Caring for patients with closed traumatic brain injury in rural settings.

The Centers for Disease Control and Prevention (CDC) has acknowledged closed traumatic brain injuries (cTBIs), a form of traumatic brain injury (TBI), as being a major public health matter in the United States. Statistical analysis, as well as public health data, has suggested that there are approximately 1,300 cases of cTBI per year in the United States alone. The standard of care for patients with a cTBI is to undergo diagnostic imaging, most commonly computerized tomography, which is considered to be a luxury and seldom exists in rural clinics. Despite increasing TBI awareness and publicity, healthcare providers, including advanced practice registered nurses, have yet to have a full understanding of the severity of damages that can result from a cTBI. The purpose of this article is to provide an understanding of cTBI and concise clinical best practice guidelines that will aid healthcare providers in rural settings to properly diagnose, treat, and provide education for patients with cTBIs.

Intracranial pseudoaneurysm after intracranial pressure monitor placement.

Traumatic intracranial pseudoaneurysms are a rare but severe complication following arterial injury. Pseudoaneurysm formation can occur secondary to blunt or penetrating trauma or iatrogenic injury. We report a case of traumatic pseudoaneurysm secondary to placement of an intracranial pressure (ICP) monitor. A 27-year-old man was involved in a motorcycle accident resulting in multiple intracranial hemorrhages. The patient underwent craniectomy and placement of an ICP monitor. 17 days later he developed dilation of his left pupil, with imaging demonstrating a new hemorrhage in the vicinity of the previous ICP monitor. A cerebral angiogram confirmed a left-sided distal M4 pseudoaneurysm which was treated by n-butyl cyanoacrylate embolization. Intracranial pseudoaneurysm formation following neurosurgical procedures is uncommon. Delayed intracranial hemorrhage in a region of prior intracranial manipulation, even following a procedure as 'routine' as placement of an ICP monitor, should raise the suspicion for this rare but potentially lethal complication.

[Modified tracheostomy management: a protocol for the application of stoma buttons in difficult decannulations]. / Modifiziertes Trachealkanülenmanagement: Platzhaltereinsatz als Option bei erschwerten Dekanülierungen (Pilotprojekt REHAB Basel).

Current approaches to decannulation management often fail to account for patients with combined swallowing and respiratory deficits. We expanded our existing weaning and decannulation protocol by adding an optional 3-day decannulation trial to evaluate readiness for decannulation. If a patient meets predefined test-decannulation criteria a tracheostomy button is inserted during a laryngoscopic examination and left in situ for up to 3 days. Before, during and after button insertion the patient's respiratory function and saliva management are closely monitored before the decision for or against permanent decannulation is made. We present evaluation criteria, protocols and flow-charts illustrating the 3-day decannulation trial as well as 2 case studies.

[Criteria of limitation of vital functions in remote consequences of closed craniocerebral trauma].

On the basis of international classification of functioning, limitations of vital functions and health (MKF) were conducted inspections patients with the remote consequences of the closed craniocerebral trauma. All of patients passed a standard clinical neurological inspection and testing with a help MKF. It is well-proven that adaptation MKF allows to apply it at expert diagnostics, and also to estimate rehabilitation potential and efficiency of leadthrough of rehabilitation measures at patients with the remote consequences of the closed craniocerebral trauma.

[Optimization of medical-diagnostic process in patients with traumatic brain injury during early rehabilitation].

The problem of cardiovascular disease and cancer, the effects of traumatic brain injury is now one of the major health and social problems. Every year in Ukraine registered 200 thousand cases of the victims of traumatic brain injury. Of these, 30% of people then have persistent signs of disability that results in a disability, sometimes painful existence the patient and his relatives. Therefore, in order to bring man back into society after a traumatic brain injury, to the rehabilitation phase of treatment, immediately after the stabilization of the patient.

Empowering the primary care provider to optimally manage mild traumatic brain injury.

PURPOSE: This article provides current, evidence-based information regarding the management of mild traumatic brain injuries for the primary-care provider. DATA SOURCES: Literature review of the evidence-based literature, including peer-reviewed articles and reviews of published randomized controlled trials and clinical practice guidelines. CONCLUSIONS: There are lessons to learn from the civilian and military care of mild traumatic brain injuries. As acute injury management improves and more patients survive their trauma to live in the chronic-care community setting, primary care clinicians will be responsible for providing and coordinating total care. A team approach is required to meet the unique clinical and personal challenges these patients face. IMPLICATIONS FOR PRACTICE: These patients are at risk of receiving suboptimal care once released to the community, in part due to an incomplete understanding of the condition by primary care providers. Other difficulties in recommending care for these patients include nonuniform clinical terminology, the lack of a uniform set of diagnostic criteria, and the lack of endorsed professional society guidelines. A clinical practice toolkit is provided to assist the primary care provider to optimize delivery of comprehensive care for this population in the community.

