Management of Traumatic Brain Injury in Disaster Situations
Original Editor - Naomi O'Reilly
Top Contributors - Naomi O'Reilly, Kim Jackson, Tony Lowe, Rachael Lowe, Jess Bell and Admin
Introduction[edit | edit source]
Disaster, as defined by the United Nations, is a serious disruption of the functioning of a community or society, which involve widespread human, material, economic or environmental impacts that exceed the ability of the affected community or society to cope using its own resources.[1] According to the International Federation of Red Cross & Red Crescent Societies a disaster occurs when a hazard impacts on vulnerable people. The combination of hazards, vulnerability and inability to reduce the potential negative consequences of risk results in the disaster. [2] While disasters can be caused by nature, the human influence on disasters have been widespread throughout the centuries, particularly in relation to conflict situations. Natural disasters and armed conflict are two of the main types of disasters and have marked human existence throughout history resulting in peaks in mortality and morbidity. [3] Find out more about the different types of disasters and disaster management here.
While accurate data is scarce, traumatic brain injury remains a common neurological consequence of disasters, natural and man made. A wide range of mild, moderate, and severe traumatic brain injury occur secondary to overpressure, penetrating wounds, and crush injuries following the huge kinetic energy released by rapid-onset natural disasters. Disaster preparedness planners and emergency medical personnel face a major challenge in preventing and managing neurotrauma within this context. As with any traumatic brian injury, management is complex and individuals often have long-term physical, cognitive and behavioural impairments with residual neurological deficits, medical complications all resulting in lifestyle consequences, which necessitate comprehensive interdisciplinary management, including medical, surgical and rehabilitation. [4]
Immediate Emergency Care[edit | edit source]
Early diagnosis and treatment of traumatic brain injuries can be challenging under normal circumstances, but are further exacerbated in the aftermath of disaster due to to the chaotic environment including damaged infrastructure, poor communication and shortages of relevant health and rehabilitation workers, particularly neurotrauma specialists. [5]
During this early stage, immediate diagnosis and treatment remains key to minimise the development of secondary brain injuries, which is a massive challenge, particularly in developing countries where medical infrastructure and availability of state-of-the-art neurological care is already scare and may be further limited as a result of the disaster. Families are often separated, and symptoms of posttraumatic stress disorder can be common during the postacute phase.
As a result, early deployment of specialised emergency medical teams to meet the immediate needs of disaster victims is a key element of the immediate emergency response, and is guided by a range of World Health Organization initiatives, including Emergency Response Frameworks (Standards and Guidelines); Coordination Mechanisms, Emergency Medical Team Accreditation Process ensuring that rehabilitation professionals form part of the Emergency Medical Teams. [5][6]Specialized care teams are defined by the World Health Organization as “national or international teams embedded into Emergency Medical Teams or a national facility to provide specialist care”, which may include rehabilitation teams and are deployed based on the response to meet specific needs required at the request of the host health authorities. These teams should be multidisciplinary and need to be integrated into a disaster response and management plan and their skills need to be shared with local rehabilitation and health-care providers through mentoring and educating/training." [4]
A specialised care team that is focused on traumatic brain injury rehabilitation in a disaster setting should include; [4][6]
Rehabilitation Interventions | General Applicability of Recommendations in Disaster Settings | |
---|---|---|
Weak | ||
Team Composition | Minimum Technical Standard;
A traumatic brian injury specialised rehabilitation team should be led by a rehabilitation physician and comprise of at least three other professionals from different disciplines, including rehabilitation medicine, nursing, physiotherapy, occupational therapy, speech and language therapy, and psychology. In addition, a team lead is required to represent the care team at health coordination level | |
Qualification and Experience | Minimum Technical Standard;
Rehabilitation professionals in a traumatic brian injury specialised care team should have at least 6 months’ experience working in a traumatic brain injury unit or with traumatic brain injury patients in a major trauma center and at least 3 years of postqualifying clinical experience At least one team member, preferable the team leader, should have experience in emergency response and all team members should have undergone training in working in austere environments | |
Rehabilitation Equipment | Minimum Technical Standard;
Specialized care teams for rehabilitation should have capability to rapidly provide the equipment listed in | |
Length of Stay | Minimum Technical Standard;
A team that embeds into a local facility should plan to stay for at least 1 month with evidence of a exist strategy and release mechanism |
Rehabilitation[edit | edit source]
The overriding objective of traumatic brain injury care in disaster settings has now extended well beyond survival and acute management to successful implementation of rehabilitation structures to work towards reintegration of the individual with a traumatic brain injury back into home and community. The World Health Organization minimum standards for rehabilitation recommendations for managing patients with traumatic brian injury following a disasters inlude; [4][7]
- Cognitive and Neurological changes should be monitored and regularly assessed
- Early referral to a step-down facility using local rehabilitation providers and support networks, as required
- Appropriate mobility aids prescribed for long-term mobility deficits using local service provider
- Patients with long term or permanent nerve injury considered for orthotic device, sought from a local provider
- Referral pathways identified for microsurgery for appropriate patients
