L3: Medical Management of ABI

Acquired Brain Injury (ABI) definition

An injury to the brain that isn’t hereditary, congenital, degenerative, or induced by birth trauma. The injury results in a change in neuronal activity, which affects the physical integrity, the metabolic activity, or the functional ability of nerve cells in the brain.

Atraumatic causes of brain injury

• Stroke

• Hypoxic

• Poison

• Virus

• Tumor

Traumatic causes of brain injury

• Fall

• Motor vehicle accident

• Struck by object

• Sports

• IED

Prehospital management of ABI

• Prevention

• Activation of 911

Up to ________ of strokes are preventable

80%

Ways to prevent a stroke

Lifestyle modification

• Diet:

  • ↑ fruits/ vegetables (fiber), ↓ saturated & trans fats, ↓ sodium

• Weight management:

  • BMI < 25

• Adequate physical activity:

  • 2.5 hrs moderate aerobic activity per week

• Smoking cessation

• Limit alcohol intake:

  • Men < 2 drinks/day

  • Women < 1 drink/day

What cholesterol levels are good for stroke prevention

• Total < 200

• LDL < 100

• HDL > 60

• Triglycerides < 150

What blood pressure is good for stroke prevention

<130/ 80 (AHA)

What glucose level (diabetes) is good for stroke prevention

A1c < 6.5

What heart conditions can lead to stroke?

• Coronary heart disease

• Atrial fibrillation

B.E. F.A.S.T acronym to identify stroke symptoms

• Balance loss

• Eye (vision) changes

• Face drooping

• Arm weakness

• Speech difficulty

• Time to call 911

(+ numbness, confusion, severe headache)

Emergency response for stroke management

• Screening and identification of stroke

• Triage and routing to hospital capable of administering anti-thrombics

Best tactics for EMS stroke assessment & management

1) Use of stroke assessment tool

2) Provide prehospital notification that a suspected stroke patient is en route

What are the Cincinnati prehospital stroke scale (CPSS) stroke symptoms

• Facial droop (one side of face doesn’t move as well as the other)

• Arm drift (one arm either doesn’t move or one arm drifts down & pronates compared to the other)

• Speech (Slurring words, says wrong words, or unable to speak)

________ of stroke patients will exhibit one or more symptoms on CPSS

80%

CPSS doesn’t identify ________ stroke

Posterior circulation

(vertebral artery; cerebellum)

What action occurs 10 minutes from arrival or sooner

Evaluation by physician

What action occurs ≤ 15 minutes after arrival

Stroke or neurologic expertise contacted

What action occurs ≤ 20 minutes after arrival

NCCT or MRI

What action occurs ≤ 45 minutes or sooner

Interpretation of neuroimaging

What action occurs ≤ 60 minutes after arrival

Initiation of IV alteplase or tissue plasminogen activator (thrombolytic medication)

You shouldn’t use anti-thrombic medication when?

The stroke is hemorrhagic

Hospital stroke teams’ role in stroke management

• Evaluation

  • In house vs. telemedicine

• Treatment

  • Stroke-specific & general medical care

Benefits of telemedicine in stroke care

• Improve prehospital care when on-site expertise isn’t available

• Teleradiology systems are recommended for timely review of brain imagining in patients with suspected acute ischemic stroke

• Telestroke/ teleradiology evaluation of patients with suspected acute ischemic stroke can be effective for correct tPA decision making

________ brain cells die every minute if there isn’t treatment

1.9 million

Clinical Practice Considerations for Stroke Management

• Be educated on how to identify s/s someone is having a stroke and educate pts. and their families

• Know how to use stroke assessment tool

• Be aware of protocol if pt. is having a stroke (call 911 so they can be transported to the nearest emergency center with stroke care capabilities)

• Distance to closest medical facility

• More centers we have the more we can focus on individual patient goals, resulting in better care and outcomes

Benefit of mobile stroke units (MSUs)

Improve rapid stroke diagnosis and thrombolysis; now guideline-supported where available

Transport decisions

Consider local systems; direct transport to EVT-capable centers may be preferred over the nearest thrombolysis site

Recommended time frames for medication administration if having thrombolysis

• Alteplase or Tenecteplase within 4.5 hours (3 hours is best practice)

  • Treat eligible pts even with low NIHSS if deficits are disabling

  • Advanced imaging allows extended windows (4.5 - 9 hours or unknown onset)

If someone has non-disabling deficits, what should be done and what meds are not beneficial

• Use dual antiplatelet therapy

• Thrombolysis not beneficial

If using IVT, are adjunct anti-thrombotics beneficial

No added benefit & not recommended

When is an endovascular thrombectomy (EVT) done?

