1. Traumatic Brain InjuryEvaluation and Management of Soldiers Jason Hawley MD
CPT MC USA
Chief, Neurology CRDAMC
3. What is TBI? Injury to the brain..duh
Concussive Blast Injuries
4. Severe TBI “I know it when I see it”
Prolonged loss of consciousness
Surgical debridment of brain tissue
“Coma for weeks.”
Marked MRI abnormalities***
Permenent and often dramatic impairments..although not always
5. Mild-Moderate TBI What is “mild TBI”
Post concussive syndrome?
Diffuse axonal injury
Persian Gulf War Syndrome?
6. Mild TBI There has to be a head injury—blast, MVA accident, fall are the common
There has to be an alteration of consciousness—stunned, dazed, LOC
Imaging is typically normal
The persistent triad of symptoms
7. Evaluating the Soldier with suspected TBI Define the injury and event…when, where, how.
Relationship of the headache to the injury
Relationship of the cognitive problems to the injury
Past history of head injury—Troy Aikman syndrome
The symptoms since the head injury…specifically the headaches
Associated dizziness, nausea, and vomitting.
8. PTSD and TBI PTSD is an anxiety disorder
TBI is a well defined injury recognized in the civilian literature
Soldier’s with mild TBI at 2.7 times more likely to have symptoms suggestive of PTSD
Mood symptoms are very common in soldiers with TBI
Irratibility, sleep, depression, flash backs, nightmares
Validate those symptoms
9. Take a step back…what is the problem they are complaining about “what bothers you the most”
The soldier with a TBI vs. the soldier with a TBI and PTSD.
“If it looks like psych, then it is psych.”
If the mood symptoms are mild, don’t call it PTSD.
***PTSD can cause all the cognitive Listen to what the soldier tells you****
10. Managing TBI Don’t be afraid of managing this…this is not hard, you won’t get in trouble, and it’s pretty easy.
11. Keep in mind… Overwelming majority of soldiers with mild TBI recovery over 6-12 months after the injury
Very few soldiers (1-2% of those screened + for TBI) get medical boards for TBI
Cognitive therapy is very limited
Medications are of secondary value
Most soldiers want to return to duty, and don’t want to be stigmatized.
12. You have a mild TBI and you’re going to be ok. Do that and you’ve treated most of the soldiers we’re worried about
Establish a real diagnosis, tell it to the patient
Explain what to expect, reassure them
Document that, tell them you will
Break down the symptom complex of cogntive symptoms—headache—mood symptoms.
Address each individually.
13. Cognitive Symptoms In the absense of significant mood symtpoms, I am concerned about these soldiers most of all.
Memory, focus, multi-tasking, concentration, attention.
Memory impairment have become a significant impairment at work and home.
Forgetting mission tasks, getting in trouble, “always writing things down.”
Our work up—neuropsych testing, cognitive therapy, possible VA rehab
14. Headaches How debilitating are the headaches
Helps the soldier potentially recognize the improvement
A word about compliance
Behavioral treatments, profiling—short term restrictions to speed recovery
Profiling PT, 24 hour duty, etc
Give them 3-6 months
15. Headache—Medication management I have come to the conclusion that this is low yield
Preventative vs. Abortive
What works—indocin, elavil, topamax, pheneragan
What doesn’t—tryptans, inderal, narcotics
Migraine features with headache (photophobia, dizziness, etc)…more likely to go with meds.
16. Mood Symptoms I need your help!
Listen to what they tell you
Don’t let the history of blast exposure (or the media) go against your better judgement. Use common sense.
The mood symptoms of mild TBI are treated just as are the mood symptoms of PTSD.
17. When the mood symptoms are present but not disabling Validate the mood symptoms as part of mild TBI.
Tell them they have a reason for feeling the way they do
Most soldiers don’t want to see psych, or be given a psychiatric diagnosis.
18. TBI at Fort Hood Our population
Most completed deployment
Most will do fine and will respond to validation, reassurance, and minor medications.
Most can be managed without profile restrictions or just mild temporary modifications to duty
Most >95% will be deployable within 12 months after the injury
I have not done an MEB on a soldier with a mild TBI who completed his deployment.
19. Soldier break down --my take on it The soldier with mild to minimal TBI
The soldier with TBI and dominating PTSD
The soldier with mild-moderate TBI
The soldier with severe TBI
20. Resources at Fort Hood Neurology—me
Speech/cogntive therapy (Ms. Smith)
TBI Team—multidisplinary team aimed at managing the most severe soldiers (roughly 30-40 soldiers).
The other several thousand—you.
21. Where this is going TBI is the injury of this war.
We in the military/VA system will be dealing with this for decades
The screening process for TBI at Fort Hood
The management of our impaired soldiers
A final word on MEB’s.