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8/15/2014 ETSU New Symbol MSHA Symbol The Epidemic of “Mild” Traumatic Brain Injury in America’s Young Adults: A Civilian and Military Team Perspective Tyler Putnam, MD, FACS, FCCM Medical Director, Trauma/Acute Care Surgery Services Mountain States Health Alliance/Johnson City Medical Center Colonel, United States Air Force (retired) Objectives • Traumatic Brain Injury Introduction • Military and Civilian Aspects of TBI– An American Medical Team Approach: – Dissecting the Current Epidemic of Mild TBI – Evaluation for Mild TBI – Treatment for Mild Traumatic Brain Injury – Prevention Strategies for Mild TBI MILD TBI A Very Current and Relevant Sports Medicine Challenge in our Community! 1 8/15/2014 Mild TBI ‐ A Very Relevant National Public Health Problem CDC, Morbidity and Mortality Weekly Report, July 12, 2014 – Traumatic brain injury ‐ #1 cause of death in ages 1‐45 yo – 75% of brain injuries are concussions/mild TBI – > 2.4 million ED visits, hospitalizations and deaths are due to TBI (latest CDC Data, 2009) – ED visits for TBI increased 14.4% (2002‐2006) – Hospitalizations for TBI increased 19.5% (same period) What do These People Have In Common? • Ryan Church-New York Mets outfielder • George Clooney- actor/director • Ben Roethlisberger-Pittsburgh Steelers quarterback • Mike Wallace-journalist • Tyler Putnam – Trauma Surgeon Answer: • They have all had one or more mild traumatic brain injuries (concussions) • They received medical and rehabilitation help and support • They all returned to work 2 8/15/2014 Mild Traumatic Brain Injury is the most common type of Brain Injury among Civilians and US Service Members • About 75-80% of all civilian traumatic brain injuries are mild (CDC 2009) – 1.6-3.8 million sports related concussions/year • An estimated 11-20% of service members sustained a mild TBI/concussion while serving in OEF/OIF (US Army Surgeon General 2008, Hoge, et. al. 2008, Taneilian and Jaycox 2008) What is Traumatic Brain Injury? “…..is caused by a blow to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI may range from “mild,” a brief change in mental status or consciousness to “severe,” an extended period of unconsciousness or amnesia after injury” Centers for Disease Control & Prevention Causes of TBI • Civilians; – Falls, Motor vehicle crashes, assaults, struck by/against events (CDC 2009) • Service Members (injured in combat); – Blast exposure, gunshot wounds, falls and motor vehicle accidents (Defense and Veterans Brain Injury Center 2009) 3 8/15/2014 “Mild” Traumatic Brain Injury (Concussion) • • • • • A confused or disoriented state Lasts less than 24 hours; Loss of consciousness for up to 30 minutes; Memory loss lasting less than 24 hours Structural brain imaging (MRI or CT scan) yielding normal results. Defense and Veterans Brain Injury Center (DVBIC) Mild TBI Definition American Congress of Rehabilitation Medicine “Traumatically induced disruption of brain function that results in loss of consciousness of less than 30 minutes’ duration or in an alteration of consciousness manifested by an incomplete memory of the event or being dazed and confused.” McCallister 2005 Moderate TBI • A confused or disoriented state which lasts more than 24 hours • Loss of consciousness for more than 30 minutes, but less than 24 hours • Memory loss lasting greater than 24 hours but less than seven days • Structural brain imaging yielding normal or abnormal results. Defense and Veterans Brain Injury Center (DVBIC) 4 8/15/2014 Severe TBI • A confused or disoriented state which lasts more than 24 hours • Loss of consciousness for more than 24 hours • Memory loss for more than seven days • Structural brain imaging yielding normal or abnormal results. Defense and Veterans Brain Injury Center (DVBIC) Penetrating TBI or Open Head Injury • A head injury in which the dura mater, the outer layer of the meninges, is penetrated. • Penetrating injuries can be caused by high‐ velocity projectiles or objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain. Concussion = “Mild” Brain Injury “To call this a ‘mild’ injury is very inappropriate” Dr. Brown, Boston Univ. Center for Study of Traumatic Encephalopathy: – 20% of concussion symptoms last months or years – Significant negative impact on performance at school and at work 5 8/15/2014 “Mild Traumatic Brain Injury (MTBI) in the United States: Steps to Prevent a Serious Public Health Problem” Report