VA Polytrauma System of Care Polytrauma Rehabilitation Centers

VA Polytrauma System of Care Polytrauma Rehabilitation Centers Tampa Richmond Palo Alto Minneapolis San Antonio (2012) 1

Continuity of Care: From Battlefield to VA TBI/Polytrauma System of Care Landstuhl Regional Medical Center Minneapolis PRC Walter Reed Army & Bethesda National Naval Medical Centers Iraq Palo Alto PRC Richmond PRC Tampa PRC Balad, Iraq Bn Aid Station 2 2

Learning Objectives • Talk 1 • Differentiate Acquired Brain Injury from Traumatic Brain Injury (TBI) • List types of TBI • List stages of recovery from severe TBI 3

Acquired Brain Injury versus Traumatic Brain Injury • ABI: Impairment of brain function that is not attributed to congenital, developmental, or degenerative conditions. • Examples include traumatic brain injury (aka closed head injury, open head injury, penetrating head injury), stroke (ischemic, hemorragic), brain tumors, anoxia, chemical exposure, etc. 4

Traumatic Brain Injury Damage caused by external, mechanical force Closed Head Injury Car accidents Falls Blunt assault Open Head Injury Penetrating Gunshot wound Stabbing wound 5

Polytrauma Patient Characteristics Sample Size (FY 03 -FY 09) N=653 Brain Injury 91. 5% PTSD 31% Vision Loss 29% Hearing Loss 21% Orthopedic Injuries 11% Anxiety Disorder other than PTSD 11% Wounds / Infections 8% Amputations 5% Burns 3% Other (Comorbidities) 99% 6

Combat Polytrauma Patient Characteristics (FY 03 – present) Age 20 -25 (46%) 26 -30 (21%) 31 -35 (12%) 36 + (20%) Male 97% Injury Mechanism Explosion (71%) Vehicle (11%) GSW (9%) Other (9%) Military Status Active Duty (84%) Branch Army (68%) Marines (23%) Deployment Iraq (89%) Referral** WRAMC (34%) NNMC (28%) Other MTF (31%) Other (8%) LOS** (Mean days) FY 03 (37) FY 04 (39) FY 05 (57) FY 06 (52) FY 07 (33) FY 08 (29) FY 09 (28) DC Destination Home (73%) MTF (17%) Home VA (6%) Private Facility (4%) Other (<1%) 7

Mandatory TBI Screening Results 14 April 2007 – 31 January 2009 y r a im en r P re Sc 270, 022 Total OEF/OIF Veterans Screened 7, 725 Veterans with Self Reported Prior TBI 53, 953 Veterans Requiring Further Evaluation 50, 068 Veterans Consenting to Further Evaluation p u - n w o tio l l Fo alua Ev 33, 250 Veterans Completed Comprehensive Evaluation 21, 292 5, 184 TBI Confirmed 15, 486 12, 580 TBI Ruled Out Diagnosis Pending 8

States of Severely Impaired Consciousness (SIC) Coma Vegetative State (VS) Persistent /Permanent Vegetative State Minimally Conscious State Emerged From Minimally Conscious State Post Traumatic Amnesia / Confusion / Delirium 9

Severely Impaired Consciousness (SIC) Coma VS MCS SIC Confused Oriented 10

Early Neurobehavioral Milestones Duration of Unconsciousness o Duration of Consciousness (2 consecutive sessions/dates o observed command following) Transition from VS to MCS o Tracking, Command Following, Verbalizations Emergence from MCS o Accurate Yes/No Response, Object Use etc. Duration or degree of impaired consciousness Post-traumatic Amnesia ( 2 consecutive sessions/dates of target range scores indicating orientation) Post-traumatic motor restlessness Post-traumatic confusion 11

Examples of Cognitive and Behavioral Changes After ABI / TBI Orientation Alertness Focusing Attention Speed of Processing Remembering New Info Remembering Past Info Perception of Environment Expressive language Receptive language Fatigue Executive Skills Reasoning Sequencing Multi-tasking Behavioral Control (start, stop, & resisting impulse) Emotional Control (inappropriate or intensity change) 12