All right. Let's go ahead and get started. Welcome, everybody, back to AAP Virtual Didactics. My name is Sterling Herring. I'm a PGY3 at Vanderbilt. Excited to have everybody on the call today and for today's speakers. So we've already gone through some of the goals. Housekeeping, as always, we're going to keep everybody's video and audio muted except for our speaker. If you have any questions, you should be able to click on the participant list. Mine's at the top, yours might be at the bottom, and you should see my name, Sterling Herring, up near the top somewhere. You can double-click my name and send me a message that I can pass along to the presenter. If you have any general questions, suggestions, or concerns with regard to this lecture series, please feel free to reach out to Candace Street. Her email is there on the screen, or you can track her down on Twitter. So without further ado, we're excited to have Dr. Oscar Sanchez here with us from the University of Colorado. Welcome, Dr. Sanchez. Hi there, thank you. Good to be here with you guys. So you should be able to, if you click the green arrow, you should be able to share your screen. I'm about to do that. Hold on one second. It'll ask you if you want to take it away from me. Yep, and share. Perfect. Is that working now? Yes, we can see it. Okay, cool. All right, are we ready then? Yes, take it away. Okay, thank you. So good morning. Here in Colorado, good afternoon somewhere in the East Coast. My name is Dr. Oscar Sanchez. I'm a clinical assistant professor for the University of Colorado in Denver, in the Department of Physical Medicine and Rehabilitation. Currently, I basically lead the consultation service for the acute brain injuries, spinal cord, and neurorehabilitation in our trauma hospital, which is called Denver Health. So I just wanted to make sure that you guys understand that So I just wanted to make sure that you guys understand that the purpose of this lecture initially was to educate the people in my hospital, especially the trauma team, that they really were interested into knowing more about what the role of physiatry is in our patients, specifically with traumatic brain injury from the beginning at the ICU level into the floor and before they go into rehab. And so that's kind of my primary role in this setting. And so initially, like I said, this lecture was geared to them. So we're going to be covering some basics about traumatic brain injury. So before we go on, just to let you know, let's see, I have no disclosures. And we're going to go over basic objectives, pretty much to understand the basics of disorders of consciousness. I know that I think yesterday or so there was a lecture about that in more depth. I'm just going to touch base a little bit, but it's not the bulk of the lecture. Develop a systematic understanding of prognosis after traumatic brain injury based on the evidence of literature. Recognize and understand the Laurentiolus-Amigo scale of cognitive functioning, which obviously most of us are already familiar with. And we're going to touch base a little bit on post-traumatic agitation in the TBI patient. The reason also I wanted to do this lecture for the trauma team in the hospital, just to get them to understand not only our role, but also prognostication in patients who have severe brain injury, where a lot of people bring a lot of biases into telling their family and their loved ones whether this patient is going to make it or not. And so sometimes we see that if they're not very familiar with these patients, they tend to give a lot of bad prognostication when actually the patient hasn't had a chance to even recover from their brain injury. And that's kind of the basis of this lecture. All right, moving on. We're going to talk a little bit about the epidemiology with traumatic brain injury. Up to 1.7 million TBIs occur every year. So obviously this is very prevalent, especially in the summer months, just because everybody's out and about. There are more accidents, you know, motor vehicle accidents, falls, diving accidents. So by definition, this happens a lot here in North America. As I mentioned previously, motor vehicle accidents are actually the most prevalent cause or ideology for our traumatic brain injury patients, up to more than 50%, up to 53% of cases. Second living cause is falls, up to 23%. And, you know, from there, we have other causes, including violence in gunshot wounds, penetrating injuries, and other causes. We see it more often in males than females. Up to 70% of the patients are males. They tend to be more prevalent in Caucasians, up to 67%. And then in African American, a minority, which is Hispanics and other ethnicities, comprise up to 10%. Obviously, depending on the region or the world, things may change, but this is what we see here in North America. This is a disease of the young, unfortunately. You know, we see big incidents between teenage all the way to the young adult between 15 and 25 years. And that kind of makes sense because that's when, you know, teenagers start getting their licenses to start, you know, driving their vehicle on their own. Probably their brain is not fully developed. They have less, you know, responsibility in terms of, or having more rules and restrictions, and they don't pay attention much as they, you know, older people. And then a second peak that we see is in the fall, especially in the elderly, because they start falling, they develop problems with memory, they're unsafe at the house, or they develop neuropathies, et cetera. That obviously we see the second peak. Not surprising that alcohol is the main compounding factor, especially driving, and then the influence that leads to the accident, and then we see that. And that's a major problem because when we're addressing and we're assessing those patients in our evaluation, a lot of those patients come already intoxicated with alcohol, so they're not going to give us a full neurological exam because they're, you know, uptended or they're intoxicated. So sometimes the classification may vary or may not be able to be done right away. Depending on the hospital that you practice, if you're in an urban center like ours here in Denver, we not only see alcohol as a main compounding factor, but also polycystic substance abuse is very common as well. So people driving under the influence of marijuana or methamphetamines, cocaine, et cetera, that also is a big compounding factor that also is going to play a role into recovery and prognostication in our patients. Unfortunately, up to 30 people per 100,000 die every year from TBI, and it's not surprising to us that all together in terms of the care of the acute TBI is very expensive, not only surgeries