PERSPECTIVE INJURY SEVERITY. REHABILITATION PHYSICIAN Team approach Functional implications Long term consequences

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1 MANAGEMENT OF INDIVIDUALS STATUS POST BRAIN INJURY: IMPACT ON LIFE CARE PLANNING Richard Bonfiglio, M.D. PERSPECTIVE REHABILITATION PHYSICIAN Team approach Functional implications Long term consequences EXPERIENCE Clinical Administrative Testimony Life care planning medical foundation life expectancy INJURY SEVERITY MILD MODERATE SEVERE MINIMALLY COUSCIOUS STATE PERSISTENT VEGETATIVE STATE 1

2 INCIDENCE MILD MODERATE SEVERE MINIMALLY CONSCIOUS STATE PERSISTENT VEGETATIVE STATE ETIOLOGIES MOTOR VEHICLE COLLISIONS ASSAULT/BLUNT TRAUMA GUNSHOT WOUNDS FALLS SPORTS RELATED ANOXIA ALCOHOL, ILLICIT SUBSTANCES 2

3 INJURY NATURE: TRIGGERING EVENTS BLEEDING Epidural Subdural Subarachnoid Intracerebral Intraventricular DIFFUSE AXONAL INJURY ANOXIA 3

4 PATHOPHYSIOLOGY OF INJURY: LACERATION Depressed skull fracture Projectile CONTUSION PATHOPHYSIOLOGY OF INJURY: ISCHEMIA/ANOXIA Vasospasm/hypoperfusion Blood loss/hypotension Impaired arousal mechanism BLEEDING 4

5 TBI CASCADE NEURONAL DEPOLARIZATION Increased vascular permeability Elevated intracranial pressure Ischemia TBI CASCADE EXCESS NEUROTRANSMITTERS Increased metabolic activity Opening of ion channels (influx of sodium, calcium & efflux of potassium) TBI CASCADE CEREBRAL EDEMA Impaired blood brain barrier Disturbed cellular osmoregulation 5

6 TBI CASCADE ISCHEMIA Hyperthermia Hypermetabolism TBI CASCADE INCREASED INTRACRANIAL PRESSURE Hypoxia/ischemia Cerebral edema Hypercapnia Venous obstruction TBI CASCADE NEURONAL CELL MEMBRANE DAMAGE Release of free radicals Release of neurotransmitters Impaired mitochondrial energy production 6

7 PHASES OF RECOVERY: ASSESSMENT OF COMA GLASGOW COMA SCALE Motor response Verbal performance Eye opening MEASURING EXTENT OF INJURY: INITIAL COMA SEVERITY GLASGOW COMA SCALE </= 8 (FOR 6 HOURS) 9 11 SEVERE MODERATE >/=12 MILD MEASURING EXTENT OF INJURY: POST TRAUMATIC AMNESIA < 5 MINUTES VERY MILD 5 60 MINUTES MILD 1 24 HOURS MODERATE 1 7 DAYS SEVERE 1 4 WEEKS VERY SEVERE > 4 WEEKS EXTREMELY SEVERE 7

8 MEASURING EXTENT OF INJURY: TESTING ABNORMALITIES MRI CT SCAN EEG AUDITORY, VISUAL, SOMATOSENSOARY EVOKED RESPONSE TESTING PET SCAN FUNCTIONAL MRI SPECT SCAN MEASURING EXTENT OF INJURY: PERSONALITY & BEHAVIORAL ASSESSMENT: NEUROPSYCHOLOGICAL TESTING MMPI NEUROBEHAVIOR RATING SCALE MEASURING EXTENT OF INJURY: PHYSCIAL EXAMINATION DISTRIBUTION & EXTENT OF DEFICITS Physical Motor Sensory Reflexes Cognitive Attention & concentration Orientation Memory Problem solving Interpersonal interactions 8

9 MEASURING EXTENT OF INJURY: SOCIAL ADJUSTMENT KATZ ADJUSTMENT SCALE RELATIVES FORM SOCIAL ADJUSTMENT SCALE SELF REPORT ACUTE MANAGEMENT CEREBRAL EDEMA MANAGEMENT Hyperventilation Intracranial pressure monitoring Dehydration Steroids Medication induced coma ACUTE MANAGEMENT: OPERATIVE CARE INTRACRANIAL PRESSURE MONITORING DECOMPRESSION AND EVACUATION SHUNTING FRACTURE STABILIZATION 9

10 ACUTE MANAGEMENT: ASSOCIATED TRAUMA SKULL FRACTURE LIMB FRACTURES SPINE FRACTURE/SPINAL CORD INJURY CHEST, ABDOMINAL, PELVIC INJURIES FUNCTIONAL RECOVERY: RANCHO SCALE: V confused, inappropr. I no response VI confused, appropr. II generalized response VII automatic, appropr. III localized response VIII purposeful, appropr. IV confused, agitated FUNCTIONAL RECOVERY DAILY VARIATIONS EMOTIONAL & PERSONALITY EFFECTS MEDICATION EFFECTS Effect OF OTHER MEDICAL CONDITIONS 10

11 POTENTIAL CONSEQUENCES ALL ORGAN SYSTEMS MAY BE INVOLVED TREMENDOUS VARIABILITY BETWEEN INDIVIDUALS WITH REGARDS TO DEFICITS & COMPLICATIONS RATE OF RECOVERY EXTREMELY VARIABLE MARKED CHANGE IN PHYSIOLOGY POSSIBLE MANY POTENTIAL SECONDARY COMPLICATIONS POTENTIAL CONSEQUENCES NEUROLOGICAL AROUSAL ORIENTATION & PERCEPTION INITIATION & TASK COMPLETION PROBLEM SOLVING/INTELLIGENCE MEMORY STORAGE RETRIEVAL IMPACT ON NEW LEARNING POTENTIAL CONSEQUENCES: NEUROLGICAL MOVEMENT & TONE DISORDERS Weakness Tremor Dystonia Ataxia Clonus Spasticity Rigidity Flaccidity 11

