Clinical Practice Guidelines for Managing Minimal Responsiveness after Blastrelated Injury The Polyt

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Clinical Practice Guidelines for Managing Minimal
Responsiveness after Blast-related Injury The
Polytrauma Experience

• Linda M. Picon, MCD, CCC
• Speech-Language Pathologist
• James A. Haley Veterans Hospital
• Polytrauma Rehabilitation Center
• Tampa, Florida
• ASHA Short Course
• Miami Beach, Florida
• 11/18/06

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OEF/OIF Combat Injured

• Military Service members sustaining multiple and
  severe
• injuries as a result of explosions and blasts
  from improvised
• explosive devices (IEDs), landmines and fragments
• account for 65 of all combat injuries. Of
  these, 60 have
• some degree of traumatic brain injury
  (TBI). VHA Handbook 1172.1 Polytrauma
  Rehabilitation
• OIF/OEF patients treated at VA Polytrauma Centers
• 85.5 have a diagnosis of TBI
• 54 are severe enough to result in an altered
  state of consciousness.
• 31 remain in an altered state of consciousness
  for over 30 days.

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The Minimally Responsive Patient

• Definition
• Distinguishing Between Altered States of
  Consciousness
• Scope of Evaluation and Treatment
• Challenges
• Cognitive Communication Issues
• Guidelines for Assessing Cognitive-Communication
• Interpreting Patient Responses
• Cognitive Stimulation Programs
• Measuring the Response
• Emerging into Consciousness

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The Low Level Patient - Definition

• Rancho Los Amigos Levels II and III
• Swallowing Unable to swallow anything safely by
  mouth all nutrition hydration received through
  non-oral means
• Communication Unable to communicate wants/needs
• Cognition Unresponsive to all/most stimuli

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Distinguishing Between Altered States of
Consciousness

• COMA
• A state of unarousable neurobehavioral
  responsiveness

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Distinguishing Between Altered States of
Consciousness

• Clinical Criteria
• Unresponsive follows no commands
• Eyes closed - No sleep/wake cycle
• No volitional behavior present
• Typically seen for evaluation and monitoring only
• Not a candidate for a full rehabilitation program
• Recreational stimulation
• Tone/posture management

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Distinguishing Between Altered States of
Consciousness

• VEGETATITVE STATE
• A state of arousal without behavioral evidence of
  awareness of self or capacity to interact with
  the environment

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Distinguishing Between Altered States of
Consciousness

• Clinical Criteria
• Eyes open - Sleep/wake cycle present
• Follows no commands no language comprehension
  or expression
• Limited/no interaction with environment
• No sustained or reproducible purposeful or
  voluntary response to stimuli
• Vocalizations (not verbalizations) may be present
  
• Variably preserved cranial and spinal reflexes
• Preserved autonomic functions to permit survival

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Distinguishing Between Altered States of
Consciousness

• Minimally Conscious State
• A condition in which minimal but definite
  evidence of self or environmental awareness is
  demonstrated

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Distinguishing Between Altered States of
Consciousness

• Clinical Criteria - One or more must be present
• Follows simple commands
• Some Y/N regardless of accuracy (gestural or
  verbal)
• Responsive and intelligible verbalizations
• Purposeful behavior
• Movements occur in contingent relation to
  relevant stimuli (not reflexive)
• Appropriate smile or cry
• Reaching for or holding objects

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Transitional vs. PersistentProposed Timeline

• TRAUMATIC Brain Injury
• Generally considered to be in a transitional or
  persistent state up to 6 months after injury
• ANOXIC Brain Injury
• Generally considered to be in a transitional or
  persistent state up to 3 months after injury

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SLP Scope of Evaluation and Treatment of the Low
Level Patient

• Swallowing
• Present / Absent
• Stimulating
• Communication
• Response mechanism (s)
• Providing means and environment
• Cognition
• Alertness and awareness
• Responsiveness
• Providing appropriate conditions

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General Aspects of the Clinical Assessment

• Level of alertness and awareness
• Communication skills responsiveness
• Determine state of altered consciousness
• Determine treatment plan based on
• Current state
• Time post-onset and clinical evidence of progress
• Individual needs

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Cognitive-Communication Diagnosis

• Clinical observation and interpretation
• Spontaneous movements
• Reflexive movements
• Responsive movements
• What response mechanisms are available to the
  patient?
• What triggers a specific response?
• Consistency
• Reliability

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Cognitive Communication Diagnosis

• Formal Evaluation
• Disorders of Consciousness Scale (DOCS)
• Western Neurosensory Stimulation Profile
• Rappaport Coma / Near Coma Scale
• Clinical Observation
• General stimulation
• Multi-modal stimulation

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General Guidelines for Assessment and Treatment

