Biomedical subjects

R D Zafonte

Publications and source records attributed to R D Zafonte.

32 records · Page 2Linked to original sources

PubMed1999

Clinical assessment of posttraumatic headaches.

The evaluation of the person with posttraumatic headache remains a difficult clinical task. The rehabilitation clinician seeing the person with posttraumatic headache may encounter a large spectrum of potential etiologies for cephalgia. We believe an ordered approach to the history, physical, and laboratory examination may lead to a more accurate and focused diagnosis in some cases. In an attempt to provide a directed approach to posttraumatic headaches, this discussion is divided into extracranial and intracranial sources. A brief table guide to the etiology of pain by site is presented, and the key eight steps of examination are reviewed.

Craniocerebral Trauma↗

PubMed1998

Moving bullet syndrome: a complication of penetrating head injury.

Penetrating injuries, by definition, result in retained bullets or fragments. Usually, these fragments are removed surgically during wound debridement. Occasionally, the position of the bullet may preclude removal if it is thought that surgery could exacerbate neurologic damage. Complications from retained fragments are uncommon. One rare complication is the spontaneous migration of the fragment. Two cases of spontaneous migration of retained bullets are presented. In both cases neurologic deterioration was noted and computed tomographic imaging was diagnostic. In one case, this complication delayed transfer from the acute care hospital to rehabilitation. In the other case, the migrating bullet was removed during the inpatient rehabilitation stay. Each person improved neurologically after the migrating bullet fragment was removed. Additionally, functional progress was marked in both persons and symptomatic relief noted. Rehabilitation physicians caring for survivors of penetrating brain injuries need to be aware of this potentially devastating phenomenon.

Adult↗

PubMed1998

Amantadine: a potential treatment for the minimally conscious state.

Pharmacologic strategies have been advocated to enhance the neurorehabilitation of persons with severe traumatic brain injury. Dopaminergic pathways have been felt to play a significant role in arousal. Employing single case design methodology we present the case of a survivor of severe traumatic brain injury who appeared to have a dose dependent response to the pro-dopaminergic medication amantadine. Further research is necessary to clarify the role of pharmacotherapy in the improvement of functional outcome.

Adult↗

PubMed1998

Do calendars enhance posttraumatic temporal orientation?: a pilot study.

The purpose of this study was to determine the effectiveness of an in-room calendar to correct temporal disorientation in a brain-injured population. Thirty consecutive brain injured patients (16 traumatic, 14 non-traumatic) admitted to a brain injury rehabilitation unit were randomly assigned to either a group with in-room calendars (n = 14) or a group without calendars (n = 16). A baseline Temporal Orientation Test (TOT) score was obtained. Daily TOT scores were obtained for patients throughout their rehabilitation stay or until two consecutive normal scores were obtained. When orientation errors were made, they were corrected and the attention of the patient was drawn to the calendar. There were no statistically significant associations between group and age, gender or mean GCS (for patients with traumatic etiology). Only baseline length of post-traumatic amnesia (PTA) had a significant association with eventual emergence from PTA (as defined by a normal score on the TOT). Age and presence of calendar were not significant. In-room calendars have been espoused as orientation aides. The data from this pilot study suggest that calendars do not hasten re-orientation. This finding suggests that other widely held but not rigorously tested beliefs regarding cognitive rehabilitation may need to be examined.

Age Factors↗

PubMed1997

Posttraumatic amnesia: its relation to functional outcome.

OBJECTIVE: To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population. PATIENTS: Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation. MEASURES: Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation. RESULTS: Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge. CONCLUSION: Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.

Adolescent↗

PubMed1997

Cerebral salt wasting syndrome in brain injury patients: a potential cause of hyponatremia.

Hyponatremia is a common neuromedical problem seen in survivors of central nervous system injury. The etiology of this hyponatremia is often diagnosed as syndrome of inappropriate diuretic hormone (SIADH). Fluid restriction is usually the first line of treatment. However, this can exacerbate vasospasm and produce resultant ischemia. Cerebral salt wasting is a syndrome of renal sodium loss that may occur commonly after central nervous system injury, yet remains unrecognized. Treatment of cerebral salt wasting consists of hydration and salt replacement. This article uses a case report to discuss the importance of recognition of this syndrome, and treatment concerns are reviewed.

Brain Injuries↗

PubMed1997

Kernohan-Woltman notch phenomenon: an unusual cause of ipsilateral motor deficit.

