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Assessment and Management of Post-Traumatic Amnesia in Acute Procedure Traumatic Brain Injury (Adults)

PROMPT Doc No: SNH0004137 v6.0

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Last Reviewed Date: 11/11/2020

TABLE OF CONTENTS

1. Definitions

Traumatic brain injury

Post-traumatic amnesia

Glasgow Coma Scale

Abbreviated Westmead PTA Scale

Westmead PTA Scale

Classification of traumatic brain injury

2. Precautions/Contraindications

3. Equipment

4. Standard Requirements

5. Procedure

Determining the appropriate PTA scale to use based on GCS score

Monash Health Procedure for the assessment and management of PTA in TBI and referral pathways

Screening using the AWPTAS (MILD TBI)

Guidelines to assist with decision-making in ED for admission of TBI patients to the wards of Monash Health

Screening using the WPTAS (MODERATE TO SEVERE TBI)

Complicating factors when assessing PTA

Discharge planning

Decision-making-capacity

PTA documentation and communication

Supporting and managing symptoms of PTA

6. Related documentation

7. Background

8. Key standards, guidelines or legislation

9. References

10. Keywords

TARGET AUDIENCE and SETTING

This procedure applies to all staff working with adult patients presenting to Monash Health with suspected or

confirmed traumatic brain injury (closed head injury) in the acute setting.





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PURPOSE

This document was created to provide evidence-based information on the definition of PTA, and current clinical practice guidelines for the standardised assessment and management of PTA in the context of traumatic brain injury.

This procedure was created to ensure a consistent interdisciplinary approach to the care of patients experiencing PTA, in alignment with the National Safety and Quality Health Services (NSQHS) Standard 5: Comprehensive Care. This procedure does not cover the medical and surgical management of closed head injury. Please follow the appropriate unit, hospital and state processes for the primary management of traumatic brain injury.

DEFINITIONS

Traumatic brain injury (TBI): Brain injury caused by an external mechanical force such as a blow to the head, concussive force, acceleration-deceleration force or projectile missile.

Post-traumatic amnesia (PTA): Immediate stage of recovery after a TBI when the person has emerged from loss of consciousness or coma but remains confused.

Glasgow Coma Scale (GCS): A neurological scale that provides a reliable and objective way of recording the conscious state of the patient. The GCS is a 15-point scale

The Abbreviated Westmead Post Traumatic Amnesia Scale (A-WPTAS): Screening tool used to examine PTA in people with mild TBI

The Westmead Post Traumatic Amnesia Scale (WPTAS): Screening tool used to examine PTA in adults with moderate to severe TBI

Refer to BACKGROUND for full clinical definitions, descriptions and the importance of assessment of PTA. CLASSIFICATION OF BRAIN INJURY SEVERITY USING PTA The severity of TBI can be classified based on the degree of disturbance to consciousness (coma) as measured by the GCS, in addition to the duration of PTA. A commonly identified classification system is as follow: TABLE 1: CLASSIFICATION OF BRAIN INJURY SEVERITY

Source: Guidelines for the NSW Compulsory Third Party Scheme and Lifetime Care and Support Scheme (2013) created by clinical working party review. This has been based on the combination of numerous classifications systems including the original index of severity based on GCS score (Teasdale & Jennett, 1974) and PTA duration index (Jennett & Teasdale, 1981 as referenced in Stein, 1996) and combined criteria as seen in The Mayo Classification System (Malec et al., 2007).

*Mild Traumatic Brain Injury Most mild TBIs do not result in gross structural changes to the brain (Giza & Hovda, 2004). Axons may be stretched or twisted, without being sheared or torn, and therefore recover over time (Iverson, 2005). According to consensus guidelines, it is rare (approximately 5-15%) for patients who sustain a mild TBI to obtain an abnormality on CT scan or require neurosurgical intervention (approximately 1-3%; New South Wales Ministry

MILD * MODERATE SEVERE VERY SEVERE EXTREMELY

SEVERE

GCS 13-15 (Must obtain E4 & M6 on GCS)

GCS 9-12

GCS 3-8 GCS 3-8 GCS 3-8

PTA 4 weeks





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of Health, 2011). Symptoms of a mild TBI must be separated from other factors that can result in alterations in cognition and mental state, such as substance use, medications and psychological trauma. The majority of individuals who sustain a mild TBI make a full recovery within days and weeks after the injury, and persisting symptoms are referred to as ‘post concussive syndrome’ (McHugh et al, 2006; NSW Ministry of Health Guidelines, 2011; Ontario Neurotrauma Foundation Guidelines, 2013). Excessive focus on, or failing to validate, transient symptoms of mild TBI can lead to delays and complications in recovery and adjustment processes in this patient group. Complicated Mild Traumatic Brain Injury A ‘complicated mild TBI’, is an injury that meets the above criteria for mild TBI, but also includes trauma related structural abnormality, such as a contusion on the brain (as confirmed on CT scan on the day of injury) that does not require surgery (Carroll et al., 2004). Longer-term outcome and recovery trajectories differ in mild complicated TBI as compared to typical mild TBI.

