blast injuries marc gramatges, psy.d and kyle haggerty, ph.d. january 24 th, 2013 photo from:

Blast Injuries

Marc Gramatges, Psy.D and Kyle Haggerty, Ph.D.

January 24th, 2013

Photo From: http://www.fastcompany.com/1834866/bands-ex-tour-manager-blasts-reddit-founder-alexis-ohanian-kim-dotcom-kickstarter-begging-bo

© 2013 Bancroft | All rights reserved

Learning Objects• Statistics• Mechanisms of Injury• Signs and Symptoms• TBI and PTSD• Evaluation and Detection• Multiple TBIs• Treatment• Recovery• Living with a TBI


Statistics


Prevalence

• Over 7,000 American Soldiers have been killed in action during the Operation Iraqi Freedom & Operation Enduring Freedom conflicts

• According to the Huffington Post, as of October 2012, over 50,000 soldiers had been wounded

• The majority of those injuries were the result of Improvised Explosive Devices (IED), and therefore blast injuries

• These injuries include amputations, fractures, and many include concussions which are mild Traumatic Brain Injuries (mTBI)


Prevalence

• Two-thirds of war zone evacuations and 88% of injuries treated were due to blast injury

• 50% of all wounds sustained by combatants in action were blast injuries

• Blast injuries in the civilian population are also on the rise

Photo: http://news.bbc.co.uk/2/hi/in_pictures/6177540.stm


Positive Side• More and more soldiers are surviving exposure to

blast injuries • Due largely to improvements in body armor,

which prevent penetrating injuries, and also damped the effects of the blast wave on the heart and lungs

• However, more survivors means it is becoming more important to understand the effects of being exposed to a blast, both short and long term.

Photo: 10TH COMBAT SUPPORT HOSPITAL, Baghdad--Soldiers from Troop A, 1st Squadron, 10th Calvary Regiment, 2nd Brigade Combat Team, 4th Infantry Division, surround Staff Sgt. Michell Caldwell, scout, Troop A, 1-10 Cav, following his re-enlistment. Moments after he took the oath, he was evacuated to Germany to treat gunshot wounds to both forearms sustained on a combat patrol with the men earlier the same day. (U.S. Army photo courtesy of 1-10 Cav.)


Mechanisms of Injury


Types of Blasts• High order explosive

• Explosion is supersonic • Blast contains a over-pressurized

wave• A wave where the air is

compressed to a point where it can itself be dangerous

• Followed by under-pressure as the air pressure drops before returning to normal

• Low order explosive• Explosion is not as fast as the

speed of sound• No over-pressurization wave

Photo: MIT Technology Review


Blasts• Primary: Over-pressurization shock wave followed by an

under-pressurization wave. Frequently causes TBI, lung injury, and tympanic membrane ruptures.

• Secondary: Bomb fragments and shrapnel, propelled by the explosion, impact the victim. Frequently causes lacerations, amputations, and open head injuries.

• Tertiary: The blast wind throws the body of the victim against another object. Common cause of mTBIs.

• Quaternary: Injury from exposure to the heat, chemicals, or radiation in the explosion .


Nature of Injuries• Research used to focus primarily on damage to gas

filled organs (e.g. lungs or intestines), as these were believed to be the organs most significantly affected by blast exposure

• The brain was previously believed to be largely protected by blasts due to the skull

• It has now been determined that the brain is just as susceptible to blast injury as other organs

• In fact, TBI has been identified as one of the more frequent injuries during the current conflicts, and accounts for a greater proportion of injuries than in any previous conflict


What Happens to the Brain

• Studies on rats have revealed that even when the head is protected, blast injuries causes significant neural damage

• Damage was particularly severe in the hippocampus of rats

• It was hypothesized that the hippocampus was more susceptible to injury due to its sensitivity to oxygen deprivation

• Rats showed signs of cognitive impairments and stress reactions following the injuries


What Happens to the Brain

• The blast wave or any penetrating injury may interfere with blood flow in the brain, depriving the brain of needed oxygen.

