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TBI and Stroke: What is the Same? What is Different? Carol Ann Smith, RN, CNRN Program Coordinator - Traumatic Brain Injury Center Donna Lindsay, MN, RN,

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Presentation on theme: "TBI and Stroke: What is the Same? What is Different? Carol Ann Smith, RN, CNRN Program Coordinator - Traumatic Brain Injury Center Donna Lindsay, MN, RN,"— Presentation transcript:

1 TBI and Stroke: What is the Same? What is Different? Carol Ann Smith, RN, CNRN Program Coordinator - Traumatic Brain Injury Center Donna Lindsay, MN, RN, SCRN Program Coordinator - Hennepin Stroke Center

2  At the end of this presentation the learner will be able to:  Define traumatic brain injury (TBI) and stroke  Describe similarities in TBI and stroke neurological & functional impairments  Identify differences in TBI and stroke prevention

3  TBI and Stroke are both types of acquired brain injury  Acquired brain injury is damage to the brain that occurs after birth  The two main types of acquired brain injury are:  Traumatic brain injury ▪ Direct or indirect trauma to the brain  Non-traumatic brain injury ▪ Includes brain damage from stroke, brain tumors, infection, hypoxia or substance abuse

4  In both TBI and Stroke, brain injury is often categorized as primary or secondary  Primary brain injury occurs at the time of the initial insult to the brain (trauma, hemorrhage or infarct)  Secondary injury occurs over hours to days and involves an array of cellular processes that may be the result or independent of the primary insult  Common causes of secondary brain injury are impaired cerebral perfusion, altered brain metabolism & oxygen utilization, increased intracranial pressure, cerebral edema, seizure activity, electrolyte abnormalities and hypoxemia

5  The rapid loss of brain function due to disturbance in the blood supply to the brain  Stoppage of blood flow to brain: a sudden blockage or rupture of a blood vessel in the brain  A stroke or "brain attack" occurs when a blood clot blocks an artery or a blood vessel breaks, interrupting blood flow to an area of the brain

6  Traumatic Brain Injury (TBI) is caused by a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain  Mild TBI ▪ a pathophysiological process affecting the brain induced by direct or indirect biomechanical forces ▪ GCS  Severe TBI ▪ CT scan shows bleeding, bruising, shear injury, swelling ▪ Major changes in blood flow & how the brain uses oxygen ▪ Unconscious, GCS score 3-8

7  Approximately 795,000 Americans suffer a stroke each year  Stroke is the 4th leading cause of death and the leading cause of serious, long-term disability in the US.  The cost of stroke in the US is approximately $28.6 billion annually.  On average in the US, every 40 seconds someone has a stroke and every 4 minutes someone dies.  87 % of all strokes are ischemic, 10 % are intracerebral hemorrhage, and 3 % are subarachnoid hemorrhage.

8  Over 97,000 Minnesotans have had a stroke  Approximately 11,500 new strokes occur each year  Stroke is the 5 th leading cause of death and the leading cause of long-term disability  In 2011, $414 million was spent on hospital care for stroke

9  According to research from CDC, approximately 3.5 million persons have a TBI in the United States each year.  2.1 million receive care in emergency departments,  300,000 are hospitalized,  84,000 are seen in outpatient departments,  1.1 million receive care from office-based physicians,  53,000 die ▪ TBI is a contributing factor to a third (30.5%) of all injury-related deaths  An Estimated $76.5 billion in direct medical costs and indirect costs such as lost productivity due to TBI each year  5.3 million Americans living with long term disability

10  14,548 Minnesotans sustained traumatic brain injury in 2012: (MDH - MIDAS)  10,310 were discharged from the emergency department  were hospitalized  278 died  58% male and 42% female  This only counts people who present to the ED  Over 100,000 Minnesotans live with a disability as a result of a brain injury  83% of offenders entering the Minnesota prison system have a history of TBI

11

12  Ischemic  Atherothrombotic  Embolic  Transient Ischemic Attack  Hemorrhagic  Intracerebral Hemorrhage  Subarachnoid Hemorrhage

