3- Neurological Complications

Question 1

List 5 most common affected cranial nerves in TBI and how do they present. 🔑🔑

Answer 1

Olfactory nerve (CN I)

• Anosmia, apparent loss of taste and CSF rhinorrhea.
• Result in decrease in appetite, weight loss
• Sense of smell can warn one of potential dangers such as hazardous chemicals or fire.

Optic nerve (CN II)

• Complete blindness - Blurring of vision - Homonymous hemianopsia.
• Examine: funduscopic examination - visual field - visual acuity - pupillary reflex

Vestibulocochlear nerve (CN VIII)

• Loss of hearing
• Postural vertigo and nystagmus

EOM (CN IV > CN III > CN VI)

• Diplopia - loss of the pupillary response (“blown pupil”) may signify uncal herniation.

Facial nerve (CN VII)

1. Tactile sensation to the parts of the external ear
2. Taste sensation to the anterior two-thirds of the tongue
3. Muscles of facial expression
4. Salivary and lacrimal glands

Question 2

What are 6 characteristics of frontal lobe dysfunction? 🔑🔑

Answer 2

💡 Like ACA infarction, which is Acquired brain injury.

1. Impaired concentration and executive function
2. Lack of inhibition (socially inappropriate anger, agitation, aggression).
3. Depression.
4. Non-fluent aphasia (Broca or TCM)
5. Gait apraxia
6. Motor abnormalities (contralateral spastic paralysis legs > arms).
7. Apathy/abulia (lack of initiation).
8. Release of primitive reflexes (palmomental, suck, snout, rooting, glabellar).
9. Incontinence bowel and bladder.
10. Frontal eye field involvement – deviation of the eyes to the ipsilateral side

Adams and Victors principles of neurology, 2005, pg 395.

Clinical neurology 5th edition 2002. pg 13.

ERABI case study; http://www.abiebr.com/set/case-study-7/71-frontal-lobe-dysfunction.

Question 3

Plantar Reflex (Babinski) Equivalents 🔑🔑 MOCK

Answer 3

Question 4

Fig. 43.2 (3 marks) 🔑🔑

Answer 4

Blue: Crescent-shaped subdural hematoma

Red: Lens-shaped epidural hematoma

Green: Subarachnoid hemorrhage within the sulci

Braddom 6th Edition Chapter 43 TBI pg927

Question 5

List 4 complications of sub-arachnoid hemorrhage.

Answer 5

Just like stroke with bleeding inside raising ICP

1. Sudden, transient LOC
2. Focal neurologic deficits include CN3 or CN6 palsy
3. Hemiparesis
4. Aphasia (dominant hemisphere)
5. Seizures/epilepsy.
6. Vasospasm (secondary ischemia).
7. Hydrocephalus
8. Increase ICP
9. Brain herniation

Cuccurollo 4th Edition Chapter 1 Stroke pg18

Question 6

Canadian Head CT Rule 5 marks 🔑

Answer 6

Question 7

List 4 Advantages to use CT & MRI in TBI patient

Answer 7

ADVANTAGES OF CT

1. Rapid, reliable & convenience
2. Relatively low cost
3. Detects facial and skull fractures
4. Detect mass lesions requiring immediate surgical intervention.

DISADVANTAGES OF CT

1. Poor in identifying nonhemorrhagic lesions
2. Poor corelation with neurological outcome

ADVANTAGES OR MRI

1. Good for non Hge lesions
2. Defining the lesions and extent of injury
3. Guiding treatment options
4. Prognostication of lesions in small structures such as the brainstem and for DAI.

DISADVANTAGES OR MRI

1. Time consuming (45 vs. 5 minutes)
2. Does not really affect early decision-making
3. Foreign bodies or implanted devices maybe inside the patient

Cuccurollo 4th Edition Chapter 2 TBI pg71

Question 8

Uncal herniation Location & List 5 sings 🔑🔑

Answer 8

LOCATION

Medial Temporal Lobe

SIGNS

1- Stretching of the CN 3 (oculomotor nerve)

Ipsilateral fixed pupil dilation, ptosis, and ophthalmoplegia

2- Ipsilateral hemiparesis

Pressure on the corticospinal tract located in the contralateral crus cerebri

3- Contralateral hemiparesis

Pressure on the precentral motor cortex or the internal capsule

4- Reduced consciousness

5- Central hyperventilation (Cheyne-stokes respirations)

6- Bilateral decerebration

Cuccurollo 4th Edition Chapter 2 TBI pg74

Greenberg textbook, pg 161-162.