Standard for large vessel occlusion
(now expanded to some patients with larger infarct cores)

What is the recommended time frame for EVT in someone with a Basilar artery occlusion

Within 24 hours if NIHSS ≥ 10

What to do for pediatric strokes?

• Early recognition is critical

• EVT may be safe and beneficial in select children

What should glucose control look like with a stroke?

• Avoid intensive targets (80-130 mg/dL)

  • It increases hypoglycemia risk without benefit

Should you do blood pressure intensive lowering (<140 mmHg) after IVT/EVT?

• No

• Doesn’t improve outcomes & may cause harm

What is the NIH Stroke Scale (NIHSS)

• Neurologic assessment that measures stroke severity

• Gold standard for determining tPA candidates

How many categories are on the NIHSS

• 11

  • Includes consciousness, language, motor function, sensory ability, & gaze

NIHSS score of 0

No stroke symptoms

NIHSS score of 1-4

• Mild stroke

  • Minimal neurological deficits, often limited to subtle motor or sensory changes

NIHSS score of 5-15

• Moderate stroke

  • Noticeable deficits in multiple domains (facial palsy, limb weakness, speech disturbance)

NIHSS score of 16-20

• Moderate to Severe stroke

  • Significant impairment in multiple systems, often requiring intensive care

NIHSS score of 21-42

• Very severe stroke

  • Widespread neurological deficits, high risk of mortality or major disability

What is a CTp scan used for?

• To look at where blood flow is going

  • How much brain is at risk/ salvageable

• Where blood flow is going

What is a CTa scan used for?

• Confirms large vessel occlusion & shows collateral blood flow

• Where stroke is

What is a non-contrast CT (NCCT) used for?

• Rules out hemorrhagic stroke

• Faster

Goal for treatment of ischemic stroke & how to achieve it

Promote blood flow

• TPA

• Thrombectomy

What does TPA do?

Dissolves the clot

What does a thrombectomy do?

Removes the clot

Absolute contraindications to TPA

• Any prior intracranial hemorrhage

• Known intracranial malformation or neoplasm

• Ischemic stroke <3 months

• Suspected dissection

• Recent surgery

• Recent head trauma

• Bleeding diathesis

Relative contraindications to TPA

• >75 y/o

• Current anticoagulants

• Pregnancy

• Cardiopulmonary resuscitation >10 min

• Recent internal bleed 2-4 wks

• Uncontrolled hypertension (180/110 mmHg)

• Remote ischemic stroke

• Major surgery within 3 weeks

How does TPA work?

Converts plasminogen → plasmin = dissolves fibrin (clot)

TPA must be administered within ________ hours

3-4.5

TPA is associated with complications of ________ & ________

Decreased Blood Pressure, Hemorrhage

3-24 hours post TPA precautions

• Patients typically on bedrest for 24 hours

• No rehabilitation services during this time

You should monitor for what in the first 24 hours post TPA

• Swelling of ischemic tissue causing mass effect

• Hemorrhagic transformation of infarction with/without mass effect

  • Accumulation of blood that increases pressure on brain

• Seizures

Evidence for early mobilization after TPA

• Mixed research evidence regarding safety for mobilization

• AVERT trial

  • Early mobilization did not improve 3 month recovery and may have neutral or slightly negative effect

  • Stroke progression/hemorrhagic conversion more common in very early mobilization group, especially in patients >80 y/o

  • Frequency of mobilization in first 14 days is more important than duration of mobilization

What is mechanic thrombectomy?

A catheterization procedure usually reserved for large vessel occlusion

What arteries might you get a thrombectomy for if they are occluded?

ICA, MCA, vertebral artery, ACA

When is a thrombectomy performed?