PRECAUTIONS/CONTRAINDICATIONS

Staff to maintain personal safety at all times. If the patient is agitated and the safety of staff a concern at any time, consider abandoning the clinical contact until a more appropriate time. Refer to other relevant Monash Health procedures and guidelines:

Code grey, aggressive, violent patient escalation: Implementation tool

Delirium in hospital: Clinical guideline

Acute behavioural disturbance: Clinical guideline

Preventing falls and harm from falls

EQUIPMENT

Abbreviated Westmead Post-Traumatic Amnesia Scale (A-WPTAS) – Interactive View on EMR o Set of 3 Picture Cards from the A-WPTAS in printed/paper form o A-WPTAS picture card recognition chart (option of 9 pictures) in printed/paper form o Pictures have been displayed at the end of this document

Westmead Post-Traumatic Amnesia Scale (WPTAS) – PowerForm on EMR o Set of 9 Picture Cards from the WPTAS in printed/paper form

o For weekend testing, nursing staff will require a set of 3 photos. One of the regular examiner plus photos of 2 other staff members

STANDARD REQUIREMENTS

When undertaking any clinical interaction with a patient, staff are expected to:

Perform routine hand hygiene. Refer to the Hand Hygiene Procedure.

Introduce themselves to the Patient and Carer/ Family if in attendance, as per standard clinical practice.

Check patient identification. Refer to the Patient Identification Procedure.

Obtain consent for participation.

Document interaction in the electronic medical record or health record using black pen; including date, time, signature and designation.

It is expected that staff are familiar with the relevant procedures and know when to undertake each step. Staff who are expected to undertake this procedure regularly must ensure they have completed all relevant training.





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PROCEDURE

Refer to flow chart on page 5 (figure 2) for full procedure.

Indications to suspect a traumatic brain injury (TBI) include an impact to the head resulting in confusion or

disorientation; alteration in GCS; anterograde or retrograde amnesia; or a period of loss of consciousness.

Following arrival of a patient to the Emergency Department (ED) with a suspected brain injury, or post-fall on

the ward, the GCS must be administered at the first instance.

If the person’s initial GCS score (at the scene or at presentation to ED) was less than 13, conduct the Westmead PTA scale (WPTAS)* daily when the person is admitted to a ward. If the person’s initial GCS (at the scene or at presentation to ED) was 13 or above (with optimal motor and eye opening scores), administer the Abbreviated-Westmead PTA scale (A-WPTAS)* hourly. See figure 1 below.

Figure 1. Determining the appropriate PTA scale to use based on GCS score

(Source: Adapted from Macquarie University, Sydney Australia, Department of Psychology Education Module) *Please note that this flowchart assists with determining the appropriate PTA scale to utilise ONLY, it not guide other aspects of clinical management of the patient.

* Testing considerations:

Review the patients file and liaise with treating team regarding the patient’s behaviour and most

appropriate time of day for test administration

Where possible, ensure the testing environment is quiet and free from distractions (i.e.

radios/televisions). Remove clocks and orientation boards prior to commencement of the assessment

The A-WPTAS & WPTAS are screening measures only and not diagnostic tools. Screening scores must

not be interpreted as an absolute, and clinical judgement is always required

Drug and/or alcohol intoxication is not a preclusion for assessment but ought to be factored into the

clinical assessment and decision making

The patient can provide answers via verbal responses, writing, pointing to printed answers, indicating

“yes” or “no” when prompted, or via interpreter

Further information on testing considerations can be found in the background section.





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Figure 2. Procedure for the assessment and management of PTA in TBI and referral pathways





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1. SCREENING USING THE A-WPTAS (FOR MILD TBI ONLY)

Indications:

When the patient’s initial and current GCS is between 13 and15 (with points lost only for disorientation/

verbal component of the GCS)

Administered in ED or after acute injury, as soon as possible, and when feasible with consideration of

the patient’s presentation and ability to co-operate (e.g. agitation or combativeness)

Only to be used within the first 24 hours of sustaining a brain injury*

Administration:

Refer to the ‘Interactive View’ on EMR for full administration and scoring instructions. Questions are to be asked

in the order they appear on the test forms and then scored accordingly

1.1. The A-WPTAS is initially scored out of 15 at time 1 (T1) as the first administration is the GCS only. The three

pictures are presented at this administration point and recall of the pictures is included in subsequent

administrations, i.e. time 2 (T2) and onwards.

