards
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Traumatic Stress ED Clinician RolesExample 7
yr old new Dx leukemia

• Distress
• Child worries about needles Topical anesthetic
  for IV
• Child thinks hospitals are where people die
  Clarified
• Talked with child about all of the people he will
  meet
• Emotional Support
• Family assured that mom or dad can always be
  with him
• Asked how family thinks child wants to get
  information
• Social work present during disclosure
• Family
• Family worries about death, disability
  (grief/loss)
• Assess role and involvement of other family
  members
• Barriers
• Dont have all the answers for reassurance
• Time is short

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Traumatic Stress ED Clinician RolesExample 16
yr old mva
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Traumatic Stress ED Clinician RolesExample 16
yr old mva
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Traumatic Stress ED Clinician RolesExample 16
yr old mva

• Distress
• Fears death, cant show it Reassure, be subtle
• Mistrust Explain every person, procedure and
  reason
• Angry at driver
• Alone family not there yet assign one staff
  to be with him through entire ED visit
• Emotional Support
• Eye contact allowed decision making if possible
  respect
• Provide non-judgmental space for narrative
• Try to understand meaning of the events family,
  authority, safety, medical experiences
• Family
• Manage fear, anger and mistrust again
• Larger support system Include friends
• Barriers
• Simultaneous, emergent medical treatment
• Preconceived notions by medical staff

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Traumatic stress after injury Critical issues

• Universal interventions may be harmful
• Injury severity does not reflect PTSD risk
• Time constraints
• Need practical, effective ways to assess

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Summary

• Traumatic stress is a helpful way of
  understanding reactions of patients and families
  to injury AND other medical events
• Intervention can begin at medical triage with
  trauma informed care and screening by all
  providers
• Treatment may need to continue over time

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Current / future work

• Develop other modes of delivering information and
  intervention
• interactive web-based
• in-hospital video (DVD)
• Consider other ways of engaging providers in
  secondary prevention

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Web links for resources

• Injury Tip Sheets Primary Care materials
• www.chop.edu/traumalink/carit
• Tipsheets and resources
• re medical traumatic stress
• www.chop.edu/cpts
• Pediatric Medical Traumatic Stress Toolkit
• www.nctsn.org/medtoolkit