THE ESSENTIAL BRAIN INJURY GUIDE Introduction, Overview & - - PDF document

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Introduction, Overview & Etiology Section 1

THE ESSENTIAL BRAIN INJURY GUIDE

Presented by:

Bonnie Meyers, CRC, CBIST Director of Programs & Services Brain Injury Alliance of Connecticut

Certified Brain Injury Specialist Training – October 26 & 27, 2017

This training is being offered as part of the Brain Injury Alliance of Connecticut’s

• ngoing commitment to

provide education and

• utreach about brain injury in

an effort to improve services and supports for those affected by brain injury.

Presented by Brain Injury Alliance of Connecticut staff: Rene Carfi, LCSW, CBIST, Education & Outreach Manager & Bonnie Meyers, CRC, CBIST, Director of Programs & Services

Contributors

Mark J. Ashley, ScD, CCC-SLP, CCM, CBIST Maria Crowley, MA, CRC Kevin E. Crutchfield, MD David Demarest, PhD Mark Huslage, LCSW-C, CBIST Brent E. Masel, MD Emily McDonnell Drew A. Nagele, PsyD Ronald Savage, EdD

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Brain Injury Overview

Learning Objectives

Know the symptoms clusters of neurologic disorders, neuroendocrine disorders, sexual dysfunction, and musculoskeletal dysfunctions resulting from brain injury Gain an understanding

• f the causes
• f brain injuries, both

traumatic and non-traumatic Be able to distinguish between primary and secondary injury Be able to articulate the effects of brain injury and injury severity Be able to describe the different patterns

• f brain injury observed

in specific age groups

ACQUIRED BRAIN INJURY

TRAUMATIC IMPACT

Contact Injury Head struck by or against an object

TRAUMATIC INERTIAL

Non-Contact Injury Brain moves within skull

CLOSED

(Non-Penetrating)

OPEN

(Penetrating) Skull ll Fr Fracture Meninges Breach

Rotatio ional/Ang ngular r Forces

Non-Contact Injury Brain moves within skull FOCAL

• OR -

DIFFU FFUSE PRIM IMARIL ILY Y DIF IFFU FUSE (MULTIF IFOCAL) L) PRIM IMARIL ILY FOCAL Brain n Cont ntusions ns Brain n Lacerations ns Intracerebral Hemorrhage Diffuse Axo xona nal Inj njury Epi pidu dural Hematomas Subdu dural Hematomas Intracerebral Hemorrhage Infections ns Diffuse Axo xona nal Inj njury White Matter Lesions ns Hemorrhage Blast Related Assaults Falls Vehicular Accident nts Sports Accide dents Guns nshot Stabbing ng Falls Vehicular Accident nts Sports Accide dents Falls Vehicular Accident nts Sports Accide dents

NON-TRAUMATIC

Internal Insult

Severe Reductions in Blo lood Flow Hemorrhage Due to Clo lotting White Matter Lesions ns Hemorrhage Stroke Neurotoxi xic Poisoni ning ng Hypo poxi xia/Ano noxi xia Ischemia Infection Tumors FOCAL

• OR -

DIFFU FFUSE PRIMARY INJU JURY MEC ECHANISM INJU JURY CLA LASSIFICATION INJU JURY PATHO-PHYSIOL OLOGY INJU JURY CAUSES ES

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Closed Head Injury

Causes of Traumatic Brain Injury Causes of Non-Traumatic Brain Injury

• Falls
• Assaults
• Motor vehicle crashes
• Sports and recreation injuries
• Shaken baby syndrome/abusive head

trauma

• Gunshot wounds
• Workplace injuries
• Child abuse
• Domestic violence
• Military actions (blast injury)
• Stroke (hemorrhage or blood clots)
• Infectious disease (encephalitis,

meningitis)

• Seizure disorders
• Electric shock/lightning strike
• Tumors (surgery, radiation, chemo)
• Toxic exposures (substance misuse,

ingestion of lead, inhalation of volatile agents)

• Metabolic disorders (insulin shock,

diabetic coma, liver and kidney disease)

• Neurotoxic poisoning (carbon monoxide

poisoning, inhalants, lead exposure)

• Lack of oxygen to the brain (near

drowning, airway obstruction, strangulation, cardiopulmonary arrest, hypoxia, anoxia) Acquired Brain Injury Causes – Traumatic and Non-traumatic

Primary and Secondary Injury

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Brain Injury Severity

Mild TBI

Can have either brief or no loss of consciousness and its presentation may demonstrate vomiting, lethargy, dizziness, and inability to recall what just happened

Moderate TBI

Will be marked by unconsciousness for any period of time up to 24 hours, will have neurological signs of brain trauma, including skull fractures with contusion or bleeding, and may have focal findings on an electroencephalograph (EEG)/computed tomography (CT) scan

Severe TBI

Marked by a period of loss of consciousness of 24 hours or greater

What Determines the Effects of Brain Injury?

