Traumatic Brain Injury

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Traumatic Brain Injury

• Linda Wilkinson, MSN, ACNP, LMT
• Nurse Practitioner -Trauma
• Vanderbilt University Medical Center

2
Traumatic Brain Injury

• Linda Wilkinson, MSN, ACNP, LMT
• Nurse Practitioner -Trauma
• Vanderbilt University Medical Center

3
Objectives

• Define TBI
• Overview of TBI
• Look at Statistics
• Review of types of TBI
• Discuss Long Term issues
• Acute Care Management
• Post Acute Care Considerations

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What is Traumatic Brain Injury?

• a nondegenerative, noncongenital insult to the
  brain from an external mechanical force, possibly
  leading to permanent or temporary impairments of
  cognitive, physical and psychosocial functions
  with an associated diminished or altered state of
  consciousness

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How Big a Problem?Incidence

• 1.4 million people sustain TBI annually
• Does not include
• non-diagnosed
• military
• sports-related
• 56 billion direct/indirect costs
• 50,000 die annually
• Approximately 100,000 long-term disability
• Over 5 million TBI-related patients

CDC, Report to Congress TBI, 2003
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http//www.cdc.gov/traumaticbraininjury/pdf/blue_b
ook.pdf
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How Much Does it Cost?Financial Impact

• Costs
• Acute care 8000/day
• Rehabilitation 2500/day
• Employment
• Approx 60 at time of injury
• 28 post-injury
• 34 are unable to return to work rapidly
• Majority require up to 3-6 months
• 25 over one year

Rimel Neurosurgery 1981, Boake Neurosurgery 2005,
Max JHTR 1991
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Why Is It Important?

• Traumatic Brain Injury (TBI)
• Accounts for 51.6 of mortality amongst trauma
  patients
• Dutton. J Trauma. 2010.
• Progression of Intracranial Hemorrhagic Injury
  (IHI)
• Longer hospitalizations (14.4 d vs. 9.7 d, p
  lt0.01)
• Increased mortality (24 vs. 3, p lt0.01)
• Thomas. J Am Coll Surg. 2010.

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Whos Involved? Demographics

• Traumatic brain injury effects all levels of
  society
• TBI affects all ages
• Majority (75 to 90) recover quickly
• Mild 90
• 10 to 25 have long-term deficit
• 2 of Americans living with TBI-related
  disabilities
• (313.9 Million x .02 6.3 Million) 2012 census
• The Hidden TBI patient
• Emotional distress/cognitive issues

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At Risk Groups

• Males are more likely to incur TBI compared to
  females. (3.41)
• GSW 61
• MVC 2.41
• Highest rate of injury 15-24 years old.
• Also at higher risk
• Children lt5 years old
• Elderly gt 75 years old

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• Trauma Centers are the epicenter of major TBI
• Hospitalizations increasing 10 per year
• EARLY identification improves outcomes
• Appropriate in-patient management important
• Post-hospital rehab improves outcomes
• Collaborative efforts through multi-discipline
  teams

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What Happened?Mechanism of Injury (Blunt)

• Leading causes of TBI
• Falls 35
• Half of children (lt14 yrs) eval in ED
• Two-thirds gt65y
• MVC 17
• Leading cause of TBI-death (32)
• Struck (auto-ped) 17
• Assault 10

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Traumatic Brain Injury

• Concussion
• Epidural Hematoma
• Subdural Hematoma
• Subarachnoid hemorrhage
• Intracerebral Hematoma
• Intraventricular hemorrhage
• Shear injury / diffuse axonal injury

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Normal Anatomy

• Scalp
• Skull
• Epidural Space
• Dura
• Subdural Space
• Arachnoid
• Subarachnoid Space
• CSF
• Brain

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Concussion

• A clinical syndrome characterized by immediate
  and transient alteration in brain function,
  including alteration of mental status and level
  of consciousness, resulting from mechanical force
  or trauma.