1.2. All subsequent administrations are therefore scored out of 18 (GCS assessment + memory recall

component).

1.3. Administer the A-WPTAS hourly (or as close to hourly as practical) until a perfect score of 18/18 is achieved,

whereby the test is considered to be ‘passed’. Do not exceed the T5 administration time point.

1.4. A patient is deemed to be ‘out of PTA’ when first scoring 18/18. The A-WPTAS can subsequently be ceased

and no further cognitive testing is required.

1.5. If a patient does not pass the A-WPTAS (i.e. does not achieve a score of 18/18) four times in succession, i.e.

at time 5 (T5), the patient remains in PTA and must be investigated/monitored further as per standard TBI clinical

management guidelines.

1.6. Failure of the A-WPTAS: If the patient does not pass the A-WPTAS in ED, they are to be admitted to the SSU

for a 24-hour period of monitoring (irrespective of normal CT scan results). Referral is made to an ED care-

coordinator or occupational therapist for further cognitive investigation and discharge planning.

During normal business hours the occupational therapist aligned to the treating unit in ED can prioritise the

referral and undertake further assessment, as indicated. After hours occupational therapy service in ED is not

available and weekend service is limited. Outside of normal business hours referrals are made to an ED care-

coordinator.

1.7. Determining the presence of PTA at 24 hours post-injury: The A-WPTAS can be re-administered prior to

discharge from the SSU to determine the presence of PTA, if this cannot otherwise be ascertained by

multidisciplinary review, including occupational therapy input. This re-administration must be conducted within

24-hours of the injury and using a new A-WPTAS entry in the EMR.

If the patient is still demonstrating active PTA symptoms 24-hours after the sustained injury time point and has

not been clinically improving, the brain injury is no longer considered to be mild in severity (refer to table 1 for

TBI classifications). Admission to an acute ward is now indicated. Table 2 provides clinical guidelines to aid in

deciding on the admitting unit.





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Table 2. Guidelines to assist with decision-making in ED for admission of TBI patients to the wards of Monash Health.

NEUROLOGY GENERAL MEDICINE NEUROSURGERY OTHER

Neurological trauma not deemed to be major

Complex medical co-morbidities Older adult with history of cognitive concerns No surgical intervention required

Haematoma, CSF leak or other findings that require surgical intervention or neurosurgical management

Multi-trauma - consider transfer to Level 1 Trauma Centre

At the point of admission to a medical unit/ward, the occupational therapist aligned to the unit must commence

the full Westmead PTA scale (WPTAS) as per standard protocol.

1.8. Delayed hospital presentations: If a patient presents to ED with a GCS ≥ 13 and greater than 24 hours after

the sustained injury, do not administer the A-WPTAS (the A-WPTAS was designed only for use 5min)

Witnessed seizure

On serial assessment, considerations include:

Decrease in GCS

Persistent GCS < 15 at two hours post injury

Persistent abnormalities in alertness, behaviour, cognition

Persistent PTA (A-WPTAS





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Post traumatic seizure Clinical judgement is also required in instances where there has been any of the following:

A large scalp haematoma or laceration

Associated multi-systems injuries which may distract from subtle neurological sings, and/or where analgesia, procedural sedation or general anaesthesia has been used

A particularly dangerous mechanism to the injury (e.g. pedestrian/cyclist vs vehicle; ejection from vehicle; fall >1m; or focal blunt trauma to the head)

Pre-existing neurological/neurosurgical conditions making clinical assessment difficult

Delayed hospital presentation or representation with persistence of symptoms or new symptoms

No clinical decision rule is perfect and decisions for CT scanning must always be made in conjunction with clinical

evaluation and would not override clinical judgment. Consultation must occur with the neurosurgical service.

Also refer to the Monash Health clinical guideline on minor head injury - patients on anticoagulant or antiplatelet

therapy.