12 POTENTIAL CONSEQUENCES: LINGUISTIC DYSARTHRIA APRAXIA APHASIA Receptive Expressive POTENTIAL CONSEQUENCES: NEUROLOGICAL SWALLOWING Dysphagia Silent aspiration POTENTIAL CONSEQUENCES: PSYCHOSOCIAL MOOD DISORDERS Depression Emotional lability Mania RISK TAKING LOSS OF INHIBITIONS PERSONALITY CHANGES PERSONALITY DISORDERS 12

13 SLEEP DISORDERS INSOMNIA Impaired falling asleep Frequent awakening SLEEP APNEA NARCOLEPSY FATIGUE POTENTIAL COMPLICATIONS PREVENTABLE OR TREATABLE LIFE CARE PLAN IMPLICATIONS LIFE EXPECTANCY IMPLICATIONS POTENTIAL COMPLICATIONS: NEUROLOGICAL SEIZURE DISORDER HYDROCEPHALUS High pressure Normal pressure 13

14 POTENTIAL COMPLICATIONS: CARDIOVASCULAR CARDIAC ARRHYTHMIAS POSTURAL HYPOTENSION HYPERTENSION CORONARY ARTERY DISEASE DEEP VENOUS THROMBOSIS POTENTIAL COMPLICATIONS: RESPIRATORY PNEUMONIA ATELECTASIS PNEUMOTHORAX PULMONARY EMBOLUS POTENTIAL COMPLICATIONS: MUSCULOSKELETAL OSTEOPOROSIS FRACTURES HETEROTOPIC OSSIFICATION CONTRACTURES PAIN 14

15 POTENTIAL COMPLICATIONS: NEUROGENIC BLADDER BLADDER FUNCTIONING Spastic Flaccid Detrussor sphincter dysenergia UTI s STONE FORMATION URETERAL REFLUX RENAL FAILURE NEOPLASM POTENTIAL COMPLICATIONS: NEUROGENIC BOWEL INCONTINENCE CONSTIPATION DIARRHEA ACUTE ABDOMEN POTENTIAL COMPLICATIONS: SEXUAL DYSFUNCTION FEMALES: Decreased libido Endocrine abnormalities Amenorrhea MALES: Impotence/erective dysfunction Decreased libido 15

16 POTENTIAL COMPLICATIONS: INTEGUMENT PRESSURE ULCERS Impaired sensation Mobility limitations Impaired cognition ACNE Hygiene Neuroendocrine effects PHARMOCOLOGICAL MANAGEMENT: COGNITIVE NEURAL STIMULANTS Anti parkinsonism Activating antidepressants Alzheimer medications Avoidance of sedating medications PHARMOCOLOGICAL MANAGEMENT: BEHAVIOR SEDATING ANTI DEPRESSANTS ANTI SEIZURE ANTI HYPERTENSIVES ANTI ANXIETY STIMULANTS LITHIUM CARBONATE 16

17 PHARMACOLOGICAL MANAGEMENT: SEIZURES PHENOBARBITOL DILANTIN CARBAMAEPINE VALPROIC ACID GABAPENTIN EEG MONITORING REHABILITATION & LONG TERM MANAGEMENT MAINTENANCE OF FUNCTION QUALITY OF LIFE ENHANCEMENT PREVENITON OF COMPLICATIONS FAMILY PREFERENCES & ISSUES REHABILITATION & LONG TERM MANAGEMENT COMMUNITY RE ENTRY Home Personal care home Group home Supported living/assisted living Facilitator 17

18 REHABILITATIONS & LONG TERM MANAGEMENT: FUNCTIONAL IMPROVEMENTS COGNITIVE Orientation Attention & concentration New learning Problem solving Safety judgement Initiation/task completion REHABILITATIONS & LONG TERM MANAGEMENT: FUNCTIONAL IMPROVEMENTS MOBILITY & BALANCE Transfers Ambulation Wheelchair propulsion REHABILITATION & LONG TERM MANAGEMENT: FUNCTIONAL IMPROVEMENTS ACTIVITIES OF DAILY LIVING Performance Safety Task completion 18

19 REHABILITATIONS & LONG TERM MANAGEMENT: FUNCTIONAL IMPROVEMENTS LINGUISTIC Making needs known gestures vocalizations Articulation precision word finding Reading Writing REHABILITATIONS & LONG TERM MANAGEMENT: FUNCTIONAL IMPROVEMENTS SWALLOWING Safety Nutritional adequacy REHABILITATION & LONG TERM MANAGEMENT: PSYCHOSOCIAL ADJUSTMENT TREATMENT OF DEPRESSION SAFETY ENHANCEMENT INAPPROPRIATE BEHAVIOR MANAGEMENT 19

20 LIFE EXPECTANCY REVIEW OF LITERATURE Lack of case applicability from population studies Paucity of correlation of outcome to treatment provided CLINICAL EXPERIENCE Impact of technology Health care provision, rationing Effects of life care planning Offset due to reduced risks of common causes of death in younger individuals SUMMARY & CONCLUSIONS NEED FOR STRONG MEDICAL FOUNDATION SHOULD RECOGNIZE MEDICAL CASE SPECIFICS MUST ENHANCE QUALITY OF LIFE, REDUCE COMPLICATIONS, ENHANCE FUNCTION 20