Life Care Plans in the Traumatic Brain Injury (TBI) Setting
Concussion or mild traumatic brain injury (TBI) accounts for 90% of TBI. It is defined as a clinical syndrome characterized by immediate and transient alteration in brain function including alteration of mental status and level of consciousness, resulting from mechanical force or trauma. It does not require a loss of consciousness. A concussion can affect coordination, balance, memory, and speech. Although a concussion may be mild in nature, it is critical that it’s identified and addressed in a timely manner. A second concussion shortly after can be life threatening or cause a permanent impairment or disability. Mild TBI can be easily missed on physical examination and imaging studies are not helpful in determining the presence or absence of brain damage (with the possible exception of diffusion tensor imaging, which may show diagnostic findings that correlate with reduced performance on cognitive tests). The diagnosis is determined in the patient’s history. Is the patient confused? For how long has he/she been confused? Is he/she coherent? Is the patient easily distracted? Can the patient follow simple commands? These are the questions that need to be asked to determine if the patient has a concussion. Aside from confusion, there are other symptoms commonly seen in concussions:
- Poor memory
- Poor concentration
- Tinnitus (ears ringing)
- Blurry vision
- Consistent headaches
- Nausea or vomiting
- Photophobia (sensitivity to light)
- Inability to smell or taste
- Mood swings
Concussion severity is graded with three systems: Cantu, Colorado Medical Society Guidelines, and American Academy of Neurology (AAN).
Grade 1 or mild – no loss of consciousness (LOC); post-traumatic amnesia (PTA)/post-concussion signs/symptoms (PCSS) lasting less than 30 minutes.
Grade 2 or moderate – LOC < 1 min; PTA 30 min – 24 hrs.; PCSS 30 min – 7 days.
Grade 3 or severe – LOC > 1 min; PTA > 24 hrs.; PCSS > 7 days.
Grade 1 or mild – no loss of consciousness (LOC); confusion < 15 min.
Grade 2 or moderate – no LOC; confusion > 15 min.
Grade 3 or severe – Grade 3a: brief LOC lasting seconds; Grade 3b: Prolonged LOC lasting minutes.
Moderate to Severe TBI
The Glasgow Coma Scale (GCS) is used to determine the severity of TBI: Severe TBI (Coma) – GCS score of 3-8; Moderate TBI – GCS score of 9-12; and Mild TBI – GCS score of 13-15.
After the initial injury the patient may suffer diffuse axonal injury (DAI), in which there is extensive damage in the white matter tracts of the brain. As opposed to mild TBI, when there’s DAI, a brain MRI can show white matter bleeding. Subsequent brain damage occurs due to brain swelling.
Severe brain injury can cause one of the following disorders of consciousness: coma, vegetative state (VS), and minimally conscious state (MCS). During coma, the patient has no wakefulness and his/her eyes remain closed; no evidence of comprehension; no purposeful movement. In a vegetative state, there is a sleep-wake cycle on electroencephalogram (EEG) and the patient can open his/her eyes, but there’s no self awareness; no purposeful behavior. If the VS last less than 3 months after TBI, it’s persistent VS, whereas if it lasts more than 12 months, it’s considered permanent VS (and it is irreversible). In a MCS the patient does have self-awareness and purposeful behavior, follows simple commands, visual fixation, and verbalization.
There’s no proven treatment to promote the emergence of any of the above mentioned disorders of consciousness. Treatment is centered in avoiding complications, like treating spasticity, avoid pressure sores, prevent contractures, etc. The medication regimen should (if possible) medications that adversely affect neurologic recovery. The use of stimulants has been used to improve attention and responsiveness, like ritalin and a few antidepressants.
Approximately 1.7 million TBIs occur in the US every year. Motor vehicle accident (MVAs) is the most common cause of TBI. Alcohol is found in over 80% of TBI individuals at the time of injury. Up to 64% of patients have only a high school education or less at the time of injury and up to 62% of them are employed. There are currently 5.3 million individuals in the US who are disabled because of TBI. Around 1.7 million people suffer TBI on a yearly basis, of which 52,000 result in deaths, 116,000 result in hospitalizations, and 1.36 million ER visits that are not admitted to the hospital. The economic cost of of this condition in 2000 was over $60 billion: $9 billion in lifetime medical costs and $51 billion in productivity loss.
