Clinical Practice Guidelines for Managing Minimal Responsiveness after Blast-related Injury

Transcription

1 Clinical Practice Guidelines for Managing Minimal Responsiveness after Blast-related Injury The Polytrauma Experience Linda M. Picon, MCD, CCC Speech-Language Pathologist James A. Haley Veterans Hospital Polytrauma Rehabilitation Center Tampa, Florida ASHA Short Course Miami Beach, Florida 11/18/06

2 OEF/OIF Combat Injured Military Service members sustaining multiple and severe injuries as a result of explosions and blasts from improvised explosive devices (IEDs), landmines and fragments account for 65% of all combat injuries. Of these, 60% have some degree of traumatic brain injury (TBI). VHA Handbook Polytrauma Rehabilitation OIF/OEF patients treated at VA Polytrauma Centers 85.5% have a diagnosis of TBI 54% are severe enough to result in an altered state of consciousness. 31% remain in an altered state of consciousness for over 30 days.

3 The Minimally Responsive Patient Definition Distinguishing Between Altered States of Consciousness Scope of Evaluation and Treatment Challenges Cognitive Communication Issues Guidelines for Assessing Cognitive-Communication Communication Interpreting Patient Responses Cognitive Stimulation Programs Measuring the Response Emerging into Consciousness

4 The Low Level Patient - Definition Rancho Los Amigos Levels II and III Swallowing Unable to swallow anything safely by mouth; all nutrition hydration received through non-oral oral means Communication Unable to communicate wants/needs Cognition Unresponsive to all/most stimuli

5 Distinguishing Between Altered States of Consciousness COMA A state of unarousable neurobehavioral responsiveness

6 Distinguishing Between Altered States of Consciousness Clinical Criteria Unresponsive follows no commands Eyes closed - No sleep/wake cycle No volitional behavior present Typically seen for evaluation and monitoring only Not a candidate for a full rehabilitation program Recreational stimulation Tone/posture management

7 Distinguishing Between Altered States of Consciousness VEGETATITVE STATE A state of arousal without behavioral evidence of awareness of self or capacity to interact with the environment

8 Distinguishing Between Altered States of Consciousness Clinical Criteria Eyes open - Sleep/wake cycle present Follows no commands no language comprehension or expression Limited/no interaction with environment No sustained or reproducible purposeful or voluntary response to stimuli Vocalizations (not verbalizations) may be present Variably preserved cranial and spinal reflexes Preserved autonomic functions to permit survival

9 Distinguishing Between Altered States of Consciousness Minimally Conscious State A condition in which minimal but definite evidence of self or environmental awareness is demonstrated

10 Distinguishing Between Altered States of Consciousness Clinical Criteria - One or more must be present Follows simple commands Some Y/N regardless of accuracy (gestural or verbal) Responsive and intelligible verbalizations Purposeful behavior Movements occur in contingent relation to relevant stimuli (not reflexive) Appropriate smile or cry Reaching for or holding objects

11 Transitional vs. Persistent Proposed Timeline TRAUMATIC Brain Injury Generally considered to be in a transitional or persistent state up to 6 months after injury ANOXIC Brain Injury Generally considered to be in a transitional or persistent state up to 3 months after injury

12 SLP Scope of Evaluation and Treatment of the Low Level Patient Swallowing Present / Absent Stimulating Communication Response mechanism (s) Providing means and environment Cognition Cognition Alertness and awareness Responsiveness Providing appropriate conditions

13 General Aspects of the Clinical Assessment Level of alertness and awareness Communication skills responsiveness Determine state of altered consciousness Determine treatment plan based on: Current state Time post-onset onset and clinical evidence of progress Individual needs

14 Cognitive-Communication Communication Diagnosis Clinical observation and interpretation Spontaneous movements Reflexive movements Responsive movements What response mechanisms are available to the patient? What triggers a specific response? Consistency Reliability

15 Cognitive Communication Diagnosis Formal Evaluation Disorders of Consciousness Scale (DOCS) Western Neurosensory Stimulation Profile Rappaport Coma / Near Coma Scale Clinical Observation General stimulation Multi-modal stimulation

