BRAIN INJURYPOST ACUTE CARE ISSUES

BRAIN INJURYPOST ACUTE CARE ISSUES - Bart M. Demaerschalk, MD, MSc
BASICS
DESCRIPTION
Traumatic brain injury (TBI) is broadly defined as brain injury due to externally inflicted trauma and may result in significant impairment of an individual's physical, cognitive, and psychosocial functioning.
• System(s) Affected: Nervous; Pulmonary; Skin/Exocrine; Endocrine/Metabolic; Renal/Urologic; Gastrointestinal (GI); Musculoskeletal
GENERAL PREVENTION
Improved safety standards and programs designed to minimize injury from vehicular-related events (motor vehicle, motorcycle, bicycle, pedestrian), falls, violence, sports, and recreation provide the best prevention against TBI. (1,2)[C]
EPIDEMIOLOGY
• Predominant age: Highest incidence persons 15-24 years of age and those >75 years, with additional smaller peak in children 5 years.
• Predominant sex: Male > Female (2:1)
Incidence
An estimated 1.2 million-1.7 million Americans sustain TBI per year. Incidence of TBI is 100/100,000 in the US, 230,000 hospitalizations, 50,000 deaths per year, and an estimated 80-90,000 sustain long-term disabilities.
Prevalence
Prevalence estimates range from 2.5 million-6.5 million individuals living with consequences of TBI.
RISK FACTORS
See "Brain Injury, Traumatic"
ETIOLOGY
Motor vehicle, bicycle, or pedestrian-vehicle incidents (50%), falls, acts of violence and assault, and sports and recreation-related injuries are the leading causes of TBI.
ASSOCIATED CONDITIONS
• Psychosis
• Suicide attempts
• Substance abuse
• ADD

DIAGNOSIS
SIGNS AND SYMPTOMS
• Consequences of TBI often influence human functions along a continuum from altered physiological functions, through neurological, psychological, cognitive, and behavioral impairments, to medical problems and disabilities that affect the individual, family, and community.
• Nonneurological complications include pulmonary, metabolic and endocrinological, nutritional, gastrointestinal, musculoskeletal, genitourinary, dermatologic, and chronic pain.
• Most neurological complications are apparent within the 1st days or months following injury. Long-term sequelae include seizures, headache, visual defects, and movement and sleep disorders.
• Cognitive consequences include memory impairment, difficulties in attention and concentration, language deficits, visual perception problems, and poor executive skills, problem solving, reasoning, insight, judgment, planning, information processing, and organization.
• Behavioral problems include decreased ability to initiate responses, verbal and physical aggression, agitation, learning difficulties, shallow self-awareness, altered sexual functioning, impulsivity, and social disinhibition.
• Psychological consequences include mood disorders, personality changes, altered emotional control, depression, and anxiety.
• Social consequences include risk of suicide, divorce, unemployment, economic strain, and alcohol/substance abuse.
ALERT
Pediatric Considerations
• Interactions of physical, cognitive, and behavioral sequelae interfere with new learning. The effect of early TBI may not become apparent until later in the child's development.
TESTS
• Evoked potentials (auditory, visual, and somatosensory)
• Behavioral assessment, neuropsychological testing, and vocational assessment
• Cognitive test for orientation and arousal; use Western Neuro Sensory Stimulation Profile or Galvest. Orient. Amnesia Test
• EEG
Lab
• CBC, electrolytes, blood urea nitrogen creatinine, calcium, albumin, vitamin B12, folate, thyroid stimulating harmone, alkaline phosphatase, aspartate aminotransferase (AST), alanine amino- transferase (ALT), morning cortisol level, urine culture
• Culture, ova, and parasites for diarrhea
• Skin culture
• Culture tracheal site
• Endocrine workup as indicated
Imaging
• Bone scan: Heterotopic ossification
• CT: Hydrocephalus, atrophy, hematoma
• Video pharyngeal fluoroscopic swallowing study
• MRI to evaluate diffuse axonal injury
Diagnostic Procedures/Surgery
• Altered arousalvisual, auditory, and somatosensory evoked potentials
• Neurogenic bladder-check post-void residuals 3-4 times. If >50 cc or 20% of voided volume, urodynamics
• Ultrasound of bladder and kidney: Urolithiasis and hydronephrosis
• Endoscopy: Cause of dysphagia
• Contractures and spasticity: Examination under anesthesia
• Respiratory and neurologic: Sleep/oxygen saturation study, bronchoscopy for stricture
Pathological Findings
• Hydrocephalus with periventricular edema
• Joint contractures results in collagen cross linking: Decreased range of motion
• Heterotopic ossification: Disorganized osteoid calcification in soft tissue
DIFFERENTIAL DIAGNOSIS
Differential Diagnosis of Pain after TBI: (5)
The diagnosis of pain following TBI can be difficult in light of the limitations imposed by cognitive, language, and behavioral deficits. The differential diagnosis includes
• Dysautonomia: Characterized by episodes of tachypnea, hypertension, painful posturing/contractions, and diaphoresis
• Neuropathic pain: Described as burning, shock-like, or pins and needles; Allodynia/hyperpathia. The 3 most common forms are complex regional pain syndrome, central pain syndrome, and peripheral neuropathy.
