Traumatic Brain Injuries - Allison Bailey, Susan Beiting, Zach Paff, & Caitlin Chicoine - APP Conference 2026

My name's Susie Biding. I'm a trauma nurse practitioner here at Cincinnati Children's. Um, Alison Bailey is one of my trauma nurse practitioner colleagues. Uh, Doctor Caitlin Chicoin is one of our rehab medicine physicians, and Zach Paff, one of our PICU nurse practitioners. And we're gonna talk today about traumatic brain injury, um, and the management of TBI from injury to discharge and beyond. And so learning objective is basically that we're gonna take you through the management of TBI. So with that, I'm gonna invite Alison up to kind of start. Oh. You're still gonna be my clicker, yeah. Um, so to start, we can just briefly define traumatic brain injury or TBI. At its core, TBI is a disruption of the normal brain function caused by an external force. So this force can be a blow to the head or from a penetrating injury that directly damages the brain tissue. Most of the injuries we see clinically are closed or blunt head injuries. In these cases, the skull remains intact, but the impact causes the brain to Rapidly shift inside the skull. Common causes include falls, uh, motor vehicle crashes, sports injuries, physical abuse or assault. Less commonly, we see penetrating, uh, injuries where an object breaks through the skull, um, and actually enters the brain tissue itself. And so these injuries can result from gunshot wounds, blast injuries, stabbings, or severe trauma in which, uh, the bone fragments themselves penetrate the brain tissue. So this CDC data here is just highlighting the leading causes of traumatic brain injury in children in the United States. So falls account for approximately 50% of pediatric TBIs, making them the most common mechanism, often related to stairs, playground equipment, or bicycles. Being struck in the head by an An object such as a ball during sports or recreational play accounts for about 28% of cases, and then motor vehicle crashes remain the leading cause of TBI-related death in children older than 5, whereas homicide is the leading cause of TBI-related death in children ages 4 and younger. So, we'll start here just with assessing mental status in the trauma patient. And so, one of the most widely used, uh, tools for assessing neurologic status in traumatic brain injury patients is the Glass Cow Coma Scale or GCS. So, the GCS is a standardized assessment that allows us to objectively evaluate a patient's level of consciousness. So, it examines three key components, eye-opening, verbal response, motor response. Each of these components is, um, assigned a numerical score, and so together they produce a total score ranging from 3 to 15, uh, with lower scores reflecting severe, uh, neurologic impairment. Um, so, understanding these GCS categories is important because, um, each level of injury is associated with different clinical features and then management considerations. Um, so clinically, we're categorizing TBI severity based on those initial GCS scores, a mild TBI corresponding to a score of 13 to 15, moderate TBI 9 to 12, and then a severe TBI is a score of 8 or less. So, mild TBI is the most common and includes concussion. Patients are awake, may have symptoms such as, um, uh, confusion, headaches, some nausea, and usually recover with observation and supportive care. Your moderate TB your moderate TBI involves, um, a decreased level of consciousness and more significant neuro symptoms such as persistent confusion or even focal deficits. So these patients do typically require neuroimaging and hospital admission for monitoring. And then finally, severe TBI reflects a profound impairment of consciousness. These patients often cannot protect their airway and require intensive care monitoring and neurosurgical evaluation. Um, so Allison, I heard you mention for moderate TBI that these likely require neuroimaging. So are you telling us all that every kid who bonks their head at home, mom brings them into the emergency room, does that mean that they're not going to get every single one of them is not going to get a head CT? Correct. Correct. So we're not going to scan every kid. And so kind of the next question is, when should we scan their head. And so, in pediatrics, clinical decision rules like the PCA and head CT rule are gonna help us identify children, uh, at risk for clinically important brain injuries, enabling us to use imaging then judiciously and safely. So, the pediatric Emergency Care Applied Research Network head CT rule is a validated tool designed to pinpoint those children at very low risk of clinically important brain injuries after minor blunt head trauma. So it helps us avoid unnecessary CT scans and radiation exposure but still helps us identify significant injuries. So for both age groups, children younger than 2 and those 2 years or older, a CT scan is recommended if the child has altered mental status, um, a GCS less than 15 are signs of a skull fracture. If none of these high-risk criteria are present, the rule then is going to guide us to weigh other factors such as loss of consciousness, vomiting, severe headache, uh, or a severe mechanism of injury to, to then decide between observation or CT imaging. OK. With that, let's look at a patient scenario. This is 15-year-old Margot. She fell playing soccer. She struck her head on the ground. She had a brief loss of consciousness, lasting around 2 seconds, and cried immediately afterwards. According to her parents, she's been acting normally since the fall. On exam, she has a frontal scalp hematoma, a GCS of 15, and a normal neuro exam. She has no severe headache or vomiting, and there are no signs of skull fracture. So you all are emergency department providers. We just gave you the answer. Why is it doing this? It's not going backwards. Anyway, no, she does not need a head CT. Um, all right, moving on. We are not going to scan her because she's got a GCS of 15, um, no vomiting, no signs of skull fracture. So typically we're going to observe these kids in the emergency