Traumatic Brain Injury (TBI) is on the upswing. Researchers are scurrying to find better ways to assess, diagnose, and treat TBI while the ranks continue to swell.
The statistics are overwhelming. In 2010 alone, over 2.5 million people were diagnosed with TBIs either as an isolated injury or along with other injuries. Over the past decade (2001–2010), rates of TBI-related ER visits increased by 70 percent. In 2009, an estimated 250,000 children (age 19 or younger) were treated in U.S. ERs for sports and recreation-related injuries that included a diagnosis of concussion or MTBI, and from 2001 to 2009, the rate of ER visits for sports and recreation-related injuries with a diagnosis of concussion or TBI, alone or in combination with other injuries, rose 57 percent among children (age 19 or younger).
“Sports injuries, childhood pranks, kitchen falls and more puts patients at risk for mild to severe head trauma,” says Dr. Silke Bernart, Director of the Brain Injury Unit at Cardinal Hill and an assistant professor at the University of Kentucky Physical Medicine and Rehabilitation Department. The people most at risk of traumatic brain injury include:
- Children, especially newborns to 4-year-olds
- Young adults, especially those between ages 15 and 21
- Adults age 75 and older
Traumatic brain injury is defined as trauma to the brain by blunt, penetrating or acceleration/deceleration forces. The degree of damage depends on several factors, including the nature of the event and the force of impact. TBI is divided into mild, moderate or severe based on an individual’s arousal and duration of amnesia, motor and verbal response (GCS).
“All severity levels of TBI can cause long lasting significant and potentially disabling symptoms,” cautions Bernart. In mild TBI most patients experience resolution of their posttraumatic complaints within 3 months post injury, however about 10 percent of patients report persistent symptoms.
Children are particularly sensitive to brain injury resulting in longer recovery periods and increased likelihood of permanent or severe neurologic damage. “Second Impact Syndrome” is caused by an often only mild second injury to a brain in a vulnerable phase after prior traumatic injury, and can have devastating consequences. “Any athlete after concussion should not be allowed to return to play unless cleared by a physician experienced in concussion management,” Bernart says.
Repeated mild traumatic brain injury may not only result in prolonged recovery periods and successively worsening symptoms, but this may also lead to progressive neurologic symptoms termed Chronic Traumatic Encephalopathy.
Initial assessment of a traumatic brain injury should include a comprehensive approach to the patient including mechanism of injury, duration of loss of consciousness, assessment of posttraumatic amnesia and other injuries as well as evaluation of possible preceding events or factors leading to TBI including orthostatic hypotension, syncope, cardiac conditions, intoxication and others. WPTAS and GCS are helpful in assessment of the acutely injured. Evaluation must include a comprehensive medical and neurological exam.
Any of the following signs or symptoms represents an indication for a head CT:
change or loss of consciousness, progressive headaches, unreliable or inadequate history, age < 2, vomiting, posttraumatic amnesia, signs of basilar skull fracture, significant subgaleal swelling, seizures, Alcohol and/ or drug intoxication, any focal neurological findings, penetrating skull injury and others. Examiners need to exercise extreme caution as there are 15 percent of patients who do not initially present with signs of significant brain injury, but may decline in a delayed fashion and can die.
Mild TBI may be difficult to detect on the primary assessment. Signs and symptoms of MTBI generally fall into four categories: physical, cognitive, emotional, and sleep problems. This includes, but is not limited to headaches, nausea, balance impairment, vertigo, fatigue, drowsiness, light or noise sensitivity, problems with attention, memory or processing speed, irritability, anxiety, insomnia or hypersomnia.
The CDC has created a tool, the Acute Concussion Evaluation (ACE) available at http://www.cdc.gov/concussion/headsup/pdf/Facts_for_Physicians_booklet-a.pdf. This tool was developed to provide physicians with an evidence-based protocol to conduct an initial evaluation and diagnosis of patients with MTBI.
The ACE contains three major components that require evaluation:
• Characteristics of the injury;
• Types and severity of the symptoms; and
• Risk factors that can lead to a protracted period of recovery
With proper diagnosis and management, most patients with MTBI recover fully. If necessary follow up with a neurologist or brain injury rehabilitation specialist should be arranged.
Current research is changing how we think about, and how we diagnose and treat brain trauma, as we learn more about increased risk with history of concussion and the variability of symptoms. Keeping up-to-date with these new directions is critical to your ability to treat patients effectively.
by Doris Settles, Staff Writer