Managing Agitation in Traumatic Brain Injury Jennifer E. Marks, D.O. Department of PM&R LSUHSC.

Managing Agitation in Managing Agitation in Traumatic Brain InjuryTraumatic Brain Injury

Jennifer E. Marks, D.O.

Department of PM&R

LSUHSC

TBITBI

#1 cause of TBI is MVAMales at higher risk in all age groupsPeak risk 18-25 years

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

Mild TBIMild TBI

GCS 13 or greater Equivalent to concussion

Moderate TBIModerate TBI

GCS 9-12Follows commandsDoes not answer questions appropriately

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

ManagementManagement

EnvironmentEducate Staff and FamilyBehaviorMedication

Environmental ManagementEnvironmental Management

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

Vail BedVail 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.

RCT studies 1966-presentRCT studies 1966-present

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

FOR SEVERE AGITATIONFOR SEVERE AGITATION, , Lorazepam 1-2 mg IM/IV !Lorazepam 1-2 mg IM/IV !

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!