2. SCREENING USING THE WPTAS (FOR MODERATE TO SEVERE TBI ONLY)

Indications:

When initial GCS on presentation was less than 13

When the A-WPTAS was not-passed at the T5 administration time point and PTA is ongoing and present 24 hours after the injury and the person is admitted to a ward

When the patient has regained consciousness and can communicate intelligibly Administration: Refer to the WPTAS PowerForm on EMR for full administration and scoring instructions. Questions are to be

asked in the order they appear on the form and then scored accordingly

2.1. Administered once daily (every 24 hours) by the same person, at the same time of day (where possible).

Typically conducted by the ward occupational therapist

2.2. The WPTAS is scored out of 7 on day 1 (first administration time point), as questions relating to recall of the

name and face of the examiner and recall of the picture cards can only occur after initial learning of this

information

2.3. The WPTAS is scored out of 12 on day 2 and subsequent days

2.4. Continue the WPTAS assessment over weekends and public holidays. If the occupational therapists are unavailable, an alternate appropriately trained staff member would continue the assessment of the WPTAS, i.e. nursing staff, ANUMs and/or trained medical practitioners. 2.5. The period of PTA may be deemed over on the first of 3 consecutive days of a score of 12/12. However, this

must not be interpreted as an absolute rule. Use clinical judgement to cease administration of the WPTAS prior

to 3 consecutive days of scoring 12/12 if the patient does not display behavioural manifestations of PTA.





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3. Complicating factors when assessing PTA

Complicating factors and confounders can be present in the screening of PTA. Sub-optimal screening results may

be due to factors other than PTA. These include the following:

Pre-existing acquired brain Injury or intellectual disability

Non-English speaking background and cultural differences

Previous level of education

Drug &/or alcohol history: Recent usage, withdrawal or detoxification

Medications affecting alertness (specially opioids or psycho-active medication)

Speech and language deficits (pre-existing or new)

Participation factors: e.g. unwillingness to engage in assessment, frustration, agitation, anxiety

Psychiatric conditions

Dementia and/or delirium

Physical condition of the patient (e.g. pain)

Vision and hearing difficulties (ensure aids are used)

In such instances the WPTAS or A-WPTAS may not be the most appropriate tool to use, and alternative or

adjunctive screening measures is to be considered by appropriately trained ward staff. Examples of alternative

measures include the Galveston Orientation and Amnesia Test (GOAT) and/or the Orientation Log (O-Log).

Referral to neuropsychology can assist in these instances.

Determination of the presence of PTA must not be solely based on a screening results alone and ought to be a

combination of screening and information regarding the patient’s behavioural and psychological function as

witnessed by family and staff. If the patient’s PTA score is not improving, consider referral to neuropsychology

prior to terminating PTA assessment. The neuropsychologist can assist in identifying ‘non-PTA factors’ that may

be accounting for the patient’s clinical presentation.

Neuropsychology services are only available during business hours and not on weekends.

4. Discharge planning

Accurate assessment and management of PTA requires an interdisciplinary approach, and careful and higher-

level discharge planning. Interdisciplinary input includes:

Neuropsychology to establish the presence of PTA, if this has been difficult to ascertain

Neuropsychology for formal cognitive assessment and management of TBI symptoms, once PTA has resolved (this may occur as an outpatient or via inpatient rehabilitation)

Occupational therapy for functional cognitive assessment and management

Speech pathology if speech, language, cognitive-communication and/or swallowing issues are present

Physiotherapy for rehabilitation of motor and sensory impairments, spasticity management and support of respiratory function as required

Social work to support patients and their families

Consultation-Liaison Psychiatry and Addiction Medicine services for patients with co-morbid or pre-existing psychiatric conditions, behaviour disturbance, and/or substance use history

Rehabilitation and Aged Care Liaison Services (RALS) for consideration for inpatient rehabilitation/subacute admission, as necessary





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4.1. Appropriate discharge destination

Optimally, patients in active PTA are not discharged home, but if so, they are discharged into the care of a responsible adult with sufficient education for management

The treating medical team, in consultation with the allied health team, have responsibility for determining the patients’ appropriateness for discharge

If the patient is still experiencing PTA, and once medically stable, they can be transferred to subacute or a referral made to a specialist inpatient ABI unit. A complete handover of the patient’s PTA assessments to the subacute ward is required, in addition to their management plan

If a patient in PTA absconds from hospital, the treating team must contact the police and next of kin immediately

4.2. Discharge supports

If a patient who initially presented to ED with a GCS of ≥ 13, passes the A-WPTAS within the first 24-

hours of the injury / admission, and is discharged home, ensure they receive a diagnosis of mild TBI and

obtain adequate education regarding their condition (refer to Mild traumatic brain Injury: Information

for patients, families and carers)

Refer these patients for outpatient neuropsychology for follow-up by the ED medical team. The Monash