room for a period of time, make sure that they don't decline, and then, um, we would give her strict return precautions. So things to look out for at home that should bring them back in. So next patient. Well, now I can't move it forward either. Where's my clicker guy? Oh, there we go. OK, so this is Richard. Richard is a 10-year-old boy who fell approximately 10 ft from a tree and presents to the emergency emergency department about 30 minutes after his injury. He experienced a brief loss of consciousness lasting around 1 minute. Since the fall, he's been complaining of a severe headache and has had 3 episodes of vomiting. He appears sleepy and it is difficult to keep awake. On exam, GCS is 14. He has no focal neurodeficiits, and there are no signs of skull fracture on physical exams. So, back to you all in the audience, does Richard need a head CT? Oh. Sorry, does the pole pop up automatically? OK. And the answer is yes, as evidenced by. This. So then, OK. Like when I press How do I get to the next slide? Cuz for me, it looks like it is on the next slide. Anybody? Any tech people? OK, there we go. OK. So, on Richard's head CT radiology reads it as left parietal hemorrhagic contusion, a small left subdural hematoma, and early cerebral edema. So, we call our neurosurgery colleagues and they tell us that they don't see an imme an immediate surgical lesion, but he is at significant risk of swelling. So Um, we get him back to the trauma bay after the scanner, and his mental status worsens, his GCS declines from 14 to 7. What is our priority intervention here? Are we gonna obtain a stat repeat head CT right now? Are we gonna call neurosurgery again for urgent consultation? Are we gonna administer hypertonic saline for suspected increased ICP? Or are we gonna intubate to protect airway and assist ventilation? What's that I used it and then it goes. a second. give it as It's in. we're throwing it back there. So then we're gonna give it a minute to pull questions come in and then you can say, but you're clicking off of that, yes, and then you put it back to. Thank you. I was. All right. So, yes, we want to intubate, intubate to protect his airway and assist ventilation. Given his declining neuro status and GC GCS below 8, the immediate priority is protecting this kid's airway to prevent hypoxia and hypoventilation. There's a saying that we use GCS less than 8, intubate. Um, in reality, we're actually doing a lot of this stuff simultaneously. He's probably getting 3% on the side by one of our trauma nurses. Um, we're probably letting our neurosurgery colleagues know about his decline. Um, he does not need a repeat head CT right at this moment since he just got out of the scanner. So, Richard is intubated. He's admitted to the PICU, and with that, I'm gonna turn it over to Zach to tell us about his course in the PICU. Thanks, Susie. Yeah, that prior question is an interesting one that um. We went back and forth on really what we, uh, wanted the right answer to be, but, uh, maintaining the ABCs and, uh, gaining control of their airways probably the highest priority and like you said, at the same time we're given, uh, 3% sailing, so. What really guides our management of these patients in the PICU is a a doctrine called the Morano-Kelly doctrine. Um, it, it's a concept, um, that we follow, and really what it says is that the skull is a, a fixed rigid, um, space, right? So the volume in there can expand without pressuring. There's 3 things, uh, in that space, the brain, there's blood, and CSF. Uh, so if any one of those increase, um, then pressure rises. Uh, and as pressure rises, um, they're at increased risk of decompensation and herniation, um. The body can compensate, the brain can compensate, it'll push out, uh, CSF, um, and reduce, uh, venous blood flow, uh, but there's limitations, uh, to that, um, as well. Ultimately what we're trying to prevent is this secondary injury or progression to herniation. Um, herniation, there's kind of 3 or 44 main types of herniation, and it kind of is described as different areas that occur in the brain. Um, soface, uh, herniation, there's uncle herniation, uh, central. Uh, and the most common one that we kind of think about is tonsillar herniation, where the cerebral tonsils actually get pushed downward through the base of the skull, um. Resulting in respiratory arrest and death, um, all of our actions are really trying to prevent this evolution. The early signs are the Cushing's triad, or hypertension and bradycardia. Um, they'll have posturing. Uh, the emergency interventions that we do, we'll hyperventilate them, lower their CO2 down by bagging them. We'll put them on 100% oxygen. If they're not intubated, obviously they'll be intubated. We have them 3% saline. If they have an EVD, we'll open that, drain CSF, um, and depending on the interval, uh, we'll repeat head CT imaging to see what's going on with them at that time. Can we pause right here? Um, knowing from experience, I know that the trauma service is usually asking you ICU folk the next day within those 1st 24 hours if you can please order a rehab medicine consult. So I wanna kinda turn to Caitlin for a second, Doctor Chico, excuse me, um, and help us understand what is your role in, in those early days, even though Richard. And not participate in therapies that's a really good question. Um, so we really like getting involved early in the PICU part of what we do is introduce the role of our team we work closely with the therapists in the ICU to help promote early mobility, help with positioning, and then there are some TBI specific medical issues that can arise early in the child's course in the PICU that our team can help with. And with that, we have a physical medicine and rehabilitation service that's consulted with a character based on Doctor Shikoin. Um, and it looks like for poor Richard, neurosurgery wanted to insert an ICP monitor in his forehead at the bedside. So Zach, take it over. So once these patients come into the ICU, uh, we have kind of goals of care for them. We'll post, uh, kind