1. Management of
Traumatic Brain Injury
in the
Australian Defence Force
Dr Duncan Wallace
Consultant Psychiatrist
Australian Defence Force Centre for Mental Health
Joint Health Command

2. 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]

3. • What is TBI?
• Management of TBI in ADF
– Initial presentation
– Persistent symptoms

4. 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]

5. 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]

6. Classification of TBI Severity
US VA/DoD ibid
Criteria Mild Moderate Severe
Structural
imaging
[CT/MRI] Normal Normal or abnormal Normal or abnormal
LOC 0–30 min
> 30 min and < 24
hours > 24 hrs
AOC
a moment
up to 24
hrs
> 24 hours. Severity
based on other criteria
> 24 hours. Severity
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

7. Mild Traumatic Brain Injury = Concussion
Do not need to have lost consciousness to suffer
a concussion

8. Mechanism of Concussion
[Ropper A and Gorson K. Concussion. N Engl J Med
2007;356:166-172]

9. 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

10. 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]

11. 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

12. • The majority of patients with concussion/mTBI
do not require any specific medical treatment
[US VA DoD CPG]

13. Management of mTBI
• Pre-deployment testing
–Cogstate Sport baseline questionnaire
–Pilot

15. 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

16. Cogstate Sport
Practice tests 105
Baseline tests 202
After injury 28
Total 335
As at 20 October 2010

17. Management of TBI
Initial assessment
– By Medic/MO
– Moderate and Severe TBI is managed in
appropriate Neurosurgical unit

18. 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

19. 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

20. 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

21. 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

22. 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

23. Management of mild TBI
ACUTE Phase <7 days
– MO to consider activating Critical Incident Mental
Health Support response

24. 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

26. 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

27. 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]

29. Management of mild TBI
US VA DoD CPG
• Initial presentation
• Delayed presentation- treat as Initial
presentation
• Persistent symptoms

30. 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)

31. 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

32. Management of mild TBI
Persistent Symptoms
• Post-Concussion Syndrome
– Various definitions
– Headache, dizziness, irritability, depression,
cognitive impairment
– Controversial

33. 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]

35. 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]

36. 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]

37. Persistent Symptoms
• Avoid medications that contribute to
cognitive slowing, fatigue or daytime
drowsiness.
[US VA DoD CPG]

39. 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]

40. • What is TBI?
• Management of TBI
– Initial presentation
– Persistent symptoms

41. QUESTIONS?