Health neuropsychology Unit will make contact with them in the weeks following their hospital

presentation to ensure they are progressing well. If further assessment and intervention is required, the

patient can attend neuropsychology outpatient for full review

5. Decision-making capacity

Patients in PTA are typically NOT capable of making their own decisions due to being in a confusional state. If a patient is in PTA and wishes to self- discharge against medical advice, and cannot be redirected, a Code Grey must be called and staff must obtain security support to attempt to maintain the patient in a safe environment with supervision

If there is doubt around the patient’s PTA status (e.g. end stage PTA) the treating medical team is required to make a decision as to whether the patient is able to competently self-discharge. This decision usually involves consultation with key staff involved in the patient’s care. Referral to neuropsychology can be made to assess decision-making capacity formally, if this is not clear from a medical perspective

In instances of more complex decision-making capacity or consent, refer to Consent to Medical Treatment: Operational Policy and also consult with the Office of Public Advocate and Monash Health Legal Office (as needed). In some cases, consultation or referral to Social Work and/or neuropsychology may be necessary.

6. Third party interview and/or access to a patient experiencing PTA within the hospital setting

All police, media and third-party requests to access a patient and/or their personal health information are

required to go through the hospital Legal Office and/or Medical Information Unit of Health Information Services.

Refer to Privacy Release of Information: Procedure

7. PTA documentation and communication

Document the overall PTA score after each administration time point. Cross-reference PTA screening results in the inpatient progress note entry, using standard hospital documentation procedures: i.e. date, time, name of examiner, profession, designation, signature and contact details





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Include a summary of errors made and the patient’s presenting behaviours during the assessment

Document implications of the PTA score and implications for ED/ward management and discharge planning and update the treating team regularly

Once you have appropriately assessed and documented PTA for moderate to severe TBI patients (typically on the ward), provide carers and families with written and verbal education regarding PTA. Refer to: Post Traumatic Amnesia: Information for patients, families and carers. Document in the progress note that you have done so.

Once you have appropriately assessed and documented mild traumatic brain injury (typically in ED) and/or after a fall or new injury during a hospital admission, provide patients, carers and families with written and verbal education regarding mild TBI. Refer to: Mild traumatic brain Injury: Information for patients, families and carers. Document in the progress notes and discharge papers that you have done so.

8. Supporting and managing symptoms of PTA

The following are important considerations and management strategies for patients in PTA and during acute

recovery from TBI. These will assist in maximising the patient’s recovery, supporting their behaviour, and

reducing the potential of further risk to patient, staff and visitors.

8.1. Physical environment:

Monitor sensory information, including noise and visual stimulation, and the effect on the patient’s behaviour

Reduce lighting or minimise TV or radio if this is beneficial, but also be aware if these are helpful in soothing the patient.

Carefully monitor for increases or decreases in agitation in response to the environment and amend accordingly

Reduce clutter within the immediate environment

Consider placing the patient in a high visibility room and/or consider a single room to minimise sensory overload

Minimise the number of room changes to prevent further confusion/disorientation

Assess and manage the environment for patients at high risk of falls

Assess and manage pressure injuries in restless and agitated patients e.g. those with padded cot sides

Utilise staff who are trained in the management of PTA for patients that require frequent re-direction or de-escalation

8.2. Communication strategies:

Use the patient’s preferred name

Use signs to label the patient’s environment and frequently refer back to these

Implement simple, clear, and consistent instructions

Educate and involve family/carers of the patient’s presentation and progress

8.3. Daily routine and structure:

Provide a structure for the day including rest periods

Ensure the person’s immediate needs are being met e.g. personal care and eating at regular meal times at regular intervals

Minimise interruptions during meal times





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Modify interventions and rehabilitation/therapy sessions that rely heavily on memory and recall of information. Consider implementing memory techniques such as procedural or errorless learning to facilitate therapy sessions during active PTA (refer to Trevena-Peters et al., 2017. Efficacy of Activities of Daily Living Retraining During Posttraumatic Amnesia: A Randomized Controlled Trial. Archives of physical medicine and rehabilitation).

