Day 4 - Agitation, Concussion & Fatigue

Question 1

List 4 components of Agitation.

Answer 1

1. Aggression مشاعر الغضب أو الكراهية التي تؤدي إلى سلوك عدائي أو عنيف
2. Akathisia الأرق الحركي
3. Disinhibition عدم القدرة على منع السلوك غير اللائق
4. Emotional lability تغييرات مبالغ فيها في المزاج

Question 2

First-Line Interventions for Posttraumatic Agitation 🔑🔑

Answer 2

Environmental Management of Posttraumatic Agitation:

Reduce the level of stimulation in the environment

• Remove noxious stimuli if possible
• Reduction of lines/direct restraints
• Scheduled toileting program
• Place patient in quiet, private room
• Limit unnecessary sounds and visitors

Protect patient from harming self or others

• Place patient in a floor bed with padded side panels (Craig bed).
• Assign 1:1 or 1:2 sitter to observe patient and ensure safety

Reduce patient’s cognitive confusion

• One person speaking to patient at a time
• Minimize contact with unfamiliar staff

Tolerate restlessness when possible

• Allow patient to pace around unit with 1:1 supervision.
• Allow confused patient to be verbally inappropriate

Question 3

What pharmacological interventions are recommended for the management of severe aggression and agitation following an ABI? 🔑🔑

Answer 3

1. Intramuscular benzodiazepines
   
   • lorazepam (Ativan)
   • Midazolam
2. Oral atypical antipsychotic medication
   
   • Quetiapine (Seroquel)
   • Risperidone (Risperdal)

Question 4

What medications can be used to treat non life-threatening aggression? 🔑🔑

Answer 4

1. Propranolol (420-520mg/day)
2. Anticonvulsants: Carbamazepine, Valproic acid

Question 5

What medications are recommended for the management of agitation in persons with impaired arousal or attention?

Answer 5

Methylphenidate.

Amantadine.

Question 6

List 4 Types of restrains

Answer 6

Chemical

• Beta blocker
• Antidepressents
• Anticonvulsant

Physical

• Bed rails
• Feeding tray
• Chest strap or jacket restrains
• Seat belt
• Ankle wrist restrains

Question 7

List 4 possible differential diagnosis for agitations 🔑🔑

Answer 7

1. Drug withdrawal
2. Delirium tremens (DTs)
3. Infection
4. Pain
5. Hypoxia
6. Seizure disorder

Question 8

List 4 manifestations of mild TBI based on American Congress of Rehabilitation 🔑🔑

Answer 8

1. Any loss of consciousness (LOC)
2. Any alteration in mental status at the time of the accident
3. Any loss of memory for events immediately before or after the injury
4. Focal neurologic deficits that may or may not be transient

Question 9

List the severity criteria for mild TBI 🔑🔑

Answer 9

1. LOC ≤ 30 minutes
2. PTA ≤ 24 hours
3. Initial GCS ≥ 13

Question 10

List 8 sign and symptoms mild TBI

Answer 10

1. Headache (most common)
2. Attention and concentration deficits
3. Slowed mental processing
4. Memory impairment
5. Dizziness
6. Tinnitus
7. Impaired balance
8. Hearing loss
9. Blurred vision
10. Altered taste and smell
11. Sleep disturbances/insomnia
12. Fatigue
13. Sensory impairments
14. Lability
15. IrritabilityDepression
16. Anxiety

Question 11

What is Second Impact Syndrome? Why it’s important? 🔑

Answer 11

Morbidity and mortality rates close to 100% and 50% respectively.

Results from a person (usually an athlete) sustaining a second brain injury (that may be minor inseverity) before symptoms of a prior concussion have cleared.

Immediately following the second head injury, patients become dazed, and within 15 seconds to several minutes can rapidly decompensate—collapse, pupil dilation, loss of eye tracking, respiratory failure, semicomatose state.

Question 12

Criteria for post concussion syndrome (PCS) includes

Answer 12

1. History of head trauma with loss of consciousness preceding symptom onset by a maximum of four weeks.
2. There must be symptoms in at least three or more of the following categories:
   
   • Headaches
   • Noise intolerance
   • Dizziness
   • Malaise
   • Fatigue
   • Light intolerance
   • Irritability
   • Anxiety
   • Depression
   • Emotional lability
   • Subjective concentration, memory, or intellectual difficulties without neuropsychological evidence of impairment
   • Reduced alcohol tolerance

Question 13

List the 4 domains of concussion.
When to say this patient is case of concussion? 🔑

Answer 13

1. Somatic (headache, dizziness, visual disturbances, nausea)
2. Cognitive (confusion, LOC, inability to concentrate, and memory problems)
3. Affective (emotional lability, anxiety, sadness, and irritability)
4. Sleep changes (insomnia, or sleeping more or less than usual)

Question 14

Return-to-play (RTP) criteria

Answer 14

1. No RTP on the day of a concussive injury regardless of the severity.
2. Physical and cognitive rest until the acute symptoms resolve (usually 24–48 hours).
3. Athlete can only proceed to the next level if asymptomatic at the current level.
4. At least 1 week to proceed through the full rehabilitation protocol. Each step should take at least 24 hours.
5. If any post concussion symptoms occur, the athlete is to drop back to the previous asymptomatic level and try to progress again after another 24-hour period of rest has passed!

Question 15

Common signs and symptoms of depression following an Acquired Brain Injury.

Answer 15

1. Feeling low, sad, or hopeless consistently over at least two weeks.
2. Disinterest in pleasurable activities, or activities that were previously enjoyed.
3. Feelings or worthlessness, excessive guilt, and failure.
4. Disturbances in sleep or appetite.
5. Social withdrawal.
6. Lethargy.
7. Thoughts of death or suicide.
8. Difficulty concentrating.

ERABI Model 5

Question 16

List 2 assessment tools help in diagnosis for mood and behavioral disorders following an ABI?

Answer 16

1. Patient Health Questionnaire
2. Hospital Anxiety and Depression Scale
3. Agitated Behavior Scale

Question 17

Pharmacological treatments which have been shown to be effective in the treatment of depression specifically in those with an ABI.

Answer 17

1. Methylphenidate (Stimulant)
2. Sertraline (SSRI)

Question 18

What pharmacological interventions are recommended for the treatment of anxiety following an ABI?

Answer 18

SSRIs, are the only pharmacological intervention recommended for the treatment of anxiety following an ABI.

Question 19

List 2 pharmacological interventions for learning and memory deficits? What are their recommended daily dosages?

Answer 19

1. Donepezil, recommended 5-10 mg/day
2. Rivastigmine, recommended starting dosage of 1.5 mg/day, increasing by 1.5 mg until maintenance at 3-6 mg/day.

Question 20

What screening tools can you use to further examine the extent PTA?

Answer 20

1. Galveston Orientation and Amnesia Test (GOAT)
2. Orientation Log (O-Log)