to Congress, September 2003 Report to Congress on Traumatic Brain Injury in the United States: Understanding the Public Health Problem among Current and Former Military Personnel DoD Report, 2013 United States Civilian Traumatic Brain Injury: Hospitalizations by Age Group National Hospital Discharge Survey — United States, 2001–2010 (Hospitalizations 6 8/15/2014 Worldwide numbers represent medical diagnoses of TBI that occurred anywhere U.S. forces are located including the continental United States since 2000. Evaluation of Mild TBI Acute Concussion Evaluation (ACE) Civilian (Forms Available – PDF) Management of Mild TBI CARE PLAN 7 8/15/2014 Management of Mild TBI CARE PLAN (Adult) US Military’s Emphasis on TBI The “Signature” Wound of Iraq/Afghanistan Traumatic Brain Injury A TRAUMA SURGEON’S PERSPECTIVE In Johnson City Initial Evaluation in the Trauma Bays (Emergency Department) 8 8/15/2014 The Trauma Path Leads to East Tennessee! Wilford Hall Medical Center, Texas Level 1 Trauma Center Misawa Air Base, Japan University of Maryland Shock Trauma Center Traumatic Brain Injury Pathophysiology • Primary Brain Injury • Secondary Brain Injury – Hypotension – Hypoxia – Anemia 26 The Primary Goal after Brain Injury (Mild,Moderate or Severe) • Prevent secondary brain injury – Maintain adequate oxygenation (airway/breathing) – Maintain adequate blood pressure and cerebral perfusion (circulation) • Rapid evacuation of mass lesions/hematomas – CT scan, rapid neurosurgical evaluation 9 8/15/2014 Maintaining Cerebral Perfusion After Injury Cerebral perfusion pressure = Mean arterial pressure _ Intracranial pressure • Preserve cerebral blood flow by keeping – Cerebral Perfusion Pressure > 70 – Mean Arterial Pressure > 90 – Intracranial Pressure < 20 28 Types of Head Injury • Scalp • Skull • Intracranial – Diffuse • Concussion • Diffuse Axonal Injury – Focal • Contusion • Hematomas ‐ Epidural, Subdural, Intracerebral 29 After Initial TBI Evaluation and Diagnosis of Mild TBI 10 8/15/2014 • • • • • Common Mild TBI/Postconcussive Symptoms Poor concentration Memory difficulty Headache Irritability Fatigue • • • • • Depression Anxiety Dizziness Light sensitivity Sound sensitivity Immediately post‐injury 80% to 100% describe one or more symptoms Most individuals return to baseline functioning within a year Ferguson et al. 1999, Carroll et al. 2004; Levin et al. 1987 Terrio, H., Brenner, L.A., Ivins, B., Cho, J.M., Helmick, K.,Schwab, K., Scally, K., Bretthauser, R., Warden, D. Traumatic Brain Injury Screening: Preliminary Findings Regarding Prevalence and Sequelae in a US Army Brigade Combat Team. Journal of Head Trauma Rehabilitation. 2009 Terrio, H., Brenner, L.A., Ivins, B., Cho, J.M., Helmick, K.,Schwab, K., Scally, K., Bretthauser, R., Warden, D. Traumatic Brain Injury Screening: Preliminary Findings Regarding Prevalence and Sequelae in a US Army Brigade Combat Team. Journal of Head Trauma Rehabilitation. 2009 11 8/15/2014 Mild TBI Question: Does a person always get “knocked out” or loose consciousness when they have a brain injury? Answer: No!! They may however experience a period of feeling dazed, they may look fine, but their brains have been knocked “off line” and are unable to lay down new memories For Example….. 12 8/15/2014 “That first morning, wow, I didn’t want to move, I was thankful that nothing’s broken, but my brain was all scrambled” Ryan Church, New York Times 3/10/08 “All he remembers from the collision with Anderson is the aftermath, being helped off the field by two people, although he said he did not know who they were until he saw a photograph later” Ben Shpigel New York Times reporter Signs of “Mild” Traumatic brain Injury Early Signs • confusion • blank staring • decreased response time for directions and/or answering questions • dizziness/sensitivity to light and/or sound • vomiting • headache • nausea BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30‐37 After mild TBI. for many, the symptoms go away within hours or days. If they do not and/or an individual gets another mild traumatic brain injury they may experience additional symptoms…. 