Rehabilitation is a vital element of the treatment and management process post traumatic brain injury in a disaster setting and should prepare individuals with long-term impairment, their care providers and local rehabilitation personnel to manage their ongoing needs over a longer term and should be started early following any disaster.[7] Rehabilitation should focus on comprehensive assessment for neurological and functional limitations and individualized treatment program for specific functional goals with ongoing monitoring of outcomes. The goal of rehabilitation in a disaster setting is to improve functional outcomes, minimize secondary complications, and successful reintegration into the community, with an emphasis on patient and care giver education and self-management. Survivors of traumatic brain innjury need support for acquisition of essential skills for maximum return to their previous level of functional independence, regardless of whether specific impairments can be eliminated. [4]
Role of the Physiotherapist[edit | edit source]
Physiotherapists intitally involved in disaster settings, were physiotherapists employed in military service including the United States and British Armed Forces, whose primary role involved triage of acute orthopaedic trauma, wound care, as well as respiratory care in critical settings. Despite the range of roles these physiotherapists and others have provided in disasters situations, many disaster response organizers did not know how to utilize physiotherapist skills to provide maximum effect as a result of a lack of clearly defined roles within the emergency reponse teams in disaster settings.[8] Historically physiotherapists were not routinely included in immediate post disaster emergency medical teams, but this is slowly changing and physiotherapists are now being recognised for the role they can play in disaster response. Discussions between the World Confederation for Physical Therapy and physiotherapists involved in humanitarian responses identified a need to advocate for the presence of rehabilitation professionals, including physiotherapists, in all phases of disaster management and to affirm the need for the establishment or development of physiotherapy services in disaster settings through strengthening of the physiotherapists role in preparedness and promotion of our role within emergency medical teams. This led to development of a wide range of resources and increased awareness of physiotherapists role, and with that an increase in physiotherapists involved in all phases of disaster management.[8]
According to Pete Skelton, Physiotherapist and Rehabilitation Project Manager at Humanity and Inclusion and UK International Emergency Trauma Register member, ‘Physiotherapy is starting to become a central part of the global humanitarian response... and we play a critical role, which goes way beyond just rehabilitation. The role of physiotherapists in emergency situations differs significantly depending on the context.... but may include working in a field hospital providing acute surgical care, working on an outpatient basis, providing care in people’s homes or providing prosthetic provision in a temporary clinic.’
Humanity & Inclusion has played a huge role in working towards integration of rehabilitation into the UK Emergency Medical Team, which has involved the recruitment and training of rehabilitation professionals to join the teams, and working with partner organisations to ensure the field hospital is fully equipped and accessible with all relevant equipment required by rehabilitation professionals. This has enabled early access to rehabilitation including the provision of essential equipment such as wheelchairs and orthotics, psychosocial support, and onward referral.
Responsibilities[edit | edit source]
You are only expected to work to your level of expertise, knowledge and competence. If an assessment is needed that you are not competent to complete, ask and see if there is anyone else available or who will be available in the future to complete it if it can wait for specific expertise. The assessment of a patient in a humanitarian crisis where possible should still be the same as the assessment you would complete in a typical brain injury setting.[9]
Role in Preparation Phase[edit | edit source]
Physiotherapists have a significant contribution to make in disaster preparedness and should be included in disaster management planning and implementation. Specific humanitarian and clinical training and registering with international medical teams or international non-governmental organisations (INGOs) is key for any physiotherapists interested in international humanitarian response.[8]
Role in Response Phase[edit | edit source]
Growing evidence supports the role that rehabilitation, including physiotherapy, should be considered a central part of the disaster response from the onset of a disaster with physiotherapists involved not only in direct provision of rehabilitation, but also involved in assessment, coordination, psycho-social support and advocacy. Rehabilitation in humanitarian disasters is best provided by experienced local providers, with support from specialist disaster response rehabilitation expertise as resquired, working as an integral part of specially trained emergency medical teams.[8]
Before commencing rehabilitation ensure that any contaminant injuries have been treated/ stabilised and consider what influence these may have on your treatment choices, as it is unlikely that patients will present only with an acquired brain injury following a sudden onset disaster. Likely other injuries are fractures, amputations and especially spinal cord injury that can be easily missed.[9]
The use of detailed outcome measures may not be appropriate in the early stages of an emergency response, but as you enter the rehabilitation phase you still need to be able to demonstrate change in your patient’s abilities in order to help shape future therapy sessions and rehab goals.[9]
Role in Recovery Phase[edit | edit source]
Physiotherapists provide a key link between disaster response and recovery through rehabilitation capacity building and planning service delivery, accessibility, and inclusion. As is normally expected with traumatic brain injury rehabilitation, planning for recovery should be initiated as early as possible and should incorporate a team based approach. Where possible, the recovery phase should be locally led and following a disaster will also often incorporate a range of multi-agency stakeholders, often supported by international respondents. Where these international repondanst are physiotherapist, a large part of their role should focus on local capacity building, through training, service development, and the establishment of formal education programmes where they are absent.[8]
The following reports and clinical manual provide more detailed information in relation to the role of the Physiotherapist in a disaster setting.
