Managing Agitation in Traumatic Brain Injury

1. Managing Agitation in Traumatic Brain Injury Jennifer E. Marks, D.O. Department of PM&R LSUHSC

2. TBI • #1 cause of TBI is MVA • Males at higher risk in all age groups • Peak risk 18-25 years

3. TBI • Severe TBI estimated to be only 6% of all hospitalized brain injury cases • However,the health care costs and residual deficits are much greater than with mild/moderate TBI

4. TBI • Mechanisms of injury: • PRIMARY: Occur at the moment of impact • SECONDARY: Triggered by primary mechanisms, cause more damage to the brain

5. Primary Injury Mechanisms-TBI • Most brain damage caused by acceleration-deceleration • Diffuse axonal injury: Widespread stretching of axons caused by the rotation of the brain around its axis • DAI may be seen on brain MRI

6. Diffuse axonal injury • Aka Shear injury • Occurs in 50% of all head trauma cases • Characterized clinically by LOC at time of impact • Multiple b/l focal lesions throughout white matter • Most commonly seen in the corpus collosum, brain stem, and frontal/temporal lobes

7. Secondary TBI Injury Mechanisms • ICH (ex. SDH) • Brain edema • Oxidant injury • Hypoxia secondary to cerebral perfusion pressure • Excitotoxicity: Neuronal damage caused by accelerated release of excitatory neurotransmitters by injured neurons

8. Glasgow Coma Scale • No direct way to measure the severity of brain injury • The Glasgow Coma Scale is used to measure TBI severity • The GCS evaluates the patient’s eye, motor, and verbal response • The lowest score obtainable is 3, the highest is 15 • The lowest post resuscitation score is the preferred value

9. GCS Pitfalls • Score can be affected by intoxication • Intubation can obscure the difference between a mild and moderate TBI • Also unscorable if patient cannot understand the examiner’s language

10. Mild TBI • GCS 13 or greater • Equivalent to concussion

11. Moderate TBI • GCS 9-12 • Follows commands • Does not answer questions appropriately

12. Severe TBI • GCS < or = to 8 • Patient was in a coma • Permanent neurological sequelae and functional disability • At least one year for maximal return to functioning • Large majority of patients in rehab units

14. TBI patient issues • Spasticity • Hetereotopic ossification • Posttraumatic epilepsy • Postraumatic hydrocephalus • Cranial nerve damage • Sleep disorders • Dysphagia • DVT • Skin breakdown • Post traumatic amnesia/AGITATION

15. Definition of agitation in TBI • A consensus at this time has not been reached on the exact definition of agitation. • “Subtype of delirium occurring during the period of post traumatic amnesia, characterized by excessive behaviors including some combination of aggression, disinhibition, akathisia, and emotional lability.” • A 1996 literature review featured in the Archives of PM&R by Sandel &Mysiw, 77:617-623

16. Etiology of agitation • Brain trauma disrupts the catecholamine/neurotransmitter pathways: surges of norepinephrine and epinephrine have been documented in the plasma and CSF. • TBI patients can also have hypothalamic dysfunction affecting temperature, blood pressure, etc.

17. Diagnosing agitation • A diagnosis of exclusion after medical and neurological conditions have been ruled out • Must rule out metabolic derangement, hypothyroidism, infection/sepsis, hypoglycemia , hypoxemia, medications such as anticholinergics • Drug withdrawal (ex. Sedatives, hypnotics)

18. Diagnosing agitation continued… Neurologic complications such as seizures, hydrocephalus, IC mass lesions, and migraine are possibilities that must be investigated NEVER FORGET THAT THE PATIENT COULD BE IN PAIN ALSO!!!

19. Tests suggested to evaluate the agitated patient • CMP, Thyroid function, CBC with differential, UA, B12/folate, tox screen, Brain CT/MRI, EEG, XR (see if occult fractures/heterotopic ossification causing pain)

20. Agitation Behavior Scale • Plan for ABS to be instituted at Charity in the near future • Patient given a rating of 1(absent) to 4 (severe) on 14 subcategories • Subcategories include distractibility, impulsivity, violence, alterations of mood • High inter-rater reliability

21. Rancho Los Amigos Scale of Cognitive Functioning • Developed at the California Hospital of the same name • Rancho I: No response to any stimulation; appears to be sleeping • Rancho II: Generalized Response • Rancho III: Localized response

