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Mild traumatic brain injury and PTA testing

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Mild traumatic brain injury and PTA testing

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									Mild Traumatic Brain Injury
         (MTBI)
     and PTA testing




 Karen Braid – Project CNS, ED Nepean Hospital
Mild Traumatic Brain Injury
         (MTBI)

Mild traumatic brain injury is generally
defined as an injury caused by blunt head
trauma or a rapid acceleration/deceleration
injury
 Typical Characteristics
A period of unconsciousness for less
then 20 mins &/or
Brief retrograde amnesia
A Glasgow coma scale score of 14-15
No focal neurological deficit
No intracranial complications
           Symptoms
Headache            Memory problems
Dizziness           Fatigue
Sensitivity to      Irritability
noise or bright     Anxiety
light               Depression
                    Mood swings
Blurred or double
                    Reduced speed
vision              of thinking
Restlessness        Concentration
Insomnia
Post Traumatic Amnesia (PTA)
 Is defined as a disturbance pattern characterized by
 disorientation, impaired attention, memory failure for
 day to day events, and misidentification of family,
 friends and medical staff.

 It is the period of time in which the brain is unable to
 lay down continuous day-to-day memories

 Has been shown repeatedly to be one of the best
 single predictors of residual problems with cognitive
 function or functional independence
           Evidence
MTBI’s represent approximately 80% of all
head injuries sustained

Evidence that cognitive and behavioural
symptoms are present early and resolve
within 3/12

A small but significant minority report
persisting symptoms at 6-12 months post
injury and beyond
             Scenario
Nepean hospital identified a problem
with the management of theses patients
through subjective and anecdotal
reports of the difficulties experienced by
patients in the area
          Collaboration




Neurosurgery, Occupational Therapy,
Quality unit, Rehabilitation Emergency,
Consumers and the Westmead Brain
Injury Unit
    Traditional Practice:
 Discharged with head injury advice card
 Referred to GP for follow-up

Or if admitted:
 Occasionally referred to occupational
 therapist
 If under Neurosurgeon, patient was
 seen by CNC and OT
      Literature Review
Includes
 – Patient identification
 – Early reassurance
 – Education
 – Screening to prevent or manage
   ongoing issues
               Project
A clinical pathway for ED
Education updates to ED
A clinical guideline for patients requiring
admission
Intensive care management
Rehabilitation referral processes
       Clinical Pathway
Clinical pathway
- designed to ensure best practice with
identification, assessment,
management, treatment and referral of
patients presenting with MTBI

Released in November 2005 & has
continued to evolve
            Pathway
Inclusion/ exclusion criteria
Guideline for the management of MTBI
Clinical observations to include GCS
and PTA assessments
History and exam
CT guidelines
Admission process
   Westmead PTA Scale
Is a tool to measure PTA
Modified to contain 10 items assessing
orientation and memory
It is completed at hourly intervals in
conjunction with a GCS
Testing ceases once 3 consecutive
scores are obtained
Allows more appropriate timing of
discharge and accurate prognostic
information.
Modified Post Traumatic
   Amnesia Protocol
    How old are you?
    What is your date of birth?

    What month are we in?

    What time of day is it?
    What year are we in?

    What is the name of this place?

    Face recall (from photos)?
    Recall of 3 pictures?
             Education
•   To teach staff PTA assessments
    and the clinical significance of
    PTA

•   Update education material for
    patients and relatives
            Admissions
1. Admit patients previously discharged
2. Streamline acceptance of care through
   collaboration
3. Use the ED EMU for prolonged PTA
   assessments
            Outside ED
Ward and Intensive care protocols

Rehabilitation processes
                 MTBI
Measurements of success
– Increased referrals to mild brain injury
  clinic
– Improved coding of concussion as reason
  for presentation
– Increase in patients documented out of
  PTA on discharge from 5% to 70%
– Appropriate admissions for further
  assessment
      MTBI – Staff Survey
100% of ED staff were aware of the pathway
100% had used the pathways
83% found it useful
72% found it took more time- average 5-10 mins
77% found it helped to manage the patient better
83% agreed that pathway should continue to be used
–
                 MTBI
The ED clinical pathway has evolved
since its commencement to
– incorporate CT guidelines
– improvements to the PTA tool
– the addition of definitions to help educate
  staff
– improvement in the structure of the
  pathway itself
               MTBI
Consistent with the ITIM guideline

The pathway will continue to evolve with
the ED quality improvement systems
           Adaptation
The MTBI pathway could be adapted to
any ED depending on their local needs
and resources.
              Case Study
65yr old male presented to ED with a
head and facial injury
–   LOC day before
–   Headache
–   Dizzy and vague
–   Amnesic to events before and after injury
–   GCS 15/15
–   Observations satisfactory
Commenced on MTBI pathway
Medical assessment and CT scan
CT showed bifrontal contusions
Consequently failed PTA
Admitted
Discharged 19 days later
           Case Study 2
41yr old male playing soccer.
Head clash with another player
2min witnessed LOC
Otherwise well
Observations stable
GCS 14 on arrival
Commenced on MTBI pathway to
include PTA/GCS assessments.

Passed assessments as per pathway

Discharged at 4/24 with discharge
information.
                         References
Adult Trauma Clinical Practice Guideline. 2007. Initial Management of
        Closed Head Injury in Adults, Institute of Trauma and Injury
        Management .

Brown,S.J.,Fann,J.R and Grant,I. 1994 Postconcussional Disorder: Time to
      Acknowledge a Common Source of Neurobehavioural Morbidity,
      The Journal of Neuropsychiatry and Clinical Neurosciences, Vol 6,
      pp15-22.

Duff, J. 2005. Post Concussion Syndrome: Minor Traumatic Brain Injuries,
         Behavioral Neurotherapy, cited on 17th September 2007
         http://www.adhoc.com.au/Post_concussion_Syndrome.htm

King NS 1999, Early prediction of persisting post-concussion symptoms
         following mild and moderate head injuries, British Journal of
Clinical         Psychology, vol 38, pp15-23

Motor Accidents Authority. 2006. Adults with Mild Traumatic Brain Injury.
Guidelines for the NSW CTP Scheme.
Motor Accidents Authority. 2006. Children with Mild Traumatic
  Brain Injury. Guidelines for the NSW CTP Scheme.

Ponsford J, Willmott, C, Rothwell A, Cameron P, Kelly AM, Nelms
  R, Curran C, Ng K 2000, Factors influencing outcome following
  mild traumatic brain injury in adults, Journal of the International
  Neuropsychological Society, vol 6, pp568-579.

Ponsford J, Willmott C, Rothwell A, Cameron P, Kelly AM, Nelms
  R, Curran C 2002, Impact of early intervention on outcome
  following mild head injury in adults, Journal of Neurology,
  Neurosurgery Psychiatry, vol 73, pp330-332.

Ponsford J, Cameron Facem P, Willmott C, Rothwell A, Kelly AM,
  Nelms R, Ng K 2004, Use of the Westmead PTA scale to
  monitor recovery of memory after mild head injury, Brain Injury
  vol 18(6), pp603-614.

Ruff R 2005, Two decades of advances in understanding of mild
        traumatic brain injury, Journal of Head Trauma
  Rehabilitation, vol    20 (1), pp5-18.
Thank you.

								
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