13 8/15/2014 Signs of Mild Traumatic Brain Injury Late Signs • • • • • • • Persistent headache Poor attention Irritability/aggression Hearing problems Ringing in the ears Restlessness Depressed mood • • • • Decreased memory Sleep disturbances Fatigue and anxiety Blurry vision/visual problems • Lightheadedness • Difficulty making decisions BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30‐37 When to seek help after mild TBI... If things that have always come easily to patient, are harder, take longer, especially if their ability to multi-task is not what it was prior to the incident and/or Their family, friends, fellow soldiers/players or superiors/coaches comment negatively on performance of duties, their responsiveness to new situations and ability to communicate. Per Military Behavioral Health, individuals concerned about lingering symptoms after mild TBI can... • Speak to a chaplain • Go to their installation Department of Behavioral Health or Community or Division Mental Health (www.behavioralhealth.army.mil) as well as... • Thoroughly respond to the questions asked in the Post-Deployment Health Assessment (PDHA). Several items screen for possible traumatic brain injury 14 8/15/2014 Mild TBI The Good News: With treatment and time the brain will usually heal and allow a functional recovery! After TBI: Suggested services/strategies may include... • Consultation with a neurologist and or a neuropsychologist • Work with a speech, occupational, and or physical therapist as recommended by medical personnel • Scheduling breaks/down time • Minimize alcohol intake as it can depress brain cell growth/regeneration after injury • Follow recommendations for physical exercise-it supports brain health Mild Traumatic Brain Injury: Clinical Practice Guidelines for Acute and Chronic Management in the DoD (CONUS) 300,000 American TBIs in Recent Wars Largest number of well documented young adult mild TBI victims Extensive efforts to diagnose and manage TBI, especially mild TBI 15 8/15/2014 Definition • Mild TBI/Concussion (DoD definition) – – – – LOC: 0-30 minutes AOC: up to 24 hours PTA: 0-24 hours Structural Imaging (if done): normal • All head injuries do not result in TBI • Level of injury severity does not equal level of functional impairment 46 Management Overview • Clinical guidance based upon time of presentation – Acute = < 7 days – Sub-acute/Chronic = > 7 days • Acute management: Symptom Management in Mild TBI - Health Affairs Policy Memo (May 2008) • Sub-acute/Chronic management: VA/DoD Clinical Practice Guideline for the Management of Concussion/mild Traumatic Brain Injury (March 2009) 47 Mild TBI Management Overview • Identification of injury • Evaluation for potential red flags • Symptom management • Rest • Prevention of further injury • Education 48 16 8/15/2014 Mild TBI ‐ Asymptomatic • Closely monitor for symptoms and provide supportive education up to 30 days post injury • Provide reassurance about recovery • Advise about precautionary measures to prevent future head injury • Provide written contact information for healthcare provider and instructions to contact for follow-up for changes in condition or development of symptoms • Document concussion in medical record 49 Post Concussive Symptoms Emotional • Anxiety • Depression • Irritability • Mood lability Physical Cognitive • Slowed processing Dizziness • Decreased Sleep Disturbances attention • Poor Balance problems Concentration Nausea/Vomiting Fatigue • Memory Problems Visual disturbances • Verbal dysfluency • Word-finding Sensitivity to light/ • Abstract reasoning noise • Headache • • • • • • • Ringing in the ears Mild TBI Codependent Symptoms mTBI Symptom Interaction Sleep Headache Cognitive Irritability/ Mood 17 8/15/2014 Clinical Practice Guideline Symptomatic mild TBI Summary of Algorithm B: Management of Symptoms Step One: History and Physical Exam Confirm diagnosis of mild TBI Characterize initial injury and identify detailed information of the injury event Patient’s symptoms and health concerns Are symptoms related to the event characterized as a mild TBI Pre-morbid conditions, potential co-occurring conditions, other psychosocial risk factors Evaluate signs and symptoms indicating potential for neurosurgical emergencies that require immediate referrals Assess danger to self or others Complete history Physical Exam Focused neurological examination Focused vision examination Focused musculoskeletal examination of head and neck Lab Tests Not necessary for mild TBI (may consider lab tests for evaluating other non-TBI [52] causes of symptoms) Imaging Not recommended in patients who sustained mild TBI beyond emergency phase (72 hours post-injury) unless condition deteriorates or red flags noted CT scan - modality of choice for acute mild TBI. Absence of abnormal