and the acute care in the ICU, inpatient rehabilitation, but also the time where the patient is absent from work and the potential of a patient being disabled where basically the cost of taking care of just one patient is going to be elevated. The economic impact is huge, up to $60 billion per year. This was in the year 2000, obviously it's a lot more now because the statistics are a little bit old already. Moving into classification and assessment, once we start seeing these patients, you know, if you read this in the books, we try to classify it into mild, moderate, and severe. And the inclusion criteria for this classification is variable. We try to kind of have some variables that are more consistent, including not only evaluating the image, loss of consciousness, post-traumatic amnesia, as well as the Glasgow Coma Scale. So as many of us know, these are the very minimum information that we need when we're evaluating these patients in the acute setting, just so we can get an idea of what we're dealing with. Usually in tertiary hospitals or trauma level hospitals, we don't get to see a lot of mild brain injuries because usually those patients do very well and they tend to be discharged pretty soon and they go home and they follow us an outpatient. We tend to see more frequently the moderate and severe brain injuries, obviously, just because those patients are sicker and they require hospitalization and prolonged care. For patients with mild brain injury, usually the imaging is normal. The CAT scan or the brain MRI may not show any bleeding or anything significant. However, those patients still may present with some minimal loss of consciousness up to 30 minutes. They may have some post-traumatic amnesia. Usually it doesn't last more than 24 hours and the Glasgow Coma Scale is pretty good between 13 and 15. Again, those patients have good prognosis. Usually we will see those patients in the outpatient arena where they may develop some cognitive deficits, some memory, post-concussive syndrome, etc., but this is not the purpose of this topic today, of this talk. Moderate and severe is where we're going to start seeing more abnormalities, obviously, in the imaging of the brain. In the moderate arena, the patient may have a longer loss of consciousness between 30 minutes up to one day. Post-traumatic amnesia obviously is going to last a little longer, up to a week, and the GCS is less, between 9 and 12. In the severe category of our brain injury patients, as you can imagine, obviously almost everybody is going to have abnormal imaging, including subarachnoid hemorrhage or midline shifting, epidural hematomas or interparenchymal contusions, diffuse axonal injuries, so significant abnormalities that are very obvious to the naked eye and the clinician. Patients may actually have sustained loss of consciousness up to one day or 24 hours, and obviously post-traumatic amnesia may last several weeks. So you may see those patients in the inpatient rehab units where they still don't know where they are or they're confused, they can't remember what happened because of the severity of their brain injury, and the GCS in presentation is usually very low, between 3 to 8. So I'm going to do just a few questions here to see what, you know, to keep you guys engaged. Which of the following is the most common cause of TBI in USA? Is it domestic violence, diving accidents, motor vehicle accidents, or penetrating injuries? You guys can actually answer in the chat feature just to see what you guys think. And I don't see that chat feature, so I assume... It's on here, I can tell you we're getting C, a lot of C. Okay, and obviously that's the, thank you for letting me know because I cannot see it, so that's correct. As we said earlier, motor vehicle accident is the most common cause. Depending on the country as well, things may change. I am originally from Colombia, and we don't have huge highways, we don't have specialized access and transportation in many areas of the country. So actually, motor vehicle accidents are not as common there, but penetrating injuries, unfortunately, and violence, as you may imagine, is one of the most common causes of TBI. All right, we're going to move on into disorders of consciousness, and the reason we're going to touch base on this is to understand as to why a brain injury patient may develop a disorders of consciousness that actually could be very stressful and very difficult to treat at the very beginning for the trauma team, to understand the implications of that, to understand that whether is it going to be a permanent thing, or is it going to be a transitional state, and that's going to lead us into, if we know this very well, what to expect with these patients. We can actually counsel the families accordingly, because as you can imagine, in the acute care setting, we may not be able to do much at the very beginning because they're intubated, they're in the ICU, you know, we bring recommendations medically, but I think one of the most important roles as physiatrists is to inform the loved ones and the families that they have no clue what's going on. Obviously, they're having a significant amount of stress with their loved one. And that's when we actually can take advantage of our knowledge and explain in reality what could happen with them, the expectations in rehab and recovery. And I think we're one of the best specialties and suited for this. We're gonna talk about the reticular activating system just because we're talking about awareness, which obviously is a very complex understanding as to what entails awareness in our brain. And it's obviously comprised of a lot of parts and connections in our brain. Stemming from the brain stem, obviously, as we know, we have the reticular activating system and the nuclei there that are actually reaching a neurotransmitter called dopamine. And from here we have connections into the thalamus that actually is gonna basically keep all that information coming from the activating system and basically get radiations into the cortex in different areas, especially the frontal lobes, obviously into the cortex and the occipital, just to integrate visual stimulation, auditory stimulation, as well as tactile stimulation to be able to kind of see, okay, we're aware, we know where we are and what is going on. As you can expect with brain injury, especially in the moderate and severe category, these pathways may be disrupted, especially when patients have diffuse axonal injury or interparenchymal bleeds, et cetera. One of the beliefs is that due to the deceleration forces that happen in the brain with coup and countercoup injuries, there is a significant amount of axonal damage in these pathways