Mechanisms and consequences of head injuries in soccer: a study of 451 patients.

OBJECT: The goal of this study was to evaluate the incidence and mechanisms of head injury during soccer games and to describe the results after spontaneous resolution of symptoms or after treatment. METHODS: In a retrospective study from 2005, records on 451 players from the German Soccer Association who had suffered various injuries were collected. The study used a questionnaire in which the player described the accident and the playing situation as well as the clinical course after trauma. This questionnaire also included information about the physical symptoms of the players and the length of their rehabilitation. Two groups were formed: one with head injuries (case group), and the other with injuries of other body parts (control group). RESULTS: Of the injuries reported, 108 (23.9%) were related to the head, 114 (25.3%) to the knee, 58 (13%) to the ankle, 56 (12%) to the calf, and 30 (7%) to the shoulder. The areas of the head most frequently involved were the facial and occipital regions. In the head injury group, the head duel was the most common playing action to lead to trauma. In those cases, the body part that hit the injured player was the elbow, arm, or head of the opponent. The most common playing situation was combat in the penalty area. The median hospitalization time after the trauma was 2 days for the case group and 5 days for the control group. The rehabilitation time for the case group was also shorter (median 6.5 days) than for the control group (median 30 days). CONCLUSIONS: Trivial head injuries in soccer can have a long and complicated course. Nevertheless, the temporary disability is shorter in most cases than for players with injuries to other parts of the body. Modifying the rules of play would be necessary to reduce the incidence of head trauma.

[Medical expert criteria of limitations of vital functions from remote consequences of closed craniocerebral trauma].

On the basis of international classification of functioning, limitations of vital functions and health (MKF) were conducted inspections patients with the remote consequences of the closed craniocerebral trauma. All of patients passed a standard clinical neurological inspection and testing with a help MKF. It is well-proven that adaptation MKF allows to apply it at expert diagnostics, and also to estimate rehabilitation potential and efficiency of leadthrough of rehabilitation measures at patients with the remote consequences of the closed craniocerebral trauma.

Treating underlying attention deficits as a means for improving conversational discourse in individuals with closed head injury: a preliminary study.

BACKGROUND: It is documented that individuals with closed head injury (CHI) demonstrate difficulty with narrative and conversational discourse. Effective conversational discourse requires a complex interaction of linguistic, cognitive, and social abilities [6]. Reduced attention and concentration are among the most common cognitive sequela following CHI [39]. AIMS: The present study investigated whether treatment of attention would facilitate conversational discourse for individuals with CHI. Two treatment protocols were investigated, the first social skills-based, and the second attention-based. It was hypothesized that attention training would improve not only attentional skills but also conversation, however social skills training, would only facilitate conversational skills. METHODS AND PROCEDURES: A single subject multiple treatments comparison design was employed with two individuals who were post-onset of CHI. Treatment effects on conversational performance were calculated using the f statistic [18] for measures of response appropriateness during conversations. OUTCOMES AND RESULTS: Effect sizes suggested that both treatments were active; however, the participants' performances were variable reducing the magnitude of change observed. Results indicated minimal change from baselines, only partially supporting the research hypotheses. CONCLUSIONS: Although the two treatment regimens had some effect on the participants' conversational performances it was not to the extent anticipated. The issues of candidacy for such treatments as well as the importance of incorporating natural contingencies into interventions for conversation training are discussed.

Communicating using the eyes without remembering it: cognitive rehabilitation in a severely brain-injured patient with amnesia, tetraplegia and anarthria.

We describe here a case of cognitive rehabilitation in a young patient with closed head injury, who had dense anterograde amnesia and such disabling neurological defects (tetraplegia and anarthria) that the condition evoked some features of an incomplete locked-in syndrome. After a prolonged period of no communicative possibility, the patient underwent a specific training, based on principles of errorless learning, with the aim of using a computerized eye-tracker system. Although, due to memory disturbances, the patient always denied ever having used the eye-tracker system, learned to use the computerized device and improved interaction with the environment. This favourable outcome may serve as a stimulus for devising new training approaches in patients with complex patterns of cognitive impairments, even when associated with severe motor impairments.