Posttraumatic ipsilateral motor deficits are rare and raise etiologic and prognostic concerns for the rehabilitation team. We present two cases with an unusual central neurologic cause of ipsilateral weakness. The first patient was assaulted, with a resultant severe traumatic brain injury. Initial computed tomography showed a large right subdural hematoma (SDH) with significant mass effect. Following a craniotomy for evacuation of the SDH, the patient was noted to have paradoxical right-sided (ipsilateral) motor deficits. Postoperative magnetic resonance imaging (MRI) showed compression of the contralateral (left) cerebral peduncle against the tentorium, thus resulting in ipsilateral (right-sided) motor weakness (the Kernohan-Woltman notch phenomenon). Prior limited reports carried a grave prognosis for these patients. On discharge from inpatient rehabilitation, the patient was functioning at a Rancho Los Amigos Scale VI. The second patient was involved in a motor vehicle accident and was found to have a large left frontotemporal subdural hematoma with shift. A dense left hemiplegia was noted after hematoma evacuation. MRI also showed a right cerebral peduncle hypointensity. At discharge, the patient was rated a Rancho Los Amigos Scale VI. Physiatrists need to be aware of the causes of ipsilateral motor weakness as well as the limitations of prognostic data.

Adolescent↗

PubMed1997

Risk factors for acute care transfer among traumatic brain injury patients.

OBJECTIVE: Acute inpatient traumatic brain injury (TBI) rehabilitation has seen a jump in complexity of medical patient care over the past several years, often necessitating transfer back to an acute care facility. The purpose of this study was to determine the association between selected clinical variables and transfer from inpatient rehabilitation to an acute care facility. DESIGN: A retrospective review of cases from 1992 to 1994. SETTING: A TBI unit in a freestanding rehabilitation hospital. PATIENTS: Twenty-two patients were identified as having received acute care transfer. This group was compared with 78 patients, admitted in the same interval, who did not require acute care transfer. The variables evaluated included recent surgery, pneumonia, fracture, intracranial blood, tracheostomy use, percutaneous feeding tube use, deep venous thrombosis, focal neurological examination, following simple commands, serum sodium level of < 135 mmol/L, serum white blood cell count of > 11,000 cells/microL, and serum hemoglobin level of < 10.0 g/dl. ANALYSIS: Chi-square analysis was performed on the association between acute care transfer and the noted variables. RESULTS: History of pneumonia (p < .03) and history of recent surgery (p < .02) were both associated with acute care transfer, and serum hemoglobin of < 10.0 g/dL had a trend towards association (p < .10). CONCLUSION: Physiatrists caring for the TBI patient may warrant more acute observation of individuals with these parameters to prevent the problems necessitating acute care transfer.

Brain Injuries↗

PubMed1997

Functional outcome after violence related traumatic brain injury.

Violent injuries have become an increasingly prevalent cause of traumatic brain injury (TBI). These injuries can be classified as either penetrating or non-penetrating in nature. While much of the research on violence has been within a military population, there exists a marked difference between military and civilian injuries. Prior work has reported relatively poor outcomes for those individuals who have suffered penetrating TBIs, but little has been done to assess specific functional outcome parameters in survivors. We examined 25 subjects that had sustained blunt injuries and 25 cases with penetrating injuries as a result of a violent act. Cases were matched by initial Glasgow Coma Scale (GCS), age and educational level. Mean GCS for this study sample was 8.8. The following outcome variables were assessed at rehabilitation admission and discharge and at 1 year post injury: Disability Rating Scale (DRS), Rancho Los Amigos Scale (LCFS), Functional Independence Measure (FIM) (ambulation, expression items), length of stay, and cost of care. Student's t-tests were performed to assess for differences between the two groups. No significant differences were noted between the groups for any of the outcome variables. Although penetrating injuries may have a higher initial mortality, those who survive to come to rehabilitation appear to have similar outcomes to those patients with non-penetrating violence related injuries.

Adult↗

PubMed1996

Air embolism in the agitated traumatic brain injury patient: an unusual complication.

Central venous catheters are often utilized in the acute care management of the traumatic brain injury (TBI) patient. While in the agitated phase of recovery, TBI patients often focus on removing indwelling tubes or venous access lines. Air embolism is among the most serious complications reported in the use of central venous catheters. We present a case of air embolism in an agitated patient, and discuss prevention methodologies. A 38-year-old male was involved in a fall, with an initial Glasgow Coma Scale of 12. CAT scan imaging revealed a left frontal intracerebral haematoma. He required central venous catheter placement for management of associated chest and abdominal injuries. Agitated from early in his stay, the patient was able to twist off several hubs from the central venous catheter with his teeth, resulting in an air embolus. The patient experienced sudden clinical deterioration with oxygen saturation decling to 70%. The patient's course improved after several days of ventilatory support. He eventually successfully completed inpatient rehabilitation, achieving independence in activities of daily living and ambulation. This case illustrates a serious potential complication in the agitated patient. Physicians and rehabilitation specialists should advocate for secured taping of central venous catheter hubs and adequate padding of catheter dressings in agitated patients.

