evaluation tools tbi severity - cloudcme · 2017-09-07 · tbi severity centers for disease control...
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TBI Severity &Evaluation Tools
Cherry Junn, MDMarch 10th 2017
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Learning Objectives
• Define TBI severity using GCS• Identify cognitive functional level after TBI
using Rancho Los Amigos level• Assess PTA using GOAT and O-Log• Describe major findings of the amantadine
trial
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Learning Objectives• List key parameters of:– Glasgow Coma Scale (GCS)– Galveston Orientation & Amnesia Test (GOAT)– Level of Cognitive Functioning Scale (Rancho)– Disability Rating Scale (DRS)
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Case• Mr. TBI is a 25 yo office manager who was in
a MVC 2 weeks ago– Speed was 45mph– LOC 5 minutes– Initial head CT with right frontal IPH, left occipital small SDH, diffuse petechial hemorrhage
– Reports dizziness, headaches, irritability, sleep changes, and cognitive impairment
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Case - Common Mechanisms• Is his mechanism of injury common or
uncommon for his age?– YES– NO
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Answer
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Clinical Diagnosis of TBI
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Diagnose TBI – clinical diagnosis1) Reasonable mechanism of injury
1) LOC / Dazed / Amnesia at the time of injury
1) Objective neuro/psychological abnormalities
Differentiate from whiplash
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Reasonable Mechanism of Injury• Blunt Trauma• Penetrating Trauma• Acceleration/deceleration–MVC– Collision (sports, transportation injuries)
• (Blast)
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Case• Mr. TBI is a 25 yo office manager who was in
a MVC 2 weeks ago– Speed was 45mph– LOC 5 minutes– Initial head CT with right frontal IPH, left occipital small SDH, diffuse petechial hemorrhage
– Reports dizziness, headaches, irritability, sleep changes, and cognitive impairment
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Case - Diagnosis• Did Mr. TBI have a TBI?–What is his mechanism of injury?–What suggests change in consciousness?–Where were his neuro/psych/behavioral symptoms and signs?
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Determining TBI Severity
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TBI Severity
Centers for Disease Control and Prevention. "Report to congress on traumatic brain injury in the United States: Epidemiology and rehabilitation." National center for injury prevention and control (2014).
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** TBI Severity Using GCS **• Mild: 13-15 –Mild-complicated: 13-15 with CT or MRI findings
• Moderate: 9-12
• Severe: 3-8 = Coma• Intubate
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GCS • Predictive: best motor response is the most
valuable/predictive acutely, especially if overt decorticate/decerebrate posturing is seen
Healey, C., et al. "Improving the Glasgow Coma Scale score: motor score alone is a better predictor." Journal of Trauma and Acute Care Surgery 54.4 (2003): 671-680.
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Case - Severity• After resuscitation he:– Opens eyes to pain– He is able to use exclamatory articulated speech, but no conversational exchange. Speaks words but no sentences
–Withdraws from pain
• What is his GCS score?A. 10B. 9C. 8D. 7
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Case question• What is his injury severity based on his GCS?
A. MildB. Mild-complicatedC. ModerateD. Severe
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Post-traumatic amnesia• Most commonly used predictors of functional
outcome and is associated with DAI1
• What correlates with resolution of PTA clinically?
Zafonte RD, Mann NR, Millis SR, et al: Posttraumatic amnesia: its relation to functional outcome. Arch Phys Med Rehabil 1997; 78: pp. 1103-1106
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TBI Severity Using PTADuration of PTA Severity
< 5 minutes Very mild
5-60 minutes Mild
1-24 hours Moderate
1—7 days Severe
1-4 weeks Very severe
> 4 weeks Extremely severe
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GOAT
• Assess both remote memories, time of injury memories, and post-injury memories
• Score ranging from -3 to 100 • PTA ends when GOAT scores are greater than 75 for two consecutive trials, 24 hours apart beginning at the end of the coma
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Case - Post-traumatic amnesia• His GOAT score today is 78, is Mr. TBI out of
PTA?
