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Mild traumatic brain injury and PTA testing
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.
"Mild traumatic brain injury and PTA testing"