With the advent of newer and better therapies available, patient safety is emerging as a new topic. Pediatric patient safety is relatively new, in that there are few guidelines available. Safety in children with traumatic brain injury (TBI) given the incidence of TBI is very vital. This is an attempt to identify the key points in TBI.
NM is a 10-year-old boy who sustained traumatic brain injury (TBI) after a motor vehicle accident. He was an unrestrained front seat passenger while returning from school when the car was T-boned on the passenger side by a pickup truck. He sustained a right temporoparietal fracture, subdural hematoma, right humeral fracture, and right femur fracture. His Glasgow Coma Score at the scene was three. He was taken emergently to the operating room, where he underwent a craniectomy, placement of skull in abdomen, open reduction and internal fixation of the femur fracture, and cast placement for the fractured humerus. He was found on secondary survey to have cervical ligamentous laxity, and was placed in a cervical collar for 12 weeks. His father was deceased and his mother, who was also in the accident, experienced a TBI. His maternal grandmother was involved in his care. The patient was admitted to the rehabilitation unit after being medically stabilized.
At admission, the patient was reported to be in a coma (Ranchos Los Amigos scale level II), was non–weight-bearing on the right side, and was wearing a cervical collar. He was also noted to be hemiparetic on the left side and dependant for all his care. During inpatient rehabilitation, NM was treated for agitation, spasticity, aggressive behavior, and autonomic instability. He was noted to have an electrolyte imbalance and was taking phosphenytoin for prophylactic management of seizure risk.
TBI is termed the silent epidemic , with an estimated 10 million people being affected annually worldwide. The prevalence of TBI in children that is severe enough to require hospitalization is estimated to be 70 per 100,000. Head trauma constitutes approximately 80% of traumatic pediatric injuries, with 5% dying at the scene of accident and 5% to 10% discharged to long-term care facilities. Nonaccidental trauma is most common in infants, whereas falls and sports-related injuries are seen in toddlers and school-aged children, respectively. Motor vehicle accidents are seen in young adults, with an increasing incidence of concussion in amateur and professional athletes. Demographics, development, epidemiology, and dependency for care make safe and efficient care challenging to provide. Concussion is a separate topic and is not addressed in this article.
Most patients have been already been medically stabilized by the time they reach the rehabilitation setting. Hence, this article discusses the rehabilitation aspects, with an emphasis on patient safety. The goal of rehabilitation is to maximize current function, enable patients to be self-sufficient, and teach compensatory strategies to achieve the new potential and educate families about these functions.
A detailed history must be obtained from the caregivers when the patient is admitted to the rehabilitation unit. Practitioners must recognize that families are under a lot of stress and hence may not be able to provide an accurate history, and therefore a secondary history must be obtained a day or two later when they are more ensconced in the setting. A history of attention deficit hyperactivity disorder (ADHD) is important in children with a TBI, because a 10% to 20% prevalence of preinjury ADHD exists. The family must also be included in the goal-setting and be provided with a detailed explanation of the rehabilitation process. Information about the patient should be obtained before admission to accommodate any medical needs. Box 1 outlines key points in the safe inpatient rehabilitation of children with a TBI.
History and physical examination on admission to unit: includes detailed description of patient’s injury; medical and surgical treatments rendered; past medical, developmental, and birth history; pertinent allergies; medications; family history; previous level of function and performance in school (if applicable)
Medication reconciliation: review medications for potential drug–drug interactions and polypharmacy
Transition in care: review discharge summary from previous hospital and double-check treatment plan to ensure safe transition from one facility to another
Rehabilitation prescription with safety precautions (ie, seizure risk, fall risk, weight bearing status, range of motion restrictions)
Education: patient and family/caregiver on TBI and its treatment
Communication: between rehabilitation team members and between medical and surgical specialists involved in the patient’s care, especially at transition points in care, including hand-offs
Monitoring: laboratory value abnormalities, infections (urinary tract, pneumonia), missed fractures, agitation (Rancho Los Amigos scale, Rappaport scale, impulsivity, bowel/bladder function, swallowing function, skin breakdown, sleep-wake cycle)
Spasticity management (range of motion, splinting, casting, medications, chemodenervation, operative procedures [intrathecal baclofen, dorsal root rhizotomy], contracture release)
Deep vein thrombosis prophylaxis
Transition discharge with appropriate discharge summary
The weight-bearing status must be noted to ensure proper transfer techniques and ambulatory processes. Identification and documentation of the stages of coma is important to assess the efficacy and safety of medications being used. Use of neurostimulants has been studied, although some studies were retrospective as opposed to prospective. Hence, the use of neurostimulants should be judicious, with close attention being paid to variations in autonomic instability.
Cognitive status is delicately balanced after any injury to the brain. As sleep-wake cycles are altered, mental status is precipitously balanced, and use of medicines in arousal and sleep should be vigilant. Use of medications such as N-methyl D-aspartate antagonists (amantadine) should be used carefully because they promote apoptosis through blocking excitatory effects of glutamate in young rats. Use of other medications, such as bromocriptine, methylphenidate, and donepezil, requires close monitoring because their efficacy is still unclear.
Altered mental status, either agitation or somnolence, should prompt a search for cause. Box 2 lists some common causes to consider. Laboratory tests should be obtained, such as complete blood cell count, chemistry and blood culture, chest radiographs, urine analysis, and culture studies. Use of imaging studies such as noncontrast CT or MRI may be ordered; however, radiation exposure from CT and radiographs should be considered before these tests are ordered.