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Orientation-Log (O-Log)• Like the GOAT, also focuses on disorientation
and amnestic symptoms • Puts more equal weight into scored items and
reduces difficulty verifying some responses.• 2 consecutive scores of 25 and higher indicate resolution of PTA
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O-Log
http://www.tbims.org/combi/olog/olograt.html
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Question• Which of the following case is unlikely to
result in severe disability after TBI?A. Post-traumatic amnesia (PTA) greater than 3
monthsB. Age > 65 yearsC. Age < 5 yearsD. PTA less than 2 monthsE. Impaired doll’s eye sign
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Functional Prognosis Mod-Severe TBI
• Threshold values what’s unlikely to happen
– Severe disability unlikely • Time to follow commands less than 2 weeks• Duration of PTA less than 2 months
– Good recovery unlikely• Time to follow commands more than 4 weeks• Duration of PTA more than 3 months• 65+ years old and less than 5 years old
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TBI Outcome Studies GOS• 1 = DEAD• 2 = VEGETATIVE STATE
Unable to interact with environment; unresponsive• 3 = SEVERE DISABILITY
Able to follow commands/ unable to live independently• 4 = MODERATE DISABILITY
Able to live independently; unable to return to work or school
• 5 = GOOD RECOVERY Able to return to work or school
http://www.tbims.org/combi/gos/index.html
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Mortality / VegetativeJennet (1979)• GCS 3-4: death or vegetative in 87%• GCS 5-7: death of vegetative in 53%
McMillan (2011) and other cohort studies• 30% mortality in severe TBI• Increased mortality 13 years post injury
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Mod-Severe TBI: Trends to worse outcome
– Lower GCS– Longer duration of coma
– Longer PTA– Older age– Deeper lesions on imaging
– Fixed pupils
– Associated injuries– Hypotension– Hypoxia– Pyrexia– Elevated ICP– Bleeding issues
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COAT• Neurosurgery. 1990 Nov;27(5):683-91; discussion 691.• The Children's Orientation and Amnesia Test: relationship to severity of acute head injury and to recovery of memory.• Ewing-Cobbs L, Levin HS, Fletcher JM, Miner ME, Eisenberg HM.• Source• Department of Pediatrics, University of Texas Medical School, Houston.• Abstract• The Children's Orientation and Amnesia Test (COAT) was developed to assess cognition serially during the early stage of
recovery from traumatic brain injury in children and adolescents. The norms for the COAT, which is composed of 16 items evaluating general orientation, temporal orientation, and memory, were defined from data obtained from 146 children aged 3 to 15 years. In 37 patients with head injuries, the duration of posttraumatic amnesia, as indicated by the number of days COAT scores were in the impaired range, was significantly related to both verbal and nonverbal memory at the baseline and 6 and 12 months after injury. COAT scores were a better predictor of verbal and nonverbal memory performance than the Glasgow Coma Scale score at 6 and 12 months after the injury. This study shows that the COAT has adequate reliability and validity as a measure of the duration of posttraumatic amnesia in children and adolescents.
• PMID2259396
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Rancho Los Amigos Level of Cognitive Function Scale
• Scale to help interpret the cognitive behavioral recovery process after a brain injury
• Ranges from I to VIII • Lower score indicates a more severe
impairment of consciousness
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Rancho Los Amigos ScaleLevel Description
I No response
II Generalized response
III Localized responses
IV Confused – agitated
V Confused – inappropriate
VI Confused – appropriate
VII Automatic – appropriate
VIII Purposeful and appropriate
http://www.tbims.org/combi/lcfs/lcfs.pdfhttp://www.rancho.org/research_rancholevels.aspx
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Level of Cognitive Functioning Scale
I - No responseII - GeneralizedIII - LocalizedIV - Confused-agitatedV - Confused, inappropriate,
non-agitatedVI - Confused-appropriateVII - Automatic-appropriateVIII - Purposeful-appropriate
3
3
2
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Case - Rancho• Now Mr. TBI shows bizarre, nonpurposeful,
incoherent or inappropriate behaviors, has no short-term recall, attention is short and nonselective
• What Rancho level of cognitive functioning would you label him with?A. IIIB. IVC. VD. VI
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Identifying Rancho Level• A different patient who sustained a severe TBI
3 weeks ago gives random, fragmented, and nonpurposeful responses to complex or unstructured stimuli. She is able to follow simple commands consistently though her memory and selective attention are impaired. She cannot retain new information.