Question 9

When is ET intubation indicated? One caution?

Answer 9

ET intubation

• Comatosed GCS ≤ 9

Benefits

1. Desaturation to maintain oxygenation
2. Airway protection is indicated in patients with GCS <9
3. Correction of hypoxia

Caution

• Cervical spine injury (avoiding neck manipulation/hard cervical collars) in patients with severe TBI or those with a high index of suspicion for spine trauma.

Cuccurollo 4th Edition Chapter 2 TBI

Question 10

List 4 Indication for surgical management in TBI & 2 surgical options 🔑🔑

Answer 10

Indication

1. Penetrating injury
2. Compound depressed skull fracture
3. Epidural hematoma > 30 cc in volume (1 oz)
4. Subdural hematoma > 1cm thickness (1 cm)
5. Focal contusion or intracerebral hemorrhage
6. Midline shift > 5mm.

Surgical operations

1. Craniotomy
2. Emergency Burr Hole

Cuccurollo 4th Edition Chapter 2 TBI pg73

Brain injury medicine textbook pg 272-273.

Question 11

List 4 preventive measures to be implemented in newly admitted TBI 🔑🔑

Answer 11

1. Manage bowel and bladder function
2. Maintain nutrition
3. Maintain skin integrity
4. Control spasticity
5. Prevent contractures

Cuccurollo 4th Edition Chapter 2 TBI pg61

Question 12

What are the different time frame of epilepsy/seizure post TBI?🔑🔑 EXAM 2021

Answer 12

CLASSIFICATION

1. Immediate Post Traumatic Seizure (Immediate PTS)

Single or recurrent seizure after TBI within the first 24 hours post-injury

Treat for 7 days

2. Early Post Traumatic Seizure (Early PTS)

Occurs within the first week (24 hours to 7 days) → Treat for 1 year

3. Late Post Traumatic Seizure (Late PTS) or Post Traumatic Epilepsy (PTE)

Occurs after the first week → Treat for 2+ years

STATUS EPILIPTICUS

• More than 5 minutes of continuous seizure activity
• Two or more seizures, without full recovery of consciousness between seizures.

Cuccorollo 4th Edition Chapter 2 TBI pg74

ERABI Module 7 pg3 & pg9

Question 13

List 6 risk factors for late post-traumatic seizures after TBI (late seizures).🔑🔑 EXAM 2021

Answer 13

1. Prolonged coma or PTA (>24 hours): 35%
2. Depressed skull fracture: 3% to 70%
3. Penetrating head injury: 33% to 50%
4. Intracranial hematoma: 25% to 30%
5. Early PTS (>24 hours to 7 days): 25%
6. Age
7. Presence of foreign bodies
8. Focal neurological deficits (aphasia, hemiplegia)
9. Alcohol abuse
10. Use of TCAs

Cuccurollo 4th Edition Chapter 2 TBI pg75

Question 14

Why penetrating injuries increase the risk of post-traumatic seizures?

Answer 14

They result of abnormal electrophysiological activity in the brain at the site of injury.

ERABI Module 7 pg7

Question 15

List 6 complications of post-traumatic seizures.🔑🔑

Answer 15

PATIENT

1. Accidental injuries
2. Loss of driving privileges
3. Status epilepticus
4. Death

RECOVERY & FUNCTION

1. Deterioration in functional status
2. Deterioration in cognitive status
3. Negative impact on neurological recovery

ERABI Model 7 pg10

Question 16

TBI patient is seizing, what could be your differential diagnosis?

