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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