• Injury severity
• Age at injury
• Alcohol misuse
• Domestic violence
• Service in the military
• Participation in sports
• Number of brain injuries

a person experiences

Information about Incidence and Prevalence

• TBI is a contributing factor to a third (30.5%)
• f all injury‐related deaths in the US
• 75% of TBIs that occur each year are mild

TBI

• An estimated 2.5 million people sustain a

TBI yearly

• 2,214,000 emergency department visits

(81%)

• 284,000 hospitalizations (16%)
• 53,000 deaths (3%)

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• Highest Rates of TBI due to Falls by Age

Group

• Children 0-4 (50% of all TBIs)
• Adults 65 or older (61% of all TBIs)
• Highest Rates of Death from TBI due to

Falls

• Adults aged 75 or older
• Highest Rates of Death from TBI (All

Causes)

• Adults aged 75 or older
• Highest Rates of Death from TBI

(Firearms)

• Adults Ages 20-24
• Adults 75 or older

Age and Mechanism of Injury

At any age, males have a higher rate of TBI- related death than females

• Percentage of Children with TBI

from Physical Abuse

• Children 0-3 years old (67%)
• Highest Rates of TBI from Motor

Vehicle Crashes

• Adults 20-24 years of age
• Highest Rates of TBI Related Death

from Motor Vehicle Crashes

• Adults 16-19 years of age

Domestic Violence

A study found that 67% of women victims of domestic violence also had symptoms associated with brain injury

Each year, two million to four million women are physically abused by someone with whom they are intimate The head, face and neck are the most frequent sites

• f injury

Intimate violence is the leading cause of serious injury to American women between the ages of 15 and 44 It is estimated that a woman is beaten every 12 seconds in the U.S.

Brain Injury in Prisons

A high proportion of the 2 million people currently in U.S. prisons have a brain injury Between 25 and 87 percent of inmates report having experienced a TBI, compared with a report rate of 8.5 percent in the general population These injuries are not necessarily recognized, diagnosed, or treated

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Screening for TBI

• Brain injury is often

undetected in children, sports, the military, and prisons

• Thorough screening is

important so that appropriate services can be provided

Continuum of Care National Accreditation Agencies

• Commission for the Accreditation of

Rehabilitation Facilities (CARF)

• For post-acute BI programs
• Residential
• Outpatient
• Vocational
• Home and community programs
• Stroke & pediatrics
• Joint Commission on the Accreditation of

Healthcare Organizations (JCAHO)

• For most hospital‐based programs
• May also have CARF accreditation

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Funding

• Auto insurance
• Workers compensation

insurance

• Commercial health insurance
• HMOs
• PPOs
• POSs
• HDPs
• Medicaid provides health care

for more than 49 million low‐income people

• Medicare provides healthcare

to 44 million Americans who are blind, aged 65 and older,

• r who have disabilities
• Patient Protection and

Affordable Care Act (PPACA)

• f 2010

Private Funding Public Funding

Federal Programs

• Rehabilitation Act of 1973
• TBI Model Systems -1987
• TBI Act of 1996
• TBI State Grants
• Centers for Disease Control and

Prevention (CDC)

• Olmstead Decision - 1999

Home and Community‐Based Waiver Programs (HCBS)

• Case management
• Homemaker service
• Home health aide services
• Personal care
• Adult day health
• Respite care
• Habilitation services
• Services for chronic mental illness
• Other services that help avoid

institutionalization (such as assistive technology, etc.)

• Allows states, with

approval, to try new approaches for delivering health care providing costs do not exceed costs of institutional care

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Reversing the Silent Epidemic

• Current advances have not yet resulted in dramatically

increased funding for services, basic research or prevention of brain injury

• There is continued need for:
• Public health education
• Funding to ensure ongoing support and services
• Awareness about concussion
• Epidemiological data collection
• Brain injury screening

TBI AS A CHRONIC DISEASE

Mortality and Morbidity

• Persons with a TBI have a

life expectancy reduction.