findings does not preclude presence of mild TBI Clinical Practice Guideline ‐ Symptomatic mild TBI Step Two: Clarify Symptoms Duration Frequency Onset and triggers Location Previous episodes Intensity or severity Previous treatment and response Patient perception Impact on functioning Assess exacerbating factors: Prescribed and OTC medications Caffeine, tobacco and other stimulants (energy drinks) Sleep patterns & sleep hygiene Co-existing illnesses Step Three: Evaluate and Treat Co-Occurring Disorders Mood disorders Anxiety Stress Substance use disorders Step Four: Determine Treatment Plan Document summary of patient’s problems Develop treatment plan that includes severity and urgency for treatment interventions Emphasize good prognosis and empower patient for self-management Step Five: Educate Patient and Family (written & verbal) Review potential symptoms of mild TBI Review expected outcomes and recovery Educate about prevention of further injuries Empower patient for self management Techniques to manage stress Step Six: Provide Early (Non-Pharmacologic) Interventions Sleep hygiene education Relaxation techniques Limiting use of caffeine, tobacco, alcohol Graded return to exercise with close monitoring Monitored progressive return to normal duty, work or activity Clinical Practice Guideline ‐ Symptomatic mild TBI Step Seven: Consider Case Management Consider case management if all symptoms not sufficiently resolved within days. Assign case manager to: oFollow-up and coordinate (remind) future appointments oReinforce early interventions and education oAddress psychosocial issues (financial, family, housing or school/work) oConnect to available resources Step Eight: Initiate Symptom-Based Treatment See specific symptom tabs for symptom management Step Nine: Follow Up and Reassess Follow up and reassess in 4-6 weeks, sooner if clinically indicated Encourage and reinforce positive expectation of recovery Monitor for co-morbid conditions Address: oReturn to work, duty or activity oCommunity participation oFamily/social issues Step Ten: If Symptoms Not Sufficiently Resolved Continue to Algorithm C Management of Persistent Concussion/mild TBI Symptoms Re-assess symptom severity and functional status and complete psychosocial evaluation Possible referrals to mental health, occupational therapy, vocational therapy Continue case management 18 8/15/2014 Clinical Practice Guideline ‐ Symptomatic mild TBI Management of Headaches Post Traumatic Headaches (Includes Tension and Migraine) History Characterize headaches Pre-existing headache disorder Assess sleep/wake cycles (lack of sleep is an exacerbating factor and mTBI is also associated with impaired sleep) Patient Examination Head and neck Complete cranial nerve, fundoscopic and pupil exam Muscle strength and tone Gait Upper and lower extremity coordination Medication Review Chronic daily use of non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (alone or combined with caffeine) may lead to rebound headaches Excessive use or rapid withdrawal of caffeine or tobacco can trigger headaches Referral * – Emergency Department Fever – Stiff neck • Neurology - Worsening headache -Seizures - Blackout -Any abnormality found during neurological or musculoskeletal exam Patient Education Perform series of neck stretches Review sleep posture and make adjustments to ensure neck and spine are in a neutral position Awareness and avoidance of migraine triggers Maintaining regular exercise, sleep and meal schedules Recognize warning signs (aura) Headache diary Clinical Practice Guideline ‐ Symptomatic mild TBI Management of Headaches (cont’d) Tension Migraine Pharmacologic Treatment ** NSAIDs Acetaminophen Prophylactic therapy Non-Pharmacologic Treatment Relaxation training and biofeedback in combination with medication Physical therapy Increased physical activity Alternate ice and heat on neck and head 2-3 times per day for about 20 minutes Therapeutic massages to help with headaches from neck tension •Relaxation •Biofeedback •Visualization •Extracranial pressure •Cold compress •Regular exercise •Alternate ice and heat on neck and head 2-3 times per day for about 20 minutes •Therapeutic massages to help with headaches from neck tension Analgesic washout period Limit to 3 treatments/week or less Prophylactic therapy Clinical Practice Guideline ‐ Symptomatic mild TBI Management of Dizziness Dizziness Physical Assessment Medication Review (for medications that