Accidental Falls↗

PubMedDate not supplied

Relationship between Glasgow coma scale and functional outcome.

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.

Adolescent↗

PubMedDate not supplied

Revised trauma score: an additive predictor of disability following traumatic brain injury?

Recent studies have clarified the role of hypoxic-ischemic damage as a secondary factor in traumatic brain injury (TBI). Many trauma centers are now consistently using the Revised Trauma Score (Glasgow Coma Scale, systolic blood pressure, and respiratory rate) to assist with triage of multitrauma patients. This study investigated the predictive power of the Revised Trauma Score (RTS) instead of the Glasgow Coma Scale (GCS) in determination of disability as measured by the Disability Rating Scale (DRS). Data were obtained as part of the National Institute for Disability and Rehabilitation Research TBI Model Systems database on 501 patients receiving acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial RTS and GCS were obtained on admission to the emergency department, along with the lowest GCS measured in the first 24 h. Analysis of initial RTS and GCS demonstrated modest, but statistically significant Pearson's correlations with DRS at rehabilitation admission (-0.18 and -0.25, respectively) and discharge (-0.22 and -0.24, respectively). Lowest GCS within the first 24 h postinjury also failed to show a strong relationship with DRS at rehabilitation admission (-0.28) and discharge (-0.24). Multiple regression analysis performed on RTS subsets for systolic blood pressure and respiratory rate did not reveal an added predictive value. Although RTS may be important in emergency triage for its ability to predict mortality, this study indicates its limited usefulness in prediction of disability.

Blood Pressure↗

PubMedDate not supplied

Psychogenic polydipsia after traumatic brain injury. A case report.

Electrolyte abnormalities are common medical complications of traumatic brain injury (TBI). Hyponatremia is the most common of these disorders. The syndrome of inappropriate antidiuretic hormone and cerebral salt-wasting are the most well known causes of hyponatremia following TBI. In the presence of polydipsia and polyuria, psychogenic polydipsia should be included in the differential diagnosis. It is important to distinguish among these entities because treatment differs to such an extent that improper diagnosis may lead to a worsening of the patient's condition. We present a patient who presented with a new onset of polyuria and polydipsia after sustaining a TBI. Evaluation, including monitoring of fluid intake and output, serum and urine sodium and osmolarity, as well as a fluid deprivation test revealed the cause to be psychogenic polydipsia. The patient's symptoms improved after institution of a behavioral program and fluid restriction. Various models of drinking behavior have been used to identify the site of dysregulation. Dopaminergic, cholinergic, and hippocampal etiologies have been implicated in this abnormality of fluid homeostasis. If disorders of these systems can lead to psychogenic polydipsia, it is reasonable to believe that a person who has sustained a TBI would be at higher risk of developing psychogenic polydipsia.

Adult↗

PubMedDate not supplied

Penetrating head injury: a prospective study of outcomes.

The purpose of our study was to describe the outcomes of persons with penetrating brain injury resulting from a gunshot wound to the head. It is a prospective study of 442 patients admitted with gunshot wounds to the head over a 7 year period to our University Trauma Center Emergency Department, an urban trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. Measures and factors described include initial Glasgow Coma Scale score, Revised Trauma Score, the Disability Rating Scale, Functional Independence Measure, levels of cognitive functioning, patient demographics, length of stay, hospital charges, and discharge disposition. Initially 36% of patients expired in or were dead upon arrival to the Emergency Department; 64% of patients survived to be admitted for inpatient care. Of those admitted, 41% expired within the first 48 h of admission. Fifty-two percent of those admitted had severe injuries, 7% moderate injuries, and 42% had mild head injuries. Sixty-two percent of the survivors were discharged from acute care to private residences. The remaining 38% were discharged to programs providing varying levels of care depending upon their level of functioning and care needs. Patients sustaining severe injuries following gunshot wound(s) to the head have high early mortality. Survivors able to participate in an inpatient rehabilitation program have good potential for functional improvement.

Adolescent↗