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Concussion Symptoms

• Prolonged headache
• Vision disturbances
• Dizziness / fogginess
• Nausea or vomiting
• Impaired balance
• Confusion
• Irritability
• Labile / exaggerated emotions

• Memory loss
• Ringing ears
• Difficulty concentrating
• Sensitivity to light
• Sensitivity to sound
• Loss of smell or taste
• Sleep disturbances
• Repetitive questioning

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Post Concussive Syndrome

• May last for weeks or months.
• Symptoms include memory and concentration
  problems, mood swings, personality changes,
  headache, fatigue, dizziness, insomnia and
  excessive drowsiness.
• Patients with postconcussive syndrome should
  avoid activities that put them at risk for a
  repeated concussion.

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Normal Head CT

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Epidural Hematoma

• Collection of blood between the skull and the
  dura
• Often caused by laceration of middle meningeal
  artery by parietal skull fracture
• Classic LOC, lucid interval, neurologic
  decline (signs of ICP)
• Biconcave on CT
• Most common in temporal area
• Often little or no contusion
• May be surgically evacuated (gt1 cm)

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EDH Signs / Symptoms

• Lucid period then decreased LOC
• Headache
• Vomiting
• Seizure
• Unilateral babinski
• Contralateral hemiparesis
• Ipsilateral pupil dilation
• Mortality 20-55

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Subdural Hematoma

• collection of blood below the dural membrane
• usually venous
• may develop more slowly (venous vs. arterial
  bleeding)
• may spread over wider surface (not restrained by
  dura)
• often associated with cerebral contusion and
  edema
• May occur spontaneously in alcoholics and elderly
  (atrophy)
• Crescent shaped on CT
• May be surgically evacuated if large mass effect.
  (gt1 cm)

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SDH - Signs / Symptoms

• Headache
• Decreased level of consciousness
• Abnormal cortical function

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Subarachnoid Hemorrhage

• Collection of blood between arachnoid membrane
  and brain
• Often little mass effect, due to diffuse spread
• Irritating to brain

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SAH Signs / Symptoms

• worst headache of my life
• Hypertension
• Obtunded
• Nuchal rigidity

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Intraparenchymal Hemorrhage

• Bleeding into the tissue of the brain
• Symptoms dependent on area of brain affected

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Intraparenchymal Hemorrhage

• Symptoms vary depending on size and location of
  bleed.
• May require surgical intervention / craniotomy

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Diffuse Axonal / Shear Injury

• Usually occur with sudden rotation of the head
• Shearing forces stretch axons.
• If axon injured but not severed, may recover
  without secondary injury.

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DAI Symptoms

• Headache
• Vary depending on
• Location
• Number
• Size
• May be asymptomatic
• Rarely fatal
• May result in persistent vegetative state

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Injury Severity
Concussion - Less than 30 min - Greater than 30
min Post-traumatic amnesia Intracranial
Hemorrhage (ICH) Glasgow Coma Score (GCS) Mild
13-15 Moderate 9-12 Severe 3-8
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Glascow Coma Scale

• Motor
• 6- Follows commands
• 5- Localizes to pain
• 4- Withdraws to pain
• 3- Flexion
• 2- Extension
• 1- No movement

• Verbal
• 5- Oriented/Conversant
• 4- Confused
• 3- Inappropriate
• 2- Incomprehensible
• 1- None

Eyes 4- Opens Spontaneously 3- Opens to
voice 2- Opens to pain 1- None
Teasdale, Lancet, 1976
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What Do We Do?Management

• Immediate
• Time is brain
• Short-term Intensive care / Acute Care
• Monitors
• Surveillance
• Management
• Long-term Post-discharge

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Immediate

• Trauma Team Manage Resuscitation
• Protection
• Anoxia
• Hypotension
• 25 Increased Mortality
• Individually
• 75 Increased Mortality
• Combined

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Acute Care Management

• CT scans?
• Head up
• Sedation
• ICP/CPP management
• Osmolar therapy
• Hypertonic saline
• Decompressive craniotomy
• Induced coma
• Hypothermia

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• Repeat head CT scans
• Beneficial in setting of neurological
  deterioration
• Brown. J Trauma. 2007.
• Kaups. J Trauma. 2004.
• Debated for patients with normal or stable
  clinical exams
• Wang. J Trauma. 2006.
• Sifri. J Trauma. 2006.

