managing agitation in traumatic brain injury jennifer e. marks, d.o. department of pm&r lsuhsc
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Managing Agitation in Managing Agitation in Traumatic Brain InjuryTraumatic Brain Injury
Jennifer E. Marks, D.O.
Department of PM&R
LSUHSC
TBITBI
Severe TBI estimated to be only 6% of all hospitalized brain injury cases
However,the health care costs and residual deficits are much greater than with mild/moderate TBI
TBITBI
Mechanisms of injury:PRIMARY: Occur at the moment of impactSECONDARY: Triggered by primary
mechanisms, cause more damage to the brain
Primary Injury Mechanisms-Primary Injury Mechanisms-TBITBI
Most brain damage caused by acceleration-deceleration
Diffuse axonal injury: Widespread stretching of axons caused by the rotation of the brain around its axis
DAI may be seen on brain MRI
Diffuse axonal injuryDiffuse axonal injury
Aka Shear injury Occurs in 50% of all head
trauma cases Characterized clinically
by LOC at time of impact Multiple b/l focal lesions
throughout white matter Most commonly seen in
the corpus collosum, brain stem, and frontal/temporal lobes
Secondary TBI Injury Secondary TBI Injury MechanismsMechanisms
ICH (ex. SDH)Brain edemaOxidant injuryHypoxia secondary to cerebral perfusion
pressureExcitotoxicity: Neuronal damage caused by
accelerated release of excitatory neurotransmitters by injured neurons
Glasgow Coma Scale Glasgow Coma Scale
No direct way to measure the severity of brain injury
The Glasgow Coma Scale is used to measure TBI severity
The GCS evaluates the patient’s eye, motor, and verbal response
The lowest score obtainable is 3, the highest is 15 The lowest post resuscitation score is the preferred
value
GCS PitfallsGCS Pitfalls
Score can be affected by intoxicationIntubation can obscure the difference
between a mild and moderate TBIAlso unscorable if patient cannot
understand the examiner’s language
Severe TBISevere TBI
GCS < or = to 8Patient was in a comaPermanent neurological sequelae and
functional disabilityAt least one year for maximal return to
functioningLarge majority of patients in rehab units
TBI patient issuesTBI patient issues
Spasticity Hetereotopic ossification Posttraumatic epilepsy Postraumatic hydrocephalus Cranial nerve damage Sleep disorders Dysphagia DVT Skin breakdown Post traumatic amnesia/AGITATION
Definition of agitation in TBIDefinition of agitation in TBI
A consensus at this time has not been reached on the exact definition of agitation.
“Subtype of delirium occurring during the period of post traumatic amnesia, characterized by excessive behaviors including some combination of aggression, disinhibition, akathisia, and emotional lability.”
A 1996 literature review featured in the Archives of PM&R by Sandel &Mysiw, 77:617-623
Etiology of agitationEtiology of agitation
Brain trauma disrupts the catecholamine/neurotransmitter pathways: surges of norepinephrine and epinephrine have been documented in the plasma and CSF.
TBI patients can also have hypothalamic dysfunction affecting temperature, blood pressure, etc.
Diagnosing agitation Diagnosing agitation
A diagnosis of exclusion after medical and neurological conditions have been ruled out
Must rule out metabolic derangement, hypothyroidism, infection/sepsis, hypoglycemia , hypoxemia, medications such as anticholinergics
Drug withdrawal (ex. Sedatives, hypnotics)
Diagnosing agitation Diagnosing agitation continued…continued…
Neurologic complications such as seizures, hydrocephalus, IC mass lesions, and migraine are possibilities that must be investigated
NEVER FORGET THAT THE PATIENT COULD BE IN PAIN ALSO!!!