exacerbate or worsen symptom) Referrals * Pharmacologic Treatment Non-Pharmacologic Treatment Patient Education – – – Neurological examination Vision Auditory Sensory Motor Coordination Stimulants Benzodiazepines Tricyclics Monoamine oxidase inhibitors Tetracyclics Neurology Lateral abnormality Nystagmus Abnormal Romberg Not shown to be effective in chronic dizziness after mild TBI Consider only if symptoms are severe enough to significantly limit functional activities May be helpful during acute period Vestibular and balance rehabilitation Vestibular Evaluation of functional and balance activities Turning – Neuroleptics Anticonvulsants Selective serotonin agonists Beta blockers Cholinesterase inhibitors Emergency Department CSF leak Meclizine Scopolamine Dimenhydrinate Lorazepam Clonazepam Diazepam Perform neck stretches Modify activity and change positions slowly Change sleep position Perform vestibular rehabilitation exercises Talk with your healthcare provider if exercises do not help your dizziness 19 8/15/2014 Clinical Practice Guideline ‐ mild TBI: Fatigue and Sleep Disturbances Fatigue Sleep Disturbances Management of Fatigue and Sleep Disturbances History Pre/post-injury level of physical activity, cognitive function and mental health (identify and treat underlying medical and psychological disorders) Physical Assessment Multidimensional Assessment of Fatigue (MAF) Fatigue Impact Scale (FIS) Fatigue Assessment Instrument (FAI) Laboratory tests (CBC, Metabolic panel, Vitamin B12 & folate, Thyroid function test, Erythrocyte Sedimentation Rate (ESR)) If medication appears contributory, perform Applied Behavioral Analysis (ABA) trial to determine the association Medication Review (for medications that exacerbate or worsen symptom) Referrals * Sleep routine Alcohol and substance abuse Sleep activity Nightmares Frightened arousal Epworth Sleepiness Scale Consider Pittsburgh Sleep Quality Index (PSQI) Neck size, airway, height, weight Sleep study referral Apnea ESS>12 Address modifiable factors prior to initiating pharmacotherapy Persistent symptoms (> 4 weeks) without improvement with management of sleep, pain, depression, lifestyle, may consider neurostimulant: Medication trial for at least 3 months Well balanced meals Sleep hygiene Regular exercise Cognitive behavioral therapy Pharmacologic Treatment ** NonPharmacologic Treatment Patient Education BMI>30 Prazosin Zolpidem Trazodone (sleep maintenance) Amitriptyline (headache benefit) * Well balanced meals Sleep hygiene Regular exercise Cognitive behavioral therapy Sleep hygiene Reduce stimulation before bedtime No caffeine, heavy exercise, alcohol, nicotine or heavy meals 3 hours prior to bedtime Avoid bright light exposure near bedtime Keep regular bedtime and wakeup hours Foster quiet, pleasant sleep environment Stop work or TV viewing at least one hour before bedtime Use bed only for sleep and sex Clinical Practice Guideline ‐ Symptomatic mild TBI Management of Sensory Changes Management of Vision, Hearing & Olfactory Symptoms Vision Hearing History Pre-injury visual deficits Pre-injury hearing deficits (common) Physical Assessment Otologic examination Decreased auditory acuity Sensitivity to noise Referrals Ophthalmologic examination Extraocular movements Pupils Visual fields by confrontation o o o Optometry and Ophthalmology NonPharmacol ogic Treatment Initial use of sunglasses followed by formal weaning program (decrease by 15 minutes every 2 hours) Sunglasses Intermittent patching for double vision Reassurance, pain management, controlling environmental light Olfactory Pre-injury causes of anosmia Decreased appetite Perform nasal and oropharyngeal examination Perform depression screen Audiology (if no other cause is found) ENT * (Hemotympanum, FB, TM perforation) ENT (if needed) Reassurance Pain management Controlling environmental noise White noise generators Reassurance and monitoring Increase spicing of foods (+/dietary referral) Monitor weights Clinical Practice Guideline ‐ Symptomatic mild TBI Management of Irritability History Evaluate specific history and symptoms, physical fighting, alcohol intake, relationship problems, suicidal, homicidal Physical Assessment Referrals Psychiatry, psychology and social work Outward violence Excessive alcohol intake Suicidal ideation Homicidal ideation Pharmacologic Treatment Sertraline Citalopram Allow 3-4 week therapeutic trial of each drug Refer to psychiatry, psychology, social work for