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Mild Traumatic Brain Injury

Mild Traumatic Brain Injury. Identifying Which ED Patients Are At Risk . Barbara Stuart, APRN, MSN, CEN. Objectives. Clarify definition of “mild” traumatic brain injuries. Review pathophysiology of MTBI. Recognize which patients are at risk. Provide resources for MTBI education.

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Mild Traumatic Brain Injury

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  1. Mild Traumatic Brain Injury Identifying Which ED Patients Are At Risk Barbara Stuart, APRN, MSN, CEN

  2. Objectives • Clarify definition of “mild” traumatic brain injuries. • Review pathophysiology of MTBI. • Recognize which patients are at risk. • Provide resources for MTBI education.

  3. Can you define Mild TBI • Acute brain injury from mechanical energy to the head with: • Confusion and/or disorientation. • Loss of consciousness for up to 30 minutes. • Glascow Coma Scale of 13 – 15. • Post-traumatic amnesia for < 24 hrs. • Transient neurological signs (nausea, HA). • A, C & E • All of the above.

  4. Why this topic?

  5. The “Silent Epidemic” (CDC) • Two million TBI’s annually. • Nearly 90% of all treated head injuries areclassified as “mild”. • Estimated cost is $17 billion dollars per year in the United States alone.

  6. Increasing MTBI’s • Severe TBI’s were an epidemic. • 1980’s CDC started pushing use of seatbelts. • Airbags in cars. • Seatbelt Laws

  7. Mechanism of Injury • Falls (28%) • MVC (20%) • Acceleration – deceleration injury • Struck by events (19%) • Violence (11%) • (CDC, 2009) • No studies have identified injury severity as a factor contributing to ongoing disability following a MTBI.

  8. It happens everyday!

  9. Emergency Departments • Estimates indicate Emergency Departments (ED) treat 100 to 300 head injuries per 100,000/population per annum. • However, a large number of MTBI cases are not treated in hospital EDs so the actual rate may be in excess of 600 per 100,000cases . Ponsford, 2005

  10. Defining MTBI • A blow or jolt to the head that disrupts brain function. • Often called a “concussion” or “closed head injury”. • Center for Disease Control and Prevention, 2009

  11. Defining MTBI • Criteria for clinical identification one or more of the following: • confusion or disorientation • loss of consciousness (LOC) < 30 minutes • post-traumatic amnesia < 24 hours • transient neurological abnormalities: • Seizure, HA, nausea • Glasgow Coma Scale score of 13 – 15 for < 30 minutes post-injury • World Health Organization Collaborating Centre Task Force on Mild Traumatic Brain Injury

  12. Powell, et al., 2008 • Two year study • On site / real time • Using CDC MTBI definition • Only 56% of MTBI’s were documentedas such in the ED record. • Patients meeting criteria: • Documented MTBI • Only 72% w/ LOC • Not documented • 94% reported confusion • Both hallmark symptoms of MTBI

  13. Anatomy of the Brain

  14. Frontal Lobe • Organization • Problem solving • Selective attention • Higher cognitive functions • Behavior • Emotions • Difficulty learning

  15. Temporal Lobe • Auditory receptive area. • Expressed behavior. • Language: • Receptive speech. • Memory: • Information retrieval.

  16. Limbic System • Olfactory pathways • Amygdala • Memory formation of emotional events. • Hippocampi • Long & short term memory • Spatial navigation • Limbic lobes: • Sex, rage, fear; emotions. Integration of recent memory, biological rhythms. • Hypothalamus • Temperature, hunger, thirst, fatigue, sleep and circadian cycles.

  17. Pathophysiology • Primary Brain Injury • Tissues and blood vessels are stretched, compressed and torn. • Secondary Brain Injury • Cellular processes • Biochemical cascades • Minutes to days after injury

  18. Axonal Injury

  19. Damaged axons can separate from their cell body. • Astrocytes nourish neurons and are phagocytic.

  20. Symptoms of MTBI • Headaches • Balance problems • Dizziness • Visual changes • Fatigue • Sensitivity to noise • Sleep disturbances • too much • insomnia • Difficulty concentrating • Memory problems • Emotions can also be heightened: • irritability • sadness • nervousness • anxiety See Concussion Information Sheet

  21. ED Focus of Care • Focused on identifying emergent conditions; not the subjective complaints that are the feature of these patients' persisting disability. • Physicians who are accustomed to dealing with severe head injures are apt to view the mildly concussed patient as fortunate to have escaped serious brain damage.