leading to loss of consciousness. So once we evaluate our patients, we need to determine what kind of disorders of consciousness they may have, and based on this, we can make some assumptions and prognostication or treatment plan for them. As I said earlier, the consciousness is obviously a function of the cortex in correlation with the reticular activating system. And then patients can present with three major categories, including coma, vegetative state, and minimally conscious state. As we have seen patients in coma, those patients obviously lack wakefulness. So they look, they're asleep, they're not responding to the environment. Their eyes are usually closed. They may have, you know, you would try to kind of stimulate them painfully or whatnot. They may not have any response to that stimuli. They do not have sleep-wake cycles usually. That's one of the main differences between that and the other disorders of consciousness. That, by the way, is a board question that we get a lot. And how do we know that? Obviously doing an EEG on those patients and see if there's any sleep-wake cycle patterns or not. One thing to understand is usually coma is a transitional state. It's very infrequent to see a patient to be in coma for a very long time. Usually they transition into a vegetative state or anything else. And usually after four weeks is when we start seeing those changes. Patient on a vegetative state, they may have, they will have sleep-wake cycles. They may open the eyes spontaneously. However, they don't interact with you. So therefore they don't track even if you try to kind of tell them, okay, talk to me, look at me and whatnot. They open their eyes and they close it spontaneously without any consistency. Obviously the patient does not seem to have any awareness. They don't track. However, they may have a generalized auditory startle. So, or even to painful stimuli, they may move spontaneously. They may posture either inflection or an extension. So we see a little bit of more response to the environment, but obviously nothing that we can consistently say, he's reacting to me or she's reacting to me and following commands, et cetera, obviously. Now, patients may stay in this state for a longer time. If they persist for more than one month, we can call this a persistent vegetative state. And then there's stages where it can be chronic. In the past, and I'm going to talk about it in a little bit about the guidelines that we use for this, for this sort of consciousness, we, they used to use the word permanent. If it lasted more than three months in non-traumatic brain injury or lasted more than 12 months in patients with traumatic brain injury, we're trying to get away from that word and use actually chronic state. Why? Because that basically implies that it's pretty much a dynamic state that actually may evolve eventually into something else, as opposed to when it's permanent, it gives the idea that it's there forever. And if we use that word when counseling, it kind of has a negative connotation because it's permanent. It's like, we're it, there's nothing to do, and that just doesn't help. So we use chronic, people tend to understand a little bit, okay, there's something that is may going to stay there for a while, but it may change over time. When patients actually start emerging from this, they actually can become minimally conscious, where actually we start seeing some emergence of wakefulness. So patient actually obviously may open their eyes, they actually may start tracking to stimuli, whether it's auditory or tactile or even painful. Obviously this tracking is inconsistent still, so it can be frustrating because the nurse or the family, or the family actually tells them, they're always by the side and say, I swear to God, my son just opened the eyes and looked at me. And of course the nurse goes back and is like, she's crazy, that patient is still in vegetative. And people tend to kind of unfortunately do that a lot and ignore that. So I usually, the first thing is I pay attention to what the family has to say and pay attention because they know their patient very well. They're there most of the time, unlike us. So they're telling me that, I pay attention, probably the patient is emerging into minimally conscious. And even if they're getting better, they may do some verbalization or noises. They may be able to do some object manipulation. They may track familiar voices of their loved ones. But again, they're not following commands consistently. They're not talking to you, normal conversation. But at the same time is when we get excited, we're like, ooh, we're starting to see this brain, the engines to start taking off. And then based on that, we need to kind of start making prognostication or how to counsel our families. And again, this is one of the roles that I have here in our hospital that is a big role when we have severe brain injuries. And to make a prognostication on these patients and disorders of consciousness is very difficult. That's when they're calling us. We need help because we don't know what to tell the family. The social worker is on the phone and kind of, can you help me? So it's very difficult. Obviously, there are many variables, especially with disorders of consciousness based on where they are. I believe that this is an area that needs somebody like us specialized in a brain injury or even a neurologist or somebody who understand the physiology of the brain and can counsel the patient. And usually for prognostication, time is our best friend. Many, many times we actually are telling the patient's family, we need time. It's too soon to tell you what's gonna happen. We don't know, we need time. And some people don't understand this and they may think that we don't know just because we don't give them a specific cancer timeframe. And actually that is completely fine. That's why I say time is our best friend and we need to have the family understand that despite having studies showing us this and that, and we're gonna talk about in a minute, having the best expert in the room, even we can tell them the best prognostication and we may be wrong or the opposite. Sometimes we say, this patient is looking terrible. We know that it's a severe brain injury. We don't know what's gonna happen. We don't wanna be very optimistic and sure enough, the patient does better. So therefore, there's not a single factor is involved and usually we try to avoid pessimistic talk with the patient right away at the very beginning. This leads us to talk a little bit about some practice guidelines that actually a group of people got together many years ago to kind of specifically guide us into this. And this was published by the American