The Role of Physical Therapists in Disaster Management
This report highlights the need for physical therapist involvement in disaster management and particularly in Emergency Medical Teams and provides information for physical therapists who want to work in the field, and national and international agencies who are already working in the field. Each section includes information on the role of the physical therapists and details guidelines and resources to support practice in disaster management. [8]
Rehabilitation in Sudden Onset Disasters - Chapter.8 Acquired Brain Injury
Guidelines[edit | edit source]
Independently extracted, compared, and categorized evidence-based rehabilitation intervention recommendations for rehabilitation interventions were synthesized from currently published traumatic brian injury Clinical Practice Guidelines, developed by the Department of Labor and Employment (DLE); Scottish Intercollegiate Guidelines Network (SIGN); Department of Veterans Affairs/Department of Defence (DVA/DOD); and American Occupational Therapy Association (AOTA) for applicability in disaster settings. [7] As a result of the complexities related to the environment, resources, service provision, and workforce in disasters settings many recommendations for traumatic brain injury care are challenging to implement and more advanced interventions are generally not applicable due to limited access to services, trained staff/resources, equipment, funding, and operational issues.[7] Patient/carer education, general physical therapy, practice in daily living activities and safe equipment use, direct cognitive/behavioral feedback, basic compensatory memory/visual strategies, basic swallowing/communication, and psychological input are the key recommendations from a rehabilitation perspective that have been fond to be most applicable for survivors of traumatic brain injury in disaster settings. The following table outlines the general applicability of clinical practice guildeines for traumatic brain injyry in disaster settings.[7]
Rehabilitation Interventions | General Applicability of Recommendations in Disaster Settings | ||
---|---|---|---|
Weak | Moderate | Strong | |
Patient Education |
| ||
Gait, Balance and Mobility |
|
Task-Specific Training
Repetitive Training |
|
Spasticity and Muscle Tone |
|
|
|
Sleep Disturbance Management |
| ||
Cognitive Rehabilitation |
|
|
|
Behavioural and Emotional Disorders |
|
Comprehensive Neurobehavioural Program
|
|
Activities of Daily Living |
|
|
|
Post-Traumatic Headache Management |
|
| |
Service Delivery |
|
|
|
Responding Internationally to Disasters: Do’s and Don’ts
Minimum Technical Standards and Recommendations for Rehabilitation: Emergency Medical Teams
Rehabilitation in Sudden Onset Disasters
The role of rehabilitation professionals in responding to sudden onset disasters, such as earthquakes or tsunamis, is evolving rapidly, and they increasingly find themselves at the forefront of emergency response teams. This manual is designed for Physiotherapists and Occupational Therapists who provide rehabilitation in the immediate aftermath of a sudden onset disaster. It was developed to support volunteers on the UK International Emergency Trauma Register, but with the aim of being relevant to all rehabilitation professionals interested in rapid deployment to austere environments.[13]
The Role of Physical Therapists in Disaster Management
This report highlights the need for physical therapist involvement in disaster management and particularly in Emergency Medical Teams and provides information for physical therapists who want to work in the field, and national and international agencies who are already working in the field. Each section includes information on the role of the physical therapists and details guidelines and resources to support practice in disaster management. [8]
Communicable Disease Control in Emergencies - A Field Manual
Joint Trauma System Clinical Practice Guideline: Neurosurgery and Severe Head Injury (CPG ID:30)
Provides guidelines and recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources and follow-on care may be limited.[15]
Summary[edit | edit source]
The main strengths of physiotherapy were believed to be the functional focus of the profession and the ability to carry out thorough, musculoskeletal examinations, often with limited resources. Several unique areas of skill were found to be offered by physiotherapists, including those of assessing and treating casualties with acute injuries, preventing injury among rescue workers, and possibly preventing or lessening the burden of chronic dysfunction amongst patients after the emergency phase, finance coordinator, team leader etc. In addition, it has been noted that the focus of disaster response programs primarily is medical, and that physiotherapists potentially could relieve some of the workload of the medics by attending to selected patients, as well as possibly adding a more functional and holistic balance.
