The Mild Traumatic Brain Injury Model of care in the Saguenay Lac

The Mild Traumatic
Brain Injury
Model of care in the Saguenay Lac St-Jean, Qc
CSSS de Chicoutimi
Guylaine Gobeil, clinical nurse adviser
Serge Bergeron, MD
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Creation of the traumatology network in the province of Quebec at
the beginning of the 1990s (the SAAQ being a key player)
The MTBI model exists since1994 in the Saguenay Lac St-Jean
Extension to the moderate and severe TBI in1999 (SAAQ)
Report from the SAAQ in 2003 and the TASK FORCE in 2004
The SAAQ has stimulated the creation of a committee of medical
advisers in neurotraumatology which meets regularly since 2003
Ministerial orientation for 2005-2010
Proposal to the regional committee for two models of organization
 A) Decentralization of the process by CSSS
 B) Centralization of the follow-up and screening at the CSSSC
There has been a regional consensus for the second proposal
Grouping of the medical advisers in
neurotraumatology
• Group of doctors working in the 10 neurotraumatology
centre in the province of Quebec
• Role :
– Support for the diagnosis of TBI
– Support for the coverage of TBI patients by the
team of premature rehabilitation in
neurotraumatology
– Support for the development and preservation of
the expertise in their center
Grouping of the medical advisers in
neurotraumatology
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Dr Jean-François Giguère, Hôpital du Sacré-Cœur de Montréal,
responsable of the committee
Dr Jeffrey Atkinson, Hôpital de Montréal pour Enfants (CUSM)
Dr Serge B. Bergeron, CSSS de Chicoutimi
Dre Isabelle Côté, CH Régional de Trois-Rivières
Dr Jehane Dagher, Hôpital général de Montréal (CUSM)
Dr Josée Fortier, CH Régional de Trois-Rivières
Dr Marcel Germain, CHU de Sherbrooke
Dr Khalill Khalaf , CSSS de Gatineau
Dr Marie Laberge-Malo, Hôpital Sainte-Justine
Dr Jacques Leblanc, Hôpital Enfant-Jésus (CHAUQ)
Dr Judith Marcoux, Hôpital général de Montréal (CUSM)
Dr Ysabel Michaud,CH Charles Lemoyne
Dre Geneviève Sirois, Hôpital Enfant-Jésus (CHAUQ)
Dr Simon Tinawi, Hôpital général de Montréal (CUSM)
DEFINITION
(TASK FORCE 2004)
• Clinical definition:
– « Acute brain injury resulting from mechanical
energy to the head from external physical
forces »
TBI
• Shaked brain;
• Change state of consciousness (loss of
consciousness and confusion (amnesia));
• Sometimes other neurological symptoms
related to shaked brain (ex. convulsion).
DIAGNOSIS OF TBI
• Transfer of kinetic energy
– Ischemia
– Inflammation
– Immunological reaction
– Apoptose
– Neurobiochemical perturbation
– Modification in the permeability of cell
membrane, including the hemato-encephalic
brain barrier
NEW DEFINITION OF MTBI
• Eliminate all the others causes which may be responsible
for the signs and symptoms (shock, medication, alcohol,
drug, etc.)
• Operational criteria :
• Glasgow between 13 and 15 after 30 minutes or during
the evaluation at the emergency
• 1 of these signs: confusion, disorientation, loss of
consciousness < 30 minutes, post-trauma amnesia < 24
hours, transient neurological signs including convulsion
or a cranial or intracranial non-chirurgical lesion
CARACTERISTICS
CRANIOCEREBRAL TRAUMA
CATEGORY OR GRAVITY
MILD
Duration of the loss or
the alteration*
of consciousness
Result obtained on the
Glasgow coma scale in the
emergency or 30 min after
the trauma
Structural damage (fracture
or intracranial brain lesion)
0 to 30 minutes
maximum
MODERATE
Generally between 30
min and 6 h, but
maximum duration of
24 h
SEVERE
Often > 24 h to several
days, but necesseraly
>6h
13 to 15
9 to 12
3 to 8
Positive or negative
Generally positive
Positive neuroimaging
neuroimaging
neuroimaging
Neurological exam may
Positive neurological Positive neurological
Neurological exam
be positive (possible
exam (focal signs)
exam (focal signs)
focal signs)
Variable, but generally
Post-traumatic amnesia
Variable but has to be
between
Several weeks
< 24 h
1 and 14 days
* The notion of a change of consciousness concerns essentially the mild trauma. Moderate and severe
TBI are rather associated to an initial loss of consciousness of variable duration but which respect the
indicated maximal durations.