Congress of Rehab Medicine. So this was actually a group of people including obviously, psychiatrist, neurologist, neurosurgeons, neuropsychologists, et cetera, to kind of put together the evidence that is out there and be able to prognosticate based on this evidence and tell the family, okay, based on the evidence that we have, we expect this patient to have this outcome or not. So this is very important that I want you guys to be familiar with. This was published in 2018, the latest recommendation. And so obviously, this is a relatively long paper with a lot of recommendations. I'm not gonna go in a huge detail recommendation by recommendation. Rather, I thought it was practical to come out with key points that they brought up that I thought were important for us to understand about these recommendations. In the area where they're telling us about the evidence base of brain injury patients, one study found that mortality in these patients is up to 32% with severe TBI and disorders of consciences. This is not actually due to the comorbidity or the TBI per se. This is actually due to withdrawal of care, which is very unfortunate. Those patients are not given the right time or the timeframe to survive or see their outcomes. And many instances, those patients look really bad at the beginning. Even... There myself where I see these patients, and I try to kind of guide them and say, we need time because sometimes the trauma team, they don't see what we see in rehab, right? They only see what's out there in the ICU. And if they see a patient that is not doing well in... Well, you know, prepare for the worst. And the worst have a patient of mine that I'm gonna be bringing to you all an example specifically of this, where I had this patient that, and I'm gonna tell you about a minute ago, I have some videos to show, where the trauma team was actually telling the family, I think this is not, he's not gonna make it. Be prepared to pull the plug. I think that's the best thing to do because he's not gonna make it until we get him out. I think that's the best thing to do because he's not gonna make it until we came in and gave him a different perspective and the family was able to decide based on realistic facts, whether they wanted to continue care for the patient or not. Based on these patients with disorders of consciousness that last more than a month, actually can achieve some level of independence long-term after a year, if given time and appropriate rehab. 20% of these patients with traumatic vegetative state after rehab, they have had some independence in one year. So even when those patients in traumatic vegetative state are actually long, they eventually emerge and they have some independence. Obviously, as you can imagine, the minimally conscious state has better prognosis than a patient with prolonged vegetative state within the first five months. If you have a patient already and minimally conscious to begin with, we have some basis that the patient's brain is starting to wake up and therefore that prognosis is gonna be a lot better because we can work a lot more on that. It's important to have at least, if we're gonna continue to care for these patients and if they have a prolonged disorders of consciousness, MRI at eight weeks, four to eight weeks is actually helpful for us to see what's going on in the brainstem, in the corpus callosum, the corona rarieta. Those obviously, as we spoke earlier, are part of the basis for wakefulness. And if we see a lot of contusions or let's say an ischemia on this area or bleed that went into these areas, by default, it's gonna tell us the recuperation of this patient is gonna be a lot longer and likely the prognosis is not gonna be... of these injuries. So we can tell it to the family. For example, a patient who has less than two weeks of coma, obviously the outcome is going to be better because they're going to start emerging into minimally conscious or vegetative, as opposed to somebody who's in coma for way more than four weeks, the good recovery is unlikely. Same thing with post-traumatic amnesia. Somebody who emerges from TTA pretty quick, less than two months, obviously it's very unlikely that they're going to be severely disabled. And as opposed to somebody who has prolonged TTA, which usually happens with patients with severe brain injury in some cases, you know, a complete good recovery is unlikely. Moving on with these recommendations, based on these statistics, the recommendations also say that in order to evaluate these patients and make prognosis, we want somebody who has experience, not only one person. It's a multidisciplinary evaluation from a physiatrist, the neurosurgeon, a neurologist, if we can obviously our speech therapists to kind of have all the tools in place for us to be able to recommend and tell the patient's family what's going to happen next. We should be able and we should use some standardized behavioral measures that we can use to explain the family and see what's going on. We can use a coma recovery scale on the bedside. And, you know, I've been working with my speech therapists here in this hospital and we have started doing this on whoever that we see that they have a DOC. They start early on and we're able to track more objectively what's happening with these patients. This also is very helpful when you're trying to deal with insurances that they want to approve somebody going into a DOC unit. But if you have any objective evidence that the patient is improving, less likely it's going to be approved for a patient to go there. So we should be using those more commonly or more frequently, I said, I mean. And any type of recommendation for the diagnosis of the patient needs to be addressed. What I'm talking about this is that patients obviously may have significant complications, including infections, deep vein thrombosis, respiratory issues where basically patients need to be intubated, sedated, etc. So obviously we won't be able to kind of evaluate fully their full potential. So, you know, before we start making any recommendations or any prognostication, we want to make sure those issues have been resolved. We can use also other neuroimaging, more advanced imaging, such as, you know, fMRI or MRI, electrophysiologic studies, including EEG, to kind of see how the brain is behaving. As I said before, with the imaging studies to see if there is any and to be able to do the trial, the trial routine, avoid any language of universal poor prognosis in these patients with disorders of consciousness during the first month, because usually after the first 28 days or first month, those patients start emerging and we have seen it over and over. And so therefore we need to give