Prolonged Disorders of Consciousness: Emergence … · Prolonged Disorders of Consciousness:...
Transcript of Prolonged Disorders of Consciousness: Emergence … · Prolonged Disorders of Consciousness:...
Prolonged Disorders of
Consciousness:
Emergence from minimally
conscious states Katrina Clarkson, Principal Speech and Language Therapist
[email protected] Beverley Fielding, Clinical specialist Occupational Therapist [email protected] September 2016 Regional Hyper-acute Rehabilitation Unit Northwick Park Hospital
Reality check
Likelihood of emergence diminishes over
time
Cause of brain injury is a strong indicator
of outcome
– Non traumatic brain injury (anoxic/diffuse)
– Traumatic brain injury
RCP Prolonged Disorder of Consciousness National Clinical Guidelines 2013
Emergence signal
CRS-R: Items denoting emergence from
MCS are highlighted with †
– Motor Function scale (Functional object use)
– Communication scale: Functionally accurate
to situational questions
WHIM: Items from approximately 29
onwards are starting to show possibility of
emergence from PDOC.
Emergence from MCS
Reliable and consistent responses.
Using set tasks
– 2 consecutive evaluations
In one or both
– Functional interactive communication
– Functional use of objects
(RCP National Clinical Guidelines - Prolonged Disorder of Consciousness
2013 and Giacino et al 2002)
Interfering factors
Sensory impairments
– language / vision / hearing
Motor impairments
– Weakness / contractures / ataxia
Cognitive deficits/confusion
Second language English
(RCP Prolonged Disorder of Consciousness National Clinical Guidelines 2013; Annex 1a)
Extended set of emergence
parameters Demonstrate a consistent response in one
of the following:
– Functional use of objects
– Consistent discriminatory choice-making
– Functional communication (Biographical
Questions)
– Functional communication (Situational
questions)
Case study: Mrs F
Personal Information
– 66yr old female
Social Information
– Married
– Working as an
Occupational Psychologist
– Two grown up children
CASE STUDY: Mrs F
Background:
– RTA: pedestrian v’s van March 2015
– Severe traumatic brain injury
Extensive bilateral SAH
Large haemorrhagic contusion in right temporal lobe
Bifrontal subdural hygromas (CSF)
MRI – axonal injury involving thalamus, midbrain
and cerebellum bilaterally.
– Polytrauma
Fracture of 7th cervical vertebra
Multiple rib fractures
CASE STUDY: Mrs F
Impairments on admission (May 2015):
– PDOC
– Severe tetraparesis
But: spontaneous movement in arms and legs
– Tracheostomy in situ
– Reliant on PEG feeding
– Fully dependent for all care
Management Mrs F
Assessed regularly with WHIM and CRS-R
– Upward trajectory
– Localising and differentiating responses
– Increased verbal responses
Formally emerged August (3 months later)
– Using functional objects – hairbrush, cup
– Two consecutive occasions, within 72 hrs
Case study: Mr D
Personal Information
– 35 yr old male
Social Information
– Married with 2 children,
10yr and 9yr
– Working as a Mechanic
CASE STUDY: Mr D
Background:
– Collapse at home
– CVA: Left MCA infarct (February 2015)
– Haemorrhagic transformation
– Decompressive craniectomy
CASE STUDY: Mr D
Impairments on admission (March 2015):
– PDOC – no visual fixation or tracking
– Right hemiplegia
– Severe spasticity on right
– Tracheostomy in situ
– Reliant on NG feeding
– Fully dependent for all care
Management: Mr D
Assessed regularly with WHIM
– Clear upward trajectory
– Localising and differentiating responses
Formally emerged April (1 month later)
– Using functional objects –cup, glasses, wiping
mouth with a tissue
– Two consecutive occasions
Summary
Reliable and consistent responses.
Using set tasks
– 2 consecutive evaluations
In one of:
– Functional use of objects
– Consistent discriminatory choice-making
– Functional communication
Biographical questions
Situational questions (RCP National Clinical Guidelines - Prolonged Disorder of Consciousness
2013)
References
Turner-Stokes, Bassett, Rose, Ashford and Thu (2015)
Serial measurement of Wessex Head Injury Matrix in the
diagnosis of patients in vegetative and minimally
conscious states: a cohort analysis. BMJ Open 5.
Shiel, Wilson, McLellan, Horn and Watson (2000). The
Wessex Head Injury Matrix (WHIM) main scale: a
preliminary report on a scale to assess and monitor
patient recovery after severe head injury. Clin Rehabil;
14:408–16.
Giacino, Ashwal, Childs, Cranford, Jennett, Katz, Kelly,
Rosenberg, Whyte, Zafonte, and Zasler (2002) The
Minimally Conscious State: Definitions and diagnostic
criteria. Neurology, 58: 3 349-353.