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Brain injury - post acute care issues
OVERVIEW: Post acute severely brain injured patients with complex injuries, prolonged coma, initial GCS<9 who may have limited responses to environment, are often inconsistently able to communicate their needs and manage personal affairs, and frequently have motor deficits. These patients may reside in a long term care facility or at home with attendant care. Less severely injured individuals may have more evident cognitive and behavioral problems and less physical issues. Management issues include:
• Changes in level of attention, arousal, cognition and behavior
• Neurogenic bladder and bowel
• Contractures and spasticity
• Heterotopic ossification
• Skin
• Respiratory
• Endocrine
System(s) affected: Nervous, Pulmonary, Skin/Exocrine, Endocrine/Metabolic, Musculoskeletal, Renal/Urologic, Reproductive
Genetics: N/A
Incidence/Prevalence in USA: Brain injury traumatic - 200/100,000; 500,000 hospitalizations and 75,000 deaths per year
Predominant age: Young adults
Predominant sex: Male > Female
SIGNS AND SYMPTOMS: • Neurological
• Diminished arousal leads to limited responses and may be generalized (eg, decorticate posturing or focal such as eye blink or one limb voluntary movement)
• Cognitive impairment
• Disinhibited responses and behavior
• Impaired memory
• Anosognosia (poor self-awareness)
• Focal motor deficits, eg, hemiparesis
• Cerebellar signs - ataxia, nystagmus, dysmetria, dysdiadochokinesis
• Cranial nerve palsies
• Hydrocephalus-triad of worse cognition, ataxia, incontinence
• Epilepsy - partial or generalized signs
• Urinary frequency and incontinence
• Bowel incontinence
• Spasticity
• Heterotopic ossification - erythema, pain or stiffness in soft tissue around joint
• Decubitus ulcers
• Decreased respiratory strength or poor cough
• Endocrine
CAUSES: MVA, assaults, sports injuries, falls
RISK FACTORS: See Brain injury, traumatic
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: A number of complications can create a change in functional level.
• Chronic infection (e.g., UTI)
• Depression
• Hypothyroidism, other endocrinopathy
• Hydrocephalus, hematoma
• Epilepsy
• Fractures
• Tracheal stricture
LABORATORY: • CBC, electrolytes, BUN, creatinine, calcium, albumin, vitamin B12, folate, TSH, alkaline phosphatase, AST, ALT, morning cortisol level, urine culture
• Culture, ova and parasites for diarrhea
• Skin culture
• Culture tracheal site
• Endocrine workup as indicated
Drugs that may alter lab results: Phenytoin (Dilantin), valproic acid
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS: • Hydrocephalus with periventricular edema
• Joint contractures results in collagen cross linking: decreased range of motion
• Heterotopic ossification: disorganized osteoid calcification in soft tissue
SPECIAL TESTS: • Evoked potentials (auditory, visual and somatosensory)
• Behavioral assessment, neuropsychological testing and vocational assessment in the less severe
• Cognitive testing for orientation and arousal use Western Neuro Sensory Stimulation Profile (WNSS) or Galveston Orientation Amnesia Test (GOAT)
• EEG
IMAGING: • Bone scan: heterotopic ossification
• CT: hydrocephalus, atrophy, hematoma
• Video pharyngeal fluoroscopic swallowing study
• MRI to evaluate diffuse axonal injury
DIAGNOSTIC PROCEDURES: • Altered arousal - visual, auditory and somatosensory evoked potentials
• Neurogenic bladder- check post void residuals 3-4 times. If > 50 cc or 20% of voided volume, urodynamics
• Ultrasound of bladder and kidney: urolithiasis and hydronephrosis
• Endoscopy: cause of dysphagia
• Contractures and spasticity: examination under anesthesia
• Respiratory and neurologic: sleep/oxygen saturation study, bronchoscopy for stricture
TREATMENT APPROPRIATE HEALTH CARE: Outpatient; occasional inpatient care
GENERAL MEASURES: • Diminished level of arousal: identify best modality for communication, assess functional skills (proper seating, hand function), behavioral or neuropsychologist. Respiratory therapist (for those with tracheostomy ), social work (to assist with family education and long term planning) and nursing
• Reduce sedatives
• Neurogenic bladder - treat UTI
• If post void residual < 50 cc then trial of regular voiding routine q2hr
• If still incontinent add oxybutynin
• If still incontinent try condom catheter during the day; incontinent pads at night.
• If raised post void residuals or high pressure bladder or dyssynergic bladder on urodynamics then intermittent catheter q4-6h
• Neurogenic bowel - regular bowel routine
• Contractures and spasticity: stretching
• If no progress after 4 weeks consider serial casting or custom made orthotic
• Contractures > 45° consider tendon release
• Heterotopic ossification: stretch soft tissue to decrease maturation of osteoid, consider orthotics/splinting. Bone scan at baseline.