8.4. Patient safety – As per National Safety and Quality Health Service (NSQHS) standards:

Avoid indwelling catheters

Minimise falls risk (refer to Monash Health Falls Prevention Procedure for full details: Preventing falls and harm from falls

Identify and respond to triggers that may lead to increased agitation, distress or confusion

Minimise mechanical and pharmacological restraints, where possible

Consider utilising a patient attendant if the patient is at risk of absconding

Consider using alert bracelets/arm bands for wandering patients 8.5. Family and visitor involvement:

Limit visitors (suggested maximum of two at a time) and ensure short visiting periods, in the early stages of PTA and particularly if increase noise and stimulation is agitating for the patient

Provide education to the patient’s family and significant others to assist them in understanding what PTA is

Provide education and support as to how family/visitors can assist the patient and team to support and manage PTA symptoms

Familiar faces can assist with reassuring a patient, provided that the visitors are not overstimulating or distressing to the patient

Completion of the Sunflower tool

8.6. Other behaviours of concern:

The treating team are responsible for developing a comprehensive management plan for patients requiring repeated Code Greys and demonstrating ongoing/severe behaviours of concern

Consider involvement from CL psychiatry, neuropsychology, RALS and a team meeting to ensure that an adequate plan is put in place to support behaviour

Referral to CL psychiatry and/or Addiction Medicine may be necessary to provide medication

recommendations in support of severe behaviours of concern. It ought to be noted, however, that the

Therapeutic Guidelines for the use of Psychotropic medication (2008; Version 6) recommends

minimising sedation and antipsychotic medication use as these can increase confusion and reduce

alertness during acute neurological states such as PTA. Also refer the Delirium in hospital: Clinical

guideline.

RELATED DOCUMENTATION

Code grey, aggressive, violent patient escalation: Implementation tool

Delirium in hospital: Clinical guideline

Acute behavioural disturbance: Clinical guideline

Falls prevention (adults): Procedure





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BACKGROUND

Traumatic Brain Injury

Traumatic Brain Injury (TBI) can arise from an insult to the brain from an external force or direct blow. Most

common causes to TBI include motor vehicle accidents, falls, assaults or sporting injuries. The incidence of TBI

in Australia is between 107 to 149 per 100,000 people (Australian Institute of Health and Welfare, 1999 & 2008).

The peak incidence of TBI occurs in males aged between 16 to 24 years of age (Marshman et al., 2013). The

majority (approximately 80%) of TBIs are mild in nature. Moderate to severe TBIs usually require neurosurgical

intervention (Marshman et al., 2013).

Trauma to the brain can result in diminished or altered state of consciousness and depending on the severity of

the injury can cause temporary or persisting impairments in cognitive abilities and/or physical functions (Brain

Injury Association of America, 2011; Gordner & Tuel, 1998).

Stages of disturbance, and subsequent recovery, following a TBI are characterised as follows;

(i) A period of coma with the absence of verbal and voluntary motor responses and absence of spontaneous

eye opening

(ii) Emergence from coma and a state of altered consciousness termed ‘post-traumatic amnesia’

(iii) Recovery and return to normal consciousness where cognitive, physical/sensory-motor and behavioural

functions improve and may return to pre-morbid levels (depending on injury severity)

(Katz, Zafonte & Zasler, 2006; Levin, 1979).

Recovery after a TBI is most rapid in the first 3-6 months following the insult but depending on the severity of

the injury (and other complicating factors) this can continue for several years. Numerous factors influence the

recovery process, including the aetiology of the injury, neurophysiological and structural factors, and individual

characteristics of the person (Ponsford, Sloan & Snow, 2013).

Post-Traumatic Amnesia*

Post-Traumatic Amnesia (PTA) is the transitory state between coma and return of full consciousness (Tate et al., 2006). PTA is defined as the period of time following a TBI during which the patient experiences the following:

Disorientation – confusion or loss of information related to a person’s location in time and place and in relation to their personal details

Anterograde amnesia – loss of the capacity to create and store new information or memories occurring immediately after the brain injury

Retrograde amnesia – loss of previously acquired information or memory of events occurring prior to the brain injury

(Loring, 1999; Marshman et al., 2018; Schacter & Crovitz, 1977). *The amnesia of PTA arises due to neurological disruption and is not due to any possible psychological trauma that may be associated with the injury event. The duration of PTA is defined as the time following the TBI (including coma period) until resumption of normal and continuous day-to-day memory functions. The interval of PTA can last from a few minutes to many weeks, or even months, depending on the severity of the injury (Levin et al., 1979; Schacter & Crovitz, 1977). The following lists the potential behavioural manifestations or signs and symptoms of active PTA:





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Confusion and disorientation: impaired attention and concentration, impaired memory and reduced recall of information - this can fluctuate over time

Irritability and agitation: Aggression, restlessness, altered sleep patterns, non-compliance with treatment and care

Altered thought processes: Reduced insight and reduced flexibility of thought

Odd beliefs: Beliefs that appear to be delusional/unreasonable, inaccurate memories which may lead to confabulation and fixation

