management of traumatic brain injury wallace

Management of Traumatic Brain Injury

in the Australian Defence Force

Dr Duncan WallaceConsultant Psychiatrist

Australian Defence Force Centre for Mental Health

Joint Health Command

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

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 criteriaDuration 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 TraumaticBrain 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 105Baseline tests 202After injury 28Total 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 TBIMO 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: CTIndications 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 TBIMEDICATION• 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 TBIPersistent 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?