Brain Injury. Mild to Moderate Effects Pathways. Jane Gillett MD FRCPC Medical Director ABI Program

Brain Injury

Brain Injury

Mild to Moderate

Mild to Moderate

Effects

Effects

Pathways

Pathways

Medical Director ABI Program Medical Director ABI Program

Brain Injury

Brain Injury

„

„ Commonest Cause of morbidity and Commonest Cause of morbidity and mortality in those under 40

mortality in those under 40

„

„ 70% are considered mild to moderate70% are considered mild to moderate

„

„ Often unrecognized in trauma cases Often unrecognized in trauma cases because of more obvious multi organ

because of more obvious multi organ

trauma

trauma

„

„ Moderate/Severe to Severe to Very Moderate/Severe to Severe to Very Severe are usually obvious

Definition

Definition

„

„ Somewhat controversialSomewhat controversial

„

„ GCS NOT a good predictor of severityGCS NOT a good predictor of severity

„

„ Accepted GCS is 10 to 15Accepted GCS is 10 to 15

„

„ Many have normal GCS and normal CT Many have normal GCS and normal CT scans of the head

scans of the head

„

Clinical Picture

Clinical Picture

„

„ Confusion Confusion

„

„ Word finding, and usage difficultiesWord finding, and usage difficulties

„

„ Memory problemsMemory problems

„

„ headacheheadache

„

„ GCS can be normalGCS can be normal

„

Effects

Effects

„

„ HeadacheHeadache „

„ Sleep DisturbanceSleep Disturbance „

„ FatigueFatigue „

„ PainPain „

„ Mood and Emotional Lability including Mood and Emotional Lability including

depression

depression

„

„ VertigoVertigo „

Long term

Long term

„

„ Many recover from the effects within Many recover from the effects within the first three to six months

the first three to six months

„

„ Most recover by 1 yearMost recover by 1 year

„

„ Some (10 to 90%) have persistent Some (10 to 90%) have persistent effects

Treatment

Treatment

„

„ Reassurance and InformationReassurance and Information

„

„ Sleep Hygiene +/Sleep Hygiene +/-- medicationmedication

„

„ Judicious use of Judicious use of SSRI’sSSRI’s

„

„ Migraine Prophylaxis and treatment (if Migraine Prophylaxis and treatment (if migraine headache) and pain Rx

migraine headache) and pain Rx

„

„ Positional vertigo maneuversPositional vertigo maneuvers

„

Concussion

Concussion

„

„ Three grades Three grades –– as determined by length of as determined by length of

loss of consciousness and confusion

loss of consciousness and confusion

„

„ Guidelines provided but sketchy on detailsGuidelines provided but sketchy on details „

„ More recent evidence suggests that mental More recent evidence suggests that mental

rest important for first 24 to 48 hours

rest important for first 24 to 48 hours

„

„ The younger you are the more vulnerable to The younger you are the more vulnerable to

longer effects

Return to work/sports

Return to work/sports

„

„ Must be headache and pain freeMust be headache and pain free

„

„ Walk for 15 Walk for 15 –– 30 minutes30 minutes

„

„ Ride stationary bicycleRide stationary bicycle

„

„ Tread mill Tread mill –– incline and runningincline and running

„

Trauma Follow up

Trauma Follow up

„

„ If at six weeks at time of follow up If at six weeks at time of follow up Check for

Check for

„

„ Consequences as described aboveConsequences as described above

„

„ If any relationship issues, work related If any relationship issues, work related

issues REFER to ABI

What is Available

What is Available

„

„ Adult Concussion Clinic (ACC)Adult Concussion Clinic (ACC) „

„ ABIP outpatient clinicABIP outpatient clinic „

„ ABIP MOH outreachABIP MOH outreach „

„ ABIP inpatient programsABIP inpatient programs

„

„ “traditional” rehab “traditional” rehab –– 6 beds for HGH, 2 for region 6 beds for HGH, 2 for region (CRU)

(CRU)

„

„ Severe behavioural beds Severe behavioural beds –– provincial (CBR)provincial (CBR)

„

„ Slow to Recover Program Slow to Recover Program –– provincial (STR)provincial (STR)