INCIDENCE
• In Canada,11 persons on 100 000 severe TBI
• Moderate-severe TBI 15%
• MTBI represents 85% of all the TBI treated in a
hospital environment
• MTBI 300 on 100 000 of population
• Two to three times more men than women
nevertheless the causes or age groups
• The frequency is sharply higher during the
adolescence and at the beginning of adulthood
(15-24 age group)
CAUSES
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Motor vehicle accident (+ ↑ Men)
Fall (+ ↑ children (35%) and elderly)
Sports (children 29%)
Occupational accident
Aggression
45 %
30 %
10%
10%
5%
CAUSES OF REFERRED MTBI CASES
120
107
111
100
Women
Men
88
Referred cases
80
68
60
51
42
40
32
28
27
23
20
10
10
10
0
0
Aggression
Fall
Objet
Sport
Motor vehicle Occupational
Non
accident
documented
Reference volume
Region 02 by age group
180
170
160
140
MTBI
120
100
97
87
80
69
59
60
56
40
32
37
20
0
0
age 0-10
age 11-20
age 21-30
age 31-40
age 41-50
age 51-60
age 61-70 age 71 and Unknown
up
Consultation
ADVICE GIVEN TO THE PATIENTS
WHEN LEAVING THE EMERGENCY
• Temporary symptoms;
• Drowsiness, fatigue, fatigability, decrease of
attention and concentration, headache,
dizziness and nausea, irritability, anxiety
• Frequent symptoms which can be
disturbing especially during the first two
weeks;
• Rest and the management of energy;
• Resume of the activities according to
tolerance;
ADVICE GIVEN TO THE PATIENTS WHEN
LEAVING THE EMERGENCY
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Supervision needed during the first 2 - 3 days;
Information on MTBI;
Reassuring on the favorable evolution;
Medication as needed;
Sick leave of work / study
• Sick leave recommanded for 2 weeks
• May be modified according to the evolution of the
symptoms or the type of work / study
ADVICE GIVEN TO THE PATIENTS WHEN
LEAVING THE EMERGENCY
• Come back to the emergency if ...
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Drowsiness is important and increasing;
Uncontrollable headache;
Persistent vomiting;
Neurological signs appear (paresis,
paresthesis, ataxia, convulsion, etc.).
The emergency physician
• Refer the client to the TBI program and inform the
patient about it
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Follow-up is essential + + +;
Phone contact, support, playing-down of the symptoms;
Energy and symptoms management;
Sick leave and return to work management;
Services and treatments management according to the
evolution.
Role of the clinical nurse manager
in the TBI program
• Assume the activites linked with the screening of MTBI (regional
mandate) for an ambulatory clientele having been the objet of a
case report to the Traumatology Program of the CSSSC;
• Evaluate the state of health, determine and assure the realization of
the nursing and interdisciplinary plan of the MTBI victims;
• Advice and support the users in the management of the symptoms;
• According to their needs, direct the victim of MTBI (and their family)
to the members of the interdisciplinary team or to other actors of the
health community;
• Act as a ressource person for the users, the members of the team of
care, the members of the interdisciplinary team and other local and
regional partners;
• Assure the continuity of care by establishing links of communication
with all the involved participants (doctors, employees, school,
environment,…);
• Give some formation.
