Further Outpatient Care
The outpatient setting is rarely the context for ADS to present.
The usual outpatient therapy programs and the typical concerns regarding family functioning and community re-integration issues pertain to outpatient care.
Rarely, continued medication use is required long term. Thus, monitoring for common side effects and minimizing medications that impair cognition are required.
Further Inpatient Care
The length of stay in rehabilitation is usually reported as being longer for those patients who experience ADS. Other than this observation, no specific alterations from a typical multidisciplinary, acute inpatient rehabilitation program are expected in this population.
If actual myocardial damage is identified as a result of the syndrome, observe appropriate cardiac rehabilitation principles during the head injury rehabilitation program.
Transfer
Transfer to the neurosurgery service or an ICU setting is rarely necessary for patients with ADS, although it is conceivable in the event of dangerously high blood pressure and tachycardia.
Complications
Increased sensitivity of neurons to elevated temperature occurs during the acute phase of TBI. In animals, functional differences are discernible between those with temperatures in excess of 38 º C and those whose temperature is maintained below 38 º C. In one study, 73% of patients with dysautonomia had temperatures above 38 º C for 2 weeks after injury, contrasted with only 18% of patients without dysautonomia. [8]
Posturing increases energy expenditure by 150-250%. [8] These features increase the risk that persons with dysautonomia will sustain secondary injury to the brain.
Prognosis
Although patients who have dysautonomia can make functional gains, their outcomes—as measured by Glasgow Outcome Scale (GOS) and Functional Independence Measure (FIM) scores—have been found to be poorer than those of patients without dysautonomia. [19] Individuals with dysautonomia also have more difficulty with memory and experience longer periods of posttraumatic amnesia (PTA) than do patients without dysautonomia. Research has found that for patients with dysautonomia, the duration of ICU stay is the same as that recorded for controls but that the length of rehabilitation stay is greater. On average, the duration of the dysautonomia (as measured by cessation of sweating) has been found to be about 75 days.
A study by Hendén et al suggested that measurement of heart rate variability and baroreflex sensitivity can predict late neurologic outcomes in patients with isolated TBI. The study involved 19 patients with TBI who required mechanical ventilation, sedation, and analgesia. The investigators found that those with significantly depressed measures of heart rate variability and baroreflex sensitivity tended after 1 year to demonstrate poor scores (< 5) on the Glasgow Outcome Scale-Extended (GOSE), with the difference being unrelated to the severity of TBI at admission or the extent of sedative or analgesic drug use. [20]
A retrospective study by Pozzi et al indicated that in pediatric patients with acquired brain injury, the length of coma and the mortality rate are greater in those experiencing paroxysmal sympathetic hyperactivity (also known as paroxysmal autonomic instability with dystonia [PAID]). The study involved 407 pediatric patients with postacute acquired brain injury, including 26 with paroxysmal sympathetic hyperactivity. [21]
Patient Education
Explaining ADS to the patient is rarely an issue, because patients are usually cognitively compromised at the time of manifestation of the syndrome. However, reducing the fear of family members is important. The family should understand that this syndrome is seen in persons with brain injury, that it is almost always controllable with medications, and that it does not usually remain a long-term problem.