13  Brain injuries can be classified as:  Mild, moderate or severe ▪ As determined by the Glasgow Coma Scale  Open or Closed ▪ Skull fracture or no skull fracture ▪ Linear, depressed, basilar ▪ Penetrating wound (knife, bullet or other object)  Focal or diffuse ▪ The injury is localized to one area (focal) ▪ Hematoma, contusion ▪ The injury is throughout the entire brain (diffuse) ▪ Concussion, shear injury

14  Concussion  Contusion  Epidural Hematoma  Subdural Hematoma  Intraparenchymal Bleed  Subarachnoid Hemorrhage  Intraventricular Hemorrhage  Diffuse Axonal Injury (Shear)

15  Controllable Risk Factors  High blood pressure (> 140/85 or if diabetic > 130/80)*  High cholesterol (LDL > 130 if no other risk factors, > 100 if other risk factors present)  Smoking*  Atrial Fibrillation  Heart Disease ( dilated cardiomyopathy, heart valve disease, artificial heart valve, heart failure)  Carotid Artery Disease  Diabetes*

16  Controllable Risk Factors (cont.)  Alcohol and Substance Abuse*  Physical Inactivity  Sleep Apnea  Clotting Disorders*  Vasculitis*  Uncontrollable Risk Factors  Age (every decade over age 55 the risk of ischemic stroke doubles)  Gender (men are at slightly higher risk)  Race/Ethnicity*  Family History*  Vascular Abnormality* * Risk factor for both hemorrhagic and ischemic stroke

17  It is believed that 80 – 85% of ischemic strokes could be prevented if risk factors were identified and controlled  Challenges to stroke prevention  Lack of healthcare screening (risk factors not identified)  Failure of patients to adhere to risk reduction measures  Failure of healthcare providers to implement aggressive risk reduction measures

18  Etiologies:  Falls (35.2%) ▪ Leading cause of TBI ▪ Rates highest in children 0-4 & elderly > 75  Motor Vehicle Collision (17.3%) ▪ Results in greatest # of hospitalizations ▪ Rate highest in age group  Struck by/fell against (16.5%)

19  Assault (10%) ▪ Firearm use leading cause of death related to TBI ▪ Blasts leading cause of TBI for active duty military personnel in a war zone  Unknown (0%)  Other (7%)  Bicycle/non-MV (3%)  Suicide (1% (Source CDC)

20  The only known cure for brain injury is prevention!!  Protect your brain - always wear a helmet for sports and recreational activities  Purchase only consumer product safety commission (CPSC) certified helmets  Concentrate on driving - never talk on a cell phone or text while driving  Everyone buckle up every time – infant car seats, booster seats for children under 8 or under 40 lbs, then seat belts  Stay focused & have a clear mind, do not drive impaired by drugs or alcohol  Stay steady - prevent falls from ladders and steps.  Never shake a baby, never  Keep small children away from open/screened windows and stairs  Prevent falls in the elderly  Home safety evaluations, medication & vision checks

21  Recanalization Therapy  0 – 4.5 hours after last known well ▪ IV rtPA  0 – 6 hours after last known well ▪ Mechanical Thrombectomy ▪ Intra-arterial Thrombolysis

22  Favorable outcome (complete or nearly complete recovery 3 months after stroke):  50% in treated group  38% in placebo group  For a favorable outcome, NNT = 8.3  For an improved outcome, NNT = 3.1 National Institute of Neurologic Disorders and Stroke (NINDS) Acute Stroke Trial - December 1995

23  Symptomatic intracerebral hemorrhage ▪ 6.4% in treated group ▪ 0.6% in placebo group  Mortality rate at 3 months and 1 year ▪ 17% and 24% in treatment group ▪ 20% and 28% in placebo group National Institute of Neurologic Disorders and Stroke (NINDS) Acute Stroke Trial - December 1995