Answer 16

BRAIN

1. Hydrocephalus
2. Mass occupying lesions (hemorrhage, abscess)
3. Encephalitis/meningitis

BODY

1. Sepsis/fever

ELECTROLYTE

1. Electrolyte abnormalities (Na, Mg, Ca)
2. Hypoglycemia

ORGAN FAILURE

1. Uremia
2. Hepatic encephalopathy

TOXIC

1. Alcohol, Cocaine, Ecstasy, Amphetamines
2. High dose Caffeine
3. Tricyclic antidepressants
4. Narcotics

ERABI Module 7 pg11

Question 17

TBI patient developed first episode of seizure. List 3 investigations to be done.

Answer 17

1. EEG
2. Prolactin level: ↑ prolactin level confirms true seizure activity, but normal level does not ruleout seizure activity
3. Brain MRI

Cuccurollo 4th Edition Chapter 2 pg76

ERABI Module 7 pg13

Question 18

TBI patient developed seizure for one minute 2 hours after injury. What medication you would start and for how long? 🔑🔑 MOCK

Answer 18

💡 Important to remember that all anticonvulsants may cause some degree of sedation and cognitive deficits (usually psychomotor slowing).

PROPHYLAXIS

• Phenytoin, valproic acid (Depakene) or carbamazepine (Tegretol) for 1 week
• Levetiracetam (Keppra) is as effective as phenytoin

WHEN TO STOP

• After 1 week, seizure free

RESTART

• Evidence of late PTS

WHEN TO STOP AGAIN

• After a 2-year, seizure-free interval

Cuccurollo 4th Edition Chapter 2 TBI pg76 & 78

ERABI Module 7 pg13

Question 19

Surgical Interventions for the Prevention and Treatment of PTS

Answer 19

1. Surgical excision of PTS focus
2. Vagus Nerve Stimulator
3. Deep brain stimulation of the thalamic anterior nucleus

Cuccurollo 4th Edition Chapter 2 TBI pg79

ERABI Module 7 pg16

Question 20

What lab investigations are required when initiating phenytoin and levetiracetam?

Answer 20

💡 All medications start with simple admission profile: CBC, RFT, LFT.

Phenytoin:

1. CBC
2. BUN/Cr.
3. Liver enzymes
4. Phenytoin level

Levetiracetam:

1. BUN/Cr

Question 21

What are the side effects of Levetiracetam (keppra)? 🔑🔑

Answer 21

💡 Body organs: Brain - cerebellum - eyes - muscle - heart

1. Lethargy
2. Fatigue
3. Weakness
4. Headache
5. Somnolence (Drowsiness or Sleepiness)
6. Dizziness
7. Depression
8. Ataxia
9. Diplopia

https://reference.medscape.com/drug/keppra-spritam-levetiracetam-343013#4

Question 22

What are the features of phenytoin toxicity? 🔑🔑

Answer 22

1. Ataxia
2. Nystagmus
3. Confusion
4. Hallucinations
5. Neuropathy
6. Movement disorders
7. SA/AV nodal block
8. Stevens-Johnson Syndrome

ERABI Module 7 pg19

Question 23

Why TBI patient develop Ventriculomegaly? 2 marks. 🔑🔑

Answer 23

1. Cerebral atrophy and focal infarction of brain tissue
2. CSF absorption limited by blood products, protein, or fibrosis leading to ventricular dilatation

Cuccurollo 4th Edition Chapter 2 TBI pg79

Question 24

List 3 classical manifestations of hydrocephalus in TBI patient

CT findings and how to manage? 🔑🔑

Treatment for ↑ ICP

Answer 24

Acute:

1. Headache, nausea, vomiting, and lethargy.
2. Change in mental status (confusion, drowsiness).

Chronic:

1. Incontinence
2. Ataxia/gait disturbance
3. Dementia.
4. Worsen or fail to progress adequately.

CT Findings

1. Periventricular lucency
2. Sulcal effacement
3. Uniform ventricular dilation

Treatment

1. Lumbar puncture
2. Shunting

Management for ↑ ICP

1. Avoid flat, supine position; instead, elevate head of bed to 30°.
2. Hyperventilation should be used with caution because it reduces brain tissue PO2.
3. Hyperosmolar therapy with mannitol
4. Furosemide/acetazolamide may also be used
5. Neurosurgical decompression

