Severe TBI in inpatient rehab: PTA, agitation, heterotopic ossification, driving and work

The pattern is a moderate-severe acceleration-deceleration injury with focal and diffuse components. - Focal: contusions in both orbitofrontal lobes and the left temporal pole are the classic sites where the brain is driven against the bony orbital roofs and sphenoid wing. - Diffuse: petechial haemorrhages at the grey-white junction and in the splenium of the corpus callosum indicate diffuse axonal injury (corpus callosum involvement is at least Adams grade 2). Computed tomography underestimates diffuse axonal injury; magnetic resonance imaging with susceptibility-weighted imaging would show its extent if it would change management or prognostic counselling. - Thin subdural haematoma and basal subarachnoid blood without mass effect: unlikely to need surgery, but they add to seizure risk. Expected problems: - Orbitofrontal: disinhibition, impulsivity, irritability, poor self-monitoring and insight, emotional lability, socially inappropriate behaviour; apathy is also possible. - Left anterior temporal: impaired verbal memory and new learning, word-finding difficulty. - Diffuse axonal injury: slowed processing speed, reduced attention and divided attention, fatigue. - Anosmia from shearing of the olfactory tracts (relevant to safety and appetite, and to his work as an electrician, for example detecting burning). - Increased risk of late post-traumatic seizures (cortical contusions and subdural blood are recognised risk factors).

Post-traumatic amnesia is the period after injury in which the person is confused and disoriented and cannot form continuous day-to-day memories. Liam's repetitive questioning and disorientation suggest he is still in it on day 19. Assessment and monitoring: - Westmead Post-Traumatic Amnesia Scale every day, at the same time of day, by trained nursing or therapy staff. It has seven orientation questions and five memory items (the examiner's face and name and three picture cards shown the previous day), total 12. - He is out of post-traumatic amnesia when he scores 12/12 on three consecutive days. The end date is the first of those three days, and duration is counted from the day of injury. - Record behaviour alongside, using the Agitated Behaviour Scale, because agitation and post-traumatic amnesia often go together. - Do not substitute a general cognitive screen, and do not confuse post-traumatic amnesia with sedation or a superimposed delirium (look for infection, drugs and seizures if the scores fluctuate or go backwards). Prognostic significance: - Duration of post-traumatic amnesia is one of the strongest early predictors of outcome. On the Russell and Smith classification: less than 1 day moderate, 1-7 days severe, 1-4 weeks very severe, more than 4 weeks extremely severe. Liam is already at 19 days, so at least very severe. - Longer post-traumatic amnesia predicts lower functional independence at discharge, longer length of stay, and lower likelihood of returning to work and driving. It is a guide for the family, not a certainty for an individual. Practical implications while in post-traumatic amnesia: consistent staff, structured routine, low-stimulation environment, orientation boards, family education, no formal neuropsychological testing yet, and defer significant decisions that need his capacity.

Agitation is common during post-traumatic amnesia and usually settles as he emerges, so the aim is safety while recovery happens, using the least restrictive means. 1. Measure it: Agitated Behaviour Scale every shift (14 items, total 14-56; scores above 35 are severe), with a behaviour chart to find triggers and the time-of-day pattern. 2. Treat contributors: pain from the clavicle fracture (regular paracetamol), constipation, urinary retention (bladder scan), infection, hypoxia, poor sleep, seizures (consider electroencephalography if fluctuating), withdrawal from nicotine (offer patches), alcohol or other drugs, and deliriogenic medicines (anticholinergics, metoclopramide, opioids). 3. Environment: a single quiet room, consistent staff, one-to-one nursing, an enclosed or low-floor bed in place of bed rails, remove the cannula unless it is essential, a structured day-night routine with daylight and activity by day, and limit visitors to one or two familiar people at a time. Allow supervised wandering in a secure area. 4. Behavioural approach: short simple sentences, do not argue with his beliefs, redirect, avoid crowding him during care; staff education and debriefing after the assault. 5. Medicines only if the above is not enough and risk is high: propranolol (for example 10-20 mg twice daily, titrated to heart rate and blood pressure) has the best evidence after brain injury; alternatives are valproate or carbamazepine, or low-dose quetiapine at night. Avoid routine haloperidol and benzodiazepines, which may slow cognitive recovery and prolong confusion. Review daily and taper when he emerges. 6. Legal and ethical: he lacks capacity during post-traumatic amnesia, so involve his medical treatment decision maker (Victoria) and follow the health service's restrictive practice policy, with clear documentation and incident reporting.

Differential diagnosis: - Heterotopic ossification is the most likely: hip is the commonest site after brain injury, and he has risk factors (severe injury, prolonged coma, immobility, agitation, fracture). - Deep vein thrombosis must be excluded first, as it presents similarly and is dangerous. - Others: occult fracture (from a fall during agitation), septic arthritis, cellulitis. Investigations: - Doppler ultrasound of the leg. - Triple-phase bone scan is the most sensitive early test; plain X-ray only becomes positive about 3-6 weeks after onset; ultrasound may show early changes. - Alkaline phosphatase and C-reactive protein are supportive but non-specific. - Computed tomography if surgery is later considered. Management: - A non-steroidal anti-inflammatory drug such as indomethacin or celecoxib for several weeks, after checking with neurosurgery that the contusions and subdural are stable, with gastric protection and renal monitoring. - Gentle, pain-free active-assisted range of motion to maintain movement; avoid forceful stretching. - Analgesia, positioning and seating review. - Refer for surgical excision only if a mature lesion causes significant functional limitation (sitting, hygiene, walking), with post-operative prophylaxis by non-steroidal anti-inflammatory drug or single-fraction radiotherapy.

I would hold the meeting with Liam present, his partner, and the key team members, check what they already understand, and agree what they want from the meeting. Prognosis framing: post-traumatic amnesia of 41 days puts this in the extremely severe range. Most people keep improving for one to two years, but persisting problems with memory, attention, planning and behaviour are likely, and he may not notice them himself. I would give realistic hope without promising timeframes. Driving: - He must not drive now. Fitness is judged under the Austroads "Assessing Fitness to Drive" standards, considering cognition, insight, impulsivity, vision, physical function and seizure risk; the licensing decision belongs to VicRoads. - The steps are neuropsychological assessment, then a specialist occupational therapy driver assessment (off-road then on-road). The outcome may be an unconditional licence, a conditional licence (for example local area, daylight only), or not fit for now. - Liam has a legal duty to tell VicRoads; I would explain that I may notify the authority if he drives against advice and puts the public at risk. Work: - His apprenticeship is safety-critical: live electrical work, ladders and heights, and possible anosmia (he may not smell burning). Any return must follow neuropsychological assessment and be graded, starting with non-safety-critical tasks and short hours. - The Transport Accident Commission funds vocational rehabilitation: a workplace assessment, liaison with his employer and training provider, a graded plan, and alternative duties or retraining if electrical work is not safe. I would also ask about his partner's own coping, offer carer and relationship support, give a written summary, and set a date to review.