Screening Tools[edit | edit source]
Military Acute Concussion Evaluation 2 (MACE 2)[edit | edit source]
The 2018 Military Acute Concussion Evaluation 2 (MACE 2) is an acute assessment tool for all medically trained personnel who treat service members involved in a potentially concussive event. The MACE 2 incorporates current state-of-the-science traumatic brain injury information, including vestibular-ocular-motor screening.
The Brief Traumatic Brain Injury Screen[edit | edit source]
The Brief Traumatic Brain Injury Screen (BTBIS), is a 3 Question Defence and Veterans Brain Injury Centre Screening Tool used to identify service members who may need further evaluation for mild traumatic brain injury. It was validated in a small, initial study conducted with active duty service members who served in Iraq/Afghanistan between January 2004 and January 2005.
Resources[edit | edit source]
References[edit | edit source]
- ↑ United Nations Office for Disaster Risk Reduction. Terminology. http://www.unisdr.org/we/inform/terminology#letter-p [Accessed 29 Sep 2019]
- ↑ International Federation of Red Cross and Red Crescent Societies. What is a Disaster. http://www.ifrc.org/en/what-we-do/disaster-management/about-disasters/what-is-a-disaster/. [Accessed: 9 Jan 2017]
- ↑ Leaning J, Guha-Sapir D. Natural Disasters, Armed Conflict, and Public Health. New England Journal of Medicine. 2013 Nov 7;369(19):1836-42
- ↑ 4.0 4.1 4.2 4.3 4.4 Amatya B, Vasudevan V, Zhang N, Chopra S, Astrakhantseva I, Khan F. Minimum technical standards and recommendations for traumatic brain injury rehabilitation teams in sudden-onset disasters. The Journal of the International Society of Physical and Rehabilitation Medicine. [serial online] 2018 [cited 2019 Oct 19];1:72-94. Available from: http://www.jisprm.org/text.asp?2018/1/2/72/249854
- ↑ 5.0 5.1 Regens JL, Mould N. Prevention and treatment of traumatic brain injury due to rapid-onset natural disasters. Frontiers in public health. 2014 Apr 14;2:28.
- ↑ 6.0 6.1 Vasudevan V, Amatya B, Chopra S, Zhang N, Astrakhantseva I, Khan F. Minimum technical standards and recommendations for traumatic brain injury specialist rehabilitation teams in sudden-onset disasters (for Disaster Rehabilitation Committee special session). Annals of Physical and Rehabilitation Medicine. 2018 Jul 1;61:e120.
- ↑ 7.0 7.1 7.2 7.3 7.4 Lee SY, Amatya B, Judson R, Truesdale M, Reinhardt JD, Uddin T, Xiong XH, Khan F. Applicability of traumatic brain injury rehabilitation interventions in natural disaster settings. Brain injury. 2019 Aug 24;33(10):1293-8. DOI: 10.1080/02699052.2019.1641748
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 World Confederation for Physical Therapy. WCPT Report: The Role of Physical Therapists in Disaster Management. London, UK: WCPT; 2016
- ↑ 9.0 9.1 9.2 Skelton, P and Harvey, A editors. Rehabilitation in Sudden Onset Disasters. Handicap International/ UK Emergency Medical Team Chapter.8 Acquired Brain Injury. 2015
- ↑ Skelton, P and Foo, W editors. Resonding Internationally to Disasters: Do's and Don'ts Guide for Rehabilitation Professionals. 2016
- ↑ Emergency Medical Teams: Minimum Technical Standards and Recommendations for Rehabilitation. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
- ↑ Coupland R, Breitegger A. Health Care in Danger. the Responsibilities of Health-Care Personnel working in Armed Conflicts and Other Emergencies. Geneva: ICRC. 2012.
- ↑ Skelton, P and Harvey, A editors. Rehabilitation in Sudden Onset Disasters. Handicap International/ UK Emergency Medical Team 2015
- ↑ Connolly MA, editor. Communicable Disease Control in Emergencies: A Field Manual. World Health Organization; 2005.
- ↑ McCafferty RR, Neal C, Marshall S, Pamplin J, Bell R, Rivet D, Hood B, Cooper P, Stockinger ZT. Neurosurgery and severe head injury (CPG ID: 30). San Antonio, TX: Joint Trauma System. 2017