Cuccurollo 4th Edition Chapter 2 TBI pg79 & Chapter 1 pg23

Question 25

Define Agitation, List 4 components of Agitation, Lobe location 🔑🔑

Answer 25

**Agitation** * Subtype of delirium occurring during the state of PTA * Most commonly occurs with frontotemporal lesions, which coordinate arousal, attention, executive control, memory, and limbic behavioral functions C**haracterized by:** 1. Aggression مشاعر الغضب أو الكراهية التي تؤدي إلى سلوك عدائي أو عنيف 2. Akathisia الأرق الحركي 3. Disinhibition عدم القدرة على منع السلوك غير اللائق 4. Emotional lability تغييرات مبالغ فيها في المزاج **Agitation is often accompanied by (same picture + GOAT)** 1. Disorientation 2. Post-traumatic amnesia (PTA) 3. Disinhibition 4. Aggression 5. Akathisia Cuccurollo 4th Edition Chapter 2 TBI pg80 ERABI Module 5 pg8

Question 26

List 4 possible differential diagnosis for agitations 🔑🔑 (OSCE Q) A case of TBI agitation with normal electrolytes – list 6 other causes. What to rule out in patient with agitation?

Answer 26

1. Drug withdrawal 2. Delirium tremens (DTs) 3. Infection 4. Pain 5. Hypoxia 6. Seizure disorder Cuccurollo 4th Edition Chapter 2 TBI pg84 1. Noxious stimuli (pain). 2. Environmental (overstimulation). 3. Medical conditions: 4. Infections: Systemic, encephalitis, meningitis, abscess, tertiary syphilis. 5. Endocrine: Hypothyroidism, hypo/hypercortisolism, hyperparathyroidism 6. Seizures:Ictal or post-ictal 7. Vascular: Stroke, TIA, hypoperfusion, hypoxemia, SDH, etc. 8. Medications & drugs 9. Structural: Hydrocephalus, stroke, intracranial bleed, etc. 10. Mood disorders. Flash cards 1. Severe medical illness 2. electrolyte disturbance, 3. anxiety and depression

Question 27

What is the most commonly abused substance following an ABI?

Answer 27

Alcohol ERABI Module 5 pg8

Question 28

What is the normal duration of agitation? 🔑🔑 (OSCE Q)

Answer 28

* Majority of patients with agitation recover completely in **three** **week to three months.** * Agitation is considered a normal phase of recovery in acute period (14 days) following a moderate to severe ABI * Strongly associated with frontal lobe lesions. ERABI Module 5 pg8

Question 29

List two assessments for agitation and their results 🔑🔑

Answer 29

💡 MMSE 18-23 **Agitated Behavior Scale (14-56) → 21,28,35** * Below 21: normal * 22 to 28: mild agitation → non-pharmacologcial measures * 29 to 35: moder ate agitation → pharmacological measures * 35 to 54: severe agitation → restrain? **Rancho Los Amigos (RLA) Scale** * Agitation: Level IV Confused and agitated behavior. Cuccurollo 4th Edition Chapter 2 TBI pg68 Braddom 6th Edition Chapter 43 Traumatic Brain Injury pg930

Question 30

First-Line Interventions for Posttraumatic Agitation 🔑🔑

Answer 30

**Environmental Management of Posttraumatic Agitation** 1. **Reduce the level of stimulation in the environment** * Remove noxious stimuli if possible * Reduction of lines/direct restraints * Scheduled toileting program * Place patient in quiet, private room * Limit unnecessary sounds and visitors 2. **Protect patient from harming self or others** * Place patient in a floor bed with padded side panels (Craig bed). * Assign 1:1 or 1:2 sitter to observe patient and ensure safety 3. **Reduce patient’s cognitive confusion** * One person speaking to patient at a time * Minimize contact with unfamiliar staff 4. **Tolerate restlessness when possible** * Allow patient to pace around unit with 1:1 supervision. * Allow confused patient to be verbally inappropriate Cuccurollo 4th Edition Chapter 2 TBI pg81 Table 2-11

Question 31

What medications can be used to treat life-threatening aggression following an ABI? 🔑🔑 What medications can be used to treat non life-threatening aggression following an ABI? 🔑🔑 Which medications should be minimized in treatment of aggressive/agitated behaviour? 🔑🔑

