Outpatient management of chronic severe TBI in children

Transcription

1 Outpatient management of chronic severe TBI in children Nathan K. Evanson, MD PhD Assistant Professor of Pediatrics Division of Pediatric Rehabilitation Medicine

2 Disclosures Research funding from NIH No other disclosures

3 Objectives To identify epidemiology, outcomes, and significant management issues in children with chronic TBI. To understand evidence behind current recommendations for pharmacotherapy and other therapy modalities in TBI. To identify some of the challenges and opportunities in the future of TBI intervention research.

4 Overview Focus on TBI Other injuries have similar management Focus on children Focus on chronic issues Main issues (not comprehensive) Not focused on scientific frontiers Not focused on technical details

5 Epidemiology 1.7 million TBIs occur annually Children ,174 35, ,947

6 Epidemiology by Age Per 100,000 1,400 1,200 1, Children, older adolescents, and adults ages 65 years and older are more likely to sustain a TBI Age Group ED Visits Hospitalizations Deaths

7 Cause of TBI Per 100,000 1, Falls Falls are the leading cause of TBI. Rates are highest among ages 0 to 4 and ages 75 and older. Struck By / Against Motor Vehicle Assault Age Group

8 Phases of TBI care Field/EMS ED Initial stabilization ICU, surgery, etc. Step-down care Inpatient rehabilitation Outpatient rehabilitation Acute Subacute Chronic

9 Treatment issues in chronic TBI Disorders of consciousness Motor deficits Sensory deficits Cognitive deficits Psychiatric/behavioral issues Some medical complications Community re-entry

10 Disorders of consciousness Coma Unconscious, unresponsive Acute to subacute stage Persistent vegetative state Unconscious, unresponsive Sleep-wake cycles Minimally conscious state Command following

11 Disorders of consciousness Pharmacology Limited evidence overall More often used in subacute times Amantadine most studied Other dopamine: pramipexole, bromocriptine, levodopa, methylphenidate Zolpidem (but may cause increased sleepiness) All of these are off-label for consciousness

12 Disorders of consciousness Non-pharmacological methods None well studied in children (or adults) Sensory stimulation Electric stimulation (peripheral, transcranial, deep brain) Hyperbaric oxygen Stem cells

13 Motor Deficits Tone/spasticity Velocity-dependent Usually increased Dystonia Involuntary Repetitive movements or altered posture May be painful More common with anoxic injury, kernicterus

14 Motor Deficits Spasticity Management Therapy, stretching, bracing Medications GABA: baclofen, benzodiazepines Muscle: dantrium Alpha agonists: clonidine, tizanidine

15 Motor Deficits Spasticity Management (continued) Injections Botulinum toxin Phenol Intrathecal (baclofen pump) Surgical Selective Dorsal Rhizotomy

16 Motor Deficits Dystonia Involuntary sustained or intermittent muscle contractions Twitching/repetitive, abnormal postures Medications Carbiodopa/levodopa Bromocriptine Injections Botox (if focal)

17 Sensory Deficits Olfactory dysfunction common (13-68% incidence reported) Microsmia vs. anosmia Courtesy Ignacio Icke via wikimedia commons. Used under creative commons attribution license 2.5

18 Olfactory dysfunction Social and safety implications Gas burner/fire hazard Perfume/cologne/body odor All cookies kind of taste the same Recovers over months Poor prognosis overall for anosmia (<15%?) Probably better for microsmia No evidence-based treatments

19 Sensory Deficits Hearing impairment Usually temporal fracture Sensorineural vs conductive. Usually unilateral Audiology assessment Hearing aids Deafness uncommon Chittka L, Brockmann A. Perception Space The Final Frontier, PLoS Biology Vol. 3, No. 4, e137 doi: /journal.pbio (Fig. 1A)

20 Sensory Deficits Vision Distributed

21 Sensory Deficits Focal visual injury Globe injury Optic nerve/chiasm Optic radiations Oculomotor deficits Double vision Tracking difficulties Cortical visual impairment /Wiley_Human_Visual_System.gif

