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6 Neurological Dysfunction > L14 Severe TBI > Flashcards

L14 Severe TBI Flashcards

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1
Q

TBI Causes

A

falls
assaults
MVA
sports
gun shot
workplace
child abuse
domestic violence
military

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2
Q

Non-traumatic brain injury

A

stroke
infection
electric shock
seizure
tumor
toxic exposure
metabolic disorers
poisoning
cardiac arrest
drowning
drug overdose

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3
Q

TBI Definition

A

disruption in normal function of brain that can be caused by bump, blow, jolt to head or penetrating head injury

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4
Q

Epidemiology of TBI

A

214,00 TBI hospitalizations
69,000 TBI deaths

People 75+ had highest number of deaths/hospitalizations

males are 2x more likely to be hospitalized and 3x more likely to die

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5
Q

High risk populations for TBI

A

racial and ethnic minorities
service members, veterans
houseless individuals
correctional and detention facilities
DV survivors
rural areas

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6
Q

Top causes of TBI in US

A

falls
firearm related suicide
MVA and assaults

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7
Q

Incidence of TBI in sports

A

limited data sources means that it is currently undetermined

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8
Q

Closed Head Injury

A

skull not penetrated
focal and diffuse axonal damage

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9
Q

Open Injury

A

penetrating wound
focal axonal damage

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10
Q

Deceleration Injury

A

diffuse axonal damage

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11
Q

Coup-Contracoup Injury

A

Coup = moving object strikes head
Contracoup = head hits stationary object

diffuse axonal damage to opposite poles of the brain

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12
Q

Blast Injury

A

rapid pressure shock creating kinetic energy that causes deformation of the brain

diffuse axonal damage and higher incidence of PTSD

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13
Q

What lobes are susceptible to damage from external forces?

A

frontotemporal lobes

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14
Q

Focal Axonal Injury (Primary Brain Injury)

A

necrotic area is concentrated at the coup with compromised blood supply

lead to impairments based on neuroanatomy of area

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15
Q

Diffuse axonal injury (Primary Brain Injury)

A

non-contact forces of rapid deceleration and acceleration cause shearing and stretching injury in cerebral brain tissues

presents as extensive damage of axons predominantly in subcortical and deep white matter tissue of brain stem and corpus callosum

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16
Q

Secondary Injury of TBI

A
  1. trauma disrupts BBB
  2. Leukocytes, microglia, and astrocytes produce reactive O2 species
  3. Causes demyelination of axons and cytoskeletal disruption

causes neurodegeneration, glial scar, cell death

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17
Q

MILD TBI Criteria

A

Glasgow = 13-15
Loss of consciousness = 30 min or less
Post-traumatic amnesia = less than 24 h
Alteration of mental state = up to 24 h

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18
Q

MODERATE TBI Criteria

A

Glasgow = 9-12
Loss of consciousness = 30 min - 1 week
Post-traumatic amnesia = >24 hrs, <1 wk
Alteration of mental state = >24h

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19
Q

SEVERE TBI Critera

A

Glasgow = ≤ 8
Loss of consciousness = > 1 week
Post-traumatic amnesia = > 1 week
Alteration of mental state = >24 h

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20
Q

Fiver year outcomes of persons with TBI

A

22% died
30% became worse
22% stayed the same
26% improved

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21
Q

Lifetime economic cos of TBI

A

76.5 billion

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22
Q

Glasgow Coma Scale

A

assesses pts depth and duration of impaired consciousness and coma following TBI. Also used acute brain injuries

validity and reliability decrease when given to pts who are intubated or sedated

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23
Q

13-15 Glasgow

A

mild TBI
patient is awake
presents with confusion, but can follow directions and communicate