Return of memory and sleep efficiency following moderate to severe closed head injury.

OBJECTIVE: Sleep disturbance is common in the subacute recovery phase following brain injury. A previous study from the authors' group found 68% of patients with closed head injury (CHI) had disrupted sleep on a rehabilitation unit. In the present study, the authors investigated whether improvement in sleep efficiency correlates with duration of posttraumatic amnesia (PTA) after CHI. METHODS: Fourteen CHI patients were enrolled and followed prospectively. Mechanism of injury included motor vehicle accident, fall, and blunt assault. An actigraph was placed on each subject's wrist within 72 hours of admission to the rehabilitation unit and recorded data for the duration of their stay. A minimum of 7 days of continuous actigraphy data was obtained on all subjects. PTA was measured daily using the Orientation Log (O-LOG). RESULTS: Seventy-eight percent of subjects had mean week-1 sleep efficiency scores of < or = 63%. Patients admitted having already cleared PTA had significantly better week-1 sleep efficiency scores than those with ongoing amnesia (P = .032). For those patients admitted with ongoing PTA, each 10-unit increase in sleep efficiency score correlated with 1 unit increase in O-LOG score (P = .056). CONCLUSIONS: Disrupted sleep is common in the postacute stage following CHI. Improved sleep efficiency correlates with resolution of PTA. Decreased sleep efficiency may negatively affect memory return after traumatic brain injury. Actigraphy is uniquely suited to study the sleep patterns of these patients.

Prevalence of sleep disturbance in closed head injury patients in a rehabilitation unit.

UNLABELLED: Traumatic brain injury (TBI) is a leading cause of disability in young people in the United States. Disorders of arousal and attention are common in closed head injury (CHI). Daytime drowsiness impairs participation in rehabilitation, whereas nighttime wakefulness leads to falls and behavioral disturbances. Sleep disturbances in TBI reported in the literature have included excessive daytime somnolence, sleep phase cycle disturbance, narcolepsy, and sleep apnea. Although well known to the clinician treating these patients, the extent and prevalence of disrupted sleep in patients in an acute inpatient rehabilitation unit has not been described. OBJECTIVE: To determine the prevalence of sleep wake cycle disturbance (SWCD) in patients with CHI in a TBI rehabilitation unit. DESIGN: Prospective observational. SETTING: Inpatient specialized brain injury rehabilitation unit. Patients. Thirty-one consecutive admissions to a brain injury rehabilitation unit with the diagnosis of CHI. RESULTS: Twenty-one patients (68%) had aberrations of nighttime sleep. There was no significant difference in Glasgow Coma Score on admission to trauma nor was there any significant difference in age between the affected and unaffected groups. Patients with SWCD had longer stays in both the trauma center (P < .003) and the rehabilitation center (P < .03). CONCLUSIONS: There is a high prevalence of SWCD in CHI patients admitted to a brain injury rehabilitation unit. Patients with SWCD have longer stays in both acute and rehabilitation settings and may be a marker for more severe injury.

Traumatic brain injuries sustained in the Afghanistan and Iraq wars.

UNLABELLED: Because these injuries can go unrecognized, nurses stateside need to know how to recognize possible cases and how to help. OVERVIEW: When traumatic brain injury (TBI) occurs simultaneously with more obviously life-threatening wounds, it may go unrecognized. Civilians and military personnel working in or near combat zones are at risk for this injury. Blast-related and closed-head injuries, rather than penetrating injuries, constitute the majority of TBIs in this population. The authors describe the experiences of the Defense and Veterans Brain Injury Center team at Walter Reed Army Medical Center in Washington, DC, and present a composite case to illustrate the nurse's role in the assessment and care of the TBI patient.

Second language acquisition after traumatic brain injury: a case study.