Screening by the clinical nurse manager
Cases may be reported to the Program by:
- the emergencies of the several
regional health centers
- medical clinics
- personnal initiative
- SAAQ
- health professionals
Screening by the clinical nurse manager
A- Call each referred client, ideally in the 7 days following the
case report, in order to:
1. Proceed to the collection of data and complete the
screening tool.
2. Look for convincing signs of TBI.
3. Look for the presence of factors which can negatively
affect the prognosis.
4. Look for the presence of symptoms post-TBI.
5. Look for the presence of elements of acute stress.
6. Inform the users about TBI, acute stress and the
management of the symptoms.
7- Reassure the users
8- Coordonate the Program
9- Elaborate the follow-up plan
Screening by the clinical nurse manager
B- Follow-up of the users by regular phone calls.
C- If unfavorable evolution, orientation towards another
professional according to the users needs
- family physician
- psychologist
- occupational therapist
- physiotherapist
- social worker
- emergency
- medical adviser of the TBI Program
- rehabilitation center
D- Intervene with
- teachers
- employers
Management of the symptoms
 Drowsiness:
• Very frequent;
• Allowed to sleep;
• Make sure that the person remains arousable.
 Nausea and vomiting:
• Rests often fix the problem;
• Gravol can be used as needed (but can increase drowsiness);
• Good food hygiene;
– 3 meals a day
– Regular hours
– Follow the food guide
Management of the symptoms
 Headache:
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Rest and energy management are important;
Provide relief to the symptoms, do not “endure“ them;
Acetaminophen (ex: tylenol) vs Ibuprofen (ex: advil);
Avoid the too noisy, too much lit or too hectic environment;
Avoid alcohol or drug consumption.
 Sleeping disorder:
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Frequent and temporary;
Good sleep hygiene;
Hot milk;
If the trouble persists, consult the family physician.
Zopiclone
Avoid benzodiazepines
Management of the symptoms
 Fatigue and fatigability:
• Frequent;
• Variable in duration;
• Progressive return to activities (school, work; facilitate
temporary modifications of the work load);
• Limit the time spent playing video games, using the computer
or watching TV;
• Respect threshold of energy;
• Alternation of physical and cognitve activities;
• More frequent rest period;
• Avoid complete inactivity.
Management of the symptoms
 Dizziness:
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Frequent;
Avoid precarious positions (ex: height);
Change position more slowly
In presence of vertigo (presence of free otoliths) which can be
frequent, vestibular therapy for example the Epley maneuvre.
 Attention-concentration-memory disorder:
• Frequent
• Dedramatise and normalise (put the acquaintance in the
loop… use them as accomplices)
• Use reminders (memo pads)
• Do one thing at a time
• Favor the places where stimuli are limited
• Give oneself time to find back regular activities
ACUTE AND PERSISTENT SYMPTOMS
FREQUENTLY OBSERVED IN ADULTS
Acute symptoms
(0 to 3 months)
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Fatigue
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Dizziness (mostly following
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sport accidents)
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Trouble sleeping
Attention problem or decrease in •
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the speed of treatment of the
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information
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Memory problem
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• Headache
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Persistent symptoms
(0 to 12 months and more)
Headache
Fatigue
Dizziness
Trouble sleeping
Attention problem
Depression
Memory problem
Anxiety
Irritability
Other cognitive problems
ACUTE AND PERSISTENT SYMPTOMS
FREQUENTLY OBSERVED IN CHILDREN
Acute symptoms*
(0 to 3 months)
•Headache
•Fatigue
•Attention problem or decrease in the
speed of treatment of the information
•Memory problem
•Trouble sleeping
•Light hyperactivity**
Persistent symptoms *
(0 to 12 months and more)
•Light hyperactivity ** (followed for 5
years after the MTBI)
•Negative prognosis has been noted in
one study of a follow-up of a child 6
months after the MTBI (TDM + and
deterioration > 24 h)
•Other cognitive troubles (?)