22. Rancho Los Amigos scale (continued) • **RANCHO IV: Confused, Agitated, may be aggressive • Rancho V: Confused, Inapproriate, nonagitated • Rancho VI: Confused, appropriate • Rancho VII: Automatic, appropriate • Ranch VIII: Purposeful, appropriate

23. Management • Environment • Educate Staff and Family • Behavior • Medication

24. Environmental Management

25. Environmental Management • FIRST REDUCE STIMULI- light, noise, distractions • Patient should have a limited number of visitors at a time • EVERYONE should speak in a low volume, one at a time

26. Environmental Management • To reduce patient confusion: • Consistent schedule and staffing • Don’t move patient to another room • Reorient person frequently

27. Behavioral Strategies • Tolerate patient’s restlessness as much as possible (ex. Allow patient to pace if ambulatory) • Mobile patients may need a closed unit or sensor unit for their safety • Remove lines tubes ASAP • Consider Craig bed or Vail bed

28. Vail Bed

29. Environmental Management • AVOID RESTRAINTS IF AT ALL POSSIBLE • Padded hand mittens if necessary • Soft lap belt in the wheelchair • Heavy, stable wheelchair that will not tip over

30. Medications • Since 1966, there have only been six randomized controlled trials concerning medication management of TBI agitation! • Almost all studies evaluating medications have been on subjects greater than ten years old.

31. RCT studies 1966-present

32. Measurement and Treatment of Agitation following TBI- Fugate et al. • Study of 129 physicians divided into experts or nonexperts surveyed. • Experts either had published two or greater articles on pharmacological interventions for TBI in the last 5 years, or had > or = 70% of their practice devoted to treating TBI

33. Fugate et al. continued • Experts most frequently prescribed carbamazepine, beta blockers, TCA’s • Nonexperts chose Haldol four times more frequently than experts

34. Medications • Most commonly utilized • Antiepileptics • Dopamine agonists (amantadine) • Antidepressants (TCA’S) • Antipsychotics (Haldol) • Beta Blockers(Inderal)

35. Medications for agitation • Antiepileptics: • Carbamazepine: Commonly utilized by rehab facilities. Some promise with agitation but only case reports have been published • Phenytoin, Phenobarbitol: Not recommended secondary to interfering with cognitive function and causing excessive sedation

36. Medications • Benzodiazepines: Not recommended for long term agitation treatment due to interference with cognitive function and sedation

37. FOR SEVERE AGITATION, Lorazepam 1-2 mg IM/IV !

38. Antipsychotics • Ex. Haldol: The typical agents, in both human and animal studies, have been shown to cause a decline in cognitive performance (verbal ability, memory, learning, attention, spatial ability…..once the medication was stopped, cognition improved) Stanislav et al, Brain Injury 1997, p335-41

39. Beta blockers • Two placebo-controlled, blinded studies with propanolol showed decreased agitation in patients with TBI. • Also helps to control tachycardia and hypertension many TBI patients have

40. Beta Blockers Twenty one subjects with TBI • Treated with propanolol or placebo in a double-blind study • In the treatment group the intensity of agitation was significantly lower, although the number of episodes was similar. The use of restraints was also significantly lower. • Brooke et al., Arch Phys Med Rehabil 73, Oct 1992, 917-921

41. Beta Blockers • Starting dose of propanolol at 20 mg BID • Can use QID dosing • IN ADULTS can titrate up to 60 mg/day • Usually max amount 240 mg/day in adults, but doses as high as 600 mg/day have been reported • As patient improves, can taper off

42. Medication • Dopamine agonists (amantadine, bromocriptine) , SSRIs, methyphenidate, and TCA’s have not been shown to control agitation successfully, but do improve alertness/initiation

43. Conclusion • More RCT studies need to be done to determine the optimum pharmacologic intervention for TBI

44. Sources • As previously stated, and…… • Randall L. Braddom. Physical Medicine and Rehabilitation. Second Edition. W. B Saunders Co. , Pennsylvania. 2000. • Fleminger S., Greenwood RJ, Oliver D.L. Pharmacological management for agitation and aggression in people with acquired brain injury (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd. • Thank you to Dr. Kiersta Kurtz-Burke, PM&R consult service staff at Charity!