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Management of traumatic brain injury Wallace

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Management of traumatic brain injury  Wallace Management of traumatic brain injury Wallace Presentation Transcript

  • Joint Health Command Management of Traumatic Brain Injury in the Australian Defence Force Dr Duncan Wallace Consultant Psychiatrist Australian Defence Force Centre for Mental Health
  • Traumatic brain injury (TBI) • ‘the signature wound of the war’ [Carroll, L. War on the brain. Neurology Now, 2(5),2006,12-16] • ‘Major public health issue’ [Bryant R et al. The psychiatric sequelae of traumatic injury. AJP 2010;167,312-320]
  • • What is TBI? • Management of TBI in ADF – Initial presentation – Persistent symptoms
  • Definition of TBI ‘a traumatically induced structural injury and/or physiologic disruption of brain function as a result of an external force, as indicated by at least one of the following: – any period of loss of consciousness – any loss of memory of events immediately before or after the accident [VA/DoD Clinical Practice Guideline for Management of Concussion/mTBI. Department of Veterans’ Affairs. Dept of Defense Version One 2009. Viewed at< http://www.healthquality.va.gov/mtbi/concussion_mtbi_sum_1_0.pdf> on 23 JUL10]
  • Definition of TBI – any alteration in mental state at the time of the accident eg confusion, disorientation, slowed thinking – neurologic deficit(s) that may or may not be transient eg weakness, loss of balance, change in vision, paresis, sensory loss – Intracranial lesion [VA/DoD Clinical Practice Guideline for Management of Concussion/mTBI. Department of Veterans’ Affairs. Dept of Defense Version One 2009. Viewed at< http://www.healthquality.va.gov/mtbi/concussion_mtbi_sum_1_0.pdf> on 23 JUL10]
  • Classification of TBI Severity US VA/DoD ibid Criteria Mild Moderate Severe Structural imaging [CT/MRI] Normal Normal or abnormal Normal or abnormal > 30 min and < 24 LOC 0–30 min hours > 24 hrs a moment up to 24 > 24 hours. Severity > 24 hours. Severity AOC hrs based on other criteria based on other criteria Duration of PTA < 24 hrs 24 hrs to < 7 day 7 days or more GCS 13 to 15 9 to 12 3 to 8
  • Mild Traumatic Brain Injury = Concussion Do not need to have lost consciousness to suffer a concussion
  • Mechanism of Concussion [Ropper A and Gorson K. Concussion. N Engl J Med 2007;356:166-172]
  • Why are TBI occurring? • Most casualties from IEDs – 70% from IEDS [MNC-I Medical Conference Baghdad 8 Jan 07] • Indirect Fire – Rockets, mortars • Gunshot wounds
  • ADF wounded Afghanistan 2010 • IEDs accounted for 38 out of 49 WIA • 6 suffered mild traumatic brain injury • 5 hearing loss [Viewed at<http://www.theaustralian.com.au/national-affairs/roadside-bombs-take-a-heavy-toll/story- fn59niix-1225913019854 >on 2 September 2010]
  • Management of mild TBI HD No 293: Management Of Mild Traumatic Brain Injury In Australian Defence Force Members (5 January 2010) – Early management – Military setting
  • • The majority of patients with concussion/mTBI do not require any specific medical treatment [US VA DoD CPG]
  • Management of mTBI • Pre-deployment testing – Cogstate Sport baseline questionnaire – Pilot
  • Cogstate Sport • Need to perform practice test and baseline test – Not done by all persons • Members used different ID for subsequent testing – Unable to compare to their own baseline
  • Cogstate Sport Practice tests 105 Baseline tests 202 After injury 28 Total 335 As at 20 October 2010
  • Management of TBI Initial assessment – By Medic/MO – Moderate and Severe TBI is managed in appropriate Neurosurgical unit
  • Management of mild TBI ACUTE Phase <7 days – Initial assessment by Medic/MO – Education – Symptom management – Guidance on rest and return to duty – Follow-up
  • Management of mild TBI Military Acute Concussion Evaluation (MACE)  History  Nature of injury  Helmet worn?  History of amnesia  Assessment of orientation, concentration, memory  Neurological examination  <25 = TBI
  • Management of mild TBI The most typical signs and symptoms following concussion include: a. Physical: headache, nausea, vomiting, dizziness, fatigue, blurred vision, sleep disturbance, sensitivity to light/noise, balance problems, transient neurological abnormalities b. Cognitive: attention, concentration, memory, speed of processing, judgment, executive control c. Behavioural/emotional: depression, anxiety, agitation, irritability, impulsivity, aggression