* These symptoms are generally less pronounced than in adults and have a shorter
remission time period.
** This is the case in a study in which the authors conclude that it may be the result of the
MTBI or conversely the MTBI being the result of light hyperactivity.
Factors and level of risk of morbidity
associated with MTBI
Level of risk of morbidity
High risk
Low risk
• Compensation problem • Ø compensation
( 50 %)
• Age > 40 years
problem
• Age < 40 years
• No previous history of
• Neurological integrity
neurological
being already
infringement
compromised before the
MTBI
• Absence of previous
stressors
• Previous stressors
• Gravity of the MTBI
• (complex MTBI)
Uncertain risk
• Glasgow coma scale
initial result at 13
• History of
psychological,
psychiatric or
personnality disorder
• Very young (<2 years)
• Parents anxiety
Diagnoses accompanying
MTBI
• Acute stress vs post-traumatic stress vs
adaptation trouble vs previous stress;
• Sprain cervical;
• Other injuries, insomnia caused by pain or
the hospitalization, etc.;
• Neuropathic syndrome (fibromyalgia).
SECOND IMPACT SYNDROME
• While there are still some symptoms,
another TBI occurs;
• A smaller blow will give more symptoms
and more aftereffects;
• Ex. boxers, hockey players,etc.;
• 35-40 deaths in athletes according to
the literature between 1980 and 1993;
• Morbidity 100%. Mortality > 50%.
Resuming of sport activities
• The Montreal Children Hospital has
elaborated a tool “The concussion KIT “
– 5 steps:
• Step 1: conditioning exercices;
• Step 2: conditioning and specific habilities of the
practised sport;
• Step 3: conditioning and specific habilities of the
practised sport; individually and with a teammate;
• Step 4: conditioning and specific habilities of the
practised sport; with the team (without contact);
• Step 5: Complete training with contact.
Resuming of sport activities
• There should be at least 24 h (or more) in
between each step;
• If there is an inscrease or a return of the
symptoms; stop training;
• Rest;
• Restart at the previous step;
• Consult a physian if the symptoms persist or
increase in intensity;
• Resuming contact in the sport activity is only made
when all the symptoms have disappeared.
Prevention
• Wear recommended, approved and well
adjusted equipment (ex: helmet);
• Promote team spirit and accept no violence;
• Practise sport activities in zone planned for that
purpose (ex: skate park);
• Use adequately sport facilities (ex: soccer net);
• Be visible during the evening;
Prevention
• Have the necessary habilities before increasing
the level of difficulty of certain sport activities;
• Make sure the depth of water in sufficient before
diving;
• Make sure that the equipments of the
playgrounds are secure;
• Make sure that the supervision is adequate in
school playgrounds;
• Respect the regulation when driving any motor
vehicle.
Guide for screening a TBI
• Evaluate the presence of signs
(confusion, amnesia,
loss of consciousness, headache, nausea, vomiting, dizziness, loss of vision, ringing in
the ears, drowsiness);
• Ask question in order to evaluate the
memory (How have you been hurt, where do we play, in which half are we,
who scored the last goal, etc.);
• Evaluate cognitive function
( 1: short term memory, ex:
ask to memorize 5 words; 2: ask to spell the month backward; 3: ask to count
backward; 4: ask the recall of the first 5 words).
We should suspect a TBI in case of failure of
any of these items.
Medication being used in our
patients…
• The best means to manage the symptoms after a TBI,
is to begin by avoiding that the brain is sub- or overstimulated. No medication is going to work if we do
not manage the stimuli or the cognitive and physical
efforts, if we do not alternate periods of stimuliactivities and rest, and if we do not mobilize the
patient by adjusting to the threshold of fatigability
where the symptoms appear (headache, dizziness,
decrease of attention-concentration, increase of
impulsiveness, nausea, etc.).
Medication being used in our
patients…
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Amitriptyline at dinner time (for headache, pains and sleep quality)
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Quetiapine (Seroquel) or Olanzapine (Zyprexa Zydis) (allows to
decrease the impulsiveness, and facilitate the management of
agitation and aggressiveness).