of this sheet, uh, into the room so all the team members are on the same page as we move forward with their care. Uh, one of our goals is to maintain normal oxygen levels. Uh, we're really trying to prevent secondary injury. So by maintaining those saturations, we don't have any tissue hypoxia. Normal apnea, so when they're intubated on the ventilator, we'll titrate the ventilator to maintain perfect CO2 levels. Uh, once they have an ICP monitor, we target very specific. ICP goals of less than 20, um, and then cerebral perfusion pressure measurements based on their age of a goal of 40 to 60. Uh, we try to avoid fevers. We'll put them on temperature control in addition to Tylenol, uh, to reduce metabolic demands, and like we said, we'll have PT consulted and OT rehab. They'll also be placed on video EEG, a neurology consult. Uh, we will set specific sodium goal ranges for these patients too, uh, to, to, uh, optimize their osmolar load, uh, as well, so. OK. So, Richard's ICP spikes to 24. His blood pressure is 103/57 with a mean arterial pressure of 70. Pupils are equal and reactive to light on exam. What is Richard's cerebral perfusion pressure? Is it 24, 70, 46, or 60? Some people are being brave. Great. The answer is 46. So how we calculate that, Zach, take it from here. Thanks, Susie. Yeah, clearly people don't like math, so. It's really a very easy formula once you, once you know. So we take their cerebral perfusion pressure equals their mean arterial pressure minus their ICP. Um, we titrate a lot of our interventions, uh, to achieve this goal in the ICU. Um, if you think about it, um, what's. is it's really the pushing or the driving pressure, and then ICP provides resistance to that driving pressure. So we do, we augment their mean arterial pressure by giving fluid and volume and isotropes, and we try to augment that ICP pressure by giving sedation and paralytics. And 3% saline and making sure they're correctly positioned, they're neutral and midline so that we don't impede Venus return as well. So if their mean arterial pressure's up and their ICP is up, we try to maintain that CPP and vice versa, right? The map is up, ICP low and CPP is maintained. If their mean arterial pressure is low because they're hypotensive and their ICP is up, then their profusion to their brain is, is impaired, and vice versa, right? If their map is low, ICP is low, just from hypertension, you can have decreased cerebral perfusion pressure. So poor Richard, his ICPs remain high in the twenties. What are immediate inter uh interventions for Richard? Are we going to reposition him on his side? Are we gonna continue to monitor him, ensure his head is midline and administer a sedative, or are we going to call neurosurgery? OK. It goes Do you see what's happening here? It's not me. It's not me. Um, I am pressing to go ahead, but it's not. It is for me, but not everywhere else. There we go. Um, so our answer is we are going to ensure your head is midline and we're gonna administer a sedative. But we know that those are easy things that the nurse, um, at the bedside can do pretty quickly. So, but we've already mentioned giving 3% down in the emergency room, and now we've mentioned sedation. So, Zach, tell us a little bit more about these interventions. Yeah, thanks, Susie. So hyper osmolutherapy, it's uh basically 3% saline, so like 3 times stronger than like a bag of normal saline. Normal saline is like 150 formula equivalent, so it's 3 times that amount. If you think of like a bag of normal saline is like 20 bags of Lay's chips. This is like 60, 70 bags of small bags of Lay's chips, so a ton of sodium. Um, we'll give it like a 4 per kilo bolus. Sometimes we'll do a continuous infusion for him. Uh, we're shooting for osmos, usually like 275 to 295, and what we try to do is drive that up so it's as long as it's less than 360, we're getting an osmo or shift with that. Um, there's benefits. It's over 3% versus Mannitol, you get less diuretic effect, um, you get steady ICP numbers and better, higher osmolars are are tolerated with 3%. Complications, if you drive that osmolarity up too high, you can have thrombosis and stroke and risk with that as well, so. I love talking about osmolarity because it's uh really a foundational principle in the ICU that drives so much of what we do. Um, and based on this formula, if you can see to calculate an osmolarity, um, sodium is the most important thing. It's 2 times the sodium plus your BUN and kids with renal failure and their BUN is really high, will take measures to reduce. That's, um, that's divided by 2.8, but, you know, if your BUN's normally like 5 or 6, nice and low, uh, it's a really small contributor. Uh, glucose, we divide that by 18, uh, plus the prior, uh, numbers. Um, and glucose, most of the time if you're in the 60, 80, 90 range, you're fine, but for our DK patients, this really, uh, guides what we do for them as well. Um, but sodium. The most important thing. Um, and what we're really trying to do is drive fluid out of the cells to extracellular to shrink them, right? So if the brain is swollen and there's edema, we give them a 3% bose, we waterfall with salt, so the water in the cells will move extracellular and you get some shrinkage, and in turn get a decrease intracranial pressure, so. Uh, sedation is like the backbone kind of of what really what we lay down in the PICU for our patients with a TBI. Um, it works in multiple ways, but really just by relaxing them. Sedating them, we prevent ICP spikes. So if they're fighting the vent, if they're coughing, gagging, resisting, fighting it, we decrease their metabolic demand and in turn we'll decrease their ICP with decrease brain activity. We reduce their oxygen demand and improve, decrease the cerebral blood flow with that and in turn decrease their ICP. Neuromuscular blockade, um, also, uh, a really important, um, tool that we utilize in the ICU with TBI, um. When we're temperature controlling them, they'll start shivering, and that really drives up metabolic demand. So what we'll do is we can paralyze them. It