08.c • Traumatic brain injury (TBI)

In civilian life, the vast majority of head injuries are due to acceleration / deceleration forces resulting in closed head injuries. Risk factors for sustaining a head injury include male sex, younger age (peak 15–24 years with a secondary peak in the elderly) alcohol, lower socioeconomic status and a history of psychiatric disorder. The sequelae of head injury are often long-term and can be profound, with significant psycho-social and socio-economic consequences. Early, appropriate rehabilitation provides the opportunity to actively manage the consequences of the primary brain injury and reduce secondary complications thereby improving outcome.

MDT: Inpatient clinical management considerations (acute phase)

  • optimisation of respiratory function
  • nutrition, hydration and swallowing
  • 24 hour postural management (incorporating pressure care and spasticity management)
  • heterotopic ossification
  • pain management
  • bladder and bowel management
  • communication
  • the potential for autonomic storming (also known as paroxysmal autonomic instability with dystonia (PAID))
  • management of prolonged disorders of consciousness
  • management of cognitive and neuro-psychiatric issues including
    • post traumatic amnesia (inability to lay down new memories)
    • executive dysfunction
    • agitation and aggression
    • disorientation and wandering
    • disinhibition
  • assessment under the Mental Capacity Act / Deprivation of Liberty safeguards
  • family and carer support

Other actions:

  • Communication can be made with the trauma rehabilitation co-ordinator for advice and information.
  • Refer to the Directory of Services to provide guidance on potential transfer of care options. Patients with severe injuries are likely to require Level 1 specialised rehabilitation services.

Outcome measures/assessment tools

  • Rancho Los Amigos levels of cognitive functioning
  • Rehabilitation Complexity Score Extended
  • Glasgow coma score
  • Glasgow Outcome Scale Extended
  • Barthel ADL Index
  • Northwick Park Dependency Score

References

Head injury triage, assessment, investigation and early management of head injury in infants, children and adults (NICE, 2007)

Royal College of Physicians and British Society of Rehabilitation Medicine, Rehabilitation following acquired brain injury: national clinical guidelines, (Turner-Stokes L, ed) London: RCP, BSRM (2003)

Early management of patients with a head injury: a national clinical guideline (SIGN, 2009)

Guidelines for the Management of Severe Traumatic Brain Injury, 3rd edn (Brain Trauma Foundation et al, 2007)