• Monitor testing environment distraction-free
• Establish testing readiness maximum arousal
  level
• Establish baseline response through observation
  without stimulation
• Account for changes in attention span, level of
  fatigue, distractions, time of day, illness,
  sedating medications
• Investigate varied responses using broad range of
  stimuli
• Develop balance between stimulating, observing
  and scoring
• Beware of sub cortical vs. cortical responses
• Use serial re-assessments and observation to
  confirm validity
• Observe, observe, observe
• Family, caregivers, staff
• Under different conditions and circumstances

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Clinical Challenges

• Travel/transfers negatively impact initial
  evaluations
• Paresis/paralysis, SCI, musculoskeletal injuries,
  wounds, burns, amputations
• Tracheostomies (PMV, Red Caps) long term
• Medications and Surgeries higher incidence
• Sleep/wake disruptions, fatigue
• Timing nursing care and other therapies
• Environmental distractors, space issues
• Infection control, Acinetobacter (The Iraqi bug)
• Sensory changes (vision/eye enucleations,
  hearing/deafness, smell/trach)
• Separating communication from cognition

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Sensory Stimulation Programs

• Administration of stimulation
• Structured monitoring of responses 3 to 7 days a
  week
• Informal stimulation and management occurs 24/7
• Stimuli
• Commercially available programs
• Homemade sensory stimulation kits
• Portions of formal tests

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Sensory Stimulation Programs

• Auditory
• Sounds
• Command responsivity
• Visual
• Threat
• Tracking
• Olfactory and Taste
• Variety
• Familiarity

• Tactile
• Pain
• Textures and temperature
• Vocalization

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Swallowing Stimulation and Management

• Evaluation
• Observation vs. Testing (are reflexive swallows
  present?)
• Limited clinical bedside evaluation
• Inappropriate for instrumental testing
• Management
• Trach management Passy Muir Valve or Red Cap
• Passive stimulation of the oral mechanism
• Pre-feeding stimulation
• Risks vs. benefits of feeding and testing feeding
  during minimal responsiveness

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Measuring the Response

• General
• None
• Minimal
• Partial
• Complete
• Specific
• No responsivity
• Inconsistent responsivity to one sensory modality
• Inconsistent responsivity to 2 or 3 modalities
• Consistent response to 2 modalities, inconsistent
  or partial response to commands
• Consistent response to at least 3 modalities and
  consistent response to commands

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Interpreting Patient Responses Reliability and
Consistency

• Score and maintain lists of patient behaviors
• From clinical observations
• From family/caregivers
• Family Education and involvement
• Differentiating real vs. wishful responses
• Differentiating real vs. cued responses

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Emerging into Consciousness

• Conscious State
• The person adaptively responds to ongoing sensory
  input in a purposeful and voluntary manner that
  is not reflexive, stereotypical or automatic

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Emerging into Consciousness

• Clinical Criteria
• Reliable and consistent demonstration of at least
  one of the following
• Functional interactive communication
• Six of six situational orientation questions via
  any modality
• Functional use of at least 2 objects over two
  consecutive evaluations
• Clearly discernible behavioral manifestation of
  sense of self

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Cognitive Stimulation

• Structured administration of operationally
  defined questions or prompts based on the
  patients level of functioning and ability
• Sensory functions
• can the patient see?
• Cognitive-communicative functions
• can the patient follow commands and express
  wants/needs?
• Physical functions
• can the patient manipulate objects?
• Pharmacological Management
• E.G. Ritalin and/or Bromocriptine data are
  collected to determine the effects of medication
  on specific responses and response accuracy rate.
  

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Cognitive Stimulation Program for Emergence from
MCS

• Stimulation is based on specific responses the
  individual favors and are expanded based on
  additional responses elicited
• Targets specific cognitive processes rather than
  sensory connections
• Establishes specific and voluntary links between
  stimulation and appropriate response

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Emerging into Consciousness

• Response Criteria
• Consistency
• Accuracy
• Timing (minimal to no delay)
• Response Parameters
• Presence of functional, interactive communication
  
• Generally appropriate object use
• Ability to follow simple commands via any
  modality
• Awareness of, and specific and discernible
  interaction with the environment

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Program Development

• Insufficient data to establish definite
  guidelines for program development
• How do we establish criteria for admission,
  length of stay and discharge disposition?
• Concensus statements
• 3 months ANOXIC injuries
• 6 months TRAUMATIC injuries
• Who stays in VS or MCS and who emerges?
• Do we know what happens after 12 months, 2 years?
• Careful and reliable assessment and diagnosis
  will help predict prognosis

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Planning for Positive Outcomes

• Maintain accurate and objective data
• Document behaviors, state of consciousness,
  criteria for the next level of consciousness and
  prognosis
• Establish a treatment plan and time frame, and
  check your work/outcomes regularly CLINICAL
  PATHWAYS
• Monitor regularly for progress and update
  plan/goals as necessary CHANGE in LEVEL or
  PRIORITIES
• Work diligently to move the patient towards the
  next level of care, close to home
• Educate and involve families every step of the
  way.

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Thank YouQuestions?Linda.Picon_at_va.gov