• Skin: q2hr turning, avoid seating in position of high shear on buttocks such as in bed at 45 degrees, observe for erythema around tube sites and rule out latex allergy
• Respiratory: night humidification if has a tracheotomy, may require suctioning
• Endocrine- monitor fluid balance
• Dental - assessment and dental x-rays
SURGICAL MEASURES: • Tendons releases; fundoplasty or gastrostomy; tracheostomy; ventriculoperitoneal or ventriculoatrial shunt
ACTIVITY: • As tolerated - outings in wheelchair can be beneficial - skin very sensitive to sun/wind - protect with clothing/golf umbrella clipped to chair
• Age appropriate activities related to premorbid interests yield best attention
DIET: • Consult with dietitian
• Ensure adequate hydration; 2-2.5 L of water/day. More if outside or in hot weather.
• Bolus feeds preferred if fed by gastrostomy
• Upright and quiet activity for half an hour following feeds as aspiration can occur even with a g-tube
PATIENT EDUCATION: • For information and family support groups: http://www.tbinet.org/ or http://www.biausa.org/
• Families need support, advocacy, education, information - verbally and written (audio tape meetings), opportunities to have input regarding priorities, treatment plans and discuss limits of treatment for patient (advance directive)
MEDICATIONS DRUG(S) OF CHOICE: Individualize pharmacotherapy
• Diminished arousal: Consider one of desipramine or amitriptyline 75-150 mg hs, methylphenidate (Ritalin) 20-40 mg/day in 2 divided doses, amantadine 50-200 mg bid, dextroamphetamine, bromocriptine, levodopa
• Agitation: treat epilepsy or depression otherwise, amitriptyline 75-150 mg hs, carbamazepine, valproic acid, lithium, propranolol, serotonin specific re-uptake inhibitor. Minimize use of haloperidol, antipsychotics and benzodiazepines as they worsen cognition. If necessary use antipsychotic with least cognitive side effects, eg, risperidone (Risperdal) or olanzapine (Zyprexa)
• Abulia and lack of initiation: amantadine, bromocriptine, methylphenidate, levodopa
• Epilepsy: if possible avoid phenytoin and phenobarbital - too sedating. Carbamazepine, valproic acid, gabapentin less sedating.
• Neurogenic bladder: oxybutynin 2.5 mg tid to 10 mg qid, if bladder pressures low and/or post void residuals low
• Bowel routine - stool softener such as docusate sodium (daily) combined with laxative (night before suppository), high fiber and suppository (every other day )to induce bowel movement
• Spasticity: all drugs may cause sedation; dantrolene 25-200 mg/day divided tid; or baclofen, benzodiazepines, clonidine. If focal spasticity consider botulinum toxin injection.
• Heterotopic ossification: indomethacin 25-50 mg tid. If severe, progressive or history of GI ulceration then etidronate (Didronel) 20 mg/kg for six months or alendronate 20 mg once a day.
Contraindications: Refer to manufacturer's literature
Precautions: Refer to manufacturer's literature
Significant possible interactions: Refer to manufacturer's literature
ALTERNATIVE DRUGS: N/A
FOLLOW UP PATIENT MONITORING: • Patients make slow steady gains. Ongoing outcome assessments to determine progress (or not) in abilities and medication efficacy needed. These measures do not need to be sophisticated, for example: length of time able to hold head up or ability to respond to commands written or verbal. Modify program periodically to reflect outcome measures.
• Review medical status monthly
PREVENTION/AVOIDANCE:
• Prevent further complications
POSSIBLE COMPLICATIONS: • Major affective disorder (depression, psychosis) in up to 50% of patients
• Family and caregiver burn out
• Substance abuse
• Social isolation
• May be a higher risk of dementia
• Latex allergy to g-tube, catheters
• Dental caries
• Osteoporosis
• Falls
• Aspiration pneumonia
• Pressure ulcers
• Heterotopic ossification
• Dysphagia, esophagitis
• Bladder incontinence
• Contractures/spasticity
EXPECTED COURSE AND PROGNOSIS: • Most rapid return of neurological function is during first two years but some patients continue to improve slowly for 5-10 years as long as complications are prevented or managed appropriately.
• Highly variable (80% of individuals with severe injuries become independent in dressing and self-care at 1 year
• Negative prognostic factors:
• Age > 40
• Abnormal pupillary responses
• Prolonged coma i.e., GCS < 9 seven days after injury
• Abnormal evoked potentials
• Extraocular eye movement abnormalities
MISCELLANEOUS ASSOCIATED CONDITIONS: • Psychosis
• Suicide attempts
• Substance abuse
• ADD
AGE-RELATED FACTORS:
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY: N/A
SYNONYMS: N/A
ICD-9-CM: 530.1 Esophagitis
750.6 Hiatus hernia
787.1 Heartburn
733.0 Osteoporosis
707.0 Decubitus ulcer
345.3 Grand mal status and status epilepticus
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Brain injury, traumatic
Seizure disorders
Sleep apnea, obstructive
Stomatitis
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