Tests suggested to evaluate Tests suggested to evaluate the agitated patientthe agitated patient
CMP, Thyroid function, CBC with differential, UA, B12/folate, tox screen, Brain CT/MRI, EEG, XR (see if occult fractures/heterotopic ossification causing pain)
Agitation Behavior ScaleAgitation Behavior Scale
Plan for ABS to be instituted at Charity in the near future
Patient given a rating of 1(absent) to 4 (severe) on 14 subcategories
Subcategories include distractibility, impulsivity, violence, alterations of mood
High inter-rater reliability
Rancho Los Amigos Scale of Rancho Los Amigos Scale of Cognitive FunctioningCognitive Functioning
Developed at the California Hospital of the same name
Rancho I: No response to any stimulation; appears to be sleeping
Rancho II: Generalized Response Rancho III: Localized response
Rancho Los Amigos scale Rancho Los Amigos scale (continued)(continued)
**RANCHO IV: Confused, Agitated, may be aggressive
Rancho V: Confused, Inapproriate, nonagitated
Rancho VI: Confused, appropriateRancho VII: Automatic, appropriateRanch VIII: Purposeful, appropriate
Environmental ManagementEnvironmental Management
FIRST REDUCE STIMULI- light, noise, distractions
Patient should have a limited number of visitors at a time
EVERYONE should speak in a low volume, one at a time
Environmental ManagementEnvironmental Management
To reduce patient confusion:Consistent schedule and staffingDon’t move patient to another roomReorient person frequently
Behavioral StrategiesBehavioral Strategies
Tolerate patient’s restlessness as much as possible (ex. Allow patient to pace if ambulatory)
Mobile patients may need a closed unit or sensor unit for their safety
Remove lines tubes ASAPConsider Craig bed or Vail bed
Environmental ManagementEnvironmental Management
AVOID RESTRAINTS IF AT ALL POSSIBLE
Padded hand mittens if necessary Soft lap belt in the wheelchairHeavy, stable wheelchair that will not tip
over
MedicationsMedications
Since 1966, there have only been six randomized controlled trials concerning medication management of TBI agitation!
Almost all studies evaluating medications have been on subjects greater than ten years old.
Measurement and Treatment Measurement and Treatment of Agitation following TBI- of Agitation following TBI-
Fugate et al.Fugate et al.Study of 129 physicians divided into
experts or nonexperts surveyed.
Experts either had published two or greater articles on pharmacological interventions for TBI in the last 5 years, or had > or = 70% of their practice devoted to treating TBI
Fugate et al. continuedFugate et al. continued
Experts most frequently prescribed carbamazepine, beta blockers, TCA’s
Nonexperts chose Haldol four times more frequently than experts
MedicationsMedications
Most commonly utilized Antiepileptics Dopamine agonists (amantadine)Antidepressants (TCA’S)Antipsychotics (Haldol)Beta Blockers(Inderal)
Medications for agitationMedications for agitation
Antiepileptics: Carbamazepine: Commonly utilized by rehab
facilities. Some promise with agitation but only case reports have been published
Phenytoin, Phenobarbitol: Not recommended secondary to interfering with cognitive function and causing excessive sedation
MedicationsMedications
Benzodiazepines: Not recommended for long term agitation treatment due to interference with cognitive function and sedation
AntipsychoticsAntipsychotics
Ex. Haldol: The typical agents, in both human and animal studies, have been shown to cause a decline in cognitive performance (verbal ability, memory, learning, attention, spatial ability…..once the medication was stopped, cognition improved)
Stanislav et al, Brain Injury 1997, p335-41
Beta blockersBeta blockers
Two placebo-controlled, blinded studies with propanolol showed decreased agitation in patients with TBI.
Also helps to control tachycardia and hypertension many TBI patients have
Beta BlockersBeta Blockers
Twenty one subjects with TBI Treated with propanolol or placebo in a
double-blind studyIn the treatment group the intensity of
agitation was significantly lower, although the number of episodes was similar. The use of restraints was also significantly lower.
Brooke et al., Arch Phys Med Rehabil 73, Oct 1992, 917-921
Beta BlockersBeta Blockers
Starting dose of propanolol at 20 mg BIDCan use QID dosingIN ADULTS can titrate up to 60 mg/day Usually max amount 240 mg/day in adults,
but doses as high as 600 mg/day have been reported
As patient improves, can taper off
MedicationMedication
Dopamine agonists (amantadine, bromocriptine) , SSRIs, methyphenidate, and TCA’s have not been shown to control agitation successfully, but do improve alertness/initiation
ConclusionConclusion
More RCT studies need to be done to determine the optimum pharmacologic intervention for TBI
SourcesSources
As previously stated, and…… Randall L. Braddom. Physical Medicine and
Rehabilitation. Second Edition. W. B Saunders Co. , Pennsylvania. 2000.
Fleminger S., Greenwood RJ, Oliver D.L. Pharmacological management for agitation and aggression in people with acquired brain injury (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Thank you to Dr. Kiersta Kurtz-Burke, PM&R consult service staff at Charity!