prevents them from shivering if they're posturing or storming, uh, that paralytic will stop that, and by reducing the metabolic demand, we decrease that oxygen consumption. Often they'll be. Very, uh, sedated, doesn't look like they're moving, um, but by giving a paralytic on top of that, the ICP is spiking, you can see that IP number coming down because it just relaxes everything and allows for better venous drainage as well. Ventilation in our TBI patients. CO2 really regulates cerebral blood flow, um, so a high CO2, you get, uh, vasoconstriction, um, sorry, vasodilation, so the blood flow is dilated, so there's more of that, um, volume in the blood, so you can see their ICP spike up. We'll targets very tight control, 35 to 45. We trend in our blood gasses frequently, uh, to make sure they stay in this narrow range, um, as well. Uh, with impeding herniation or really high spikes in their ICP, we can briefly hyperventilate them, um, to prevent, um, or to constrict those, uh, blood vessels, um, to hopefully prevent that herniation, but you can only do it for short, short periods because if you reduced blood flow too much, uh, then we get tissue ischemia from that along with ventilation, a big part of it is, is oxygenation, um. In the immediate time we'll put them on 100% oxygen, you know, optimize their oxygen, but one of the measures or tools we use in the ICU is peep, um, and if we. We're gonna try to keep the lungs open um in a state called FRC where the lungs are open, blood's flowing freely, but if we drive peep up too high, um, then we can also impede venous drainage. So it's a really a balancing act to keeping them in a perfect range. One of the later steps that we use, um, is basically putting a patient in a coma. um, we'll use barbiturates or pentobarbital, we'll put them in an induced coma, that is like massively reducing their metabolic demand um it. Causes significant decreased cerebral activity. We decrease that cerebral blood flow to reduce that ICP um and less volume, hopefully we'll see an improvement in their numbers when they're on EEG. We'll trend the monitoring, uh, make sure they're not seizing, uh, but in this state, uh, make sure that the brain is at rest, while they're in this coma state. There's significant side effects to everything we do. Um, barbiturates you can have severe hypotension. We'll often have to titrate inotropes. To make sure we're maintaining that CPP, it has direct cardiac suppression, um, so hypotension and uh decreased function, and then longer use, you can see immune suppression, so we're always worried about sepsis and evolving risk uh with long term use of these barbiturates. All of this is guided by kind of a tiered levels of recommendation, um, as we move through all these tiers 12, we get to tier 3, and it's kind of, if all the medical management fails, we'll look into surgical management. Sometimes surgical management is actually up front if they've got a, a depressed skull fracture or if the injury, uh, shows that they're going to have, regardless of medical management, um, refractory intracranial hypertension. Uh, neurosurgery right up front can take off part of the bone, but if we've failed medical management, we'll do a decompressive craniectomy, um, and that just goes, it, it manipulates the Monero-Kelly doctrine, right? So that thick base is now open. The brain can expand, uh, really sometimes outside that cranial circumference and herniate outward that way to hopefully preserve the uninjured brain and preserve it. So, we've talked a lot about high-level ICU medical management for these patients, and ICU rounds, for those of you who have not been there, can be way up here for some people. So, what are we doing for families to help them understand these injuries? Um, I can answer that. So, um, one of our main focuses as the trauma team is just to make sure that, um, care across all these subspecialty teams, um, I, you know, is, is clear. And so we're just ensuring that everyone is working with, you know, the same understanding towards the same goals and so we'll oftentimes sit the family down with the medical team at some point during their ICU stay and just run through injuries. And where we are in the management process and kind of what our goals are for care moving forward. And so it's often the rehab team, the ICU team, the trauma team, the neurosurgery team, the neurology team, the therapists, the nurses. I mean, so it's a, a big team that gets together just to make sure that the family, you know, just has full transparency and a shared understanding of what's going on. And the one thing we have not touched on is some, most of the time, not most. Anyway, these kids come in with other injuries, and so there are other injuries that we're addressing at the same time, which can kind of be difficult. Still, poor Richard. care conference is organized for his parents. His mom is really sad. So Richard is still in the ICU. His GCS is 12. We've started enteral feeds. He's got continuous feeds infusing. He's on a nasal cannula. He's on a methadone taper because we've had him on, um, a lot of sedation to help manage his ICPs. He's getting scheduled NG Tylenol for pain control, PRN IV morphine also for pain control, and Keppra IV for seizure prophylaxis. Um, so, question to all of you, is Richard ready to come out of the ICU? So like Oh. Everybody is that joyful. Um, so yes, Richard is finally ready to get out of the ICU. Allison, help us understand what the trauma service is doing for him on the floor. So yeah, at this point, Richard has improved enough uh to leave the ICU and come to our trauma step-down floor and so our focus is really shifting from stabilization to recovery and rehabilitation. Uh, one of our main focuses is gonna be continuing therapy services, so he'd be working with physical therapy, occupational therapy, um, and our speech therapist. This might look like relearning balance and coordination after the fall, working on daily activities like dressing and then just being. Um, you know, consistently evaluated for