• Compression of the tissue can worsen the effect, by reducing brain tissue oxygen levels


Signs and Symptoms


Mild TBI Symptoms• There are no symptoms that are unique to mTBI

• Many post-concussion symptoms can be seen within healthy individuals

• mTBI symptoms can overlap with other conditions• Post Traumatic Stress Disorder (PTSD), depression, or

other health conditions


What are Common Signs and Symptoms of TBI?• Physical

• Headache• Sleep

disturbance• Dizziness• Balance

problems• Nausea/vomiting• Fatigue• Visual

disturbances• Sensitivity to

light• Ringing in the

ears

• Cognitive• Concentration

problems• Temporary

gaps in memory immediately after injury

• Attention problems

• Slowed thinking

• Difficulty finding words

• Emotional• Irritability• Anxiety• Depressio

n• Mood

swings


Can be Difficult to Detect

• Most soldiers remain on active duty following exposure to a blast

• Some of the symptoms can worsen following the injury

• The symptoms of mTBIs can be particularly difficult to detect

Photo: Joe Radle/Getty Images


Warning Signs• Worsening headaches• Worsening balance• Double vision or other vision

changes• Decreased level of alertness• Increased disorientation• Repeated vomiting• Seizures• Unusual behavior• Amnesia/memory problems


Time of Injury

Mild TBI

Moderate TBI

Severe TBI


TBI and PTSD


Correlation Between PTSD and TBI• Research suggests that PTSD is more likely following TBI

• Incidence 13%-27%• Prevalence 3%-59%

(Bryant, 2000)

• Some researchers argued that PTSD following a head injury was not possible due to memory loss, but many of those hypotheses have not been supported by the data


Risk Factors for Developing PTSD Following a TBI • Female• Avoidant • Lesions to the left temporal lobe• Pre-morbid depression or anxiety • Early symptoms of depression following the injury


Diagnosis Criteria for PTSD

• Criteria A• The person experienced, witnessed, or was confronted

with an event involving actual or threatened death, serious injury or a threat to physical integrity of self or others

• The person’s response involved intense fear, helplessness or horror

Photo: This Sept. 29, 2009 photo shows U.S. Marine Lance Cpl. Greg Rivers, 20, of Sylvester, Ga., waiting to take psychological tests at the Marine Corps Air Ground Combat Center in Twentynine Palms, Calif. (Jae C. Hong/ASSOCIATED PRESS)


Continued• Criteria B

• The traumatic event is re-experienced in one or more of the following ways

• Recurrent images, thoughts or perceptions• Recurrent distressing dreams of the event• Acting or feeling as if the event was recurring• Intense psychological distress OR physiologic

reactivity at exposure to cues that symbolize or resemble an aspect of the event


Continued

• Criteria C• Persistent avoidance of stimuli associated with trauma

and numbing as indicated by 3 or more:• Avoiding thoughts, feelings, or discussion, activities,

places or people that bring back recollections; sense of foreshortened future

• Inability to recall; restricted affect• Diminished interest or participation• Feeling detached or estranged


Continued Some More

• Criteria D• Persistent symptoms of increased arousal by 2 or more:

• Difficulty falling or staying asleep• Irritability or outbursts of anger• Difficulty concentrating• Hypervigilance• Exaggerated startle response

• Criteria E • Duration for more than 1 month


Where Is the Difference?• All of the Criteria except for one are frequently met by

someone who suffered a significant head injury.• The exception is criteria B (Re-experiencing the

trauma)


Symptoms of TBI and PTSDPTSD Symptoms Mild TBI Symptoms

Memory Problems Memory Problems

Poor Concentration Poor Concentration

Depression Depression

Irritability Irritability

Sleep Difficulties Sleep Difficulties

Avoidance Headaches

Re-experiencing Symptoms Dizziness


PTSD

Cognitive Impairment

TBI


Detection and Evaluation


Evaluation

• The overarching goal of assessment is to identify those patients who have suffered a mTBI, treat their symptoms and identify any co-occurring conditions that may delay their return to duty.

• Imaging studies are not necessary for the majority of mTBI patients. Imaging is typically negative in this population but should be preformed whenever more severe pathology is suspected.


Detection• Diffusion Tensor Imaging (DTI)

• MRI-based neuroimaging technique that allows visualization of the brain's white matter tracts.

• Susceptibility Weighted Imaging (SWI)• Fully flow compensated, long echo, gradient echo

(GRE) scan to acquire images


Blunt Trauma• Service members almost always also suffer blunt trauma

after blasts

Photo: http://www.medpagetoday.com/CriticalCare/HeadTrauma/31744


Blast vs Blunt?• DTS and SWI shows evidence of nerve damage in 30-40

percent of service members who are symptomatic from a mTBI.

• There is no clear evidence that the types of combat-related mTBI are significantly different for blast or blunt trauma from sports.

• Recent neuropsychological studies have found no measurable differences in cognitive performance between blast and blunt injuries.