Within 6 hours of from symptom onset

(often after TPA is administered)

The retrieval technique for thrombectomy is based on ________, ________, ________, & ________

Clot properties, Anatomy of patient, Location of clot, Urgency of procedure

Retrieval techniques

• Stent retrieval

• Aspiration (vacuum it out)

Which retrieval technique is faster?

Aspiration

________ has a higher 1st time retrieval rate

Stent retrieval

Key steps in mechanical thrombectomy

1. Accessing artery (wrist, groin, abdomen)

2. Catheter insertion and fluoroscopy guided advancement to clot

3. Clot removal

• Stent retriever: net-like device guided to clot, expands to capture clot, then pulled back

• Aspiration: suction-based clot removal

Precautions after mechanical thrombectomy

Bedrest for a few hours with general femoral precautions to protect the area of incision

• Painful at the incision

• Limit hip flexion and extension

What is the goal of treatment for hemorrhagic stroke & how is it achieved?

Stop brain bleed

• Blood pressure control

• Endvascular

  • Coiling, Flow diversion, Gluing

• Surgical

  • Craniotomy

  • Craniectomy

Blood pressure control for hemorrhagic stroke treatment

• HTN is leading cause of intracerebral hemorrhage

• A major focus of early treatment is aggressive control of BP in acute phase (identify long term BP treatment)

• Acute care: IV/oral meds, special diets within hospital

• Long term: oral meds, behavior modification, continued monitoring

AHA recommendations of guidance for blood pressure management of hemorrhagic stroke

• Acute BP lowering when SBP is between 150-220 mmHg

• When SBP > 220 mmHg, lower BP by administration of continuous intravenous infusion medication with initiation of frequent BP monitoring

Bed positioning for hemorrhagic stroke

HOB elevated

Arteries used for endovascular procedures

Femoral or Carotid

Restrictions after endovascular procedures

• Bedrest for several hours

• If femoral, may have ROM restrictions

• Pain at entry site

Coiling for hemorrhagic stroke treatment

• Wire coiled into aneurysm to create a blood clot

  • Blocks flow into this area

  • Allows blood flow to continue through artery

Flow diversion for hemorrhagic stroke treatment

• Stent placed to minimize flow into the aneurysm

  • Will cause a clot that will be reabsorbed

Craniotomy/ Craniectomy will ________ intracranial pressure (ICP)

Reduce

What are craniotomies used for?

• Brain tumor removal

• Treating vascular malformations

• Hematoma evacuation

What are craniectomies?

• Skull is removed to allow a swelling brain room to expand without being squeezed

  • Relieves intracranial pressure from swelling or bleeding

  • Treatment for severe TBI or CVA when decompression is necessary

Physical Therapy post craniotomy/ craniectomy

• Can mobilize

  • Craniectomy: may require 2 person assist or helmet for safety

Medical monitoring for stroke treatment

• Neurologic status via repeat NIHSS

• Blood pressure

• Glucose

• Temperature

• Oxygenation

• Dysphagia (swallowing)

• Nutrition

• Secondary complication prevention

Acute care early mobility post stroke

• Don't want to stress the patient but low-level activity is good

  • Rest first 24 hrs

  • Relative rest = want pt sitting up, out of bed, standing, slow ambulation, w/c mobility

• Don't want to push patient too hard

  • Dependent on pt and PLOF

  • Watch for:

    • HR elevation, Blood pressure, or increases in neurological symptoms

What are the neurological symptoms that you should be aware of

• Weakness

• Slurred speech

• Dizziness

• Confusion

Most common cause of TBI

Falls

TBI prevention includes?