The above information is obtained from The National Data & Statistical Center – TBI Model Systems; CDC National Center for Injury Prevention and Control Statistics.
A study of nearly 3000 serious head trauma cases found that 52% of survivors (154/100,000 population) were moderate to severely disabled at 1-year post injury (Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny KI. Disability in young people and adults one year after head injury: prospective cohort study. BMJ. 2000;320(7250):1631–1635).
Many patients never recover full social independence, even though they may have no physical disabilities and a normal life expectancy.
At 4 years post injury, most survivors lived with their families and neither worked nor attended school, imposing significant psychological burden on families who care for injured relatives (Jacobs HE. The Los Angeles Head Injury Survey: procedures and initial findings. Arch Phys Med Rehabil. 1988;69(6):425–431). TBI survivors have strained relationships with their spouse and it is at this point that there’s an increased risk of suicide in this patient population.
There is little evidence of improvement in psychological problems between 2 and 7 years post injury, with survivors remaining largely dependent upon family support, thereby potentially imposing a lifetime burden on relatives (Willer BS, Allen KM, Liss M, Zicht MS. Problems and coping strategies of individuals with traumatic brain injury and their spouses. Arch Phys Med Rehabil. 1991;72(7):460–464).
- Post-traumatic seizures (PTS) and epilepsy (PTE)
- 5% of hospitalized TBI patients have late PTS (occurring after the first week), and about the same number have one or more seizures within the first week of hospitalization.
- Most PTS happen 1-3 months post-injury.
- TBI severity correlates with incidence of PTS.
- The greatest risk of having PTS is within the first 2 years post injury
- Seizures that don’t respond to anti-convulsant medications can be managed surgically: medial temporal and neocortical resection or vagal nerve stimulation.
- Problems with cognition: attention, executive functioning, and memory recall.
- Social isolation
- Marital problems
- Difficulty driving
- Profuse sweating
- Cranial nerve injuries
- Olfactory nerve
- Facial nerve
- Vestibulocochlear nerve
- Oculomotor nerves
- Optic nerves
- Poor appetite
- Altered feeding pattern
- Deep Venous Thrombosis (DVT)/Pulmonary Embolus (PE)
- Neurogenic bladder
- Hyper metabolic state
- Hypothalamic pituitary dysfunction
- Decrease in the release of pituitary hormones: thyroid stimulating hormone, follicle stimulating hormone, leuteinizing hormone, prolactin, growth hormone, ACTH
- Poor balance
- Vision problems
- Tinnitus (ringing in the ears)
- Post-traumatic agitation
- Emotional lability
- Heterotypic ossification (bone formation outside of skeletal tissue)
- Hyponatremia (low sodium in blood)
- Psychogenic polydipsia (when the patient drinks so much water that it causes electrolyte imbalances)
- Diabetes insipidus
Potential Costs of Care for TBI Patients
In the field of defense spending, it is estimated that as of 2006 there were 3213 soldiers — 20% of those injured in Iraq up to that point — that have suffered head/brain injuries that required lifetime continual care at a cost range of $600,000 to $5 million (Wallsten and Kosec, AEI, The Economic Cost of the War, 2005 and Department of Defense estimates for number of wounded). The government was required to commit resources through intensive care facilities, round-the-clock home or institutional care, rehabilitation and assisted living for these veterans. (Stiglitz, J, The Economic Costs of the War, 2006). In his research, Dr. Stigliz used a “midpoint estimate of a net present value of $2.7 million over a 20 year expected survival rate for this group, which is about $135,000 per year”. He goes on to say “this amount seems low for brain-injured individuals who will require round-the-clock care in feeding, dressing and daily functioning. For the moderate estimate, we use a higher cost estimate of $4 million” (Stiglitz, J, The Economic Costs of the War, 2006).
*Note, these are estimates; the lifetime cost for TBI can be more than the higher limits shown here or they can be lower than the lower limits.
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