Traumatic Brain Injury Evaluation and Management of Soldiers

Traumatic Brain Injury Evaluation and Management of Soldiers Jason Hawley MD CPT MC USA Chief, Neurology CRDAMC Outline        Semantics of TBI Evaluation of the soldier with suspect TBI Breaking down the symptom complex of TBI Managing TBI TBI at Fort Hood Where this is going….. Questions What is TBI?     Injury to the brain..duh Concussive Blast Injuries Penatrating injuries Mild-Moderate-Severe? Severe TBI  “I know it when I see it” Prolonged loss of consciousness  Surgical debridment of brain tissue  “Coma for weeks.”  Marked MRI abnormalities***  Permenent and often dramatic impairments..although not always  Mild-Moderate TBI  What is “mild TBI” Post concussive syndrome?  PTSD?  Diffuse axonal injury  Persian Gulf War Syndrome?  Stress?  Mild TBI     There has to be a head injury—blast, MVA accident, fall are the common There has to be an alteration of consciousness—stunned, dazed, LOC Imaging is typically normal The persistent triad of symptoms    Headaches Cogntive problems Mood problems. Evaluating the Soldier with suspected TBI       Define the injury and event…when, where, how. Relationship of the headache to the injury Relationship of the cognitive problems to the injury Past history of head injury—Troy Aikman syndrome The symptoms since the head injury…specifically the headaches Associated dizziness, nausea, and vomitting. PTSD and TBI     PTSD is an anxiety disorder TBI is a well defined injury recognized in the civilian literature Soldier’s with mild TBI at 2.7 times more likely to have symptoms suggestive of PTSD Mood symptoms are very common in soldiers with TBI Irratibility, sleep, depression, flash backs, nightmares  Validate those symptoms  Take a step back…what is the problem they are complaining about      “what bothers you the most” The soldier with a TBI vs. the soldier with a TBI and PTSD. “If it looks like psych, then it is psych.” If the mood symptoms are mild, don’t call it PTSD. ***PTSD can cause all the cognitive Listen to what the soldier tells you**** Managing TBI Don’t be afraid of managing this…this is not hard, you won’t get in trouble, and it’s pretty easy. Keep in mind…      Overwelming majority of soldiers with mild TBI recovery over 6-12 months after the injury Very few soldiers (1-2% of those screened + for TBI) get medical boards for TBI Cognitive therapy is very limited Medications are of secondary value Most soldiers want to return to duty, and don’t want to be stigmatized. You have a mild TBI and you’re going to be ok.       Do that and you’ve treated most of the soldiers we’re worried about Establish a real diagnosis, tell it to the patient Explain what to expect, reassure them Document that, tell them you will Break down the symptom complex of cogntive symptoms—headache—mood symptoms. Address each individually. Cognitive Symptoms      In the absense of significant mood symtpoms, I am concerned about these soldiers most of all. Memory, focus, multi-tasking, concentration, attention. Memory impairment have become a significant impairment at work and home. Forgetting mission tasks, getting in trouble, “always writing things down.” Our work up—neuropsych testing, cognitive therapy, possible VA rehab Headaches     How debilitating are the headaches Helps the soldier potentially recognize the improvement A word about compliance Behavioral treatments, profiling—short term restrictions to speed recovery Profiling PT, 24 hour duty, etc  Give them 3-6 months  Headache—Medication management      I have come to the conclusion that this is low yield Preventative vs. Abortive What works—indocin, elavil, topamax, pheneragan What doesn’t—tryptans, inderal, narcotics Migraine features with headache (photophobia, dizziness, etc)…more likely to go with meds. Mood Symptoms     I need your help! Listen to what they tell you Don’t let the history of blast exposure (or the media) go against your better judgement. Use common sense. The mood symptoms of mild TBI are treated just as are the mood symptoms of PTSD. When the mood symptoms are present but not disabling    Validate the mood symptoms as part of mild TBI. Tell them they have a reason for feeling the way they do Most soldiers don’t want to see psych, or be given a psychiatric diagnosis. TBI at Fort Hood  Our population Most completed deployment  Most will do fine and will respond to validation, reassurance, and minor medications.  Most can be managed without profile restrictions or just mild temporary modifications to duty  Most >95% will be deployable within 12 months after the injury  I have not done an MEB on a soldier with a mild TBI who completed his deployment.  Soldier break down--my take on it     The soldier with mild to minimal TBI The soldier with TBI and dominating PTSD The soldier with mild-moderate TBI The soldier with severe TBI Resources at Fort Hood        Neurology—me Care Management Case Management Speech/cogntive therapy (Ms. Smith) R&R center TBI Team—multidisplinary team aimed at managing the most severe soldiers (roughly 30-40 soldiers). The other several thousand—you. Where this is going      TBI is the injury of this war. We in the military/VA system will be dealing with this for decades The screening process for TBI at Fort Hood The management of our impaired soldiers A final word on MEB’s. Questions?