Answer 31

**LIFE THREATENING** **1- Short Acting Intramuscular Benzodiazepines** GABA receptor agonists (CNS Depressant) Lorazepam (Ativan) - Midazolam S/E May cause paradoxical agitation in the elderly & impaired motor recovery **2- Oral Atypical Antipsychotic** Dopamin 2 receptor antagonist Quetiapine (Seroquel): Start 50mg bed time or 25mg BID, max 800mg in 3 doses S/E QT prolongation, Dizziness, Extrapyramidal Sx, Fatigue, Anticholenergic Risperidone (Risperdal): 0.25mg BID to 2-8 mg/day once daily or divided q12hr S/E Insomnia, Anxiety, Headache, Agitation, Parkinsonism, Akathisia **NON-LIFE THREATENING** **1- Propranolol (420-520mg/day)** S/E Hypotension, Anxiety, Sleepiness, Insomnia **2- Anticonvulsants → pain and sleep** Carbamazepine (Tegretol), Valproic acid (Depakene), Gabapentin (Neurontin) S/E Sedation, Fatigue, Weight gain, Nausea, Edema **3- TCA: Amitriptyline → mood and sleep** S/E Anticholeregic: Urine retention, constipation, dry eyes and mouth, dizziness **4- Dopamenergic → arousal or attention** Amantadine and Methylphenidate S/E Hallucinations, Insomnia, Anxiety, Headache, Nausea **TO AVOID** 1. Benzodiazepines 2. Typical antipsychotic agents (haloperidol) Cuccurollo 4th Edition Chapter 2 TBI pg82-84

Question 32

You've asked to transfer agitated patient. Do you accept him? Why? 🔑🔑 EXAM

Answer 32

**We can't accept the patient** 1. May harm himself 2. May deteriorate 3. Will not benefit from rehabilitation at the current state.

Question 33

What is the definition of a restraint? What types of restraints exist? EXTRA BONUS

Answer 33

**Chemical restraints** Beta blockers, antidepressants, anticonvulsants, psychostimulants, propranolol, neuroleptics, valproic acid, and anti-Parkinson’s agents **Physical restraints** Bed rails, feeding trays, hand tying, chest straps, seat belts, ankle/wrist restraints, and jacket restraints ERABI Module 5 pg26

Question 34

What is the difference between typical and atypical antipsychotics?🔑🔑

Answer 34

**Atypicals are less likely to cause motor side effects than typicals:** 1. Tardive dyskinesia 2. Parkinsonism 3. Dystonia 4. Akathisia Cuccurollo 4th Edition Chapter 2 TBI pg82

Question 35

What medications are recommended impaired arousal or attention? 🔑🔑 What medications are recommended for learning and memory deficits? 🔑🔑

Answer 35

**Arousal & Attension** 1. **Amantadine:** 100 mg orally twice a day, Max dose: 400 mg/day 2. **Methylphenidate:** 20 to 30 mg orally in 2 or 3 divided doses, Max dose: 60 mg/day 3. **Bromocriptine** **Learning and memory deficits** 1. **Donepezil (Aricept):** 5-10mg starting dose ERABI Module 6

Question 36

What cognitive and behavioral changes are commonly seen in TBI?

Answer 36

**Cognitive** 1. Attention 2. Memory **Behavioral** 1. Disinhibition (anger - violence) 2. Impulsive PMR Secrets 3rd Edition Chapter 53 pg 437 Q18

Question 37

Which neurotransmitter is thought to be highly important for: 1. Memory 2. Attention 3. Mood 4. Arousal

Answer 37

1. Acetylcholine زهايمر 2. Norepinephrine انتباه 3. Serotonin سعادة 4. Dopamine اثارة

Question 38

List 4 dopaminergic and 2 non-dopaminergic medications to be used in TBI patient. 🔑🔑

Answer 38

💡 Amani leaving to the prom for myth to improve mood & memory. **Dopaminergic → Alterness, Arousal** 1. Amantadine—increases EXOGENOUS dopamine 2. Levadopa/carbidopa—increases EXOGENOUS dopamine 3. Bromocriptine—increases ENDOGENOUS dopamine 4. Methylphenidate—blocks reuptake of dopamine and norepinephrine **Non-Dopaminergic** 1. Antidepressants (TCA, SSRI, SNRI) for Mood & Sleep 2. Anticholinesterase: Donepezil (Aricept) for Memory & Attention Cuccurollo 4th Edition Chapter 2 TBI pg62 & 93

Question 39

What is Executive functions? Location in brain.