•
Zopiclone as a supplement to help sleeping (Zolpidem not being
available in Canada and being used in Europe and the USA).
Medication being used in our
patients…
• Avoid typical neuroleptic and benzo, except in the case of
withdrawal problems, use oxazepam in minimal dose with
Quetiapine and Thiamine.
• For pharmacostimulation:
amantadine
or methylphenidate
or modafinil
Medication being used in our
patients…
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Venlafaxine for additional stimulation with or without amantadine,
methylphenidate or modafinil , or for the treatment of anxiety
problem or post-traumatic stress syndrome.
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Mirtazapin in order to decrease anxiety or facilitate sleep.
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Gabapentin, Pregabalin, Topiramate and other coanalgesics (for
pain control) (adjust dosage in order to avoid adverse effects).
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For nausea, avoid Stemetil (which is a typical antipsychotic),
prefer Zofran, Gravol or Motilium (always having in mind that the
basic treatment is the management of stimuli).
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For vertigo: Serc and consider the Epley maneuvre.
PROGNOSIS OF THE MTBI
• Unfavorable outcome is not frequent
after a MTBI, but may occur (2 to 1520% according to some studies).
• The MTBI classification does not have
any predictive power on a possible
unfavorable outcome (trivial, simple or
complex).
Goal
To make sure that the
symptoms of the MTBI only
remains a hard time to pass
and without any functional
aftereffects.
Some web sites...
• www.csss-chicoutimi.qc.ca (go to the « soins et services » section,
then the « soins » section) (just in french)
or http://cssschicoutimi.com/Fichelessoins/tabid/4884/language/frCA/Default.aspx?dep=trauma
• Traumatology network (english version):
www.fecst.inesss.qc.ca/en.html
• Ministerial orientations from Quebec 2005-2010 (just in french):
http://fecst.inesss.qc.ca/fileadmin/documents/orientations_ministeriel
les.pdf
• Algorithms for decision-making for dangerousness (english version):
http://fecst.inesss.qc.ca/fileadmin/documents/
algo_traumato_EN_dec2011.pdf
Reference
J. David CASSIDY (dir.), «Best Evidence
Synthesis on Mild Traumatic Brain Injury:
Results of the Who Collaborating Center for
Neurotrauma, Prevention, Management and
Rehabilitation Task Force on Mild Traumatic
Brain Injury», Journal of Rehabilitation
Medicine, n° 43, février (supplément) 2004,
144 p.
Other references
•Neuropsychiatric aspects of traumatic brain injury, Arciniegas D.B., Topkoff J.
et Silver J.M., Current treatment options in neurology 2000
•Twenty Years of Pharmacology, Glenn M.B. et Wroblewski B., Journal Head
Trauma Rehabilitation, 2005 vol. 20 No 1
•Review of Awakening Agents, DeMarchi R. et al. The Canadian Journal of
Neurological Sciences, 2005
•Neurobehavioral sequelae of traumatic brain injury, Kile S.J. et al., site
Psychiatric times 2005
•Pharmacotherapy of posttraumatic cognitive impairments, Arciniegas D.B. et
Silver J.M., Behavioural Neurology 2006.
•Neuropsychiatric sequelae of traumatic brain injury, Nicholl J. et LaFrance
W.C., Seminar in neurology 2009
•Pharmacological interventions for traumatic brain injury, Aaron Talsky, MD,
Laura R. Pacione, MSc, Tammy Shaw, MD, Lori Wasserman, MD, Adam Lenny,
BSc, BA, Amol Verma, BSc, Gillian Hurwitz, Robyn Waxman, MD, Andrew
Morgan, MD, Shree Bhalerao, MD, FRCPC, BC Medical Journal, Vol. 53, No. 1,
January, February 2010
QUESTIONS
THANK YOU FOR YOUR ATTENTION!