• Spasticity or spastic dystonia
• Headache: Posttraumatic headache
• Myofascial pain syndrome
• Neurogenic Heterotopic Ossification: Bone formation in soft tissue
• Deep Venous Thrombosis
• Constipation and urinary retention
• Trauma: Fractures, musculoskeletal injuries
• Shoulder: Subluxation, acromioclavicular separation, rotator cuff tendonitis/tear
Differential Diagnosis of Alteration in Functional Capacity/Level after TBI:
Chronic infection (UTI, aspiration pneumonia, GI), depression, hypothyroidism or hydrocephalus, intracerebral hemorrhage, epilepsy/seizures, fractures, tracheal stricture, pain, alcohol or drugs, polypharmacy and/or central nervous system depressant/psychoactive drugs
TREATMENT
GENERAL MEASURES
• Diminished level of arousal: Identify best modality for communication, assess functional skills (proper seating, hand function), behavioral or neuropsychologist. Social work (to assist with family education and long-term planning) and nursing
• Reduce sedatives
• Neurogenic bladdertreat UTI
- If post-void residual 50 cc, then trial of regular voiding routine q2h
- If still incontinent, add oxybutynin
- If still incontinent, try condom catheter during the day; incontinent pads at night.
- If high post-void residuals or high pressure bladder or dyssynergic bladder on urodynamics: Intermittent catheter q4-6h
• Neurogenic bowel: Regular bowel routine
• Contractures and spasticity: Stretching
- If no progress after 4 weeks, consider serial casting or custom made orthotic
- Contractures >45: Consider tendon release
• Heterotopic ossification: Stretch soft tissue to decrease maturation of osteoid, consider orthotics/splinting, bone scan at baseline
• Skin: q2h turning, avoid sitting such as in bed at 45, observe for erythema around tube sites and rule out latex allergy
• Respiratory: Night humidification if has a tracheotomy, may require suctioning
• Endocrine: Monitor fluid balance
• Dental: Assessment and x-rays
• Rehabilitative practices: Rehabilitative programs should be interdisciplinary, comprehensive, and include cognitive and behavioral assessment and intervention. (1) [C]
• Non-pharmacological therapeutic interventions
- Cognitive exercises (including computer-assisted strategies), compensatory devices (memory books, paging systems), psychotherapy, behavior modification, vocational rehabilitation, school setting rehabilitation, nutritional support, music and art therapy, and therapeutic recreation (4)[C]
Diet
• Consult with dietitian
• Ensure adequate hydration; 2-2.5 L of water/day. More if outside or in hot weather.
• Bolus feeds preferred if fed by gastrostomy
• Upright and quiet for 1/2 hour following feeds, as aspiration can occur even with a g-tube
Activity
As tolerated: Outings in wheelchair can be beneficial; skin very sensitive to sun/wind
MEDICATION (DRUGS)
• Psychostimulants may affect speed of cognitive processing, mood, and behavior, but effects on attention, distractibility, and memory are less clear. Methylphenidate 20-40 mg/d in 2 divided doses; Dextroamphetamine. (9)[B]
• Agitation
- Treat epilepsy or depression
- Minimize the use of antipsychotics and benzodiazepines, as they worsen cognition.
- If necessary, use antipsychotics of the atypical class (Clozapine, Olanzepine, Quetiapine, Risperidone, Ziprasidone). (8)[B]
• Abulia and lack of initiative: Amantadine (Symmetrel), bromocriptine, methylphenidate, levodopa (8)[C]
• Epilepsy: American Academy of Physical Medicine and Rehabilitation does not recommend antiepileptic drugs for preventing late (>7 days post TBI) posttraumatic seizures. [B] If epilepsy occurs, avoid phenytoin and phenobarbitaltoo sedating. (6)
• Spasticity caution: Be aware of potential negative consequences of all agents. Dantrolene sodium 25-200 mg/day divided t.i.d.; Baclofen; intrathecal Baclofen; Diazepam, Clonidine, Tizanidine, and Gabapentin; Botulinum toxin injections for focal spasticity. (7)[B]
• Neurogenic bladder: Oxybutynin 2.5 mg t.i.d.-10 mg q.i.d. if bladder pressures low and/or post-void residuals low [B]
• Bowel routine: Stool softener such as docusate sodium (daily) combined with laxative (night before suppository), high fiber and suppository (every other day) to induce bowel movement [C]
• Heterotopic ossification: Indomethacin 25-50 mg t.i.d. If severe, progressive, or history of GI ulceration, then etidronate (Didronel) 20 mg/kg for 6 months or alendronate 20 mg once a day. [C]
• Neurobehavioral problems: Weak evidence that psychostimulants are effective in the treatment of inattention, apathy, and slowness; high-dose beta-blockers in the treatment of agitation and aggression; and anti-convulsants and anti-depressants in the treatment of agitation and aggression with an affective disorder. (3,4)[B]
• Contraindications: Refer to manufacturers' literature
• Precautions: Medications may have significant adverse effects in persons with TBI and can impede rehabilitation progress.