• What is her rancho level?
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Identifying Rancho Level• Another patient who sustained severe TBI
behaves appropriately in familiar setting and able to perform daily routines automatically.
• She is able to carry-over for new learning at lower than normal rates.
• She initiates social interactions, but judgment remains impaired.
• What is her rancho level?
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Ranchos Levels of Cognitive Functioning Scale
Amy K. Wagner, Patricia M. Arenth, Christina Kwasnica and Emily H. McCullough Braddom Physical Medicine and Rehabilitation, Chapter 43, 961-998.e13
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Quest for Neuro-recovery
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Amantadine• 184 subjects– minimally conscious or vegetative
• 4-16 weeks after TBI• Amantadine or placebo for 4 weeks– Followed for another 2 weeks
• “Amantadine accelerated the pace of functional recovery during active treatment”
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Disability Rating Scale (DRS)• “From coma to
community”– Less helpful reflecting recovery course in mTBI
• Higher score better–Max 30
• 8 categories
– Eye opening– Communication–Motor Response– Feeding– Toileting– Grooming– Levels of Function– Employability
http://www.tbims.org/combi/drs/index.html
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Scales for Assessing Disorders of Consciousness
• Coma Near Coma (CNC) Scale: – 11 item scale designed to measure small changes in response those functioning at low level after severe brain injury
• JFK Coma Recovery Scale-Revised (CRS-R)– 23 item scale assessing auditory, visual, motor, oromotor, communication, and arousal
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Questions?
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References and ReadingsBrown AW, Elovic EP, Kothari S, Flanagan SR. Congential and Acquired Brain Injury. Archives of Physical Medicine and
Rehabilitation. 2008; S1: S3-37.
Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. 2nd Ed. New York, NY: Demos; 2010: 49-90.
Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury: Observations on the use of the Glasgow Outcome Scale. Journal of Neurology, Neurosurgery, & Psychiatry. 1981; 44: 285-293.
Kothari S, DiTommaso C. Prognosis after severe TBI: a practical, evidence-based approach. In: Zafonte R, Zasler ND, Kats DI, eds. Brain Injury Medicine: Principles and Practice. 2nd Edition. New York: Demos;20012: 529-544.
Levin HS, O’Donnell VM, Grossman RG. The Galveston Orientation and Amnesia Test: A practical scale to assess cognition after head injury. The Journal of Nervous and Mental Disease. 1979; 167 (11): 675 – 684.
McMillan TM, Teasdale GM, Weir CJ, Stewart E . Death after head injury: the 13 year outcome of a case control study. J Neurol Neurosurg Psychiatry. 2011;82(8):931.
Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. British Journal of Neurosurgery. 2002; 16 (3): 220 – 242.
Signoretti S, Lazzarino G, Tavazzi B, Vagnozzi R. The pathophysiology of concussion. PM R. 2001; 3: S359 – S368.
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Supplement: Disorders of Consciousness
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Disorders of Consciousness
Sleep Cycles
Eye Opening
Follow Commands
ComaVegetativeMinimally conscious
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Disorders of Consciousness
Sleep Cycles
Eye Opening
Follow Commands
Coma - - -Vegetative + + -Minimally conscious
+ + +