Post on 14-Jan-2016
description
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VA Polytrauma System of CareVA Polytrauma System of Care Polytrauma Rehabilitation Centers Polytrauma Rehabilitation Centers
Tampa
Palo Alto
Minneapolis
RichmondRichmond
San Antonio (2012)
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Landstuhl Regional Medical Center
Landstuhl Regional Medical Center
IraqIraq
Bn Aid StationBn Aid Station
Continuity of Care: From Battlefield to VA TBI/Polytrauma System of Care
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Walter Reed Army & Walter Reed Army &
Tampa PRCTampa PRC
Richmond PRCRichmond PRC
Minneapolis PRC
Minneapolis PRC
Palo Alto PRCPalo Alto PRC
Bethesda National NavalMedical Centers
Bethesda National NavalMedical Centers
Balad, IraqBalad, Iraq
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Learning Objectives
• Talk 1• Differentiate Acquired Brain Injury from
Traumatic Brain Injury (TBI)• List types of TBI• List stages of recovery from severe TBI
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Acquired Brain Injury versus Traumatic Brain Injury
• ABI: Impairment of brain function that is
not attributed to congenital, developmental, or degenerative conditions.
• Examples include traumatic brain injury (aka closed head injury, open head injury, penetrating head injury), stroke (ischemic, hemorragic), brain tumors, anoxia, chemical exposure, etc.
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Traumatic Brain Injury
Damage caused by external, mechanical force
Closed Head InjuryCar accidentsFallsBlunt assault
Open Head InjuryPenetrating
Gunshot wound Stabbing wound
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Polytrauma Patient CharacteristicsPolytrauma Patient Characteristics
Sample Size (FY03-FY09) N=653
Brain Injury 91.5%
PTSD 31%
Vision Loss 29%
Hearing Loss 21%
Orthopedic Injuries 11%
Anxiety Disorder other than PTSD
11%
Wounds / Infections 8%
Amputations 5%
Burns 3%
Other (Comorbidities) 99%
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Combat Polytrauma Patient Characteristics (FY03 – present)
Combat Polytrauma Patient Characteristics (FY03 – present)
Age 20-25 (46%) 26-30 (21%) 31-35 (12%) 36 + (20%)
Male 97%
Injury Mechanism Explosion (71%) Vehicle (11%)GSW (9%) Other (9%)
Military Status Active Duty (84%)
Branch Army (68%) Marines (23%)
Deployment Iraq (89%)
Referral** WRAMC (34%) NNMC (28%)Other MTF (31%) Other (8%)
LOS** (Mean days) FY03 (37) FY04 (39) FY05 (57) FY06 (52) FY07 (33) FY08 (29) FY 09 (28)
DC Destination Home (73%) MTF (17%) Home VA (6%)Home VA (6%)Private Facility (4%) Other (<1%)
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Primary
Primary
Screen
Screen
270,022270,022 Total OEF/OIF Veterans Screened
50,06850,068
21,292
Follow-up
Follow-up
Evaluation
Evaluation
Veterans Consenting to Further Evaluation
Mandatory TBI Screening ResultsMandatory TBI Screening Results14 April 2007 – 31 January 200914 April 2007 – 31 January 2009
Mandatory TBI Screening ResultsMandatory TBI Screening Results14 April 2007 – 31 January 200914 April 2007 – 31 January 2009
53,95353,953
7,7257,725
Veterans Requiring Further Evaluation
Veterans with Self Reported Prior TBI
TBI ConfirmedTBI Ruled OutDiagnosis Pending
33,25033,250 Veterans Completed Comprehensive Evaluation
15,486
12,580
5,184
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States of Severely Impaired States of Severely Impaired Consciousness (SIC)Consciousness (SIC)
ComaComa Vegetative State (VS)Vegetative State (VS)
Persistent /Permanent Vegetative Persistent /Permanent Vegetative StateState
Minimally Conscious StateMinimally Conscious State Emerged From Minimally Conscious Emerged From Minimally Conscious
StateState Post Traumatic Amnesia / Post Traumatic Amnesia /
Confusion / DeliriumConfusion / Delirium
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ComaComa VSVS MCSMCS
Severely Impaired Consciousness Severely Impaired Consciousness (SIC)(SIC)
SICSIC ConfusedConfused OrientedOriented
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Early Neurobehavioral Milestones
Duration of Unconsciousnesso Duration of Consciousness (2 consecutive sessions/dates
of observed command following)
Transition from VS to MCS o Tracking, Command Following, Verbalizations
Emergence from MCSo Accurate Yes/No Response, Object Use etc.
Duration or degree of impaired consciousness Post-traumatic Amnesia ( 2 consecutive sessions/dates of
target range scores indicating orientation) Post-traumatic motor restlessness Post-traumatic confusion
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Examples of Cognitive and Behavioral Changes After ABI / TBI
Orientation Alertness Focusing Attention Speed of Processing Remembering New Info Remembering Past Info Perception of
Environment Expressive language Receptive language
Fatigue Executive Skills Reasoning Sequencing Multi-tasking Behavioral Control
(start, stop, & resisting impulse)
Emotional Control(inappropriate or intensity change)
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Outcome Trajectory for Outcome Trajectory for Disorders of Consciousness Disorders of Consciousness
unpublished dataunpublished data
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Outcome Trajectory for Outcome Trajectory for Disorders of Consciousness Disorders of Consciousness
unpublished dataunpublished data
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““To Care For Him Who Shall Have To Care For Him Who Shall Have Borne the Battle, And For His Widow Borne the Battle, And For His Widow and Orphan”and Orphan”
- Abraham Lincoln