RULE 17, EXHIBIT 2B Moderate/Severe Traumatic Brain Injury Medical Treatment Guideline Revised: 12/7/2018 Effective: 1/30/2019 Revised: January 8, 1998 Effective: March 15, 1998 Revised: March 1, 2005 Effective: May 1, 2005 Revised: September 29, 2005 Effective: January 1, 2006 Revised: November 26, 2012 Effective: January 14, 2013 Presented by: DIVISION OF WORKERS' COMPENSATION Moderate/Severe Traumatic Brain Injury – Referenced Version Exhibit Page Number 1 Table of contents A. Guideline introduction .............................................................................................................. 6 B. General guideline principles ..................................................................................................... 7 B.1 Application of the guidelines ............................................................................................. 7 B.2 Education ........................................................................................................................... 7 B.3 Informed decision making ................................................................................................. 7 B.4 Treatment parameter duration ............................................................................................ 8 B.5 Active interventions ........................................................................................................... 8 B.6 Active therapeutic exercise program ................................................................................. 8 B.7 Positive patient response .................................................................................................... 8 B.8 Re-evaluation of treatment no less than every 3 to 4 weeks .............................................. 8 B.9 Surgical interventions ........................................................................................................ 8 B.10 Six-month time frame ........................................................................................................ 9 B.11 Return to work ................................................................................................................... 9 B.12 Delayed recovery ............................................................................................................... 9 B.13 Guideline recommendations and inclusion of medical evidence .................................... 10 B.14 Treatment of pre-existing conditions ............................................................................... 11 B.15 Post maximum medical improvement (MMI) care ......................................................... 11 C. Introduction to traumatic brain injury (TBI) ........................................................................... 12 C.1 Definitions of TBI ............................................................................................................ 12 C.1.a Mild TBI (mTBI) ..................................................................................................... 12 C.1.b Complicated mTBI .................................................................................................. 13 C.1.c Moderate/severe TBI (M/S TBI) ............................................................................. 13 C.1.d Other terminology .................................................................................................... 13 C.2 Prevention ........................................................................................................................ 14 C.3 Interdisciplinary rehabilitation professionals .................................................................. 16 C.4 Disability .......................................................................................................................... 20 D. Overview ................................................................................................................................. 22 D.1 Early specialty intervention ............................................................................................. 22 D.2 Support system education ................................................................................................ 22 D.3 Course of recovery ........................................................................................................... 23 D.4 Guardianship and conservatorship ................................................................................... 23 D.5 Systems of care ................................................................................................................ 24 E. Diagnosis ................................................................................................................................. 28 E.1 Initial diagnostic procedures ............................................................................................ 28 E.1.a History of injury ....................................................................................................... 28 E.1.b Physical examination ............................................................................................... 31 E.1.c Neurological examination ........................................................................................ 31 Moderate/Severe Traumatic Brain Injury – Referenced Version Exhibit Page Number 2 E.1.d Neuropsychological evaluation ................................................................................ 31 E.1.e Neurodiagnostic tests ............................................................................................... 33 E.2 Further diagnostic procedures.......................................................................................... 38 E.2.a Electrodiagnostic studies ......................................................................................... 38 E.2.b Electroencephalography ........................................................................................... 40 E.2.c Neuroimaging .......................................................................................................... 40 E.2.d Laboratory testing .................................................................................................... 43 E.2.e Lumbar puncture ...................................................................................................... 43 E.2.f Nerve blocks – diagnostic ........................................................................................ 44 E.2.g Further neuropsychological assessment and testing ................................................ 44 E.2.h Psychological, psychiatric, or psychosocial evaluations ......................................... 46 E.2.i Neuro-otology: vestibular and audiological evaluation ........................................... 50 E.2.j Swallowing evaluation ............................................................................................. 54 E.2.k Vision evaluation ..................................................................................................... 56 E.2.l Return-to-work assessment and special tests ........................................................... 59 F. Treatment ................................................................................................................................ 63 F.1 Acute-stage therapeutic procedures ................................................................................. 63 F.1.a Resuscitation ............................................................................................................ 63 F.1.b Intracranial pressure (ICP) management and cerebral perfusion pressure (CPP).... 64 F.1.c Hyperventilation ...................................................................................................... 64 F.1.d Medications .............................................................................................................. 65 F.1.e Hypothermia ............................................................................................................ 70 F.1.f Surgery ..................................................................................................................... 71 F.1.g Hyperbaric oxygen (HBO2) ..................................................................................... 72 F.2 Operative procedures ....................................................................................................... 73 F.2.a Brain ......................................................................................................................... 73 F.2.b Decompressive craniectomy .................................................................................... 73 F.2.c Cerebral spinal fluid (CSF) ...................................................................................... 76 F.2.d Extracranial soft tissue ............................................................................................. 78 F.2.e Maxillofacial ............................................................................................................ 78 F.2.f Cranial nerve decompression or repair .................................................................... 78 F.2.g Ophthalmologic ....................................................................................................... 78 F.2.h Orthopedic ............................................................................................................... 79 F.2.i Otologic ..................................................................................................................