Screening

• Individuals who sustain a mTBI often do not seek out medical attention

• In 2011 the Department of Defense instituted a requirement that all service members exposed to a blast event (within 50 meters), or who were inside a vehicle or building exposed to a blast, must be removed from combat for at least 24 hours and be medically evaluated prior to return to duty


Evaluation

• In the military, corpsmen and medics are expected to use the Military Acute Concussion Evaluation (MACE) which consists of standardized testing of cognition, neurologic functions including balance, and a symptom screen.

• Those individuals who remain symptomatic 24-48 hours after the injury are often referred for further testing.


Multiple TBIs


Cumulative mTBI

• Prior history of mTBI may be associated with slower recovery.

• Thus, there is a substantial body of evidence that suggests worsened brain injury, and worsened neurologic outcomes, associated with multiple mTBI.


Long Term Effects of mTBI

• Increased sensitivity to future head injuries• Athletes with a history of 3 or more mTBI are more likely to

lose consciousness, experienced amnesia and confusion, and emergency symptoms following another mTBI.

• Studies have shown neurological changes in individuals who have sustained multiple mTBI.• However, the exact nature of the deficits seen in individuals

who suffer multiple head injuries has not yet been clearly identified.

•Collins, M. W., Lovell, M. R., Iverson, G. L., Cantu, R. C., Maroon, J. C., Field, M (2002). Cumulative Effects of Concussion in High School Athletes. Neurosurgery, 51, 1175-1181.


Cumulative mTBI

• Chronic traumatic encephalopathy (CTE), a form of dementia, may result from multiple mTBI, either those sustained in the military from multiple blast injuries, or from contact sports such as boxing and football.

• CTE appears as a progressive decline of memory and cognition, as well as depression, suicidal behavior, poor impulse control, aggressiveness and, eventually, dementia. In addition, long term and possibly permanent damage to the pathways, or wiring, of the brain can be caused by mTBI.


Treatment


Medical Evacuation• Initial life saving treatment begins on the battlefield but often leads to

medical evacuation.– Combat support hospitals – Landstuhl Regional Medical Center (LRMC) in Germany

• Trauma surgery• Neurosurgery• Neurology• Critical care doctors and nurses

– Designated inpatient TBI centers in continental United States (CONUS)• Walter Reed National Military Medical Center in Bethesda, Md.• Brooke Army Medical Center in San Antonio, Texas.

• This cycle of evacuation can occur in as few as 72 hours — much more quickly than in previous conflicts which sometimes took 30 days or more.



The IndividualThe Individual

• Treatment for post-concussional syndrome should be developed around the specific symptom constellation presented by an individual patient.

• Psycho-education has been shown to significantly decrease distress in response to post-concussional symptoms.

Photo: http://www.army.mil/article/11222/neurologist-brings-important-skills-to-iraq/


Interdisciplinary Therapy• Interdisciplinary teams are common and sometimes necessary for the

management of TBI:– Audiology/vestibular– Cognitive rehabilitation– Neuropsychology – Occupational therapy– Optometry – Pharmacy – Physical therapy – Primary care – Speech and language pathology – Other specialties


•Psychotherapy and psychopharmacology have been found to be effective in treating many of the psychological symptoms of mTBI.

•Pharmacologic therapy of mTBI is often necessary for the treatment of symptoms such as headache, nausea and insomnia. It is also critical to identify co-occurring conditions such as depression, anxiety and PTSD. A key point to consider when prescribing medications are low dose with slow titration.

•However some psychotropic medications have been shown to slow cognitive recovery.

ContinuedContinued


Continued• Rest is often the best way for the brain

to recover from a mTBI.• This means avoiding general physical

exertion as well as mental exertion (including school and leisure activities like watching TV).

• AVOID A SECOND TBI• As previously described, it can be

very dangerous to suffer a second mTBI before the symptoms of the first have subsided.


Recovery


Prognosis

• The vast majority of those with mTBI have a complete recovery, usually within minutes or hours.

• Risk factors for prolonged symptoms include loss of consciousness associated with the impact, history of previous mTBI, or a history of certain behavioral problems such as anxiety.


Prognosis

• For the small proportion who remain symptomatic, the most common mTBI symptoms are headaches, sleep disturbances and balance problems or dizziness.

• Approximately 50 percent of those with post-traumatic stress disorder have had a mTBI, and approximately 50 percent of those with a mTBI who remain symptomatic for weeks or months will develop post-traumatic stress disorder.

• Multiple mTBIs may lead to prolonged or permanent cognitive and other neurologic problems.


Why Does mTBI Affect Returning to Duty?• Symptoms after a mTBI can affect performance and place

the service member or their unit in danger.