  22. Diagnostic Challenges • Many MTBI’s do not have the hallmarksymptoms used for definitive diagnosis. • Difficult to diagnose at the time of injury. • Emergent neuro-imagingwill not detect an injury to the neurons. • Symptoms may not present for days to weeks after the injury.

  23. MTBI Treatment • Over the past five years, a number of studies have focused on the benefits of early recognition of MTBIwith appropriate interventions. • A multi-disciplinary approach to care provides the best patient outcomes. • Concussion clinics • Acute Concussion Evaluation (ACE)

  24. Patients seen in the ED who sustained any acceleration – deceleration-type injury are at increased risk for a MTBI regardless of the initial severity of the injury. Research Hypothesis

  25. Research Methods • UVRMC 2009 ED computer logs were reviewedto identify patients discharged with the following diagnoses: • CHI/concussion • MVC • Head laceration • Whiplash • cervical strain • Multiple injuries • other

  26. Inclusion Criteria • Age 18 – 28 years old when injury occurred. • Speaks English. • No previous health problems. • No psychiatric illness. • No illegal drug or alcohol use. • Not currently taking any mood altering medications. • Treated and released from the ED at least two weeks prior to completing the survey.

  27. Post Concussive Symptom scale • Post concussive symptom scale (PCSS) • MTBI sensitivity = 81.9% • MTBI specificity = 89.4% • Internal consistency = (a = 0.93) • Measures symptoms in four categories: physical, thinking, sleep and emotional. • Likert scale of 0 – 6 • Mild = 1 – 2; Moderate = 3 – 4; Severe = 5 – 6

  28. Study Demographics • Average age: • 22.75 years • Male = 51% • Female = 49% • Number of symptoms: • Males = 6.76 • Females = 12.68 • Education: • 54.8% > 2 years college • Students • 75% • Employed • 73.3% working part-time • Time off • Students: < 1 wk = 65% • Employed: < wk = 70.6% • 3 to 4+ wks = 23.6% *Some reported working and being students concurrently which accounts for percentage discrepancies.

  29. Description of Injury • Three common categories: • Collision into something/someone: 45.4% • Motor vehicle crash: 32.8% • Falls: 21.8% • How long after your injury did you seek care? • 92% sought care in the ED the same day as the injury occurred

  30. PCSS Symptoms • No symptoms: (14%) • Reported 1-23 symptoms: (86%) • Average number of symptoms = 9.57 (SD = 6.99) • Most common symptoms: • Physical symptoms: • Headache ~ 69.2% • Fatigue ~ 61.5% • Thinking symptoms: • Difficulty remembering ~ 57.6% • Difficulty concentrating ~ 51.9%

  31. PCSS Symptoms • Sleeping symptoms: • Trouble falling asleep 51.9% • Sleeping > usual 40.3% • Emotional symptoms: • Irritability 50% • More emotional 42.3%

  32. Severity Scores by Diagnosis • Concussion: • Sleep category: 2.43 (SD = 0.38) • MVC: • Emotional category: 3.37(SD = 0.34) • Head Laceration: • Sleep category: 2.38 (SD = 1.31) • Whiplash/cervical strain: • Thinking category: 3.31 (SD = 0.68)

  33. Most Severe Symptoms • Concussion: • Headache: 62.9% • Difficulty remembering: 55.5% • Drowsiness: 51.8% • Head lacerations: • Fatigue: 31.2% • Sensitivity to light: 31.2% • Headache: 25% • MVC: • Headache, difficulty concentrating & irritability:100% • Whiplash/cervical strain: • Feeling slowed down & more emotional: 100% • Difficulty remembering: 83.3%

  34. Head Injury Education

  35. Implications & Recommendations • Insignificant injuries= MTBI symptoms • Education for all acceleration-deceleration type injuries in the ED is important. • Early recognition of MTBI with appropriate treatment will improve outcomes. • ED providers need to use appropriate ICD.9 codes and diagnoses to identify MTBI.

  36. Implications & Recommendations • Standardized plan of care for MTBI patients. • Define the “mild” category of brain injury more definitively. • Better patient histories taken by providers for pt with cluster of MTBI symptoms. • Early referral to concussion clinics. • Additional research is needed.

  37. Provide discharge Head Injury Education to patients based on mechanism of injury and not their presenting symptoms. We cannot predict which patients sustained a MTBI based on what we see in the ER. You can make a difference!

  38. Using the classification "mild" in describing any type of brain injury predisposes both provider and patient to minimize the impact of the injury. No brain injury is “mild” for the person suffering long-term sequelae!

  39. Questions?

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