I am a registered nurse working in a very busy and dynamic Emergency Department. We belong to the biggest catchment area in Metropolitan Sydney and a major level 6 trauma centre for the South Western Sydney Local Health District which takes trauma patients from up to Bowral and District Hospital, another 90 km south west of the city. According to the data I have gathered from 2018, a total of 686 documented presentations of “Head Injuries” which includes Traumatic Brain Injuries.
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A traumatic brain injury (TBI) is defined as “the result of the forceful motion of the head or impact causing a brief change in mental status (confusion, disorientation or loss of memory) or loss of consciousness for less than 30 minutes” (Symptoms of TBI, 2006). Patients who presents to the Emergency Department with a fall who have claimed to have hit their head on the ground, a sports related injury whereas the patient sustained a blunt force to the head or those who are amnesic to events following the trauma immediately meet the criteria for an A-WPTAS. A GCS score of 15 does not always signify a return to normal cognitive function. Individuals with a GCS score of 15 who may have had acute cognitively impairment are at risk of not being identified accurately. An addition of an amnesia score to the GCS in the Abbreviated Westmead Post-traumatic Amnesia Scale will be expected to assist in making a diagnosis of mild traumatic brain injury (mTBI) (Meares, et al., 2015).
The A-WPTAS is designed to assess the duration of post-traumatic amnesia (PTA) in patients after a mild traumatic brain injury and scored a Glasgow Comma Scale (GCS) of 13-15 (ACI, 2019). The A-WPTAS starts by assessing the GCS to ensure the patient is suitable to use the form. The patient must be able to open eyes spontaneously and obey commands for them to be suitable to an A-WPTAS assessment. The current state-wide form developed in 2013 states that the A-WPTAS is only to be used within 24 hours of the suspected closed head injury. An addition of the memory test using picture recognition is administered following the Glasgow comma scale to test whether the patient is suitable for the A-WPTAS.
The A-WPTAS was created by the NSW Institute of Trauma and Injury Management (ITIM) and the NSW Emergency Care Institute (ECI) by a group of researchers from Westmead Hospital, to which it derives its name. It is aimed to avoid unnecessary admissions and inappropriate discharges for patients who experienced a mild traumatic brain injury. A study was conducted in April 2017 conducted over a 2 year period concluded that 94% of the patient who presented with mTBI cleared post-traumatic amnesia testing within 4 hours (D’Amours, Watson, Jaeger, & Clous, 2017). A later study has been conducted where level of education, effect of age, blood alcohol level, injury status, verbal learning and administration of drugs that may affect cognitive function such as morphine further proved that these control factors did not provide a fail performance towards the already accepted scale (Mears, Shores, Taylor, Lammél, & Batchelor, 2011).
Overall, the A-WPTAS is a fast-standardised bedside assessment tool used to assess cognition. It involves three added questions for new learning but its efficiency is solely based on the initial cognitive assessment which is the Glasgow Coma Scale.
The assessment tool has been validated in survivors of a severe TBI with a 8.4 days mean duration of coma and a of post-traumatic amnesia mean duration of 56 days” (Elizabeth Sandel & Jerry Mysiw, 1996) and has been tested multiple times in studies conducted since 2008. Whilst the GCS has been the widely used and accepted assessment of mTBI, It may not be enough. Some factors including Mental Health and other contributing factors such as anxiety and depression should be treated before administering the AWPTAS and a diagnosis of mTBI can be met.
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The AWPTAS has been introduced interstate into the Royal Melbourne Hospital in 2011 and a study to evaluate nursing staff conducting the AWPTAS’ knowledge was conducted in August 2013 revealed that 60% are of trauma patients presenting with mTBI were screened accurately by the nursing staff although 89% of the nursing staff administering the test have stated full confidence in administering the test. The study concluded that there is some level of inconsistency between the nursing staff knowledge and clinical practice (The Royal Melbourne Hospital, 2014).
The post amnesia scoring has been widely used in adults presenting in the Emergency Department with suspected mTBI, however the measure to assess children remains controversial (Rocca, Wallen, & Batchelor, 2008). Some research suggest that the assessment is suitable for children aged greater than 7 years. An evaluation of the scale has been tested with developing children aged 4-5 years. The study concluded that the AWPTAS used in children below 6 years old gave a high unsatisfactory false positive rate.
The Abbreviated Westmead Post Traumatic Amnesia Scoring is a widely used tool in the major trauma centres and Emergency Departments around NSW, it is a valid scale and has been tested in many studies involving both adults and children. PTA assessment can, in specific circumstances, decrease the observation time required, including the total amount of time a patient may spend in the emergency department. In essence, the A-WPTAS has been a very effective scale to assess possible outcomes of patients with mTBI in a time acceptable to the key performance indicators in the Emergency Departments which is 4 hours. When a patient has failed the assessment, they are recommended for admission within the 4-hour time frame. Although the scale is valid and reliable to adult population presenting with mTBI, the assessment is not very reliable when used in children below 7 years of age. The form does not come in different languages but because of the pictographic memory testing of the AWPTAS, it is certain that language barrier is not a factor for a false reading. However, it is recommended that the person using the test should use an interpreter to ensure correct details are relayed and that the test parameters are met.
- ACI. (2019, 03 22). Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/274068/awptas-form-explanatory-notes.pdf
- D’Amours, S., Watson, C. E., Jaeger, M., & Clous, E. (2017). Introduction of the Abbreviated Westmead Post-Traumatic Amnesia Scale and Impact on Length of Stay. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society, 106.
- Elizabeth Sandel, M., & Jerry Mysiw, W. (1996). The Agitated Brain Injured Patient. Part 1: Definitions, Differential Diagnosis, and Assessment. Archives of Physical Medicine and Rehabilitation, 621.
- Kerr, H. A. (2013). Closed Head Injury. In H. A. Kerr, Clinics in Sports Medicine (pp. 273-287). Elsevier. Retrieved from ClinicalKey.
- Meares, S., Shores, E. A., Smyth, T., Batchelor, J., Murphy, M., & Vukasovic, M. (2015). Identifying posttraumatic amnesia in individuals with a Glasgow Coma Scale of 15 after mild traumatic brain injury. Arch Phys Med Rehabil, 96(5):956-9.
- Mears, S., Shores, E. A., Taylor, A. J., Lammél, A., & Batchelor, J. (2011). Validation of the Abbreviated Westmead Post-traumatic Amnesia Scale: a brief measure to identify acute cognitive impairment in mild traumatic brain injury. Brain Injury, 1198-1205.
- Rocca, A., Wallen, M., & Batchelor, J. (2008). The Westmead Post-Traumatic Amnesia Scale for Children (WPTAS-C) Aged 4 and 5 Years Old. ResearchGate.
- Symptoms of TBI. (2006). Retrieved from traumaticbraininjury.com: http://www.traumaticbraininjury.com/symptoms-of-tbi/mild-tbi-symptoms/
- Symptoms of TBI. (2019, 03 22). Retrieved from TraumaticBrainInjury.com: http://www.traumaticbraininjury.com/symptoms-of-tbi/mild-tbi-symptoms/
- The Royal Melbourne Hospital. (2014, June 12-19). Retrieved from The Royal Melbourne Hospital: https://www.thermh.org.au/sites/default/files/media/documents/research/MH_Research_Week_2014.pdf