• Significant possible interactions: Refer to manufacturers' literature.
SURGERY
Tendons releases; fundoplasty or gastrostomy; tracheostomy; ventriculoperitoneal or ventriculoatrial shunt
FOLLOW-UP
PROGNOSIS
• Most rapid return of function is during 1st 2 years, but some improve slowly for 5-10 years
• Highly variable (80% of individuals with severe injuries become independent in dressing and self-care at 1 year)
• Negative prognostic factors
- Age >40
- Abnormal pupillary responses
- Prolonged coma (i.e., GCS 9, seven days after injury)
- Abnormal evoked potentials
- Extraocular eye movement abnormalities
COMPLICATIONS
• Major affective disorder (depression, psychosis) in up to 50% of patients
• Family and caregiver burn out
• Substance abuse
• Social isolation
• May be at higher risk of dementia
• Latex allergy to g-tube, catheters
• Dental caries
• Osteoporosis
• Falls
• Aspiration pneumonia
• Pressure ulcers
• Dysphagia, esophagitis
• Bladder incontinence
• Contractures/spasticity
PATIENT MONITORING
• Patients make slow steady gains. Ongoing outcome assessments determine progress (or not) in abilities and medication efficacy.
• Review medical status monthly
REFERENCES
1. NIH Consensus Development Panel on Rehabilitation of Persons with Traumatic Brain Injury. Rehabilitation of persons with traumatic brain injury. JAMA. 1999;282(10):974-983.
2. Lovasik D, Kerr M, Alexander S. Traumatic brain injury research: A review of clinical studies. Crit Care Nurs Q. 2001;23(4):24-41.
3. Shoumitro D, Crownshaw T. The role of pharmacotherapy in the management of behaviour disorders in traumatic brain injury patients. Brain Injury. 2004;18(1):1-31.
4. Glenn MB. A differential diagnostic approach to the pharmacological treatment of cognitive, behavioral, and affective disorders after traumatic brain injury. J Head Trauma Rehab. 2002;17(4):273-283.
5. Ivanhoe CB, Hartman ET. Clinical caveats on medical assessment and treatment of pain after TBI. J Head Trauma Rehab. 2004;19(1):29-39.
6. Bushnik T, Englander J, Duong T. Medical and social issues related to posttraumatic seizures in persons with traumatic brain injury. J Head Trauma Rehab. 2004;19(4):296-304.
7. Zafonte R, Elovic EP, Lombard L. Acute care management of post-TBI spasticity. J Head Trauma Rehab. 2004;19(2):89-100.
8. Elovic EP, Lansang R, Li Y, Ricker JH. The use of atypical antipsychotics in traumatic brain injury. J Head Trauma Rehab. 2003;18(2):177-195.
9. Whyte J, Vaccaro M, Grieb-Neff P, Hart T. Psychostimulant use in the rehabilitation of individuals with traumatic brain injury. J Head Trauma Rehab. 2002;17(4):284-299.
MISCELLANEOUS
• Rehabilitation program guidelines
- Individualized goals: Behavioral approach emphasizing reinforcement of task behavior
- Flexible: Alter to meet changing needs
- Functional (based on activities of daily living): Self care activities involve range of motion exercises
- Consider patient's attention span and best time of day when planning
- Allow for as patient control and choice when able (e.g., choice of clothes, music, etc.)
- Consistency and familiarity
- Quality of life issues vital (e.g., comfort measures, sensory stimulation, address spiritual and/or cultural needs, and positioning)
- For agitated behavior, consider consult with behavioral psychologist to design program integrating medications and behavior therapy techniques. Minimize use of punishment and reinforce correct behavior.
• See also: Brain Injury, Traumatic; Constipation; Dysphagia; Fecal Impaction; Gastroesophageal Reflux Disease; Hemorrhoids; Osteoporosis; Pressure Ulcer; Seizure Disorders; Sleep Apnea, Obstructive; Stomatitis; Stroke (Brain Attack); Stroke Rehabilitation