those patients a chance of recovery before we say, nope, this is it. When we're counseling the family, we need to be obviously realistic, but also show them not only compassion and understanding of the reality and the severity of the problem, but give them a hopeful message. We can always come and say, this is it. You know, I've had instances with the trauma team, unfortunately, when they tell the poor little intern or the PGY2, talk to the family and tell them that this is it. This patient is not moving. So number one, that should not be a resident's responsibility, especially a resident who isn't training and doesn't have an attending, and if possible, by a PMNR that can gather the family together with the resident to understand and learn how to counsel these families. These family meetings can be very tough, and I think the more we're comfortable treating these patients and the more we're comfortable counseling these patients' family, the better we will be. Also at the end of these recommendations, we're going to be talking about neurostimulants, especially amantin, where we, as we know, we use it a lot in these patients to start early as a neurostimulant to improve their wakefulness as a dopaminergic, and so we try to kind of start this medication early on, even, you know, once the patient is somewhat more medically stable. All right, now I'm going to move on into a case that I want to share with you of a patient I had in October. A motor vehicle accident came in with a severe brain injury, GCS of three, and responsive. As you can see, he had a significant brain injury. I think this was the very first scan on the left of the screen, where he had significant contusions on the frontal lobe. Obviously, he had a fracture here. He had a subarachnoid hemorrhage. He had signs of increased intracranial pressure, so he went to the OR for a craniectomy emergently. You know, the typical patient that we see in the trauma hospital. They didn't consult me until later on. The patient stayed in the ICU for at least two weeks without PMR being consulted, because he was acutely ill. You know, after the surgery, pressures kept going up, so they had to go back and re-evacuate another hematoma he had. Then he had to be put on a vault to, you know, control pressures. Obviously, the patient was sedated, was looking terrible. The family was very anxious. They didn't really know what to expect. The trauma team obviously kept them very well informed about every single thing that they were doing. You know, we're doing these measures, we're trying to keep him alive. They were great. Nobody would actually tell them what's going to happen next. Eventually, PMR thankfully was consulted, and we came in to the rescue, so to speak, to kind of counsel the family. They just basically were very anxious to know, is he going to make it or not? Again, one of the interns in one of the family meetings pretty much told them, you need to be ready to unplug the patient. He's not doing better. Unfortunately, that was told to the family, because that week the patient really was very sick. He had a bit of fevers. They found out to have infection in the brain. So obviously, you know, one complication after another, obviously you're saying, well, you know, this is unfortunate. Eventually, the patient was stable, still alive. They treat him accordingly with infection, and we finally were able to control the intracranial pressure. And this is one of the evaluations I had right at the beginning. His name is Chewy, and I have permission from the family to share this with you guys. So this is a very short clip that I had. Let me see if this works. Okay, this is Chewy, one of our patients who's been here in the ICU for about five weeks or so with significant disorder of consciousness as well as severe brain injury. We've been assisting him with arousal and doing some medications to see if we're seeing some improvement. So far, we have a very low level. Obviously, he sometimes responds to painful stimuli. Sometimes he doesn't. Chewy? Hola, Chewy. Soy Oscar Sanchez, el doctor de la medicación. How are you? So obviously, he's not responding. He, at that time, was in vegetative state and pretty much stayed in this state for at least three months. So eventually, he went to the floor and, you know, trauma team was done in the ICU, and obviously, that's when we became more active in his care. You know, I started with him on a monthly and early on to try to kind of improve his wakefulness and got the team involved to move him and avoid complications of immobility, etc. And unfortunately, you know, our hospital is a safety net hospital, so he did not have insurance. So the family was really desperate to know, okay, what are we going to do? So I kept them really informed from the beginning, okay, he's going to do better if we, you know, I gave him all the statistics. I said, we need to give him time. He may get better. And then we need to start kind of working from the social work perspective and insurance, try to get him something, somewhat coverage, so we can actually give him some rehabilitation that I wanted. So we were able to kind of get him an insurance with the family. We worked closely with that and the social workers. In the meantime, our therapist kept, you know, working with him. And at one point, our therapist actually started to give up because he wasn't improving. He wasn't showing any, you know, motion. He wasn't following commands. We're too busy, doctor. We need to see, you know, other patients. So they started seeing him like once a week. And so I had to really stay on top of him to avoid, you know, complications from immobility. Even our own biases, even the rehab team was starting to give up, which was, you know, quite shameful. However, you know, it depends on us to see whether we want to kind of keep that route or not. Eventually, after he spoke Spanish and spoke to me, obviously, you know, a lot. She said he started moving his right hand. He's moving the right hand. I think he's listening to me. And I stayed there. And of course, I said, no, I don't think that's the case. But look at this. So this was about three months later. He's already on the floor. Hello, Chuy. I'm Dr. Sanchez. How are you? How are you? This is Dr. Sanchez. Can you squeeze my hand like we did just now? Squeeze my hand. Very good. Show me a finger. Show me my finger. The big finger up. There it is. Okay. Squeeze my hand. Squeeze my hand. Squeeze my hand very hard. Okay. Open your hand. There we go. Open your hand. He's moving it more. On command. He's now grasping me. So, before we go to this, we're going to go this in a second. I just wanted to kind of say that at that moment, the patient was already on minimally