Traumatic Brain Injury Evaluation and Management of Soldiers

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Traumatic Brain InjuryEvaluation and Management
of Soldiers

• Jason Hawley MD
• CPT MC USA
• Chief, Neurology CRDAMC

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Outline

• Semantics of TBI
• Evaluation of the soldier with suspect TBI
• Breaking down the symptom complex of TBI
• Managing TBI
• TBI at Fort Hood
• Where this is going..
• Questions

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What is TBI?

• Injury to the brain..duh
• Concussive Blast Injuries
• Penatrating injuries
• Mild-Moderate-Severe?

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Severe TBI

• I know it when I see it
• Prolonged loss of consciousness
• Surgical debridment of brain tissue
• Coma for weeks.
• Marked MRI abnormalities
• Permenent and often dramatic impairments..although
  not always

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Mild-Moderate TBI

• What is mild TBI
• Post concussive syndrome?
• PTSD?
• Diffuse axonal injury
• Persian Gulf War Syndrome?
• Stress?

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Mild TBI

• There has to be a head injuryblast, MVA
  accident, fall are the common
• There has to be an alteration of
  consciousnessstunned, dazed, LOC
• Imaging is typically normal
• The persistent triad of symptoms
• Headaches
• Cogntive problems
• Mood problems.

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Evaluating the Soldier with suspected TBI

• Define the injury and eventwhen, where, how.
• Relationship of the headache to the injury
• Relationship of the cognitive problems to the
  injury
• Past history of head injuryTroy Aikman syndrome
• The symptoms since the head injuryspecifically
  the headaches
• Associated dizziness, nausea, and vomitting.

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PTSD and TBI

• PTSD is an anxiety disorder
• TBI is a well defined injury recognized in the
  civilian literature
• Soldiers with mild TBI at 2.7 times more likely
  to have symptoms suggestive of PTSD
• Mood symptoms are very common in soldiers with
  TBI
• Irratibility, sleep, depression, flash backs,
  nightmares
• Validate those symptoms

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Take a step backwhat is the problem they are
complaining about

• what bothers you the most
• The soldier with a TBI vs. the soldier with a TBI
  and PTSD.
• If it looks like psych, then it is psych.
• If the mood symptoms are mild, dont call it
  PTSD.
• PTSD can cause all the cognitive Listen to
  what the soldier tells you

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Managing TBI

• Dont be afraid of managing thisthis is not
  hard, you wont get in trouble, and its pretty
  easy.

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Keep in mind

• Overwelming majority of soldiers with mild TBI
  recovery over 6-12 months after the injury
• Very few soldiers (1-2 of those screened for
  TBI) get medical boards for TBI
• Cognitive therapy is very limited
• Medications are of secondary value
• Most soldiers want to return to duty, and dont
  want to be stigmatized.

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You have a mild TBI and youre going to be ok.

• Do that and youve treated most of the soldiers
  were worried about
• Establish a real diagnosis, tell it to the
  patient
• Explain what to expect, reassure them
• Document that, tell them you will
• Break down the symptom complex of cogntive
  symptomsheadachemood symptoms.
• Address each individually.

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Cognitive Symptoms

• In the absense of significant mood symtpoms, I am
  concerned about these soldiers most of all.
• Memory, focus, multi-tasking, concentration,
  attention.
• Memory impairment have become a significant
  impairment at work and home.
• Forgetting mission tasks, getting in trouble,
  always writing things down.
• Our work upneuropsych testing, cognitive
  therapy, possible VA rehab

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Headaches

• How debilitating are the headaches
• Helps the soldier potentially recognize the
  improvement
• A word about compliance
• Behavioral treatments, profilingshort term
  restrictions to speed recovery
• Profiling PT, 24 hour duty, etc
• Give them 3-6 months

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HeadacheMedication management

• I have come to the conclusion that this is low
  yield
• Preventative vs. Abortive
• What worksindocin, elavil, topamax, pheneragan
• What doesnttryptans, inderal, narcotics
• Migraine features with headache (photophobia,
  dizziness, etc)more likely to go with meds.

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Mood Symptoms

• I need your help!
• Listen to what they tell you
• Dont let the history of blast exposure (or the
  media) go against your better judgement. Use
  common sense.
• The mood symptoms of mild TBI are treated just as
  are the mood symptoms of PTSD.

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When the mood symptoms are present but not
disabling

• Validate the mood symptoms as part of mild TBI.
• Tell them they have a reason for feeling the way
  they do
• Most soldiers dont want to see psych, or be
  given a psychiatric diagnosis.

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TBI at Fort Hood

• Our population
• Most completed deployment
• Most will do fine and will respond to validation,
  reassurance, and minor medications.
• Most can be managed without profile restrictions
  or just mild temporary modifications to duty
• Most gt95 will be deployable within 12 months
  after the injury
• I have not done an MEB on a soldier with a mild
  TBI who completed his deployment.

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Soldier break down --my take on it

• The soldier with mild to minimal TBI
• The soldier with TBI and dominating PTSD
• The soldier with mild-moderate TBI
• The soldier with severe TBI

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Resources at Fort Hood

• Neurologyme
• Care Management
• Case Management
• Speech/cogntive therapy (Ms. Smith)
• RR center
• TBI Teammultidisplinary team aimed at managing
  the most severe soldiers (roughly 30-40
  soldiers).
• The other several thousandyou.

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Where this is going

• TBI is the injury of this war.
• We in the military/VA system will be dealing with
  this for decades
• The screening process for TBI at Fort Hood
• The management of our impaired soldiers
• A final word on MEBs.

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Questions?