Mod-Severe TBI Flashcards by Lauren Wolfe

Prognosis

Highly variable

Depends on
- severity of injury
- age
- CT abnormalities
- concomitant injuries
- length of post-traumatic amnesia (PTA)

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Post-traumatic amnesia (PTA)

Inability to create new memories

Mild: <24 hours
Mod: 1-7 days
Severe: >7 days

> 2 weeks, prognosis is less optimistic

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Glasgow coma scale

Measures severity

3 categories
- verbal response
- eye opening
- motor response

Mild: 13-15
Moderate: 9-12
Severe: 3-8

See chart

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Primary brain injuries

Concussion
Diffuse axonal injury
Anoxic/hypoxic brain injury
Contusion
Laceration
Hemorrhage

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Secondary brain injuries

Hypotension
Hypoxia
Increased ICP
Cerebral edema
Vasospasm
Failure of autoregulation
Excitotoxicity
Production of free radicals

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Diffuse brain injuries

Concussion
Diffuse axonal injury (DAI)
Anoxic/hypoxic brain injury
Metabolically active areas (hippocampus, purkinje cells, basal ganglia)

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Focal brain injuries

Contusion
Laceration
Hemorrhage

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Diffuse axonal injury (DAI)

Widespread stretching of axons caused by rotation of the brain

Involves white matter, deeper structures if more severe

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Anoxic/hypoxic injury

Oxygenation status
MOI: asphyxiation, drowning, anaphylaxis

Parietal/occipital cortices, hippocampus, cerebellum, basal ganglia

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Poor prognostic factors

Hypotension
Hypoxia
Apnea
Cyanosis
Increased intracranial pressure

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Intracranial pressure

Increased volume in one area decreases volume in another

Increased pressure can cause midline shift of herniation

Management
- surgical decompression
- elevate HOB
- cooling
- diuretics

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How to limit secondary injury

Decrease brain metabolism/energy needs
- paralytics decrease stimulation
- barbituates decrease metabolic rate
- hypothermia decreases metabolic rate

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Possible consequences of TBI

Focal deficits based on area of injury

Cranial nerve damage

Cognitive and neurobehavioral issues

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Occipital contusions

visual processing difficulties or cortical blindness

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Motor cortex injury

contralateral paresis or paralysis

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Brainstem injury

disruption in cardiac and respiratory function

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Possible complications of TBI

heterotopic ossifications
Intracranial infection
Seizures

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post ictal

period after seizure ends but before patient has returned to his or her baseline mental status

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status epilepticus (SE)

A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes

Medical emergency, can be fatal

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Potential causes of acute seizures

Metabolic
Drug induced
Illness
Neurologic

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Epilepsy prognosis

Increased mortality
Increased risk of death by asphyxia
Increased risk of drowning
Increased risk of depression/suicide

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Focal onset seizure

Abnormal electrical discharge in specific part of brain (focused)

Awareness is retained during, no LOC

Jerking, paresthesia, or hallucinations

Auras

Focal dyscognitive seizure

Awareness is altered or LOC

Temporal or occipital lobe

Person appears confused

45-90 seconds

Focal absence seizure

Sudden cessation of ongoing conscious activity

Minor convulsive m. activity

Staring/eye blinking

Common in childrren

Generalized onset

Abnormal electrical activity wide-spread throughout brain

Generalized myoclonic seizure

Quick muscular jerky movement of body part or entire body Potential LOC Duration of seconds, may cluster

Generalized B tonic-clonic seizure

B convulsive seizures w/ tonic and/or clonic manifestations LOC, rigidity (tonic), jerking (clonic) Post: headache, soreness, mental dulling Complications: fractures, shoulder dislocation, aspiration, death

Generalized atonic seizure

Brief LOC and loss of postural tone "drop attacks" Common in children

Gabapentin

Seizure med anticonvulsant tonic-clonic

Lamotrigine

Seizure med acts on sodium channels

Topiramate

seizure blocking sodium channels

Tiagabine

seizure block reuptake of GABA

Seizure safety protocol

Call for help or code Secure patient - ease patient to ground or chair - clear space around, pillow behind head - careful logroll to clear secretions if necessary Do not put anything in pt. mouth or hold patient down (risk of fracture)

ED visit post-seizure

May not be necessary if - return to cognitive baseline - no physical injuries - fall w/ seizure was witnessed - no neck pain, concussion, vomiting, numbness, weakness

Seizures and exercise

- Hx of seizures - medications - patient education for medication consistency - seizure triggers - type/frequency - refer for depression Activity restriction for 2-3 months after new seizure diagnosis Ask neurologist if vigorous activity is safe

Side effects of seizure medication

slowed cognition altered reaction time nystagmus ataxia dysarthria lethargy nausea irritability skin rash

Coma recovery scale revised (CRS-R)

Assists w/ diagnosis, prognosis, treatment planning Coma vs vegetative state vs minimally conscious monitors changes over time

Rancho los amigos (RLA)

cognitive-behavioral stages of recovery from TBI

CRS-R: Coma

RLA I: no response complete loss of arousal no sleep/wake cycle

CRS-R: vegetative state/unresponsiveness wakefulness syndrome

RLA II: generalized response return of sleep/wake cycle no behaviors indicating awareness of self or environment

CRS-R: minimally conscious state

RLA III: localized response behavior indicates awareness of self and/or environment

CRS-R: emerging consciousness

RLA IV: confused-agitated

CRS-R: post traumatic confusional

RLA V: confused, inappropriate

CRS-R: post traumatic cognitively impaired

RLA VI: confused, appropriate emerged from PTA

RLA level II-III goal

main goal - stimulation

RLA level IV-V goal

allowing encouraging patient to be a more active participant in therapy

RLA level VI-X goal

initiation, more structure, new learning, gaining independence return to optimal level of function and participation

retrograde amnesia

partial or total loss of ability to recall event that have occurred during the time immediately before the brain injury

anterograde memory

ability to form more complete new memories, complicated by decreased attention and perception

post traumatic amnesia (PTA)

the time between the injury and the point at which functional memory returns

CRS-R: consciousness has emerged; RLA VII

automatic, appropriate min A needed for daily living skills ability to functionally communicate or use objects

CRS-S: consciousness has emerged; RLA VIII

purposeful, appropriate SBA needed for cog-behavior

CRS-R: consciousness has emerged; RLA IX/X

purposeful, appropriate SBA upon request for cog-behavior; modified independent