Answer 39

**Executive functions** * Complex processes, such as goal setting and execution, decision making, human adjustment, problem solving, and long-term planning. **Location** * Prefrontal cortex (medial prefrontal network & dorsolateral prefrontal network) ERABI Module 2 pg7

Question 40

List 2 test for cognitive function and their figures 🔑🔑

Answer 40

1. **Montreal Cognitive Assessment (MoCA)** * ≤25 out of 30 indicates impairment 2. **Mini-Mental State Examination (MMSE) “ABS is 21,28,35”** * 18-23 mild cognitive impairment * 0-17 severe cognitive impairment ERABI Module 2 pg11

Question 41

Intervention for Attention, Concentration and Information Processing Speed.

Answer 41

**Non-Pharmacological** 1. Dual-Task Interventions 2. Computer-based programs and virtual reality 3. Goal Management Training **Pharmacological** 1. Methylphenidate twice a day with a total daily dosage of 20-30mg, max 60mg per day

Question 42

What pharmacological interventions are recommended for the remediation of executive function following an ABI?

Answer 42

None. Unfortunately, there are no pharmacological interventions which have consistently shown improvement of executive function in the ABI literature. ERABI Module 2 pg26

Question 43

How to deal with schooling after TBI? 🔑🔑 (OSCE Teenager with mTBI)

Answer 43

1. Frequent breaks 2. Reduced workload 3. Modified assignments 4. Additional time to complete assignments 5. Preferential seating in the classroom 6. Reduced auditory stimulation 7. Reduced visual stimulation.

Question 44

What are the three stages of memory?

Answer 44

1. **Encoding** * Integration of hearing, vision, verbals, and personal experiences and information through cognitive mechanisms 2. **Consolidation** * Creating interactions between the cortex, the limbic system, more specifically the hippocampus 3. **Retrieval** * Process of accessing these memories through either recognition or recall. ERABI Model 2 pg5

Question 45

List 4 brain structures involved in memory. 🔑🔑

Answer 45

1. Mammillary body (general memory). 2. Fornix (carries signals from hippocampus to mammillary bodies and septal nuclei). 3. Hippocampus (spatial learning, declarative learning, explicit memory). 4. Dentate gyrus (new memory formation). 5. Parahippocampal gyrus (spatial memory). 6. Amygdala (emotional memory). Wikipedia, [http://en.wikipedia.org/wiki/Limbic\_system](http://en.wikipedia.org/wiki/Limbic_system)

Question 46

What are the only two pharmacological interventions supported by the ABI literature for learning and memory deficits? What are their recommended daily dosages? 🔑🔑

Answer 46

1. Donepezil (Aricept), 5-10 mg/day 2. Rivastigmine, starting dosage of 1.5 mg/day, maintenance at 3-6 mg/day. ERABI Module 2 pg25

Question 47

Intervention for Learning and Memory 🔑

Answer 47

**NON-PHARMACOLOGICAL:** **Internal** 1. Verbal and visual cuing 2. Visual imagery. 3. Self-imagination 4. Self-talk 5. Memory training: learning to ‘chunk’ information, memory games, mnemonics. 6. Repeated Practice 7. Retrieval Practice **External** 1. Memory aids: computer, pager, diaries, agendas, calendars, family members, photos. **PHARMACOLOGICAL:** 1. Donepezil (Aricept) 2. Physostigmine: memory in men with TBI. 3. Improve attention: Amantadine, methylphenidate. EBRSR module 12 pg 34; ERABI module 12 pg 96; ERABI Module 2 pg23

Question 48

Mention 3 Anxiety Disorder associated with post-ABI

Answer 48

1. Generalized anxiety disorder (GAD) 2. Obsessive compulsive disorder (OCD) 3. Post-traumatic stress disorder (PTSD) ERABI Module 3

Question 49

List 2 assessment tools help in diagnosis for mood and behavioral disorders following an ABI?