Hydrocephalus
Infection: urinary tract infection, tracheitis, meningitis, pneumonia
Electrolyte imbalance
Venous thrombosis
Occult fracture
Environmental factors: overstimulation, altered sleep-wake cycle
Neurogenic bowel and bladder
Perforated bowel
Physical aggression, verbal aggression, and explosive anger are associated with agitation. Agitation has been defined as the “subjective evidence of one or more of the following behaviors: restlessness, derogatory or threatening demands, verbal abusiveness, sexually inappropriate comments or actions, or attempts at physical violence of sufficient severity to disrupt nursing care or therapy.” Because no one medication has been shown to manage agitation better, the risks and benefits of each medication should be considered before use. Box 3 lists medications used to treat agitation.
Benzodiazepines: lorazepam, diazepam, and clonazepam
ß-blockers: propranolol (not approved by the U.S. Food And Drug Administration [FDA] in children)
Anticonvulsants: valproic acid, carbamazepine, and lamotrigine
Antidepressants/selective serotonin reuptake inhibitors: sertraline, paroxetine, citalopram, fluoxetine, and amitriptyline
Antipsychotics: propranolol, clozapine (not FDA-approved in children), ziprasidone, quetiapine, and olanzapine
Risk of fall should be considered as consciousness improves. Impulsivity, lack of attention, lack of executive functioning, lack of insight into deficits, lack of safety awareness, urinary urgency, lack of balance, and lack of assistance at moment of wanting to go to the bathroom are a few factors that can add to the risk of falls. Once patients are able to verbalize their needs, a voiding schedule must be established. Families should be educated about weight-bearing status and taught to perform safe transfers, using gait belts as needed. Ambulation should be assessed before patients begin walking based on their weight-bearing status. Either a “one-to-one sitter” or family members must be with the patient to provide reminders of safety awareness. Depending on a hospital’s resources or policies, a safety enclosure bed can sometimes be used.
Spasticity is defined as a velocity-dependant resistance of a muscle to stretch and is a sign of upper motor neuron injury. Scales commonly used to grade spasticity include the Ashworth, modified Ashworth, and Tardieu scales. Treatment of spasticity in the acute setting is to prevent development of contracture. Range of motion exercises, stretching, use of positioning devices, and use of modalities are helpful in treating spasticity. Use of splinting or casting must be monitored carefully because skin breakdown can occur when the splint/cast remains on for a long time and when the cast is removed. Close attention must be paid to positioning. The patient should be positioned on the side with hips flexed past 90° and with neck flexion. Medications used to treat spasticity should be based on the goals: pain relief, proper positioning, caregiver ease, and hygiene issues. Many patients use their spasticity to help with positioning, transfers, maintenance of muscle tone, and prevention of deep vein thrombosis.
Pharmacologic agents used to treat spasticity include baclofen, benzodiazepines, dantrolene sodium, clonidine, and tizanidine. Chemodenervation with botulinum toxin and phenol can also complement the use of stretching, splinting, and casting. Phenol and botulinum toxin injections can be used together to target a larger number of muscles if severe spasticity is present. However, the FDA has not approved the use of botulinum toxin in children younger than 12 years in the United States, although it has been approved for use in Canada, Australia, and other countries. The potential risk of distant spread of toxin should be discussed with the patient and families before use. Furthermore, a conversion factor for different toxins does not exist, because the units of biologic activity among the products are not equivalent. The medication guide for using the toxin should be provided to caregivers. For safety reasons, the lowest possible dose should be used, based on weight. Botulinum toxin injections are easy to perform and commonly injected once every 3 months. Phenol injections can also be used to treat spasticity. However, these can be painful and are associated with a risk for deep vein thrombosis, and the effects are permanent. Factors to consider when deciding whether to use chemodenervating agents should include cost and risks and benefits; patients must be at the center of the care process and not the diagnosis.
The intrathecal baclofen (ITB) pump is an effective method of treating spasticity of cerebral origin, especially cerebral palsy. It has also been used to treat spasticity from acquired brain injury. The pump is usually implanted after the patient has had an ITB trial, helping families see the decrease in spasticity. The decision to implant an ITB pump should not be made lightly, because the consequences of improper maintenance can result in death. Importance of refilling the ITB pump should be stressed to the family, because if in the absence of commitment to regular follow-up, this procedure can be dangerous. Families should be trained to recognize signs and symptoms of baclofen overdose and withdrawal, which are outlined in Box 4 . Clinicians should be skilled in recognizing and troubleshooting malfunctioning pumps, including mechanical failure from rotor stall, computer error, no/low drug in reservoir, battery failure, catheter malfunction from migration, fracture, kink/occlusion, disconnection from pump, human error from programming error, and refill error.
Related posts:
Patient Safety and Quality Improvement in Rehabilitation Medicine
Medication Safety in Rehabilitation Medicine
Patient Safety Considerations in the Rehabilitation of the Individual with Cognitive Impairment
Patient Safety in Rehabilitation Medicine: Traumatic Brain Injury
Safety Considerations During Cardiac and Pulmonary Rehabilitation Program
Patient Safety in the Rehabilitation of Children with Spinal Cord Injuries, Spina Bifida, Neuromuscular Disorders, and Amputations
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