Management of Aquired/Traumatic Brain Injury

Question 1

Glasgow Coma Scale Scores

Answer 1

> 13-15: mild
9-12: moderate
3-8: severe

Question 2

Mayo classification of TBI

Answer 2

> Moderate-Severe TBI (death due to TBI, loss of consciousness of 30<, post-traumatic amnesia of 24h<, GCS <13 in first 24h)
Probable Mild TBI (loss of consciousness is momentary to 30min and PTA does not extend beyond 24h)
Possible TBI (blurred vision, confusion, dazed, dizziness, focal neurological symptoms, headache or nausea)

Question 3

Acute stage (severe) of TBI intervention

Answer 3

• may require ventilation and life support
• May require neurosurgical intervention (e.g. evacuation of haematoma)

Question 4

Acute stage (mild) TBI intervention

Answer 4

• may not require hospital admission
• analgesia and anxiolytics may be helpful

Question 5

What is post traumatic amnesia (PTA)?

Answer 5

Amnestic gap from moment of injury to time of resumption of normal continuous memory (minutes to weeks)

! May occur delyed or as false memories

! does not require loss of consciousness

Question 6

PTA return to work stats (expalins 25-50% of outcome)

Answer 6

<1hr: return to work within 1 month
<1 day: return to work within 2 months
<1 week: return to work within 4 months
>1 week: 1 year off work
>2 weeks: almost inevitable residual cognitive problems

Question 7

Retrograde Amnesia

Answer 7

Time between moment of injury and last clear memory before the injury (much shorter than PTA)

Question 8

Anterograde Amnesia

Answer 8

Deficits in forming new memory after injury
! often last function to return

Question 9

Head injury - Good Indicators of severity

Answer 9

• Depth of unconsciousness
• Duration of LOC
• Duration of PTA
• Evidence of delirium immdiately after injury
• Neurological symptoms and signs
• Skull fracture or other abnormalities on imaging
• Blood in CSF

Question 10

Suicide risk + risk factors in TBI

Answer 10

3-4x more common

Factors: Alcohol, Other substance misuse, shared risk factors between TBI and suicide

Question 11

Postconcussional syndrome

Answer 11

> 50% better at 2 months
90% better at 12 months

Aetiology:
- premorbid personality
-emotional factors
- possible subtle damage (e.g to white matter tracts)
- Compensation/litigation

Question 12

Frontal Lobe Syndrome

Answer 12

• Disinhibition
• Impulsivity
• Aggression
• Emotional changes: lability, blunting, euphoria
• Rigidity and stubbornness
• Dysexecutive problems (issues with planning and problem-solving
• Lack of empathy
• (Apathy)

Question 13

Pharmacological Interventions in TBI - principles

Answer 13

• Start with low doses/ beware of overmedication
• Titrate cautiously
• Monitor for adverse effects - may be unpredictable
• sedating drugs may compromise cogntive/physical gains over time
• wean down meds with improvement
• liaise with other services post-discharge
• try to avoid lengthy repeat prescriptions in community if possible

Question 14

Pharmacological interventions early (3 months post injury):

Answer 14

Agitation reduction: Propranolol (Good), Amantadine, Valproate, Carbamazepine, antipsychotics (some evidence)

Question 15

Which pharmaceuticals to avoid after TBI

Answer 15

benzodiazepines, opiates, psychostimulants, phenytoin

Question 16

Long term pharmacological intervention of agitation in TBI:

Answer 16

Anticonvulsants: Carbamazepine & Valproate

Question 17

Psychological Intervention in TBI

Answer 17

• Neuropsychological assessment
• CBT
• cogntive training
• relaxation techniques
• Mindfulness
• Anger management
• Social skills training

Question 18

How many BI survivors does Apathy affect?

Answer 18

10%

Question 19

Pharmacological intervention of Apathy in TBI

Answer 19

• Dopamine agonist (Amantadine)
• Psychostimulants in cogntive apathy (Methylphenidate)
• Antidepressants

!beware of histoy of substance misuse