  • Management of mild TBI ACUTE Phase <7 days – Observation • Direct for 4 hours • Indirect for 24 hours- Rest, written advice, restriction of duties – Symptom management • Paracetamol • Zolpidem
  • Management of mild TBI ACUTE Phase <7 days – Guidance on rest and return to duty – Education • Patients, supervisors, spouses • Describe post-concussion symptoms and outcomes • Normalize symptoms • Reassurance about expected positive outcome • Supportive therapies- advice about sleep hygiene, substance abuse, anxiety management
  • Management of mild TBI ACUTE Phase <7 days – MO to consider activating Critical Incident Mental Health Support response
  • Management of mild TBI – MO review at 24 hour and 48-72 hours – When symptom free: • repeat MACE. If >25 may return to work – MO performs exertional testing – military skills testing – May need to re-test after further 24-48 hrs if symptoms recur – Return to exercise and work schedule – Management of repeated concussions
  • Management of mild TBI MO 1 RAR (RTA Feb 2010) • TBI accounted for approx. – 50% ineffective man days – 30% of combat related injuries • Surprised at significant impairment of mentation on MACE eg calculation • 2 blast injuries = 2 weeks off work
  • Management of mild TBI MO 1 RAR (RTA Feb 2010) • Prominent symptoms – Insomnia – Anxiety – Emotional lability eg on phone to relatives • Everyone settled within a week • No one required imaging • PTSD cases seen had not suffered TBI [8 September 2010]
  • Management of mild TBI US VA DoD CPG • Initial presentation • Delayed presentation- treat as Initial presentation • Persistent symptoms
  • Management of mild TBI IMAGING: CT Indications for CT scanning in the acute phase include – drug or alcohol intoxication – physical evidence of trauma above the clavicles – age > 60yrs – seizure, headache, vomiting, and coagulopathy (Haydel, 2000)
  • Management of mild TBI IMAGING: MRI • Low incidence of positive findings on MRI [Lewine 2007] • Contraindicated with shrapnel wounds • MRI, SPECT and functional MRI may be more useful for patients with cognitive dysfunction in post-acute phase
  • Management of mild TBI Persistent Symptoms • Post-Concussion Syndrome – Various definitions – Headache, dizziness, irritability, depression, cognitive impairment – Controversial
  • Management of mild TBI Persistent Symptoms • Headache is the single most common symptom associated with concussion/mTBI and assessment and management of headaches in individuals should parallel those for other causes of headache [US VA DoD CPG]
  • Management of mild TBI MEDICATION • Data from controlled trials are lacking for pharmacotherapy for patients with mild TBI [Ropper ibid] • Warden et al conducted an extensive review of the literature – unable to recommend treatment standards – suggested only a few guidelines because of recurrent methodological problems – methylphenidate to relieve attentional dysfunction, decreased processing speed and lack of alertness – beta-blockers for aggression [Warden D, McAllister G, Silver J. et al. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury. J Neurotrauma 2006; 23:1468-1501]
  • Management of mild TBI Persistent Symptoms Cooke and Keltner recommended caution in prescribing – large differences in therapeutic responses in patients with TBI – some TBI patients seem exquisitely sensitive to side effects – suggest start with very low, even sub-therapeutic doses – increasing slowly to gauge response [Cooke B and Keltner N. Traumatic brain injury- war related: part II. Perspect Psychiatr Care 2008; 44:54-57]
  • Persistent Symptoms • Avoid medications that contribute to cognitive slowing, fatigue or daytime drowsiness. [US VA DoD CPG]
  • Management of mild TBI In patients with persistent post-concussive symptoms (PPCS), refractory to treatment, consideration should be given to other factors – psychiatric – psychosocial support – compensation and litigation [US VA DoD CPG]
  • • What is TBI? • Management of TBI – Initial presentation – Persistent symptoms
  • QUESTIONS?