24  Favorable outcome (complete or nearly complete recovery 3 months after stroke): ▪ 52.4% in treated group ▪ 45.2% in placebo group ▪ This is a modest but statistically significant difference  For a favorable outcome, NNT = 14  For an improved outcome, NNT = 8 European Cooperative Acute Stroke Study (ECASS - 3)

25  Symptomatic intracerebral hemorrhage  7.9% in treated group  3.5% in placebo group  Mortality rate at 3 months  7.7% in treatment group  8.4% in placebo group European Cooperative Acute Stroke Study (ECASS - 3)

26  Odds ratios for favorable outcome by time of drug initiation from onset of symptoms:  0 – 90 minutes2.81 †  91 – 180 minutes1.55 †  181 – 270 minutes1.3  † Alteplase Thrombolysis for Acute Non-interventional Treatment of Stroke (ATLANTIS) - IV rtPA 0.9 mg/Kg 0–5 hours from stroke onset. U.S. based, industry funded trial  Pooled data from ECASS-1, ECASS-2, ECASS-3 and ATLANTIS

27  Acute Stroke Treatment  Minimize secondary brain injury ▪ Allow “permissive hypertension” for first hours ▪ Maintain Normothermia ▪ Decompressive craniotomy/ICP management if edema is severe  Avoid complications (swallow screening and if needed modified diet, VTE prophylaxis, early mobilization, fall prevention)  Initiate rehabilitation therapies  Diagnostic work-up to identify cause of stroke and stroke risk factors  Implement stroke risk factor reduction measures

28  Intracerebral Hemorrhage  Most common type of hemorrhagic stroke  Mortality rate is 35 – 55%  Emergent reversal of INR if anticoagulated  Decompressive craniotomy, hematoma evacuation  Minimize secondary brain injury (similar to TBI)  Avoid complications  Initiate rehabilitation therapies

29  Subarachnoid Hemorrhage (non-traumatic)  Mortality rate is approximately 50% (15% die prior to reaching medical attention)  Treat the underlying cause ▪ 80% of SAH is caused by ruptured aneurysm ▪ Surgical clipping or endovascular therapy ▪ 5% is caused by arteriovenous malformation ▪ Endovascular therapy, radiosurgery and/or craniotomy  Prevent/manage secondary brain injury (vasospasm, hyponatremia)  Avoid complications  Initiate rehabilitation therapies

30  Physical and Occupational Therapy to maximize functional independence ▪ Body Weight Supported Treadmill Training ▪ Constraint Induced Movement Therapy ▪ Functional Electrical Stimulation ▪ Mirror Therapy ▪ Robotic Aided Systems ▪ Virtual Reality  Cognitive Therapy ▪ Cognitive Re-training ▪ Provide memory tools to aid in maintaining safety

31  Speech Therapy for communication disorders  Dysphagia Management ▪ May require long-term or permanent feeding tube and enteral nutrition  Depression Management  Promote Socialization (social-isolation is common)  Seizure Management ▪ prophylactic anticonvulsants are not recommended

32 - For people who have a severe TBI:  Intracranial hypertension 40-50%  Multiple injuries 50%  Surgical mass lesion 40-50%  Mortality 30-35%  Favorable Outcome 40-45%  Transfer to Level 1 Trauma Center  CDC research shows patient outcomes 25% better when sent to a Level 1 Trauma Center  For individuals hospitalized after a TBI, almost half (43%) have a related disability one year after the injury

33  Dark, quiet, low stimulus environment  HOB elevated  Neck midline  3% saline infusion  ICP & PbtO2 monitor  CSF drainage  Sedation & Pain Mgmt: Propofol, Fentanyl, Ativan  23% saline bolus  Normothermia  Selective hypothermia  Decompressive craniectomy  Paralyze with Vecuronium  Osmotic therapy  Hyperventilation rescue therapy for acute herniation

34  At least 75% of TBI are mild  CT usually “negative”  Patient usually alert and oriented  Range of symptoms that may or may not involve LOC  Manage the symptoms

