Practice pattern 5I
impaired arousal associated with coma, near coma or vegetative state. inability to responsd purposely or become consciously aroused by external or internal stimuli. cerebral cortex must be activated to reach and maintain conscious arousal. Alertness and consciousness are regulated by the RAS in the brainstem.
RAS
reticular activating system is activated by various sensory inputs. feeback mechanism between the RAS and cerebral cortex maintains consciousness. bilat. damage to the ascending RAS or brainstem will result in some level of coma.
coma
state of profound unresponsiveness. inability to obey commands. inability to verbally respond. inability to open eyes and visually track. lack of sleep-wake cycles.
minimally conscious state
aka, light coma. may present with reflex, primitive or disorganized responses to stimuli. minimal but some purposeful awareness. gestural or verbal responses even if incorrect. verbalizaions of any words even if incorrect. movement or behaviors that are environmentally triggered not reflexive.
deep coma
no response to painful or any stimuli. not even a reflex.
vegetative state
state of arousal without behavioral evidence of awareness or ability to interact with the external environment. rudimentary arousal and apparent sleep-wake cycles. may have spontaneous eye opening bu no real visual tracking or purposeful limb movements.
locked in syndrome
all higher cortical functions intact. extensive lesions in the corticobulbar and corticospinal tracts but higher CNS system intact. cannot speak, move, or breathe.
Glasgow coma scale
eye opening (E 1-4), motor response (M 1-6), verbal response (V 1-5). worst possible score is 3=deep coma. best score is 15.
Glasgow scale outcome prediction
3-5 at admission 62% chance of death. 6-8=20% death and 74% good prog w/ mod. disability. 12-14=no chance of death or severe disability.
initial neuro exam for TBI/coma
pupillary response to light, eye movements (oculocephalic), oculovestibular (COWS), motor testing, sensory testing
factors affecting outcome
severity of initial TBI, hypoxemia, arterial hypotension, intracranial pressure, cellular responses secondary to injury.
Rancho Los Amigos Scale of Cognitive Function
ten levels of cognitive functioning used extensively to document status of patient and plan for medical/rehabilitative intervention.
PT related assessment
r/o fx esp. to C-spine. note spontaneous movement, response to external stimuli, respiratory pattern (Cheyne Stokes breathing controlled by CO2 receptors in CNS, ROM, tone, pathological posturing (decorticate v. decerebrate),
decorticate posturing
(pathological) lesion of the corticospinal tracts at the thalamus and internal capsule. =flexion of UE’s, ext of LE’s
decerebrate posturing
(pathological) lower ponse intact, vestibular nucleus intact. tone influenced by tonic neck reflexes and vetibular reflexes. extension of all 4 extremities.
flaccidity after TBI indicates…
lower brainstem lesion
coma treatment approaches
ROM, Sensor stim, orientation, prevent contractures and deformity, neck and trunk mobility, education for family and care team
Coma stimulation program
facilitates neuronal reorganizatin by providin meaningful stimuli during first few weeks post injury. pt must be neurologically stable w/ normal ICP, has a 1-3 in Ranch scale. can be noxious as last try. use tactile, kinesthetic, gustatory, olfactory, auditory, visual
positioning goals
to avoid contractures, deformity and skin breakdown. identify involuntary reflexes that influence posture. use splints or positioning devices as necessary.
positioning solutions for high extension tone
ABduction wedge between legs to prevent adduction, and heel lifter off the bed like the multi-podus boot.
positioning solutions for high flexor tone
can use long leg brace and a child’s size long leg brace on the arm
positioning solutions
hand cones, AFOs, dynasplint, functional hand splint, philadelphia collar if it will help hold up the head
severe posturing interventions
1st r/o medical deterioration. baclofen oral or intrathecal, botox for smaller mm.
TBI
dx post coma.
signs for TBI
LOC, pupil dilation uni/bilateral, motor weakness, confusion, disorentation, headache, blurred vision, vertigo, memory loss
epidural hematoma
between the inner skull and dura. tends to result in arterial bleed with fast onset of symptoms. “space occupying lesion”
subdural hematoma
btwn dura and arachnoid. can progress in days or even 2 weeks. “space occupying lesion”
subarachnoid hematoma
between the arachnoid and the pia-mater.most comm site of hemorrhage. AVM, aneurism, trauma. worst headache ever.
Grade 1 concussion
transient confusion. no LOC. sx resolve in 15 minutes.
Grade 2 concussion
takes longer than 15 minutes to resolve.no return to activity until a week after any symptoms have cleared.
Grade 3 concussion
LOC, seconds or minutes, immediate hospitalization.
2nd impact syndrome
sustaining a second head injury soon after the first, possibly before the brain has healed.
post concussion syndrome
dizziness, impaired memory and concentration, sensitivity to light, headache, irritability. weeks-months to resolve.
concussion tx
eval at 1-3 and 24 hours. rest, monitor sign and symptoms and get imaging if symptoms persist. risk of concussion goes up with each concussion and more so after a 2nd or third.
CTE
chronic traumatic encephalopathy-only diagnosed on autopsy. come on 10-15 later. often seen first as a personality change (depression and emotional lability w/ lack of impulse control). some movement abnormalities and cognitive changes.