Brain Injury. Mild to Moderate Effects Pathways. Jane Gillett MD FRCPC Medical Director ABI Program

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1 Brain Injury Mild to Moderate Effects Pathways Jane Gillett MD FRCPC Medical Director ABI Program

2 Brain Injury Commonest Cause of morbidity and mortality in those under 40 70% are considered mild to moderate Often unrecognized in trauma cases because of more obvious multi organ trauma Moderate/Severe to Severe to Very Severe are usually obvious

3 Definition Somewhat controversial GCS NOT a good predictor of severity Accepted GCS is 10 to 15 Many have normal GCS and normal CT scans of the head Clinical picture permits diagnosis

4 Clinical Picture Confusion Word finding, and usage difficulties Memory problems headache GCS can be normal +/- LOC (?up to 24 hours)

5 Effects Headache Sleep Disturbance Fatigue Pain Mood and Emotional Lability including depression Vertigo Cognitive veil

6 Long term Many recover from the effects within the first three to six months Most recover by 1 year Some (10 to 90%) have persistent effects

7 Treatment Reassurance and Information Sleep Hygiene +/- medication Judicious use of SSRI s Migraine Prophylaxis and treatment (if migraine headache) and pain Rx Positional vertigo maneuvers Functional cognitive strategies

8 Concussion Three grades as determined by length of loss of consciousness and confusion Guidelines provided but sketchy on details More recent evidence suggests that mental rest important for first 24 to 48 hours The younger you are the more vulnerable to longer effects

9 Return to work/sports Must be headache and pain free Walk for minutes Ride stationary bicycle Tread mill incline and running Cardio work out

10 Trauma Follow up If at six weeks at time of follow up Check for Consequences as described above If any relationship issues, work related issues REFER to ABI

11 What is Available Adult Concussion Clinic (ACC) ABIP outpatient clinic ABIP MOH outreach ABIP inpatient programs traditional rehab 6 beds for HGH, 2 for region (CRU) Severe behavioural beds provincial (CBR) Slow to Recover Program provincial (STR) BEATS program provincial outreach for behaviour

12 Adult Concussion Clinic Will see only those who live in Hamilton Accepts referrals from ER directly Concussion, mild and some moderate Has MD to see ER referrals for medical issues Has CIC (community integration co- ordinator), Neuropyschology,, OT, Rehab therapist Also sees referrals from ABIP if mild

13 Outpatient clinic Accepts referrals from the region and occasionally the province (>2000 visits) Must have MD referral Two MDs involved (neurologist, physiatry) Access to neuropsychology,, social work, pyschiatry All patients have a CIC assigned for case management

14 Outreach Must have defined functional goals (time management, banking, organization, community activity) Time limited Rehab therapist Neuropsychology Live within 1 to 1 ½ hours away

15 CRU Referral from Community MD but usually referred in by ABIP consultation team at HGH In need of 24 hour supervision and assistance with ADL s because of cognitive reasons Be medically stable Have endurance for rehab for several hours Provides consistent approach and repetition

16 CBR Provincial program Major cognitive and behavioural issues Exhausted all other avenues Be medically stable Multiple repetitions, medication trials, behavioral analysis

17 STR Provincial program More than 6 months from onset of injury Have place to live Have defined goals around lessening burden of care Careful assessment of neuro status, responses, drug effects

18 BEATS Provincial program Provides behavioural consultation in person s environment Assesses environment influences, cognitive difficulties and behaviour and provides suggestions on management without use of medication

19 How to Refer If in HGH ER recognize ABI If no admission -- refer to ACC if lives in Hamilton; to family MD if not live in Hamilton If admission refer to ABIP consultation team

20 How to Refer If Community ER recognize ABI If no admission to family MD and if needed from there to ABIP If admitted refer to ABIP

21 Pathways ER recognizes ABI Concussion No admission If Hamilton -- ACC Family MD Moderate ABI Admitted Refer to ABIP Mild ABI Admitted refer to ABIP ABIP follows and refers to ACC if OK

22 Contacts ABIP Consultation team Elaine Nisbet ext Outpatient Clinic Referral package needed Contact ABIP at ext BEATS Contact ABIP ACC Contact Dorothy Scierko ext 44812