22 Sensory Deficits Treatment Ophthalmology Optometry Neuro-optometry/neuro-ophthalmology Corrective lenses, prism lenses Visual rehabilitation for cortical vision loss

23 Sensory deficits Vestibular dysfunction Vertigo Oculomotor insufficiency Balance issues Postural instability Treatment Drugs not a permanent fix Vestibular therapy (PT) Pfeiffer 2014:

24 Cognitive Deficits Younger age (often) leads to more cognitive impairment than later childhood Higher level processing difficult to assess until later Executive function, attentional deficits common Motor recovery occurs earlier than cognitive recovery

25 Cognitive Deficits Memory Working/Short term/long term Amnesia (not like the movies though) Severe injury more memory problems Treatment Speech therapy/ot Memory cues/compensation Working memory training? (limited evidence)

26 Cognitive Deficits Communication Aphasia (receptive vs expressive) Oral motor deficits Memory or other issues Treatment Speech therapy Exact approach depending on deficit

27 Cognitive Deficits Executive Function Planning Setting goals Breaking up complex tasks Treatment Compensatory strategies, help Cognitive therapy Working memory training (limited evidence)

28 Cognitive/Behavioral Deficits Social Function Difficulty interpreting social cues Difficulty reading facial cues Deficits in abstract thinking Less developmentally mature social problemsolving strategies Treatment therapy based Cognitive behavioral therapy Neuropsychotherapy (emerging evidence)

29 Behavioral Deficits Impulsivity, personality changes, depression, frustration, aggression Pre-injury behavior post-injury behavior Family burden increased Behavioral management Structure, routine Behavioral medicine May need medicine medicine (psychiatry)

30 Sleep Disorders Common after TBI Decreased sleep efficiency Sleep onset, night-time awakening Contributes to depression, behavior, other Poor evidence for medications Melatonin? (also slim evidence) Cognitive behavioral (some evidence) Bright (blue) light therapy (some evidence)

31 Psychiatric Disorders New psychiatric disorders after TBI True after all severities, severe is worse ADHD most common Also more likely to have TBI Depression 2 nd Often improves over first year Overall incidence ~50-80% in severe TBI

32 ADHD ~ 20% pre-injury ~ 40-50% + new onset post-injury Behavioral interventions Medications (similar to regular ADHD) Several trials for methylphenidate Behavioral medicine + meds?

33 Medical Conditions Neuroendocrine Posterior Pituitary Vasopressin Diabetes Insipidus Not enough AVP DDAVP SIADH Too much AVP Fluid restriction

34 Medical Conditions Neuroendocrine Anterior Pituitary GH Thyroid ACTH FSH/LH Screen 3, 6-12 months Endocrine referral

35 Medical Conditions Dysphagia Impaired swallowing Interferes with nutrition More common with worse injury Assess with swallow study Barium swallow or FEES Treatment Speech therapy +/- G-tube r/article/view/1071/1285

36 Medical Conditions Neurogenic Bowel/Bladder Urinary incontinence Toilet in advance of need. Constipation Can be BIG deal Diet (fiber, vegetables, water) Medications Suppository, enema if needed

37 Community Re-entry Therapeutic recreation School re-entry School intervention specialist Vocational rehabilitation In conjunction with other therapy BVR can help Project SEARCH

38 CCHMC BRAIN clinic Brain Recovery After Injury Pediatric Rehabilitation Medicine division Multi-disciplinary clinic PM&R, neurology, neuropsychology School intervention, social work Nursing, MA Long-term care of moderate-severe injury

39 BRAIN clinic Medical care of multiple issues Neuropsychology Evaluation, treatment

40 BRAIN Clinic School intervention Primarily with inpatients Expanding coverage School meetings, IEPs, etc. Social work Utilizing community resources Interfacing with programs etc.

41 BRAIN clinic Nursing p/physical-medicine-rehab/brain-injuryprogram/ (Just Google CCHMC brain injury)

42 Questions?