• Individuals surviving a TBI

are at increased risk of death.

• Individuals surviving a TBI

are at increased risk for certain associated conditions.

• It is unclear if chronic damage is

due to the initial traumatic insult or progressive secondary injury.

• TBI may reset the cellular timer

and cause early degeneration and death of cells.

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Mild Traumatic Brain Injury Learning Objectives

Understand the concepts of mild traumatic brain injury and its related health risks Be able to describe common symptoms of concussion and the physiologic processes that underlie them Be able to discuss the concept of persistent post-concussive symptoms, along with appropriate diagnostic methods and treatment Be able to explain the most common form of damage to a brain structure Be able to distinguish between treatments for migraines and those appropriate for headache secondary to brain injury

UNKNOWN

• mTBI represents 75% of all TBIs that
• ccur in the U.S.
• The true incidence may be higher

as 16-25% of those injured do not seek medical care

mTBI-Incidence

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Definition of mTBI

Mild Moderate Severe

Normal structural imaging Normal or abnormal structural imaging Normal or abnormal structural imaging LOC = 0-30 min LOC > 30 min and < 24 hr LOC > 24 hr AOC = from a moment up to 24 hr AOC > 24 hr severity based

• n other criteria

PTA = 0-1 day PTA > 1 and < 7 days PTA > 7 days GCS = 13-15 GCS = 9-12 GCS = 3-8

mTBI Causes

Primary causes:

• Acceleration-

deceleration

• Striking head against

hard surface

• Blasts or explosions
• Blast Related
• Assaults
• Falls
• Vehicular

Accidents

• Sports Accidents

TRAUMATIC INERTIAL

Brain moves within skull

• Falls
• Vehicular

Accidents

• Sports Related

Accidents

TRAUMATIC IMPACT

Contact Injury Head struck by or against an object

mTBI-Symptoms

Physical/Somatic Cognitive Behavioral/ Emotional

Headache Light Sensitivity Inattentiveness Depression Fatigue Noise sensitivity Diminished concentration Anxiety Seizure Impaired hearing Poor memory Agitation Nausea Blurred vision Impaired judgement Irritability Numbness Dizziness/loss of balance Slowed processing speed Aggression Poor sleep Neurological abnormalities Executive dysfunction Impulsivity

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Acute Symptoms: mTBI-Frontal Release

Damage to the frontal lobe can result in disinhibition and changes in behavior

ACUTE SYMPTOMS

mTBI Interventions

Research shows that early intervention and management

• f mTBI is the most effective

means of reducing disability

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mTBI Headaches

Immediately after a TBI, a rapidly progressing severe headache signals a need for medical attention

• Most common complaint after

mTBI

• Primary reason for patients

seeking medical attention

• Typically occur with exertion

rather than at rest

mTBI SYMPTOM MANAGEMENT

Psychological Features and mTBI

Concussion Stress Anxiety Depression PTSD Headaches X X X X X Drowsiness X X X X X Irritability X X X X X Depression X X X X X Poor memory X X X X X Attention/ Concentration X X X X X Fatigue X X X X X Poor sleep X X X X X Nausea X X X X X Worry X X X X Dizziness/Loss of balance X X Impaired hearing X X Blurred vision X

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Persistent Post- Concussive Symptoms: Risk Factors

• Over age 40
• Female
• Traumatically injured
• Low socioeconomic status
• History of substance abuse
• Positive mental health

history

• Pending litigation
• Persistent headache, dizziness,

and/or nausea

• Post-traumatic amnesia greater

than 1 hour

• GCS of 13 or 14

mTBI-PPCS Post- Injury Risk Factors Diagnosis & Treatment of PPCS

• A neuropsychological evaluation is

invaluable in determining symptom causation

• Should be considered necessary

with complicated PPCS

• Neuropsychologists can:
• Provide early intervention
• Make recommendations for

therapies

• Monitor return to work, school
• Treat emotional problems that

arise during recovery

• Treatment should be:
• Symptom focused
• Based off careful diagnosis
• Emphasize both functional

resolution and compensatory strategies

• Provide an optimistic outlook

and clear path for the patient to improve

• Teams should be

multidisciplinary Diagnosing Treating

Rare Complications

• Second-Impact Syndrome
• Chronic Traumatic

Encephalopathy (CTE)

?

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Q & A

200 Day Hill Road, Suite 250 Windsor, CT 06095 Office 860.219.0291 Helpline 800.278.8242 general@biact.org BIACT.org

Thank You!