conscious state, obviously, because he was starting to follow some commands, you know, moving the right hand a little bit so the family was right. And again, the nurse also was kind of getting excited about it. And eventually, everybody said, oh my god, now we can talk. Now we can start working with him. So, we just said, sure. He's always being the patient that always we needed to work with him. Thankfully, at that time, he had insurance. Then we were able to start thinking about the next level of care. Eventually, we were able to bring him to Craig Hospital, which is obviously one of our TBI models here in Colorado. We'll have another video of his progress. We're going to do a little parenthesis about this patient. Before we go into that, I'm going to touch base in a few other topics, including post-traumatic agitation. Obviously, as patients emerge into this disorder of consciousness, they're going to likely start getting more alert and eventually agitated. As we know very well with our Rancho Los Amigos scale, it was developed mainly for us to communicate better, in my opinion, to have a group of symptoms and signs of the patients as they go through different stages of brain injury and describe them in a more systematic and consistent way. As you know, it can go from Rancho Level 1 all the way to 8. The first three levels pretty much are consistent with the disorders of consciousness type of patients that we just spent some time on. Level 4, usually the patient already is following commands inconsistently, but mostly they do. They may be more agitated and confused. Those are the typical patients that are more distressing in the floor, that they're calling us to see what to do. They're on restraints. Those are the ones that make more noise in the rehab units or in the floor. Eventually, once they emerge from that, they go into Rancho 5 and beyond where they're less agitated, but obviously, they're still in post-traumatic amnesia, likely, so therefore, they're confused. They can be inappropriate. They may be grabbing somebody says behind, or they may be saying some comments that are not appropriate with females, et cetera. As they emerge, they become more automatic and they follow more commands. They're less agitated, and eventually they become more purposeful. Moving into post-traumatic agitation. Basically, I'm bringing this up because depending on the area of the brain that has been affected with brain injury, we may expect different behaviors. I'm not going to go into many details, but at least to notice that usually most of our patients may have a lot of frontal lobe problems. As you may imagine, most of the accidents are head-on collisions. They go forward, they go backwards, so they have a lot of frontal or occipital type of contusions and bleeding. As you know, with the frontal lobe, as you know very well in uranatomy and uranatomy is in charge of a lot of problem solving, judgment, inhibiting behaviors or not, and rules. When we have a patient with a frontal lobe syndrome, they're going to be disinhibited. They're going to be likely agitated, and that's what we see a lot in our patients once they start emerging from the source of consciousness. That's going to be the first manifestation. Some of the older patients may have problems in their prefrontal cortex in the parietal area where they're going to have significant cognitive deficits, memory problems, insight, so they don't know where they are, and therefore they become more agitated. Other patients may have problems in the posterior fossa in the occipital area, so they may have problems with visual integration, cortical blindness. Those patients actually may become even more agitated as they cannot see. They cannot integrate visual aspects of their room into their wakefulness or environment. There are a lot of issues just from the brain per se that can give you agitation or restlessness to begin with. Then before we move on, let's check. What was the name of the patient in the video? Was it Miguel? Was it Chewy, Fernando, or Steven? I can't see. I'm seeing a lot of B, Chewy. B, Chewy. There we go. He's my poster child, so his name is Chewy. Absolutely. Good job. Moving on. We're going to talk a little bit about post-traumatic restlessness. We consulted a lot on these patients just because of the nature of the injury and many people really don't know what to do with them. Most of my patients that come to my I'm sorry, residents that come to my rotation, they get a little bit of the flavor of this. I always tell my residents, once you start addressing this, you need to ask yourself why. Why is the patient restless or agitated? Before you start thinking about medication A, B, or C, go to your basics. Obviously, this is a multifactorial problem. Obviously, there may be medical problems, including keeping in mind the brain injury itself, but also patients may have infection or they may have post-traumatic seizures. Withdrawal from alcohol, as we said, is a very common confounding factor or opioids that may manifest in agitation. Like I said, infection, or a very common one is altered sleep. With brain injury, those patients do not sleep. So they stay up all night. They tend to get sleepy sometimes during the day, but at the same time, they just become agitated. They wanna sleep, they can't. Encephalopathy from other factors. And one of the main factors is also pain, which is not listed here, but it should be. As you know, those patients not only come just with a brain injury itself, they usually come with polytrauma. So they may have fractures, fractures in their jaw, their face, that stuff hurts. So we need to make sure that we're treating the pain very well, that they're sleeping. And obviously, once we start seeing this, we kind of start ruling out those factors and move on to our little checklist of why is this patient agitated. Another issue is that we wanna modify the environment. As you may know very well in the ICU setting or even in the floor, they may have injured tubes, a foley, the minute the patient is awake and able to kind of see what's going on, they just wanna pull the tube. So the nurse is putting them on four-point restraints, which are gonna make them more agitated and the cycle goes on and on and on. And so, you know, some of us just roll our eyes as like, oh my God, but it's tough to us to kind of come in and break that cycle in the best way possible and educating the team that is taking care of the patient. I cannot stress this enough, as physiatrists, we really are good at engaging people, educating people. This is our opportunity to have the nurse, the tech, the resident that is taking care of him in the acute setting while we're doing things. So we try