16 General Guidelines for Assessment and Treatment Monitor testing environment distraction-free Establish testing readiness maximum arousal level Establish baseline response through observation without stimulation ion Account for changes in attention span, level of fatigue, distractions, tions, time of day, illness, sedating medications Investigate varied responses using broad range of stimuli Develop balance between stimulating, observing and scoring Beware of sub cortical vs. cortical responses Use serial re-assessments and observation to confirm validity Observe, observe, observe Family, caregivers, staff Under different conditions and circumstances

17 Clinical Challenges Travel/transfers negatively impact initial evaluations Paresis/paralysis, SCI, musculoskeletal injuries, wounds, burns, amputations Tracheostomies (PMV, Red Caps) long term Medications and Surgeries higher incidence Sleep/wake disruptions, fatigue Timing nursing care and other therapies Environmental distractors, space issues Infection control, Acinetobacter (The Iraqi bug) Sensory changes (vision/eye enucleations, hearing/deafness, smell/trach) Separating communication from cognition

18 Sensory Stimulation Programs Administration of stimulation Structured monitoring of responses 3 to 7 days a week Informal stimulation and management occurs 24/7 Stimuli Commercially available programs Homemade sensory stimulation kits Portions of formal tests

19 Sensory Stimulation Programs Auditory Sounds Command responsivity Visual Threat Tracking Olfactory and Taste Variety Familiarity Tactile Pain Textures and temperature Vocalization

20 Swallowing Stimulation and Evaluation Management Observation vs. Testing (are reflexive swallows present?) Limited clinical bedside evaluation Inappropriate for instrumental testing Management Trach management Passy Muir Valve or Red Cap Passive stimulation of the oral mechanism Pre-feeding stimulation Risks vs. benefits of feeding and testing feeding during minimal responsiveness

21 General Measuring the Response None Minimal Partial Complete Specific No responsivity Inconsistent responsivity to one sensory modality Inconsistent responsivity to 2 or 3 modalities Consistent response to 2 modalities, inconsistent or partial response to commands Consistent response to at least 3 modalities and consistent response to commands

22 Interpreting Patient Responses Reliability and Consistency Score and maintain lists of patient behaviors From clinical observations From family/caregivers Family Education and involvement Differentiating real vs. wishful responses Differentiating real vs. cued responses

23 Emerging into Consciousness Conscious State The person adaptively responds to ongoing sensory input in a purposeful and voluntary manner that is not reflexive, stereotypical or automatic

24 Emerging into Consciousness Clinical Criteria Reliable and consistent demonstration of at least one of the following: Functional interactive communication Six of six situational orientation questions via any modality Functional use of at least 2 objects over two consecutive evaluations Clearly discernible behavioral manifestation of sense of self

25 Cognitive Stimulation Structured administration of operationally defined questions or prompts based on the patient s s level of functioning and ability Sensory functions can the patient see? Cognitive-communicative functions can the patient follow commands and express wants/needs? Physical functions can the patient manipulate objects? Pharmacological Management E.G. Ritalin and/or Bromocriptine data are collected to determine the effects of medication on specific responses and response accuracy rate.

26 Cognitive Stimulation Program for Emergence from MCS Stimulation is based on specific responses the individual favors and are expanded based on additional responses elicited Targets specific cognitive processes rather than sensory connections Establishes specific and voluntary links between stimulation and appropriate response

27 Emerging into Consciousness Response Criteria Consistency Accuracy Timing (minimal to no delay) Response Parameters Presence of functional, interactive communication Generally appropriate object use Ability to follow simple commands via any modality Awareness of, and specific and discernible interaction with the environment

28 Program Development Insufficient data to establish definite guidelines for program development How do we establish criteria for admission, length of stay and discharge disposition? Concensus statements 3 months ANOXIC injuries 6 months TRAUMATIC injuries Who stays in VS or MCS and who emerges? Do we know what happens after 12 months, 2 years? Careful and reliable assessment and diagnosis will help predict prognosis

29 Planning for Positive Outcomes Maintain accurate and objective data Document behaviors, state of consciousness, criteria for the next level of consciousness and prognosis Establish a treatment plan and time frame, and check your work/outcomes regularly CLINICAL PATHWAYS Monitor regularly for progress and update plan/goals as necessary CHANGE in LEVEL or PRIORITIES Work diligently to move the patient towards the next level of care, close to home Educate and involve families every step of the way.

30 Thank You Questions?