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24
Q

9-12 Glasgow

A

moderate TBI
drowsy or obtunded
can open eyes and localize pain

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25
3-8 Glasgow
Severe TBI pt is obtunded to comatose unable to follow directions decorticate or decerbrate posture
26
Obtunded
dulled or reduced level of alertness or consciousness
27
Glasgow scale test areas
eye opening response best verbal response better motor response
28
Decorticate Posture
Closed hands legs IR Feet inverted Arms are adducted and flexed
29
Decerebrate Posture
head and neck arched legs straight toes are PF arms are extended hands curled
30
Decorticate and Decerbrate posturing...
both abnormal responses indicates lack of cortex motor function worse prognosis for recovery is cause is not treated immediately
31
Diagnostic Procedures
urgent exam by ed team neck immobilization CT scan to look for fx, hemorrhage, edema once medically stable, MRI to look for more detailed injury
32
ER Medical Management of TBI
limit development of secondary brain damage, maintaining airway, replacement of fluid
33
Early Medical Management of TBI
coma inducing meds to reduce brain O2 demands diuretics to reduce fluid and intracranial pressure anti-epileptic meds to prevent seizure
34
Surgical Intervention for TBI
decompression of injured brain craniotomy removal of hematoma removal of skull fragments insertion of ICP external ventricular drain
35
External ventricular drain
drains CSF from ventricles in real time to external bag RN has to clamp it before PT used for TBI, stroke, brain tumor
36
Normal ICP
4-15 mmHG
37
Types of ICP Monitors
1. Subarachnoid bolt 2. Epidural bolt 3. EVD 1 + 2 only look at ICP data 3 does data and drains
38
Disorders of Consciousness Continuum
Brain Death Coma Unresponsive Wakefulness (vegetative) Minimally Consciousness Post-Traumatic Confusional
39
Arousal is supported by
brainstem defined as eye-opening
40
Awareness is controlled by
cerebral cortex wide frontoparietal network known as command following
41
Consciousness is controlled bu
cerebral cortex, thalamus, brainstem
42
Recovery from COMA or DOC
consciousness mesocircuits (widespread anatomical connections) facilitate recovery restoration of excitatory neurotransmission along subcortical and cortical pathways
43
Stages of recovery of consciousness
1. Wakefulness 2. Awareness, Arousal, Attention 3. Perception and Recognition 4. Speed of Info Processing 5. Memory 6. Reasoning and Problem-Solving 7. Executive Functioning
44
CP of Diffuse Axonal Injury
altered level of consciousness due to disruption of circuits between brainstem and cortex can have many impairments because of large volume of axonal damage in cortex and brainstem
45
Rancho of Cognitive Functioning Scale
used by brain injury HCP measures individual's recovery over time after brain injury recovery can plateau at any level and pt can fluctuate between stages
46
Rancho 1
"no response" individual appears to be in a deep sleep and is unresponsive to any stimuli total assist
47
Rancho 2
"generalized response" individual reacts inconsistently, delayed, and non-purposefully to stimuli limited responses that may include gross motor, vocalization, physiologic changes. Deep pain causes response Total assist
48
Rancho 3
"localized response" individual responds specifically but inconsistently to direct stimulus responses are directly related to type of stimulus may follow simple commands total assist
49
Rancho 4
"confused agitated" -heightened state of activity -decreased ability to process info -behavior is not related to environment -common hostility and attempts to climb out of bed -may perform actions but not upon request at times max assist
50
Rancho 5
"confused inappropriate" -appears alert and responds to simple commands consistently -agitation is out of proportion, relates to stimuli -inappropriate responses and high distractibility -impaired memory -requires assistance for self-care max assist
51
Rancho 6
"confused appropriate" -goal-directed behavior -needs external input -response to discomfort is appropriate -simple commands -carry-over for relearned activities -orientation is inconsistent -awareness of self and others is increased mod assist
52
Rancho 7
"automatic appropriate" -acts appropriately -robot like -poor recall of activities done -absent to minimal confusion -lacks insight -poor judgement and problem solving -unrealistic future plans -can begin to initiate tasks or social activities with schedule min assist routine ADLs
53
Rancho 8
"Purposeful appropriate" -alert and oriented -able to recall and integrate past events -aware and responsive to surroundings -independence at home and community -carryover for new learning -doesn't need supervision for learned activities -social/emotional/cognitive not at prior to injury level stand by assist
54
Rancho 9