BACKGROUND: Post-traumatic language and memory impairment, as well as a subsequent recovery in monolinguals have been widely documented in the literature, yet little is known about learning the second language after a severe head trauma followed by coma, as well as the relationship of this process with cognitive recovery, psychological status and quality of life. PURPOSE: The present study investigates the relationship of learning the second language (English) in the process of rehabilitation, with quality of life in a Polish female university student who, as a result of a car accident, suffered a major closed-head injury and was comatose for a month. METHOD: The subject was enrolled in an English learning program nine months after the trauma. The experiment lasted six months and comprised monthly meetings. RESULTS: The patient improved the major components of the second language, including vocabulary. Within the 6 months, the subject was gradually capable of learning additional and more complex lexical items. DISCUSSION: Learning the second language after traumatic brain injury may positively influence emotional well-being, self-esteem, and, perhaps, recovery of quality of life. A long-term beneficial effect of learning L2 was a consequential improvement of the patient's memory.

A neuropsychiatric perspective on traumatic brain injury.

Traumatic brain injury (TBI) due to closed mechanisms causes strain injuries to axons that increase in number and severity as injury severity increases. Axons that project up from the brain stem are vulnerable, even in milder concussive injuries, and include axons that participate in key monoaminergic pathways. Although called diffuse axonal injury, the supra-tentorial injury component typically shows an anterior preponderance in humans. As the injury forces increase, cerebral contusions may be superimposed on the axonal strain injuries, and these contusions show an anterior preponderance as well. The chronic neuropsychiatric manifestations of TBI reflect this injury distribution. In the cognitive sphere, these manifestations almost always include power function disturbances marked by difficulties with cognitive processing speed, multitasking, and cognitive endurance. These disturbances may then be followed by disturbances in executive function and self-awareness as injury severity increases. In the behavioral sphere, mood disturbances and disorders of behavioral control and regulation are particularly common.

Posttraumatic balance disorders.

Head trauma is being more frequently recognized as a causative agent in balance disorders. Most of the published literature examining traumatic brain injury (TBI) after head trauma has focused on short-term prognostic indicators and neurocognitive disorders. Few data are available to guide those individuals who see patients with balance disorders secondary to TBI. Our group has previously examined balance disorders after mild head trauma. In this study, we study all classes of head trauma. We provide a classification system that is useful in the diagnosis and management of balance disorders after head trauma and we examine treatment outcomes. As dizziness is one of the most common outcomes of TBI, it is essential that those who study and treat dizziness be familiar with this subject.

Training-induced brain remapping in chronic aphasia: a pilot study.

BACKGROUND: The neural correlates of training-induced improvements of cognitive functions after brain damage remain still scarcely understood. In the specific case of aphasia, although several investigations have addressed the issue of the neural substrates of functional recovery, only a few studies have attempted to assess the impact of language training on the damaged brain. AIMS: The main goal of this study was to examine the neurobiological correlates of improved picture-naming performance in 2 aphasic patients who received intensive and specific training for a chronic and severe phonological anomia. METHODS: In both participants, picture-naming performance was assessed before and after phonological cueing training. Training-induced changes in patients' performance were correlated to brain activity patterns as revealed by pre- and post-training event-related functional magnetic resonance imaging scanning. RESULTS: Training-induced improvement was observed concurrently with changes in the brain activation patterns. Better performance was observed in the patient with the smaller lesion, partially sparing Broca's area, who showed a left perilesional reactivation. Conversely, the patient with complete destruction of Broca's area showed a posttraining activation in the right mirror frontal region. CONCLUSIONS: The results show that, even in the chronic stage, phonological strategies may improve impaired naming and induce cerebral reorganization.

Rehabilitation of endogenous task shift processes in closed head injury patients.

This paper reports a study that was aimed to rehabilitate executive functions in CHI patients. When a subject is engaged in two speeded tasks, not simultaneously but with some form of alternation, the response is slower to an item of task A if it was preceded by an item of task B, than when it was preceded by an item of task A. This shift cost is small when subjects can prepare in advance for the new task (endogenous task shift), whereas the cost is much greater when preparation is not possible (exogenous task shift). The groups tested comprised 20 severe closed head injury (CHI) patients (10 who underwent treatment and 10 controls), 8 mild CHI patients, and 18 non-brain damaged (NBD) controls. In the present study, the shift cost was greater for severe CHI patients than for NBD controls. Treatment consisted of five sessions, in which an endogenous task shift paradigm was used. A significant reduction of the endogenous shift cost from assessment to retest was found. The reduction remained stable at the 4-month follow-up session. These results are not simply due to retesting, as the control patients did not show any improvement at retest. Interestingly, no reduction of exogenous task shift cost was found. The results showed also that the beneficial effect of the treatment generalises to other executive functions.