Answer 49

1. Patient Health Questionnaire (PHQ9) 2. Hospital Anxiety and Depression Scale

Question 50

What pharmacological interventions are recommended for the treatment of anxiety following an ABI?

Answer 50

SSRIs (Prozac, Cipralex), are the only pharmacological intervention recommended for the treatment of anxiety following an ABI. ERABI Module 5 pg23

Question 51

How is fatigue defined? How is it classified? 🔑🔑

Answer 51

**Fatigue** * Feelings of physical and/or mental exhaustion during or after usual activities * Feelings of inadequate energy to begin activities. ERABI Module 13 pg4 & pg8

Question 52

TBI patient in the clinic c/o fatigue. Take history of fatigue and manage it 🔑🔑 OSCE Dr. Nasser

Answer 52

Sign & Symptoms of Fatigue 1. **PHYSICAL** * Lack of energy, weakness, or light headedness * Yawning * Nodding off or head drooping 2. **MENTAL** * Difficulty concentrating * Making mistakes on well-practiced tasks * Forgetfulness * Difficulty thinking clearly * Poor decision makine 3. **PSYCHOLOGICAL** * Lack of motivation * Irritable Causes of Fatigue (Table) **OSCE was RLS & Management** **1) Iron correction 2)** Dopaminergic agents, Anticonvulsants, Benzodiazepines ERABI Module 13 Fatigue

Question 53

Management of Fatigue 🔑🔑 List 6 elements of sleep hygiene include 🔑🔑

Answer 53

**Non-Pharma** 1. Conserving energy and pacing: Prioritize their commitments & plan important activities when they feel they are at their best 2. Exercise: Start with aerobic exercise for cardiovascular health, general well-being, emotional and immune system functioning. 3. Sleep hygiene 4. Cognitive Behavioural Therapy (CBT) 5. Lifestyle management: Adaptive coping, goal management, healthy diet and self care for emotional, physical, and mental health 6. Light Therapy: expose to a short wavelength light (430-475 nm; blue wavelength light) upon awakening to alter melatonin production and secretion leading to increased daytime alertness and earlier onset of evening sleep **Sleep Hygiene** 1. Going to bed and getting up at the same time every day, including weekends 2. Avoiding naps, or taking naps for no longer than 20 minutes if necessary 3. Avoiding caffeine, alcohol and nicotine 4. Regular exercise 5. Avoiding heavy exercise and heavy meals for several hours before bedtime 6. Keeping bedroom quiet, dark, and at a comfortable temperature 7. Keeping stress and work out of the bedroom 8. No TV or computer while in bed 9. If unable to sleep, don’t lie in bed; get up and do a relaxing activity for a short while **Pharma (Dopamenergic)** 1. Methylphenidate 2. Modafinil ERABI Module 13 pg13 & Module 7

Question 54

List 4 causes of poor sleep in TBI 🔑🔑

Answer 54

1. Pain 2. Irritability 3. Anxiety 4. Obstructive sleep apnea 5. Restless leg syndrome → OSCE station 6. Trauma damaging reticular activating system (RAS) affecting sleep-awake cycle 7. Fatigue DeLisa 5th Edition Chapter 24 TBI pg595 PMR Secrets 3rd Edition Chapter 53 TBI pg437

Question 55

What are the three most common sleep disorders following an ABI?

Answer 55

1. Insomnia 2. Sleep apnea 3. Hypersomnia ERABI Module 13 pg17

Question 56

Patient with poor sleep quality. What would the adverse effect on rehab sessions?

Answer 56

1. Easily distracted and unable to focus on more than one task at a time 2. Rapid mental fatigue and may require frequent breaks 3. Complain of fatigue or frequently ask to return to their room or bed 4. Rest-seeking behaviors such as excessive time in bed, frequent naps, and inactivity 5. Asleep mid-task during a therapy session or require frequent cues to remain awake 6. Alterations in circadian rhythms, sleep patterns, and sleep quality.