cognitive and communication changes from his brain injury. We're working on normalizing his medical care, so ideally, he's transitioning to a regular diet or, you know, continuing enteral, enteral feeds, but we're really moving away from IV fluids, um, and IV medications. Pain control is obviously still important, but we're aiming for adequate control with oral medications just so he can participate fully in, um, therapy without excessive sedation. And then finally, a traumatic brain injury like this can just be really overwhelming, um, for both patient and family, and so we just continue to support them, watching for signs of acute stress and involving social worker. Psychology is needed, um, and all of these goals are just really geared towards preparing, um, Richard for the next step, which in his case is transfer, um, to inpatient rehab where he can continue more intensive recovery and on. Trauma service, we love to get that text from our rehab colleagues that says we're submitting for insurance approval today. So, Doctor Chicoin, what are the things you're looking for to give us that text? Absolutely. So, um, often these patients with severe traumatic brain injuries will benefit from some time on inpatient rehab before they transition to ongoing outpatient care and outpatient therapies. To be a candidate for inpatient rehab, kids need to require at least 2 of the 3 primary therapy disciplines, which are physical, occupational, and speech therapy. The type of patients we're talking about likely have needs in all of those areas. Um, they also, by definition, um, need to tolerate at least 3 hours of therapy per day on at least 5 days per week. That's the. Definition of inpatient rehab in our hospital, what that looks like is kids getting twice daily therapies Monday through Friday and once daily on Saturday with each of those disciplines. Um, they need to be able to benefit from that level of therapy, um, of course, depending on the severity of their injury and where they're at in their recovery, how they're participating in those therapies is going to look different. Um, to be ready for us on inpatient rehab, they do need to be fairly medically stable because we want to shift the focus, like Allison said to their therapies and their recovery. Um, a lot of the things that she mentioned are what we are looking for. So, we typically want kids to be afebrile for at least 24 hours, tolerating full enteral nutrition. Having their pain controlled on oral medications and having a stable plan for any respiratory support, um, but they will be seen regularly, daily in our hospital by a PMNR physician who will continue to manage medical issues and we'll talk about some of those. Um, inpatient rehab is considered a separate hospital stay from an insurance standpoint, even in an institution like ours where the child doesn't leave the building, so we do always have to get insurance prior authorization. Well, Richard's been doing great with therapies. He's ready for inpatient rehab. He looks ready. Um, so although qualifying for inpatient rehab is related to the child's medical, PT, OT, and speech needs, there are many members of the inpatient rehab team that a child like Richard would meet on our unit. Um, this includes. nursing who provide a ton of education to families, therapeutic recreation, music therapy, integrative care, child life, our school team, psychology, nutrition, social work, care manager. Um, this is a really integrated team. In a unit like ours, we're also lucky to be within the children's hospital and so the child still has access to all of the other medical and surgical sub-specialists who may have been caring for them thus far during their stay. Yeah, sorry, go ahead. Um, within a few days of a patient's admission, we have something called an evaluation and planning meeting. This is when our entire team meets to review the patient's case, their current status, what goals we have to work on in therapy. We then have the family join us, so similar to a care conference that might happen in the ICU to kind of review where the child. That talk about our plans, answer any questions, and also set a tentative discharge date. Um, this date is definitely not set in stone, but it can be helpful to have as a target, um, for the team, but also for the family who may be mentally and logistically preparing to bring home a child with very different needs than before their injury. Um, our team also meets weekly to talk about all of our patients who are on inpatient rehab, review their progress, their goals, and where we are on, on track for discharge. Um, sometimes we are able to send home, send kids home sooner than we expect. Sometimes we see that they're really benefiting from this intensive therapy setting, and so we want to keep them longer. Um, and hopefully the interdisciplinary care and the role of all of these different team members will become clear as we talk a little more about the different medical issues that we're managing. Want to talk a little bit about the most severe end of the spectrum. So some patients with traumatic brain injury will experience a disorder of consciousness or DOC. This is an alteration in their level of awareness of themselves and their environment. Disorder of consciousness is divided into three different states, coma, unresponsive wakefulness, which was previously called vegetative state, and minimally conscious. Um, in a coma, a patient is unresponsive. They don't have clear sleep, wakes. Cycles and they don't open their eyes. In unresponsive wakefulness, patients are still largely unresponsive as the name implies, but they do have sleep-wake cycles. They do have times when their eyes are open. They are not yet clearly interacting with their environment. And then minimally conscious patients are starting to show some clear but inconsistent responses to their environment. This might look like visually tracking, being more specific with how they localize to pain, and starting to follow some commands. Patients are considered to have emerged from their disorder