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ICP Monitoring when?

• Intracranial Pressure Monitoring
• All salvageable severe TBI patients
• GCS lt8
• CT scan with pathology
• ICH
• Swelling
• Herniation
• Normal CT scan
• Age gt40
• Posturing
• Sys BP lt90mmHG

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TBI GCSlt9 Protocol
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Hyperosmolar Therapy

• Hyperosmolar Therapy
• Mannitol to maintain ICPs lt20mmHg
• Early okay
• Late not much data
• Hypertonic Saline-no current evidence to support
  the use/disuse
• Does decrease ICPs
• No change in outcomes

Shackford, JoT, 1998
Himmelseher, Cur Op An, 2007
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• Antiseizure Prophylaxis
• Decrease incidence of EARLY seizures (lt7d)
• Dilantin, maybe Valproate
• NO prevention of LATE seizures (PTS)
• Steroids
• No use
• Hyperventilation
• No use

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• Sedation/Induced Coma - EEG burst suppression
• Prophylactically not recommended
• Refractory elevated ICP after med mgmt YES
• Criteria
• Refractory intracranial hypertension
• Na 145-155 (but lt 160), Osm 320-330
• Repeat Head CT without surgically treatable
  lesion
• Nsgy eval recommends non surgical treatment

Jiang, Neursurg, 2000
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Pentobarbitol Coma Protocol

• 10mg/kg bolus over 30 minutes
• 5mg/kg/hr continuous infusion x 3 hours
• Then 1mg/kg/hr
• Titrate based on EEG burst suppression (2-5/min)
• Continue for at least 72 hours, then wean to keep
  ICPlt20
• Failure
• ICP 21-35 gt 4 hrs, 36-40 for 1 hr, or gt 40 for 5
  minutes
• ICP not lt20 in 7 days without pentobarital
• Brain death/herniation
• Side effect requiring discontinuation
  (hypotension, sepsis, etc)

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Decompressive Craniotomy

• Indications elevated ICP refractory to medical
  management
• Aims to decrease ICP / increase perfusion, by
  opening a closed system, allowing room for
  swelling /expansion

• Some studies show decrease ICP, decreased LOS,
  worse outcome
• - problematic study Bad patient selection, Bad
  operative intervention
• Intervention period too long, ICP elevation too
  low, Poor oxygenation remains a problem, No
  measure of cerebral blood flow

Cooper, NEJM, 2011
Editorial Reply, NEJM, 2011
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• Prophylactic Hypothermia
• Not significant data
• Early work suggests mortality benefit
• Abiki, Br Inj, 2000

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• Other issues Ongoing Study
• Beta-blockade of adrenergic/sympathetic surge
• Alpha agents for adrenergic/sympathetic surge
• Progesterone for early TBI

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Sympathetic Storming

• Most commonly seen in Severe TBI (GCS 4-8)
• Periods of unmodulated sympathetic activity
• Symptomsalterations in level of consciousness,
  increased posturing, dystonia, hypertension,
  hyperthermia, tachycardia, tachypnea,
  diaphoresis, and agitation.
• Must rule out other causes (infection, pain, etc)

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• DASH

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What do we see?Presentation (Mild, Moderate,
Severe)

• Physical
• Cognitive
• Behavioral

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Physical Impairments

•   Speech, vision, hearing, other sensory
  impairments
•  Headaches
•  Lack of coordination
•  Muscle spasticity
•  Paralysis
•  Seizure disorders
•  Problems with sleep
•  Dysphagia
•  Dysarthria (articulation and muscular/motor
  control of speech)

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Cognitive Impairments

• Short- and long-term memory deficits
• Slowness of thinking
• Problems with reading and writing skills
• Difficulty maintaining attention /
  concentration
• Impairments of perception, communication,
  reasoning, problem solving, planning,
  sequencing and judgment
• Lack of motivation or inability to initiate
  activities

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Behavioral Impairments

• Mood swings
• Denial
• Depression and/or anxiety
• Lowered self esteem
• Sexual dysfunction
• Restlessness and/or impatience
• Inability to self-monitor, inappropriate social
  responses
• Difficulty with emotional control and anger
  management
• Inability to cope
• Excessive laughing or crying
• Difficulty relating to others
• Irritability and/or anger
• Agitation
• Abrupt and unexpected acts of violence
• Delusions, paranoia, mania

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What Can We Do?