Question 57

List some methods to improve sleep quality 🔑🔑

Answer 57

**Non-Pharma** 1. Sleep restriction (fewer naps during the day) 2. Sleep hygiene (turning off television or other sources of stimulation near bedtime) 3. Relaxation Strategies (warm footbath) 4. Lifestyle Management Strategies 5. Cognitive Behavioural Therapy 6. Regular Exercise 7. Light Therapy 8. Blood draws could be rescheduled to maximize uninterrupted sleep. 9. Alterations in therapy schedule may improve arousal and provide rest breaks at times of day when arousal is low. **Pharma** 1. Melatonin 0.5-1mg night time up to 5-10mg 2. Tricyclic antidepressants: Amytriptalin 25mg night time 3. Modafinil 100-200mg morning to improve circadian rhythm ERABI Module 7

Question 58

How do you approach and manage sleeping disorder in any patient? Management of Insomnia, Restless legs syndrome (RLS) and Sleep apnea 🔑🔑

Answer 58

**INSOMNIA** ≥3 nights per week for ≥3 months Causes: - Advanced age - Psychological factors - Lifestyle behaviours - sleep apnea Medications: Psychostimulants, anticonvulsants, antidepressants Medical: Growth hormone deficiency, hyperthyroidism Treatment 1. CBT 2. Sleep hygiene 3. Regular exercise 4. Avoid caffeine, other CNS stimulants 5. Melatonin 6. Tricyclic antidepressants **CIRCADIAN RYTHM** Causes: Lifestyle habits - Advanced age - Environment or occupation Medications: CNS depressants or stimulants Treatment 1. Sleep hygiene 2. Light therapy **RESTLESS LEG SYNDROME** ≥ 3 months and occurring ≥3 nights per week Causes: akathisia, periphral neuropathy, iron deficiency Medications: antihistamines, dopamine antagonists such as anti-emetics or antipsychotics, lithium, antidepressants such as SSRIs and TCAs, substances (caffeine) Treatment 1. Iron supplementation 2. Avoid caffeine, nicotine, alcohol 3. Exercise program 4. Dopamine agonists 5. Gabapentin **SLEEP APNEA** ≥15 obstructions per hour of sleep. Causes: central sleep apnea, obstructive sleep apnea, obesity hypoventilation syndrome, and sleep-related hypoventilation Others: Excess weight - Chronic nasal congestion - Smoking - Diabetes - Asthma - Hypertension Treatment 1. Morning modafinil 2. CPAP 3. Sleep specialist refferal **HYPEROSMIA** Medications: CNS depressants, opioids or other pain medications, anticonvulsants, anti-emetics, antihistamines, antidepressants, anxiolytics, beta-blockers, anti-spasticity medications, muscle relaxants Others: hypothyroidism - sleep apnea Treatment 1. Modafinil 2. Re-evaluate contributory medications ERABI Module 13 pg25

Question 59

Common signs and symptoms of depression following an Acquired Brain Injury. 🔑🔑

Answer 59

**At least 2 of the following core for the last two weeks:** 1. Depressed mood: feeling low, sad, or hopeless 2. Lethargy: reduced energy/ increased fatiguability 3. Anhedonia/loss of pleasure and interest **In addition:** 1. Ideas of guilt, unworthiness and failure 2. Disturbances in sleep 3. Diminished appetite. 4. Thoughts of death or suicide. 5. Difficulty concentrating. 6. Social withdrawal. ERABI Model 5 1. Reduced self-esteem and self-confidence 2. Bleak and pessimistic view of the future **ICD 10**

Question 60

Pharmacological treatments which have been shown to be effective in the treatment of depression specifically in those with an ABI.

Answer 60

💡 We want to increase both dopamin and seratonin. 1. Methylphenidate (Dopamenergic) 2. Citalopram (SSRI): start at 10mg, and increase to a daily dose of 20-40mg. ERABI Module 5 pg21

Question 61

Types of Post-traumatic Seizure (PTS) 🔑🔑

Answer 61

💡 Majority of PTS are simple partial 1. **Partial seizure** * Simple partial, preserved consciousness * Complex partial, impaired consciousness 2. **Generalized seizure** * Grand mal or tonic–clonic Cuccorollo 4th Edition Chapter 2 TBI pg74 ERABI Module 7 pg3 & pg9

Question 62

Incidence of post traumatic seizure? 🔑

Answer 62