„

„ BEATS program BEATS program –– provincial outreach for provincial outreach for

behaviour

Adult Concussion Clinic

Adult Concussion Clinic

„

„ Will see only those who live in HamiltonWill see only those who live in Hamilton „

„ Accepts referrals from ER directlyAccepts referrals from ER directly „

„ Concussion, mild and some moderateConcussion, mild and some moderate „

„ Has MD to see ER referrals for medical issuesHas MD to see ER referrals for medical issues „

„ Has CIC (community integration coHas CIC (community integration co-

-ordinator

ordinator), ), NeuropyschologyNeuropyschology, OT, Rehab , OT, Rehab therapist

therapist

„

Outpatient clinic

Outpatient clinic

„

„ Accepts referrals from the region and Accepts referrals from the region and

occasionally the province (>2000 visits)

occasionally the province (>2000 visits)

„

„ Must have MD referral Must have MD referral „

„ Two MDs involved (neurologist, Two MDs involved (neurologist, physiatryphysiatry)) „

„ Access to Access to neuropsychologyneuropsychology, social work, , social work,

pyschiatry

pyschiatry

„

„ All patients have a CIC assigned for case All patients have a CIC assigned for case

management

Outreach

Outreach

„

„ Must have defined functional goals Must have defined functional goals (time management, banking,

(time management, banking,

organization, community activity)

organization, community activity)

„

„ Time limitedTime limited

„

„ Rehab therapistRehab therapist

„

„ NeuropsychologyNeuropsychology

„

CRU

CRU

„

„ Referral from Community MD but usually Referral from Community MD but usually

referred in by ABIP consultation team at HGH

referred in by ABIP consultation team at HGH

„

„ In need of 24 hour supervision and assistance In need of 24 hour supervision and assistance

with ADL’s because of cognitive reasons

with ADL’s because of cognitive reasons

„

„ Be medically stableBe medically stable „

„ Have endurance for rehab for several hoursHave endurance for rehab for several hours „

CBR

CBR

„

„ Provincial programProvincial program

„

„ Major cognitive and behavioural issuesMajor cognitive and behavioural issues

„

„ Exhausted all other avenuesExhausted all other avenues

„

„ Be medically stableBe medically stable

„

„ Multiple repetitions, medication trials, Multiple repetitions, medication trials, behavioral analysis

STR

STR

„

„ Provincial programProvincial program

„

„ More than 6 months from onset of More than 6 months from onset of injury

injury

„

„ Have place to liveHave place to live

„

„ Have defined goals around lessening Have defined goals around lessening burden of care

burden of care

„

„ Careful assessment of Careful assessment of neuroneuro status, status, responses, drug effects

BEATS

BEATS

„

„ Provincial programProvincial program

„

„ Provides behavioural consultation in Provides behavioural consultation in person’s environment

person’s environment

„

„ Assesses environment influences, Assesses environment influences,

cognitive difficulties and behaviour and

cognitive difficulties and behaviour and

provides suggestions on management

provides suggestions on management

without use of medication

How to Refer

How to Refer

„

„ If in HGH ER If in HGH ER –– recognize ABI recognize ABI

„

„ If no admission If no admission ---- refer to ACC if lives in refer to ACC if lives in

Hamilton; to family MD if not live in

Hamilton; to family MD if not live in

Hamilton

Hamilton „

„ If admission If admission –– refer to ABIP consultation refer to ABIP consultation

team

How to Refer

How to Refer

„

„ If Community ER If Community ER –– recognize ABI recognize ABI

„

„ If no admission If no admission –– to family MD and if to family MD and if

needed from there to ABIP

needed from there to ABIP „

Pathways

Pathways

ABIP follows and refers to ACC if OK ER

Contacts

Contacts

„

„ ABIP Consultation teamABIP Consultation team

„

„ Elaine Elaine NisbetNisbet 905 521 2100 ext 74668905 521 2100 ext 74668

„

„ Outpatient ClinicOutpatient Clinic

„

„ Referral package neededReferral package needed

„

„ Contact ABIP at 905 521 2100 ext 74101Contact ABIP at 905 521 2100 ext 74101

„

„ BEATSBEATS

„

„ Contact ABIP Contact ABIP

„

„ ACCACC

„