of consciousness if they demonstrate accurate yes, no responses, as well as functional object use. So, for example, if I hand them a comb, they may know to run it through their hair. Patients, oh, sorry, uh, patients experiencing a disorder of consciousness, I do want to say are appropriate candidates for inpatient rehab. How they engage in therapies will look different, um, but they, they are candidates to come. So your patient has his eyes open during the day and closed at night. He does not startle to loud noises, turn to your voice, or clearly track objects. How would you guys describe his consciousness? Great job. Yeah, he is an unresponsive wakefulness. So, one of our main goals for a patient with disorder of consciousness on rehab is to try to stimulate wakefulness. We do this by weaning, sedating medications if able, um, as we talked about, they often come from the ICU on some medications that are sedating. We work to optimize their sleep at nighttime, and we provide stimulation during the day, both through their therapeutic activities with our team, as well as oftentimes with medications, usually dopaminergic medications. The progress that these patients show while we make these adjustments may be very subtle, and so we use targeted neurobehavioral assessments to help us monitor if the changes we're making are helping them be more alert and moving through those stages of disorder of consciousness, and I'll show you an example of one of those. The rehab stay for these patients is also heavily focused on prevention of secondary complications such as pressure wounds or joint contractures from high muscle tone and decreased mobility. And then we also are working a lot on caregiver education. We always hope we will see progress and emergence from the disorder of consciousness while the patient is with us in inpatient rehab, but the course is typically challenging to predict. And so we do prepare families from early in their stay that we will teach them to provide the level of care that. The child is requiring at that time, um, in case that is still what's needed when they do go home. So this includes a lot of education about brain injury itself, but also practical care needs such as possibly tube feeds or physically supporting the child with transfers or daily activities. So this is an example of one of those neurobehavioral assessments that we use on our unit here. It's called the Coma Recovery Scale Revised, and you can see that it's comprised of 6 scales looking at auditory function, visual function, motor function, oromotor and verbal function, communication and arousal. The score. Can help us track subtle changes in a child's responsiveness as we adjust medications and work with them in therapy. Um, so, for example, looking at auditory function, a score of 0, it represents no response to an auditory stimulus, and then there are higher scores for a startle response, localizing to sound or following commands. A common medical issue that we see following traumatic brain injury, especially severe traumatic brain injury and those in a disorder of consciousness, is paroxysmal sympathetic hyperactivity, which is a mouthful, so you'll often hear us call it PSH or you've probably heard the term storming. It's a type of dysautonomia, um, and this is one of those medical issues that I was referencing. Arise as early as the PIC use day and so we, our team can help manage that, um, from, you know, from early on in the child's course. But this, um, phenomenon is essentially hypothesized to represent excessive sympathetic nervous system activity due to a loss of normal inhibitory influences from the brain. This leads to non-noxious or minimally noxious stimuli being perceived by the person as noxious. So, for example, being constipated or laying in an uncomfortable position in bed, rather than, you know, not really making. Causing much of a response will lead to this big sympathetic storm of symptoms. So what this looks like is spells of increased sympathetic activity, high heart rate, high blood pressure, high respiratory rate, increased temperature, and posturing. Um, this is in some ways a diagnosis of exclusion. We have to consider other medical problems that could present in the same way, such as infection, pulmonary embolism, and it's also possible that the patient is showing an appropriate response to pain. Um, like Susie said, these patients sometimes have multiple injuries and multiple reasons to have pain. Um, but if it is truly consistent with PSH, the first step in treatment is to alleviate potential triggers with environmental interventions, so making sure the room is calm, repositioning the patient, changing any soiled clothes. Sometimes medications are required either on an as needed or scheduled basis to help resolve or prevent these episodes. Some common medications we might use are propranolol, clonidine, benzodiazepines, or gabapentin. Um, several of these medications though can be sedating, so that's that balance of sort of symptom management while trying to help these patients be as awake and alert as possible. Cognitive and behavioral recovery after a traumatic brain injury can also be described with the Ranchos Los Amigos skill. It's named for the rehabilitation hospital where it was developed. The descriptions of these levels are maybe a little bit more relevant for adult patients, but they can give you a sense of what we might see as patients recover on our unit. Movement through these different levels may not be linear and some people may not experience all levels or achieve the higher levels of interaction, but understanding the scale can help us prepare families for what may be coming. The early levels kind of overlap with our descriptions of disorder of consciousness. So, a rancho level 1 is someone with no response to their environment. Level 2 has inconsistent, generalized or non-purposeful responses like a generalized startle. Level 3, you'll start to see people with inconsistent but more localized and specific responses to external stimuli. You might start