treatment failure of 2 medications Patient Education Understand that it is normal to have feelings of anxiety, depression, agitation and feeling overwhelmed Replace negative thoughts and actions with positive ones Do not call yourself bad names or put yourself down Talk to someone you love and trust about these concerns Seek emergency care if you have thoughts or feelings of hurting yourself or others Seek psychological support if these feelings are causing you problems at work or home Administer PCL-M screening questionnaire Consider PHQ-9 or other depression inventory 20 8/15/2014 Clinical Practice Guideline ‐ Symptomatic mild TBI Management of Appetite Changes & Nausea Appetite Changes Nausea History Pre-injury causes of appetite issues Define triggers and patterns of nausea Physical Assessment Medication Review Assess medication list for agents that can cause olfactory or gustatory abnormalities (centrally acting medications, in particular antiepileptics, some antibiotics) Assess medication list for agents that may cause or worsen GI symptoms Non-Pharmacologic Treatment Perform nasal and oropharyngeal examination Review neurovegetative signs (assess for depressed affect or clinical depression) Reassurance and monitoring Increase spicing of foods (+/- dietary referral) Monitor weights Perform oropharyngeal examination Reassurance and monitoring Encourage rapid management of dizziness and return to activity Clinical Practice Guideline Symptomatic mild TBI When to Refer Symptoms cannot be linked to a event (suspicion of another diagnosis) An atypical symptom pattern or course is present Findings indicate an acute neurologic condition that requires urgent intervention Presence of other major co-morbid conditions requiring special evaluation When to Refer to Specialists 62 Clinical Practice Guideline ‐ Symptomatic mild TBI Return to Duty (Return to Play) When to Return to Activity When to Apply Duty Restrictions Period of rest for individuals with post-injury symptoms Encourage gradual return to normal activity as clinically appropriate Suggest exertional testing if a person’s normal activity involves significant physical activity If exertional testing results in a return of symptoms, recommend additional rest until symptoms resolve A duty specific task cannot be safely or competently completed based on symptoms The work/duty environment cannot be adapted to the patient’s symptom- based limitation The deficits cannot be accommodated Symptoms reoccur 63 21 8/15/2014 mTBI and "Co‐occurring" Conditions The polytrauma clinical triad: Distribution of patients with 1. chronic pain, 2. posttraumatic stress disorder (PTSD), and 3. persistent postconcussive symptoms (PPCS) in a sample of 340 Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans evaluated at Department of Veterans Affairs Boston Polytrauma Network Site (PNS). Lew et. al., Prevalence of chronic pain, posttraumatic stress disorder and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad. JRRD, 2009, 46(6), 697-702. Clinical Practice Guideline Symptomatic TBI Recently Published Clinical mild Recommendations • Co-occurring conditions toolkit • Cognitive rehabilitation in mild TBI • Driving assessments after TBI 65 Defense and Veterans Brain Injury Center (DVBIC) • Established in 1992, • Unique collaboration between: – Department of Defense (DOD) – Department of Veterans Affairs (DVA) – Brain Injury Association of America (BIAA). • Goal of DVBIC: – To ensure that active duty military and veterans with brain injury receive the best evaluation, treatment, and follow‐ up. 22 8/15/2014 National TBI Evaluation and Care System We need to Apply Lessons Learned from Military and Veterans Healthcare Systems President Announces Concussion Prevention Partnership May 29, 2014 WASHINGTON, May 29, 2014 – At a White House Summit today on youth sports safety and concussions, President Barack Obama announced that the Defense Department is partnering with the NCAA in an effort to better prevent, diagnose and treat brain injuries. The NCAA and DOD have committed $30 million for concussion education and a study involving up to 37,000 college athletes ‐‐ the most comprehensive concussion study ever, Obama said. “And our service academies ‐‐ Army, Navy, Air Force, and Coast Guard ‐‐ are all signed up to support this study in any way that they can,” he added. “I’ve seen in my visits to wounded warriors [that] traumatic brain injury is one of the signature issues