35 A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by a least one of the following:  any period of loss of consciousness;  Only 10% lose consciousness  any loss of memory for events immediately before or after the accident; ▪ Anterograde and/or ▪ Retrograde  focal neurological deficit(s) that may or may not be transient;  any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented or confused);  but where the severity of the injury does not exceed the following:  Post-traumatic amnesia (PTA) not greater than 24 hours.  after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and  loss of consciousness of approximately 30 minutes or less;

36  Cognitive  Feeling confused  Dazed, foggy  Amnesia  Memory impairment  Trouble concentrating  Trouble with math  Trouble finding the right word to say  Affective  Irritability  Emotionally labile  Feeling anxious  Feeling depressed  Somatic  Headache  Dizziness, vertigo  Nausea  Tinnitus  Double or blurry vision  Insomnia/sleep disturbances, fatigue  Sensory disturbances, phono &/or photophobia

37  Initial Treatment is Symptomatic:  Time & Rest  Treat headache  Treat nausea & vomiting  Dark room/sunglasses for photophobia  Quiet for phonophobia and headache  No sleep medication (especially Ambien)  No video games, excessive TV watching, texting  If it causes symptoms, don’t do it

38  Rest, especially if you have any of the symptoms listed  Do not do any physical work or exercise until your symptoms go away. Anything that causes you to sweat is too much activity.  It is recommended that you see your family doctor within 2 weeks. Do not drive until your family doctor has told you it is okay to drive.  You should not work until you have not had any symptoms for 1 week.

39  If you go back to work and your symptoms come back and don’t go away for more than a week: ▪ Stop working ▪ Go home ▪ Call the HCMC TBI clinic for an appointment ▪ Do not go back to work until you have seen a TBI clinic doctor  Do not use alcohol (beer, wine, hard liquor) for at least 2 months after your TBI.  Do not play any sports until you have not had any symptoms for at least 1 month.

40  The natural evolution of concussion is that 80% of the people will be back to their usual baseline within a month  Someone still experiencing symptoms after 4 weeks should be evaluated at a comprehensive TBI Clinic  Students should be seen at 2-3 weeks if having problems in school

41  Management based on history, social situation and physical examination:  Patient history & subjective complaints  Review of medical records from TBI  Patient Education ▪ Natural History of TBI & Expectations for Recovery  Potential Referrals: ▪ Neuropsychological testing ▪ Speech Language Pathology ▪ Occupational Therapy ▪ Vision Therapy ▪ Physical Therapy ▪ Clinical Psychology ▪ Therapeutic Recreation ▪ Vestibular clinic  Medications for headache, nausea, sleep

42  Severe TBI rehab similar to stroke  Mild TBI rehab focuses on treating the symptoms. Examples include:  Energy Management and Relaxation  Vestibular Management ▪ Balance & Coordination ▪ Epley Maneuver  Neuro Visual Rehab  Cognitive & Linguistic Rehab  Management of headache & other somatic symptoms  Working with employers & schools on accommodations

43  Physical/Somatic  Hemiparesis/plegia (occasionally bilateral)  Facial droop  Hemi-sensory loss/alteration (numbness, paresthesia)  Visual Changes (visual field cuts, monocular blindness)  Dizziness, loss of balance  Altered Gait  Photo/phono sensitivity (common with SAH)*  Headache (often resolves after acute phase)  Cranial Nerve Dysfunction (with brainstem involvement)

44  Communication Disorders  Dysarthria (ranges from mild to severe)  Expressive Aphasia ▪ Word-finding difficulty ▪ Hesitant or stuttering speech pattern ▪ Fluent aphasia (word salad)  Agraphia (inability to communicate in writing)  Receptive Aphasia  Alexia (inability to understand written information)

45  Cognitive  Altered memory (especially short-term)  Slowed cognitive processing  Impaired judgment  Impulsivity  Disinhibition/boundary issues  Affective  Depression  Emotional lability  Sleep disorders

46  Post-Stroke Seizures  Approximately 12% of stroke survivors will develop seizures within 5 years  Stroke is the most common cause of seizures in the elderly  Social Isolation