to hear that they're more specifically responding to their family or people they know than to others. And then it comes level 4, which I highlight because it's a big one, which is the confused and agitated stage. This can be really stressful for families and so we do prepare them that this may be coming. Typically, patients at level 4 are not out of post-traumatic amnesia, which means that they're not yet forming new memories after their injury. And so that can make them very confused, hyperactive, and agitated. Um, we always encourage families that this is common, it's temporary, and that we know the child is not in control of their behavior during this stage. With agitation, um, we're often first trying to use environmental interventions to help with that. So avoiding overstimulation, which can be a lot to process for someone with a brain injury, turning down lights, limiting the number of visitors, minimizing tubes and lines when we can. Sometimes we will use medications, um, That to help with this, there is some overlap in the type of medications we use for agitation as what we use for, for PSH or storming, but these really are different phenomena and often are presenting at different stages of the person's recovery. Beyond that agitated stage, we can see in level 5 patients who remain confused, no longer agitated, but not yet appropriate. So oftentimes their behavior and their responses don't make sense. They typically still have pretty impaired memory and so sometimes they'll confabulate, which can also be distressing to parents who say, my child would never lie before this. And again, there's a lot of reassurance that this is something we expect to see as kids are recovering from a severe brain injury. Um, for the sake of time, I won't review the other levels in detail, but they essentially reflect ongoing improvements in memory, command following, independence with carrying out a routine, as well as awareness of their condition and of their limitations. So these patients are very complex. Um, they can have many potential impairments or medical issues related to their TBI in addition to possibly having other injuries from their trauma, and we're considering all of these during their rehab stay. I'll highlight some of these issues here as well as some of the teams from rehab and, and outside of rehab. Maybe helping to manage these and you can imagine how these are tightly interwoven. Um, so of course, motor deficits. People can have various deficits depending on the location and the extent of their injury, weakness, increased muscle tone, um, as Alison mentioned, impaired coordination and balance are really common. We will be thinking about bracing or other mobility equipment that might be needed. There are also sensory deficits, so loss of smell is actually quite common, and that can impact appetite or, um, you know, our feeding plans on rehab. Visual deficits are common due to damage anywhere along the path from the eye, the optic nerves, all the way to the visual cortex and difficulty with processing that visual information. And then hearing loss can occur due to damage to middle ear structures or to cranial nerve 8, especially if there's a temporal bone fracture. We can see dysphagia, so that's something that speech therapy may be actively working on during their time with the patient, um, but our dietitians can help us ensure that we're getting adequate intake on an altered diet, and then GI and surgery may become involved if we do need a feeding tube. Behavior issues are very common. More than 50% of children with traumatic brain injuries develop novel psychiatric disorders such as ADHD or anxiety after their injury, and as we've already discussed, agitation, impulsivity, and poor safety awareness are very common. Cognition and communication is another big bucket you can advance. Um, we can see a wide range of difficulties here including difficulty with verbal communication or aphasia, difficulty with attention, memory, processing speed, and executive functioning. And then a number of other medical issues may be present, such as seizures, pituitary dysfunction, neurogenic bowel and bladder, among others. So you can imagine how interwoven these are, you know, of course, our PT might be focused on their motor skills, but if they have cognitive difficulty or are really impulsive, that's going to impact how they work with the child in therapy. So, the ultimate goal of inpatient rehab is getting out of the hospital, but how do we actually do that? Some of the crucial players in the transition home, you can advance, are, um, are nurses who provide a lot of education to families, social work who will connect them to community resources. They may help with new transportation barriers or, um, some home modifications like if they, if the family needs a ramp, if the child's not ambulatory. Um, and then, of course, our care manager who orders all equipment and supplies and helps ensure that smooth transition to ongoing outpatient therapy because rehab is never the end of, of recovery for these kids. Um, depending on the complexity of the child's care, sometimes we'll do a 24 hour stay where the patient is still admitted to rehab, but we essentially stimulate them being at home. The family initiates all care. They give the tube feeds, they ask for meds when they're due, um, so that they can kind of practice what it will be like when they're in, when they're at home with this child, but they still have that backup and that support of the team and nursing. We do not only want kids with TBI to be at home, even these severe TBIs. Our goal is to get them back into school in the community. Um, they, however, may require supports that they didn't need before. So typically, they will complete neuropsychological testing while they're on rehab to better understand their cognitive function and inform their school plan. They might start to participate in some school tasks while they're on rehab and then our school liaison is also a critical team member. Um, they will help to communicate directly