to modify the environment by using low stimulation, soft restraints, sometimes use a sitter instead of the restraints. Avoid noxious stimuli if at all possible. Minimize lines, like I said, educate the team. We may use post-events if needed, get rid of the injured tube if we can. You know, we need to kind of get this all in consideration before we start even the pharmacological aspect of the restlessness, which we haven't even started. Sometimes the patient may need a PEG tube. If we see that his level of paroxysal is not good enough or they have severe dysphagia, it's gonna take longer than normal. Many of our teams love to keep this forever. So we try to kind of just say, you know, move on and try not to do that. We're gonna touch base a little bit on pharmacologic and management of the restlessness. Again, the first thing to address is sleep-wake cycles, in my opinion. And then try to kind of make it more, you know, normal, if you will, for somebody like, you know, sleeps during the night and stays awake during the day. So we may use a lot of medications in higher doses sometimes to achieve that purpose, including tracerone, melatonin. Melatonin, as you guys know, also has significant antioxidant properties and inflammatory properties, which actually may help with brain injury recovery. So it's not uncommon to use melatonin in those patients combined with tracerone. We may use the side effects of other medications, especially when they're sedating, to use them at night to achieve sleep. Propanol is actually, based on a Cochrane review, is one of the best medications that we can use for post-traumatic restlessness and agitation. I use it a lot. Those patients actually tolerate the medication very well. Propanol, in general, obviously, the side effect would be, you know, low blood pressure and bradycardia. But among all the other beta blockers, this one is the one that is better tolerated. The patients are not so unstable. So we can go up pretty quick, and titrate it almost like 10 milligrams a day, going up every day up to 80 milligrams, you know, TID, if needed, or even more. Obviously, as you may know, no haloperol. As we all know, haloperol, as part of the antipsychotics, is the one that has shown to delay the motor recovery and prolongs post-traumatic amnesia in humans. So this medication is highly used in acute setting by the trauma team, so they love using it. The nurses love using it because it's easy access, and obviously put the patient to sleep, so they can move on to their next, you know, to the next patient. And we obviously bring the opposite. Try not to use it. Let's try to use something different, let them be. So sometimes there's a little bit of pull and push with the team, and we need to do it in a very professional manner. Sometimes we need to use antipsychotics because the patient is too restless, is too agitated. And we try to use atypical antipsychotics. Check why. They tend to block less the D2 receptors. So in theory, they may have less motor side effects of target dyskinesia, et cetera. And so therefore, it's quote-unquote a little safer than the typical antipsychotics. Some of the ones that I'm more familiar with and I use is Cyprexa or Olanzapine. We can use the Risperidone, Seroquel or Quetiapine, or even Abilify. You know, depending on their side effect profile, we may use one or the other, but in general, these are actually used very effective for patients who have significant motor restlessness, especially Cyprexa. I like to use a PRN for when the patient is extremely agitated instead of the haloperidol. Another one that I use a lot is valproic acid as a mood stabilizer. And that one basically, patients who show a lot of anger, irritability. And I want my resident to see, okay, do you see that as a behavior as opposed to just being completely restless and moving? Then if the patient is showing a lot of anger, irritability, valproic acid, actually does a very good job bringing those, you know, instability in the mood down. I usually start at 500 milligrams three times a day. I usually don't worry so much about the level right away. I basically check in about a few days later just to make sure it's not super therapeutic. Patient actually, you know, tends to do very well on it. We can use sometimes Lamictal, Carbamazepine, but obviously they have a few more other side effects or even Gabapentin. Gabapentin, you know, is very sedating. So I tend to use it at night sometimes so we can achieve some sleep properties. You know, some people use benzodiazepines, especially when they're in ICU, when they're moving a lot. And obviously, as we know, benzodiazepines can be used for this acutely, but may cause paradoxical agitation. So we try to kind of actually wean patients from the benzodiazepines and put them on something else to avoid this. Obviously, if needed, we can use just short-term or short-acting benzodiazepines such as Midazolam or Florazepam. Real briefly, because I know we're getting close to our end of the lecture, which we are, we're gonna wind up, finish with two more videos and we'll be open for discussion. I brought this out to our trauma team when I gave this lecture initially, because amantolin, we use it a lot to wake up our patients, to stimulate them. But there is also a belief that amantolin actually creates agitation. So when a patient is somewhat restless, but we still kind of have decreased initiation, some of our trauma team, they do not like to start amantolin because they believe it can worsen the agitation. And I have yet to see a lot of those patients to really get agitated only from amantolin. And in fact, I brought this study, which is old, but actually has been used to treat that, to treat frontal disinhibition on patients with brain injury and actually can help with that. So amantolin actually can be used for cases of mild restlessness. Going back to Chewy, this is him a month later after I sent him to Craig Hospital from our hospital here in Denver Health. He was already following commands and he started doing weight assisted training. He was able to keep his head up. And at the end, the therapist asked him how he's doing and he says, yeah, he has some pain. Nice job, Chewy, keep going, keep going. You all right, Chewy? He said, yeah. So he's completely out of minimally conscious state by now, obviously. And sorry, I don't know how to, there we go. And this is him about a month ago. He's still in Craig Hospital. He's actually doing a lot better. This video is in Spanish because they speak Spanish. So this is his sister filming him when they're taking a break from therapy. And she's actually talking to him. At the beginning, you see he's not interacting. He still has significant delay