• Motor vehicle safety (seatbelts)

• Falls prevention programs

• Violence prevention

• Sports safety initiatives

Balance screenings

• 30 sec chair stand

• 5 times sit to stand test

Mild TBI severity attributes

• Loss of Consciousness = 0-30 minutes

• Alteration of Consciousness = Brief, < 24 hours

• Post-Traumatic Amnesia = 0-1 day

• Glascow Coma Score = 13-15

• Structural Imaging = Normal

Moderate TBI severity attributes

• Loss of Consciousness = > 30 minutes & < 24 hours

• Alteration of Consciousness = > 24 hours

• Post-Traumatic Amnesia = > 1 day & < 7 days

• Glascow Coma Score = 9-12

• Structural Imaging = Normal or abnormal

Severe TBI severity attributes

• Loss of Consciousness = > 24 hours

• Alteration of Consciousness = > 24 hours

• Post-Traumatic Amnesia = > 7 days

• Glascow Coma Score = < 9

• Structural Imaging = Abnormal

Mild TBI evaluation

• Symptom checklist

• Focused neurologic exam

• Standardized assessment tools

  • SAC

  • SCAT6

• Symptom scale

  • ACE

• Balance

  • Balance error scoring system (BESS)

Physical S/S of mild TBI

• Bothered by light or noise

• Dizziness or balance problems

• Feeling tired, no energy

• Headaches

• Nausea or vomiting

• Vision problems

Emotional S/S of mild TBI

• Anxiety or nervousness

• Irritability or easily angered

• Feeling more emotional

• Sadness

Thinking & Remembering S/S of mild TBI

• Attention or concentration problems

• Feeling slowed down

• Feeling froggy or groggy

• Problems with memory

• Trouble thinking clearly

Sleep S/S of mild TBI

• Sleeping less than usual

• Sleeping more than usual

• Trouble falling asleep

SCAT-6 key points

• Any athlete with suspected concussion should be removed from play, medically assessed, and monitored for injury related s/s including deterioration of their clinical condition

• No athlete diagnosed with concussion should return to play on the day of injury

• If an athlete is suspected of having a concussion and medical personnel are not immediately available, the athlete should be referred to a medical facility for assessment

• Athletes with suspected or diagnosed concussion should not take medications such as aspirin or other anti-inflammatories, sedatives, or opiates, drink alc, or use recreational drugs and do not drive motor vehicles until cleared to do so by a medical professional

• Concussion s/s may evolve over time, it is important to monitor the athlete for ongoing, worsening, or the development of additional concussion related sxs

• The diagnosis of a concussion is a clinical determination made by an HCP

• The SCAT6 should not be used by itself to make or exclude the diagnosis of a concussion. It is important to note that an athlete may have a concussion even if their SCAT6 assessment is within normal limits

How to manage your recovery from mild TBI

• Prioritize a good night’s sleep and light activity

• Minimize time using screens, around bright lights, or loud noises

• Do aerobic exercises for 20-30 minutes

• Stay connected to friends & family

• Keep track of your symptoms

At any point of your recovery, watch for these danger signs and see your doctor right away (mild TBI/concussion)

• A headache that gets worse and does not go away

• Repeated vomiting for more than 30 min

• Unusual behavior, slurred speech, increased confusion, restlessness, or agitation

• Drowsiness or inability to wake up

• Neck pain or tenderness
  Weakness, numbness, burning, tingling in arms or legs

• Convulsions or seizures

• Double vision

Concussion examination CPG strong evidence

• Vestibulo-occulomotor impairments

  • With suspect of BPPV:

    • Dix-hallpike

  • Without suspect of BPPV:

    • Ocular alignment

  • Vergence and accomodation

  • Visual motion sensitivity

  • Smooth pursuits

  • Saccades

  • Gaze stability

Concussion examination CPG weak evidence

• Autonomic dysfunction/ Exertional tolerance impairments:

  • Evaluate HR and BP in supine, sitting, and standing

• Motor function impairments:

  • Static balance

  • Dynamic balance

  • Dual-task/multitasking gait

  • Motor coordination with complex movement tasks

Concussion examination CPG worst evidence

• Cervical musculoskeletal impairments

  • ROM

  • Muscle strength/endurance

  • Tenderness to palpation

  • Cervical/scapulothoracic

  • Passive c-spine movement

  • Passive t-spine movement

  • Joint position error

Treatment for mild TBI

• Education & reassurance

• Physical and cognitive rest

• Gradual resumption of activity

Concussion intervention CPG strong evidence

• Vestibulo-oculomotor impairments

  • With suspect of BPPV:

    • Canalith reposition maneuver

  • Without suspect of BPPV:

    • Individualized vestibular and oculomotor rehab plan, individualized visual-motion habituation program