with the school about what the child's current needs are and help facilitate that transition. And then we also want kids to engage in leisure, so our therapeutic recreation, music therapy, and child life colleagues are really taking charge of this effort. Our TR will often put together a guide for the child and the family about what activities are safe right now and with what level of supervision. Especially, you know, kids really want to get back to all the things they were doing before and if, um, they may not be safe to do that, um, and especially with cognitive limitations or poor safety awareness that may be too risky and so we help give them a guide and knowing and hoping that that will be updated as they continue to fall with our outpatient team. Um, Everyone wants to know what the child will look like down the road, and this unfortunately is really challenging to predict. Um, there are, especially in the hospital, um, there are some risk factors that have, that have been found to be associated with a worse outcome. Some of these are younger age, having a lower GCS score at presentation, specifically the motor sub score, pupil reactivity, having a longer duration of coma, and then some MRI characteristics, including having a larger contusion volume, ischemic changes, or brain stem lesions, um. So how do we support families given this uncertainty? I think the most important thing to know is that recovery from a severe traumatic brain injury is measured in months to years, not weeks, not days. And so inpatient rehab is only their initial burst. They will continue to receive support outside. Sometimes we have kiddos who do not emerge from their disorder of consciousness while they're in rehab, but they emerge later, and they might return to inpatient rehab for some additional support when they're in a different place to engage with those therapies. Um, yeah. So, our multidisciplinary brain injury clinic continues to, to see these kiddos as outpatients. Well, to end our story with Richard. He makes it back. He makes it back to school. Oh. Here we go. Sorry. Anyway, our advice to all of you is wear your helmets, stay safe out there. Um, questions for the panel. Hi, great talk. um, with the growing number of NPs and PAs in the children's primary care setting and school-based settings, what guidelines recommendations do you want to give to those providers after this injury and they're going back to their providers for their well checks or sick visits? Is there anything you can recommend so that we as providers in the way outpatient setting. Know what to do with these patients. I think uh That's a really great question, I think. For these patients, especially a complex patient like Richard, encouraging them to maintain their follow up with the kind of dedicated brain injury team is really important. I think one piece that would be really helpful for primary care providers to watch out for is, um, mental health behavior concerns just since we know those are so common so having a higher level of suspicion for those things, um, since you may see the patients, you know, more often or in between when when our team is seeing them. I'll also add, um, the trauma team at discharge, and I don't know if you guys do this as much, but we try and call the pediatricians at discharge and so for the kiddos that don't need rehab and discharge from us, we're calling the pediatrician and kind of updating them where they're at, what their follow-up is, what, you know, recommendations are, and we try and be. Good about giving back to school recs so that by the time they're seeing rehab, they can kind of touch base with rehab like school is not going well or school is going well. So, I think just staying in touch with the trauma team and keeping them connected to the rehab service like Doctorcoin mentioned is like key in primary care follow-up. And we do the same thing on rehab. We always speak with the PCPs, um, before discharge. So we do try to communicate, especially if there are things that we would like to collaborate on, you know, monitoring and following up. Hi, I have a question. So a lot of your standardized assessments say things like appropriate responses and things like that. Um, I work in developmental behavioral pediatrics, so I'd be remiss if I didn't ask, like how do you adjust that for a patient who maybe doesn't follow commands at baseline or, um, and like what does that look like for their stay? It's a really good question. We certainly have kids who have baseline conditions. They were not, you know, necessarily 100% typically developing before their brain injury. I think we're very used to adjusting our approach, um, so sometimes the scales are not super applicable or, you know, we can't use those numbers in that exact way, but. So it's and some younger kids too sometimes we have um have younger kids a lot of the scales are um you know there are pediatric versions but they may not apply to our youngest patients so we just we use them when we can and they may not always apply. So what happens if somebody doesn't qualify for insurance for rehab? I hate to ask you. Yeah, a, a kid like Richard, let's say like it would be really hard to say that he wouldn't need it. There are kids who are milder, um, maybe physically are doing really well but have a lot of cognitive limitations and aren't safe with their ADLs or independent with their ADLs where insurance may take an initial look and say we don't think they qualify. We, we go through the steps to try to change their mind, um, if we absolutely can't, then they will be following up closely with our team, um, and, and we can set them up with outpatient therapies, um, and continue to, to help support the patients, but I'd say for it, it's unusual for a severe brain injury patient that we can't get that approval. Great, thanks. All right. And special thanks to the inspiration for Richard, Doctor Rich Falcone. He's one of our trauma surgeons and also your chief of staff, who knew he was going to be the inspiration, but we had so much fun with Richard.