Other behaviour changes: Wandering, inappropriate behaviour or impulsivity. (Arciniegas et al., 2010; Demery, Hanlon & Bauer, 2001; Johnson, 2001; Weinstein & Lyerly, 1968) Notes: The Monash Health procedure for assessment and management of TBI symptoms focuses on the anterograde amnesia component of PTA. It must be noted that this is one of the possible acute cognitive disturbances arising from TBI, but not the only one. Certain factors can complicate the assessment of PTA (refer to point 3 under the Procedure). Additionally, identifying the end point of PTA can also be difficult and complex. In more severe cases of TBI, the end point of PTA cannot readily be determined as symptoms represent persisting, and possible permanent, cognitive deficits as a consequence of the injury. Therefore, coordinated PTA assessment and management is vital in ensuring optimal outcomes for this patient group. A multidisciplinary team approach is key in identifying and managing symptoms of PTA. THE IMPORTANCE OF ASSESSMENT AND IDENTIFICATION OF PTA

Patient Care: Knowing whether a patient is experiencing active PTA is important for guiding appropriate patient care,

supervision requirements, length of hospital stay, discharge planning and rehabilitation needs, in addition to

ascertaining the likely functional outcomes upon discharge including cognitive prognosis (Marshman et al., 2013)

Predictor of injury severity: Duration of PTA, when measured using objective assessment scales, is a reliable and

sensitive predictor of severity of traumatic brain injury. Conversely, subjective reports or a history taken

retrospectively, is a less reliable indicator of PTA duration

Impact on rehabilitation outcomes: As patients in PTA have difficulty retaining new information, rehabilitation that

relies on explicit memory recall and new learning is not typically undertaken during the acute or active stages of PTA.

It is therefore essential to be aware of the presence of active PTA to guide rehabilitation goals and progress

Longer-term impacts: Accurate assessment of PTA assists in identifying whether a mild TBI/concussion has occurred.

Research indicates that TBI patients who receive information, support and advice post-injury demonstrate

significantly less cognitive and psychological symptoms, and social morbidity in the longer term (King, Crawford,

Wenden, Moss & Wade, 1997; Wade, King, Wenden, Crawford & Caldwell, 1998)

ASSESSMENT SCALES THAT MONITOR FUNCTION AFTER TBI The Glasgow Coma Scale (GCS) is a neurological scale that provides a reliable and objective way of recording the conscious state of the patient. The GCS is a 15-point scale. It estimates and categorises the outcomes of injury to the brain based on a person’s ability to open their eyes and provide motor and verbal responses. A lower GCS score is typically correlated with a more severe neurological injury, and poorer prognosis (Kahn, Zafonte & Zasler, 2003). The GCS measurement alone, does not assess for memory impairment, which is a pivotal





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component of PTA (Meares & Shores, 2017). Therefore, screening measures of PTA have been implemented in clinical practice to address this gap, particularly relevant for mild TBI when the GCS can be normal or return to normal quite quickly. The Westmead Post Traumatic Amnesia Scale (WPTAS) is the most commonly used adult PTA screening tool

within Australia and New Zealand (Marshman et al., 2013). The WPTAS is a 12-item screening scale originally

created by Professor Arthur Shores, Neuropsychologist, and colleagues in 1986, and adapted and used in clinical

practice in 2009. This is an objective assessment of PTA examining the person’s orientation and ability to

consistently remember and retain information from one day to another. The WPTAS, therefore, enables daily

prospective evaluation of PTA (Tate, Pfaff & Jurjevic, 2000). This assessment tool is suitable for use with a

moderate to severe TBI diagnostic group only, and has been validated for closed head injury, and not penetrating

or open head injuries. PTA testing with this measure begins when the patient has regained consciousness and

can communicate intelligibly and is conducted DAILY. The patient may be able to communicate via speech,

writing, pointing to printed answers or by indicating “yes” or “no” when prompted.

PTA may be deemed to be over on the first day of 3 consecutive days of a score of 12/12 on the WPTAS. Obtaining

a ‘perfect’ score (12/12) on three consecutive days, ensures that the person has consistently maintained

adequate memory function, rather than brief periods of sound memory followed by further confusion or

amnesia. However, this criteria must not be used as a hard-and-fast rule, and scores must not be interpreted as

an absolute, with clinical judgement required in every case.

The Abbreviated Westmead Post Traumatic Amnesia Scale (A-WPTAS) was created by Shores and Lammel in

2007 as a way of measuring length of PTA during the acute stage of a mild TBI within 24 hours of the initial injury.