47  Physical/Somatic  Headache  Dizziness/Vertigo  Weakness or paralysis  Swallowing problems  Visual changes  Occulomotor dysfunction  Tinnitus  Photo/phonosensitivity  Balance/coordination  Sleep impairments/extreme fatigue  Seizure disorder

48  Communication Disorders  Similar to stroke, especially the expressive aphasia and word finding difficulties  Affective/Emotional  Personality changes  Emotional lability/quick mood changes  Disinhibition  Irritability  Anxiety  Depression

49  Cognitive  Amnesia  Short term memory  Insight  Judgment  Confusion  Attention  Concentration  Processing speed

50 StrokeTBI Home or home with assistance51%73% Acute Rehabilitation18%11% Long Term Acute Hospital (e.g. Bethesda)1%7% Subacute Rehabilitation (SNF)24%6%

51 Donna Lindsay, MN, RN, CNS-BC, SCRN Program Coordinator Hennepin Stroke Center (612) Carol Ann Smith, BAN, RN, CNRN Program Coordinator Traumatic Brain Injury Center (612) Hennepin County Medical Center 701 Park Avenue South Minneapolis, MN 55415

52  Hennepin Stroke Center A comprehensive center of excellence providing care to patients and families who have been affected by stroke, including early treatments, acute care management, rehabilitation and research. The Stroke Center is also dedicated to increasing public awareness and education regarding stroke. ▪ ▪ Joint Commission Certified Primary Stroke Center  The Traumatic Brain Injury Center - A comprehensive, multidisciplinary center of excellence for patient care, education and research to serve people who have sustained a traumatic brain injury ▪ ▪ ▪

53  The Minnesota Stroke Association   National Stroke Association   American Stroke Association   National Aphasia Association   Minnesota Stroke Partnership 

54  The MN Brain Injury Alliance   Brain Trauma Foundation (www.braintrauma.org)  Guidelines for the Management of Severe TBI in the Adult- 3 rd Edition – Brain Trauma Foundation – May 2007  Traumatic Brain Injury: The Journey Home   TBI Model Systems 

55  American Association of Neuroscience Nurses (www.aann.org)  AANN Core Curriculum for Neuroscience Nursing – 5 th Edition  Clinical Practice Guidelines ▪ Care of the Patient with Mild TBI+ ▪ Guide to the Care of Hospitalized Patients with Ischemic Stroke ▪ Care of the Patient with Aneurysmal Subarachnoid Hemorrhage ▪ Nursing Management of Adults with Severe Traumatic Brain Injury ▪ Care of the Patient Undergoing Intracranial Pressure Monitoring/External Ventricular Drainage or Lumbar Drainage  Webinars

56  Legislation on Concussion & Youth Sports signed into law June 2010 and took effect September 2011  Most comprehensive legislation in the nation  The goal of this new law is to improve the recognition and response of youth concussion injuries within all statewide youth athletic activities. This is the most comprehensive legislation in the country.  The Minnesota law applies to all players under the age of 18 and applies to ALL youth sports organizations both PUBLIC and PRIVATE. The law requires that parents have access to information on the risks and symptoms of concussions and coaches must have training on concussions once every 3 years.  The entire text of law can be seen online at the MN Legislature website https://www.revisor.mn.gov/laws Chapter 90, Senate File 612. https://www.revisor.mn.gov/laws

57  BrainLineMilitary.org BrainLineMilitary.org  a new online service to help service members — Army, Navy, Air Force, Marines, National Guard, and Reserve —and veterans with brain injury and their families.  The Clinical Practice of Neurological and Neurosurgical Nursing – Joanne Hickey  Consensus Statement on Concussion in Sport 3 rd International Conference on Concussion in Sport – Zurich – November 2008 – McCory P., et al. Clin J Sport Med 2009;19:  “Guidelines for the Acute Medical Management of Severe TBI in Infants, Children and Adolescents”, a supplement to Pediatric Critical Care Medicine - July 2003

58  MN State Law Concussion Training for Coaches:  Information on the education for coaches can be found at the Centers for Disease Control and Prevention and their new National Center for Injury Prevention and Control website


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