• Normalize Day / Night cycles
• Lights on, activity during day
• Lights off, minimal activity at night
• Provide Safe Environment
• Provide Environmental Cues
• Provide Diversional Activity
• Provide Family / Caregiver Support

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Long Term Management

• Wide range of functional issues
• Cognitive changes
• Memory
• Reasoning
• Language difficulties (communication/understanding
  )
• Senses
• Loss of hearing, taste, smell
• Mental Health
• Depression
• Anxiety
• PTSD

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• Epilepsy
• Increased risk of CNS issues
• Alzheimers
• Parkinsons Disease
• Cerebrovascular issues
• Stroke
• Cumulative effect shown to worsen outcomes

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• Acute in-patient treatment standardized
• ICU care by guideline
• Post-discharge treatment personalized
• TBI severity
• Injury Severity
• Age
• Cost

Chestnut, JHTR 1999
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Who Can Help?Interdisciplinary Approach

• Neurosurgery Team
• PT/OT/ST
• Inpatient Treatment
• Rehabilitation Evaluation
• Cognitive evaluation / RLA Scoring
• Swallow Evaluation / Education
• Case Management
• Social Work

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Rancho Los Amigos Scoring

• I No Response Keep room calm and quiet, use
  calm voice, simple questions
• II Generalized Response Same as RLA I
• III Localized Response Limit
  visitors/stimulation, allow extra time to
  respond/periods of rest, reorient frequently,
  bring favorites
• IV Confused, Agitated Allow movement/activity
  (keep safe), limit visitors, find familiar
  activities that are calming.
• V Confused, Inappropriate, Nonagitated Repeat
  questions/comments as needed, reorient,
  calendars/lists, limit visitors, limit questions,
  make connections.
• VI Confused, Appropriate Repeat things,
  encourage them to repeat what they want to
  remember, provide cues, use calendars/lists
• VII - Automatic, Appropriate Treat as an adult,
  provide guidance and assistance.

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Cognitive Therapy

• Minimal intervention improves outcome
• Contact post-discharge 48 hrs
• Follow-up at 5-7 days
• Cognitive assessment performed
• Coping strategies for common symptoms
• Follow-up at 3 months
• Control Group had increased PCS complaints at
  follow-up

Ponsford 2002
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Post Acute Care

• CHART/FIM scores
• Severity of illness predicts poor outcome
• Discharge to LTC or NH poor outcomes
• Severity of illness predicted NEED for in-pt
  rehab
• Pre-injury working (motivated) or minority (no
  funds)
• Less likely to in-pt rehab

CHART Craig Handicap and Reporting
Technique FIM Functional Independence Measure
Mellick, Brain Injury, 2003
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Interdisciplinary Team Follow Up

• Trauma MD/NP
• Neurosurgery MD/NP
• SLP
• PT/OT
• Social Work
• Psychiatry/Psychology

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Comprehensive Evaluation Clinic

• Cognitive analysis
• Mental health survey
• Quality of life survey
• Social Work
• Peer Group

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Questions??
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References

• Brown, Carlos V. R. MD Zada, Gabriel MD Salim,
  Ali MD Inaba, Kenji MD Kasotakis, Georgios MD
  Hadjizacharia, Pantelis MD Demetriades,
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  for Routine Repeat Head Computed Tomography (CT)
  Stratified by Severity of Traumatic Brain Injury.
  Journal of Trauma-Injury Infection Critical
  Care June 2007 - Volume 62 - Issue 6 - pp
  1339-1345
• Boake, C., McCauley, S. R., Pedroza, C., Levin,
  H. S., Brown, S. A., Brundage, S. I. 2005. Lost
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  traumatic brain injury 1-year follow-up review
  of 87 cases. Journal of Neurosurgery Oct 2000 /
  Vol. 93 / No. 4, Pages 546-549

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