of the wars in Iraq and Afghanistan,” the president said. But, Obama said, most mild traumatic brain injuries in the military don’t occur during deployments. “So even though our wars are ending, addressing this issue will continue to be important to our armed forces,” he said. “And as part of a new national action plan we announced last year, we’re directing more than $100 million in new research to find more effective ways to help prevent, diagnose and treat mental health conditions and traumatic brain injury ‐‐ because the more we can learn about the effects of brain injuries, the more we can do to help our courageous troops and veterans recover,” the president said. There’s more work to do, Obama said. “We’ve got to have better research, better data, better safety equipment, better protocols,” he said. And enacting deep and real social change is a critical part of developing better prevention and treatment options for brain injuries, the president said. “We’ve got to have every parent and coach and teacher recognize the signs of concussions,” Obama said. “And we need more athletes to understand how important it is to do what we can to prevent injuries and to admit them when they do happen. “We have to change a culture that says you ‘suck it up,’” he continued. “Identifying a concussion and being able to self‐ diagnose that this is something that [you] need to take care of doesn’t make you weak ‐‐ it means you’re strong.” By Claudette Roulo, American Forces Press Service Mild TBI ‐ Resources for Field Diagnosis/Early Management CDC Concussion – Field Palm Card (1) 23 8/15/2014 CDC Concussion – Field Palm Card (2) CDC Concussion – Field Palm Card (3) CDC Concussion – Field Palm Card (4) 24 8/15/2014 Mild TBI and the Importance of Neuropsychology 1. MTBI, more than any other clinical entity, is a neuropsychological construct 2. The contribution by neuropsychologists to MTBI research is unmatched by any other discipline 3. Neuropsychologists are uniquely suited to evaluate and treat MTBI 4. Neuropsychologists should not limit their role in MTBI just to neuropsych testing Mild TBI A Multi‐disciplinary Approach Pre‐hospital to Rehabilitation • EMS education • ED consultation • Acute TBI Clinic • Multidisciplinary Approach • Neuropsychology & PM/R • Patient/family education • Supportive follow‐up • Outcome research SUMMARY The Epidemic of Mild TBI in Young Adults How Can WE Make an “Impact” • Avoidance – TRAUMA PREVENTION is THE CURE! • TBI EDUCATION • LONGER TERM FOLLOW UP WITH EVALUATION/TESTING • CONCUSSION CLINIC (431‐2477) – Mountain State Medical Group Neurosurgery/Trauma Services 25 8/15/2014 Mild Traumatic Brain Injury Conclusion • No athlete (or soldier) diagnosed with a concussion should RTP/RTD on the same day or while symptomatic. The RTP/RTD decision is a medical one. • Additional research is needed: – – – – to validate current assessment tools, further delineate the role of NP and balance testing, validate RTP/RTD guidelines Improve identification of those at risk for prolonged concussive symptoms or other short‐term or long‐ term complications. Resources • Defense and Veterans Brain Injury Center 1-800-8709244 www.dvbic.org. Check out video Survive, Thrive & Alive on brain injury and treatment and recovery of several injured service members. • Brain Injury Association of America 703-236-6000, www.biausa.org • www.cdc.gov/concussion/headsup/pdf/Facts • Brain Injury Association of Maryland 410-448-2924, www.biamd.org • Ohio Valley Center For Brain Injury Prevention and Rehabilitation, 614-293-3802, www.ohiovalley.org. • www.headinjury.com. Good resource for memory aides and tips Heads Up Facts for Physicians About Mild Traumatic Brain Injury (MTBI) U.S. www.cdc.gov/concussion/headsup/pdf/Facts 26 8/15/2014 SUMMARY Trauma Care Excellence National Outcomes Comparison Johnson City Medical Center - Level I Trauma Center Improved Survival, Improved Outcomes - World Class Care for Traumatic Brain Injury Variable JCMC Mean Comparison Group Mean Age 50 51 Hospital LOS 5 5.5 ICU LOS 4.7 5.4 ISS 9.8 10.5 Vent days 5.9 6.5 % Deaths 3.13 4.25 Deaths ISS > 25 17.0 27.7 PLEASE CONTACT ME IF YOU HAVE ANY QUESTIONS OR WOULD LIKE “Toolkit Material” FOR MILD TBI (PDF) Tyler Putnam, MD, FACS, FCCM Medical Director, Trauma Services Mountain States Health Alliance/Johnson City Medical Center Phone – 423‐794‐7789 [email protected] [email protected] • Thank yOU THANK YOU! The Mountain States Trauma Team 27