• These temporary symptoms resolve faster when the brain gets rest, so it is important to take time to recover.

• If the service member sustains another mTBI before healing from the first one, his or her recovery might take longer.


Duty Restrictions• Duty restrictions should be based on the individual needs of

the patient and their provider’s judgment.

• In the acute phase (first seven days), symptomatic patients should be considered for limited duty hours to facilitate brain recovery.

• Slowly increasing the patient’s physical activity should be encouraged and monitored.

• Exertion testing should be performed when a patient with a mTBI has recovered to a point where return to duty is considered. This helps ensure that symptoms do not recur with physical stress. (At the present time there is no clinical practice guideline for return to duty decisions).


Returning to Duty

• Rest should include physical as well as mental work.• It also is important to avoid activities that would put the

brain at risk for a second injury before the brain has been given adequate time to heal.

• A medical provider will determine when a service member should return to duty. • Going back to work too soon may cause symptoms to

recur or worsen.


What Can Service Members Do To Return To Duty Faster?• Maximize downtime and rest.• Sleep is key to recovery. Get six to eight hours of sleep.• Protect themselves from another mTBI by avoiding contact sports, combatives, etc.• Let others know that they have had a mTBI so they can watch out for them.• Drink plenty of water.• Follow their medical provider’s instructions and be honest about their symptoms.• Avoid alcohol and drug use. (Alcohol and drug use significantly slow down recovery).• Avoid caffeine, energy drinks and other “energy-enhancing” products that might

interfere with sleep.• Don’t take any medications, including over-the-counter medications, unless their

medical provider instructs them to.• Avoid sleeping aids and sedatives unless their provider advises them to take them.• Don’t do physical work, heavy lifting or exercise until cleared by their medical provider.• Limit activities that require intense concentration, such as writing reports or playing

video games.


Living with a TBI


What are Some Coping Tips for Service Members?• Write things down; carry a small pad and pen.• Store important items, such as your keys or your wallet, in the same

designated place to keep from losing them.• Keep a steady pace. Take breaks as needed.• Focus on one thing at a time.• Perform tasks in a quiet, non-distracting environment.• If feeling irritable or angry, try relaxation techniques and/or walking

away from the situation.• Think about the obvious:

• Are you irritable or having trouble concentrating? Are you getting enough sleep?

• Are you having trouble sleeping? Are you drinking energy drinks or alcohol?


Prevent Additional TBIs•Buckle seat belts

•Avoid clutter around the home

•Use caution on slippery surfaces

•Wear appropriate shoes

•Use appropriate aid devices (walkers, wheelchairs, etc.)


Resources

• Brain Injury Association of America

• Centers for Disease Control and Prevention

• The Defense and Veterans Brain Injury Center

• U.S. Department of Veterans Affairs


References Brain Injury Association of America (2013). Retrieved December 28, 2012, from http://www.biausa.org/

Bryant, R. A., Marosszeky, J.E., Crooks, J., & Gurka, J. A. (2000). Posttraumatic stress disorder after severe traumatic brain injury. American Jounral of Psychiatry, 157, 629-631.

Centers for Disease Control and Prevention (2013). Retrieved December 28, 2012, from www.cdc.gov

Defense and Veterans Brain Injury Center (2013). Retrieved December 28, 2012, from http://www.dvbic.org/

DeWitt, D., & Prough, D. (2009). Blast-induced brain injury and posttraumatic hypotension and hypoxemia. Journal of Neurotrauma, 26, 877-887.

Koliatsos, V., Cernak, C., Xu, L., Song, Y., Savonenko, A., Crain, B., Eberhart, C., Frangakis, C., Melnikova, T., Kim, H., & Lee, D. (2011). A mouse model of blast injury to brain: initial pathological, neuropathologicalm and behavioral characterization. Journal of Neuropathology, 70, 399-416.

Sullivan, E. (2012). War-related PTSD, blast injury, and anosognosia. Neuropsychological Review, 22, 1-2.

U.S. Department of Veterans Affairs (2013). Retrieved December 28, 2012, from va.gov

Wilk, J. E., Thomas, J. L., McGurk, D. M., Riviere, L. A., Castro, C. A., & Hoge, C. W., (2010). Mild traumatic brain injury (concussion) during combat: lack of association of blast mechanisms with persistent postconcussive symptoms. Journal of Head Trauma Rehabilitation, 25, 9-14.


http://www.biausa.org/

http://www.cdc.gov/

http://www.dvbic.org/

Contacts


blast injuries marc gramatges, psy.d and kyle haggerty, ph.d. january 24 th, 2013 photo from:

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