processing, but once you engage him, he takes off. And then she's asking like, say hi to the family, tell them that you love them, tell them that how much you love them. And then he engages and you'll see how nicely he responds. At the beginning, he looks like he's not there. You can say something, Chewy. Say hi, Chewy. Diles hola a tus hermanos. Come on, Chewy. What is that? She's laughing. He says, how are you, guys? The family misses you a lot. He says, I'm very tired. Soon. Mándales un beso. Kiss for the family. And then he sends a kiss right there. You know, so he's engaging, he's interacting with the family, doing a lot better from what we saw him in the ICU. This perfect example that these patients do get better if we give them the right treatment, the right choice of, you know, recovery. In summary, just to finish up, as we know, TBI is a major contributing factor for disability in the United States. It has a huge economical impact. As we discussed earlier, prognostication is very difficult to begin with. It requires significant training and experience to be able to counsel families. To remind you, coma is a transitional state. And most patients recover if given the chance and appropriate multidisciplinary treatment and rehab. Medical and behavioral management is very complex. Just a reminder, Haloperidol is the worst friend of TBI patient, and Mantain is one of the best friends for TBI. And this is it. I hope you guys enjoyed the lecture. Thank you very much. That was fantastic. I appreciate kind of the broad overview, but case presentations always bring it home, I think. So I appreciate that. I'm glad to hear it so well. It's really impressive. Yeah. Kind of makes me second think or reflect on patients I've had in the past and wonder what I could have done differently. Yeah. One question that came up for propranolol, how quickly can you increase the dosing and what would you start at? Assuming BP and heart rate can handle it. Sure. I think I'm gonna stop the sharing so I can see you all. I don't know how to do this, but. We, here, I can take it back from you. Yeah. You won't be able to see much. Let me. Okay, that's fine. Yeah, so to answer the question, propranolol, usually you can start, I usually start 10 milligrams PO, TID, to begin with and see how they do cardiovascularly. But obviously that's a low dose that is not gonna do much for the agitation. So I usually time to, every day, every 24 hours, we can go to 20, to 30, to 40. I've gone up all the way to 80 milligrams three times a day. And I know there are colleagues of mine who are going even higher. Obviously, we are, need to kind of pay attention to cardiovascular side effects. And sometimes it's not the best option if they have hypotension or other things. But in general, they respond very well. Usually, I see 30 to 40 milligrams where they start getting less agitated in that dose. Less than that, usually they need to be pumped up. Okay. And when you're prognosticating any PTA and coma, what does a good outcome mean? Again, we talk about coma less than two weeks or coma more than four weeks. Uh-huh. What's a good outcome? What are we talking about? Independent with ADLs, IADLs? Yeah, that's a great question. It's obviously the paper doesn't specifically say what outcomes they're talking about, but in general is some level of independence with ADLs and interaction with the family, probably at a wheelchair level. That for many people, that is some quality of life that the patient can participate in some of their ADLs. Obviously, the prolonged coma, that window, that percentage goes smaller, smaller, and smaller. Okay, great. Another question came through, how do you get started doing consults for TBI patients and how can we implement that in our own trauma centers? Oh, wow, so great. The first thing is to basically do, meet with the stakeholders. Say, if you are gonna be hired there for this hospital and whatnot and say, okay, I need to identify who is taking care of these patients. Is it a neurosurgeon or is it a trauma surgeon and get to know them first and establish a relationship with them as well as the social workers in the ICU. They're really, really key because they have the power to tell the team, we need a PMR consult and that's how we get a lot of them. They guide them because it's a teaching hospital. So the residents do whatever they're told to do in that setting. So that is actually a good thing to say, okay, when that happens, consult us. In our institution, one of my colleagues, Dr. Ladley and I have actually got together with people who are experienced in this field and we develop guidelines for treatment for these patients. So these guidelines are about to be published internally in our hospital so that the idea is that when the intern is admitting this patient, there's already a click to say, okay, if it's TBI, PMR consult within the first 72 hours. So it comes automatic. And we already have that for our SEI patients where they order specialty mattress, neurogenic bladder treatment, bowel program, all that comes as a set order. We're moving into doing the same thing for TBI. So there's a great opportunity for us to do that in general hospitals where they don't have the experience with these patients. That's great. I think capacity is a big piece there. I know for us, there are pieces of that puzzle that we would like to implement but we're kind of building up capacity to do that. So that's phenomenal. Okay, thank you. I don't see any more questions coming through right now but as I mentioned earlier, many of our viewers are now kind of in a delayed viewing format where they will may watch it later tonight or tomorrow, an opportunity now that various institutions are kind of rolling back into clinical schedules. So thank you so much. We appreciate you joining us today. Thank you for taking the time to teach us. Absolutely. It's been a phenomenal lecture and we appreciate it very much. You're very welcome, guys. Good luck, take care. Thank you. For everybody who joined us today or anybody who would like to, all of these videos will be hosted there at physiatry.org slash webinars and any other online activities also, including the AAP RFC wellness activities that are on the first Wednesday of every month. If you have any questions for Dr. Sanchez, his email is there on the screen and you can reach out to me or get in touch with Candice at AAP at those Twitter handles. Thank you everybody for joining us and we look forward to having you, can't remember what day it is, either tomorrow or next week. Thank you. Bye.

traumatic brain injury

TBI

management

Dr. Oscar Sanchez

physiatry

propranolol

rehabilitation

multidisciplinary approach

support

challenges