The A-WPTAS is an extension of the GCS and is based on the original WPTAS, but patients are tested in HOURLY

intervals instead of daily intervals. It was designed to prevent mild TBI patients remaining in hospital for

observation for unnecessary periods of time. Research from Shores and colleagues suggests that up to 4 hours

of observation of a person with mild TBI is sufficient to determine if discharge is safe. It is now mandatory in

NSW for all EDs to use to the A-WPTAS in suspected mild TBIs (NSW Ministry of Health, 2011). Research from

Liverpool Hospital, NSW (Level 1 Trauma centre) found that 94% of patients who were administered the A-

WPTAS were cleared of PTA within 4 hours of presentation and this reduced length of stay by 295 bed-days

(Watson et al., 2017). It is also essential to provide patients who have sustained a mild TBI with education, both

verbal and written, regarding discharge advice and how to assist with recovery. Refer to: Mild traumatic brain

Injury: Information for patients, families and carers.

The A-WPTAS encompasses the regular neurological observations of the GCS assessment, with the addition of

three pictures for the patient to learn and remember (testing memory recall). Only use the A-WPTAS for those

with a GCS between 13 and 15 (but the patient must obtain E4 & M6 on the GCS). The A-WPTAS is therefore not

suitable for those with a suboptimal motor score (i.e. score of less than 6) and reduced eye responses (i.e. score

of less than 4) on the corresponding sections of the GCS. It is also not suitable for those with a GCS verbal

component score of 2 or below. Such suboptimal scores would be suggestive of a more severe TBI, and A-WPTAS

is not indicated in these cases. If the patient obtains a score of less than 13, use the WPTAS upon admission to

a ward.

The patient is deemed ‘out of PTA’ when they obtain a score of 18/18 on the A-WTPAS. No additional or repeated

administrations are required after a perfect score (18/18) has been obtained. If the patient fails to score 18 on





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four testing occasions within 24 hours of the injury, they must be commenced on the standard WPTAS for more

detailed PTA evaluation

Testing considerations

The A-WPTAS and WPTAS are not the only screening measures of PTA, but are extensively validated and used nationally and internationally. Both the WPTAS and A-WPTAS must be administered by appropriately trained staff, such as occupational therapists, speech pathologists, neuropsychologists, nursing staff or medical practitioners. Surgical intervention does not necessarily contraindicate the use of these PTA scales. PTA screening can also be used in intoxicated individuals as long as they are cooperative and GCS requirements have been met for each test. These measures can be used with an interpreter (Meares & Shores, 2017). Refer to Monash Health EMR to view these tests: The WPTAS is a PowerForm in EMR, and the A-WPTAS is in the Interactive View of EMR.

KEY STANDARDS, GUIDELINES OR LEGISLATION

Key standards, guidelines and legislations to comply with:

Monash Health workplace safety, emergency and wellbeing

Monash Health occupational violence and aggression

Monash Health preventing falls and harm from falls

Monash Health clinical handover

Monash Health iCare

National Safety and Quality Health Services (NSQHS)

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Monash Health wishes to acknowledge the use of protocols from Alfred Health, Austin Health, South West Local Health District, Westmead Hospital, Queensland Health Royal Brisbane & Women’s Hospital, in addition to the authors of the A-WPTAS and WPTAS: Shores et al (1986 & 2007) in the preparation of this procedure. We also acknowledge Professor Arthur Shores, Neuropsychologist (NSW) for ongoing consultation and sharing of resources.

KEYWORDS

Post Traumatic Amnesia (PTA), Traumatic Brain Injury (TBI), Closed Head Injury, Concussion, Head Injury, Westmead PTA Scale (WTPAS), Abbreviated Westmead PTA Scale (A-WPTAS), Glasgow Coma Scale (GCS).

Document Governance

Supporting Policy Evidence Based Clinical Care: Operational Policy

Executive Sponsor Stuart Cavill, Chief Allied Health Officer

Service Responsible Neuropsychology Unit, Acute Neuropsychology

MMC Occupational Therapy, Neurosciences

Document Author Dr Niloufar Kirkwood, Senior Neuropsychologist

Danielle Byrne, Neurosciences Occupational Therapist

Consumer Review Yes or No No

This Procedure has been endorsed by an EMR Subject Matter Expert (SME)

There are no Order Set or Quick Reference Guides linked





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A-WPTAS TARGET PICTURES:





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A-WPTAS PICTURE RECOGNITION CHART Only to be used if the patient says “I don’t know” or “I don’t remember.”

Do not use if incorrect response provided in the first instance when testing recall.

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