The CDC estimates that about1.5 million traumatic brain injuries (TBIs) occur each year in the United States, making these injuries a leading cause of disability. The cost of TBIs has been estimated to be approximately $60 billion per year. About 52,000 deaths are attributed to TBIs annually. Roughly 80% of patients who experience a TBI have a mild TBI, or concussion, caused by a bump or blow to the head.
The American Association of Neuroscience Nurses (AANN) has existing guidelines for the care of patients with moderate or severe TBI, but until now, there have not been evidence-based, clinical guidelines for the care of patients with mild TBI. The AANN has teamed up with the Association of Rehabilitation Nurses (ARN) to create a clinical guideline called “Care of the Patient With Mild Traumatic Brain Injury,” which was released in 2011. The guidelines— available for free at www.rehabnurse.org and www.aann.org—are meant to help registered nurses, advanced practice nurses, and institutions provide safe and effective care to injured patients with a mild TBI.
“Follow-up care is critical for patients with mild TBI, along with patient education.”
“Recently, there has been a strong focus on TBIs among high school, college, and professional athletes, with new research showing the residual effects that remain in some patients with mild TBI,” says Therese West, RN, CPN, MSN, APN-C, lead author of the AANN/ARN guidelines. “Previously, it was thought that when patients received a blow to the head, they would get a little lump and maybe a headache, but they would ultimately be fine. The literature, however, is now showing that this is not necessarily the case. Most people (85%) will recover fully within 2-3 weeks. The remaining 15% of patients can have post-concussive symptoms that will last for several months. Also, the sequelae of these injuries, such as neuroendocrine dysfunction, can appear up to 36 months after injury.”
Imaging Mild Traumatic Brain Injuries
Measures that work to detect severe and moderate TBIs do not necessarily work in patients with mild TBI, explains West. “A CT scan isn’t always necessary with mild TBI as it would be with severe TBI,” she says (Table 1). “If someone has a bump on the head but has not lost consciousness, has no focal neurological deficit, has a normal neurological exam, has no post-concussive amnesia, and has no other complications, we normally can just monitor their status.” However, she notes that CT and MRI scans should be utilized in those for whom a witness confirms loss or alteration of consciousness or a neurological exam is abnormal (eg, one part of the body is week or the eyes fail to react well to tests). The age of a patient also plays a role in whether or not a CT scan should be performed, says West.
Follow-Up Care & Patient Education of TBI
Many patients with a mild TBI can have a normal CT scan and be discharged. However, patients may be home for a few days and then start having headaches or have trouble concentrating a week or so later. “Follow-up care is critical for patients with mild TBI, along with patient education,” says West. “Both of these aspects of care have been overlooked previously, especially patient education.” Patient education can be as simple as providing individuals with warnings that they may experience the aforementioned symptoms and that these experiences are normal (Table 2). If the symptoms start to affect their quality of life or have not resolved within a few weeks, patients need to be informed that they should seek follow-up care. With children, parents should be made aware that if their child cannot concentrate enough to take school tests that they are not faking an injury and should be reevaluated. Healthcare providers should not assume that patients or family members understand that concussions have side effects that can last for months or that they know how to take care of themselves. Athletes should not be returning to play the next day. Mild TBI patients usually need 1 to 5 days of mandatory rest.
West also recommends that physicians determine if nurses on staff have or are obtaining education on mild TBI and know where these resources are available. “Physicians can refer nurses to the AANN website [www.aann.org] to find educational information to give to patients and families,” West says. “The AANN/ARN guideline also includes information on a number of websites that can provide further information on and support for mild TBI. The emergency room, in particular, is where providers are working to get patients in and out quickly, but taking a little extra time to make patients aware of post-concussive symptoms is an invaluable step that can no longer be overlooked.”
Readings & Resources (click to view)
American Association of Neuroscience Nurses and Association of Rehabilitation Nurses. Care of the Patient With Mild Traumatic Brain Injury. Available at www.rehabnurse.org/uploads/files/cpgmtbi.pdf.
Schultz B, Cifu D, McNamee S, et al. Assessment and treatment of common persistent sequelae following blast induced mild traumatic brain injury. Neurorehabilitation. 2011;28:309-320.
Kwon H, Jang S. Optic radiation injury following traumatic epidural hematoma: Diffusion tensor imaging study. NeuroRehabilitation. 2011;28:383-387.
Rostami E, Bellander B. Monitoring of glucose in brain, adipose tissue, and peripheral blood in patients with traumatic brain injury: a microdialysis study. J Diabetes Sci Technol. 2011;5:596-604.
Duraski S. Clinical consultation: nonpharmacologic management of agitated behaviors after traumatic brain injury. Rehabil Nurs. 2011;36:135,145.
Catroppa C, Anderson V, Godfrey C, Rosenfeld J. Attentional skills 10 years post-paediatric traumatic brain injury (TBI). Brain Inj. 2011 Jun 29. [Epub ahead of print]. Available at http://informahealthcare.com/doi/abs/10.3109/02699052.2011.589794.
Liu M, Wei W, Fergenbaum J, et al. Work-related mild-moderate traumatic brain injury and the construction industry. Work. 2011;39:283-290.
Qu X, Shrestha R, Wang M. Risk factors analysis on traumatic brain injury prognosis. Chin Med Sci J. 2011;26:98-102.