"purposeful appropriate" -can shift between different tasks and complete independently -aware of impairments -compensatory strategies -cannot independently anticipate secondary impairment obstacles -w/assistance can understand consequences -w/assistance can understand emotional needs of others -depression, frustration stand by assist on request
55
Rancho 10
"purposeful, appropriate" -multitask with assistance -memory retention -independently anticipates obstacles from secondary impairments -takes corrective actions -requires more time or compensatory strategies -intermittent depression and frustration -can interact appropriately with others modified independent
56
Coma is equal to
Rancho 1
57
Vegetative state is equal to
Rancho 2
58
Minimally Consciousness State is equal to
Rancho 3
59
Post traumatic confusional state is equal to
rancho 4
60
Contraindications of PT for TBI
worsening or new neuro signs unstable vital signs EVD without orders from MD
61
Precautions for PT with TBI
surgical --helmet, icp neck immobilized until spine is imaged
62
PT Exam includes
brief systems review mobility assessment impairments outcome measures
63
Level of Consciousness Tests
pts in rancho 1-3 = focus of your exam document level of alertness with specific statement of what the patient did in response to particular stimuli
64
Level of Attention Tests
need to have attention before you can test cognition and executive function at least beyond rancho 3
65
Cognition and Executive Function Tests
may be ready for exam in rancho 4, but if agitated may need to wait until rancho 5 involves orientation, memory, ability to follow directions, judgement, visuospatial processing
66
Coma Recovery Scale Revised
6 sub-scales comprised of hierarchically arranged items reflecting brainstem, subcortical, cortically mediated behaviors lowest item on each subscale represents reflexive activity while highest item represents cognitively mediated behaviors
67
Coma Recovery Scale Scores
higher score indicates transition to higher arousal states scored from 0-23 >10 = minimally conscious state (rancho 3)
68
Rancho 1 PT Interventions
ongoing PT is not appropriate could see pt for 1-2 visits for family education on PROM and when PT will be provided
69
Rancho 2-3 Interventions
pts need to move position changes like PROM to AAROM, sitting at EOB with 2-3 person assist positioning devices to prevent loss of ROM and skin sensory stimulation (auditory, tactile, visual) family education
70
Monitor and document for Rancho 2-3
skin integrity joint ROM opening of eyes verbal response non-verbal responses amount of time they can tolerate activities before closing eyes or getting agitated
71
Progression/Regression for Rancho 2-3
slowly increase amount of time you provide sensory stimulation, amount of time spent sitting up (especially for ADLs), multiple sensory stimulation
72
What causes Agitation?
1. pathophysiological = neural injury leads to disinhibition of behaviors 2. behavioral = certain people 3. unmet basic needs 4. environmental vulnerability or stressors
73
PT Treatment Causes of Agitation
Too frequent feedback Task overload retention testing premature test to self-monitor contrived treatment delay in assistance
74
Warning Signs of Agitation
restlessness decreased visual contact decreased verbal output increased loudness of voice increased distractibility negative self-deprecating comments chewing
75
What to do if pt becomes agitated
1. remove them from stimuli or change stimuli 2. call a code gray 3. Avoid escalation 4. Remove yourself from the situation 5. use restraints some pts may use agitation to avoid PT. try to take note of patterns and change motivators
76
Agitated Behavior Scale
useful for pts with TBI, alzheimer's, stroke used to monitor agitation through recovery or throughout the day 14 behavior items, scored from 1 (absent) to 4 (extreme) total score is used to assess agitation, with higher scores meaning that agitation is worse
77
Measures on ABS
1. short attention span 2. impulsive 3. uncooperative 4. violent 5. explosive anger 6. rocking, rubbing 7. pulling at tubes/restraints/ivs 8. wandering from treatment 9. restlessness, pacing 10. rapid, loud, excessive talking 11. repetitive behaviors 12. sudden changes of mood 13. excessive crying or laughter 14. self-abusiveness
78
Rancho 4 PT treatment
1. Functional training using handling and neuro facilitation 2. Impairment based interventions (ROM, MMT, cognitive) 3. Assess for ADs, orthotics 4. Family Education on red flags and overstimulation
79
Tips for PTs with Rancho 4
1. Find good motivator for pt like family, tasks 2. Select interventions that maintain safety without agitating pt 3. Keep restraints on so they can be latched quickly 4. Use ADs or equipment 5. Handoff to other staff

6 Neurological Dysfunction (16 decks)

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