How is TBI severity measured? What is missing?
- ¡Glascow Coma Scale (GCS)
- ¡Loss of Conciousness (LOC)
- ¡Post Traumatic Amnesia (PTA)
- ¡imaging missing. need behavioral skills to measure severity.
Describe post traumatic amnesia. What is PTA? How is it measured? What does this test? What is the period of PTA?
- ¡PTA: The period of time after an injury where new memories are not made
- ¡Measured using the Galveston Orientation and Amnesia Test (GOAT)
- ¡The GOAT tests orientation to person, place, and time, recall of the circumstances of the hospitalization, and the last preinjury and first postinjury memories
- ¡The period of PTA is the number of days from the end of the coma to the patient passes the GOAT (Ellenberg, 1996)
Describe the Glascow Coma Scale. What does it assess? What domains is it scored on? What can it be used for? What can it help predict?
- ¡15 point scale used to assess neurological function following a trauma
- ¡Scored on 3 domains: Eye Opening, Verbal Response, Motor Response
- ¡Can be used to document changes in neurological functioning in the field
- ¡Can help predict outcomes (long run) (should be interpreted cautiously when extenuating circumstances prevent accurate responses)
- ¡Always use the highest level of skill demonstrated
Describe ow to interpret the glascow coma scale. What is mild moderate severe? What is a coma? What is the lowest score? What is a poot pronosis? What was the outcome of different scores?
- Mild - 12-15
- Moderate - 9-12
- Severe - 3-8
- ¡Lowest, most severe score= 3
- ¡Coma: 8 or less
- ¡Score of 7 or less poor prognosis
- ¡Jennet (1979): looked at outcomes
- ¡Scores of 3–4 resulted in death or VS in 87% of patients
- ¡Scores 5–7 = death or VS in 53% and moderate or good recovery in 34%
- ¡Scores 8–10 = moderate or good recovery in 68%
- ¡Score of 11 = moderate or good recovery in 87%
Describe a mild TBI. What does "mild" indicate? How much LOC do these people have? What is their GCS score? How long is their PTA? Will they recover quickly? Does it look like something is wrong?
- ¡“Mild” TBI (mTBI) indicates the severity of the damage to the brain. Does not reflect the full psychosocial and life impact
- ¡No Loss of Consciousness or LOC less than 30 mins
- ¡Glasgow Coma Scale score of 12-15
- ¡Post Traumatic Amnesia (PTA): less than 24hrs
- ¡May recover fully (like a concussion) or may have life-long difficulties with attention, executive function, sensory processing
- ¡Often don’t “look like” anything is wrong with them after acute phase - expectations
Describe moderate TBI? How long is the LOC? GCS score? PTA? What would a brain scan show? Long-term problems?
¡Loss of Consciousness between 30 mins and 24 hours
¡Glasgow Coma Scale score of 9-12
¡PTA: 1-7 days
¡May have signs of injury on a brain scan
¡Will have some long-term problems impacting work and/or daily routines
Describe severe TBI. How long LOC? PTA? What are they likely to have? Brain scan? long term?
¡Loss of consciousness/coma greater 24 hours
¡PTA: >7 days
¡Likely to have bruising and bleeding in addition to Diffuse Axonal Injury
¡Likely to have signs of injury on a brain scan
¡Will have long-term problems impacting work and daily routines
What are cognitive domains to be assessed with TBI (5)?
- ¡Problem solving
- ¡Executive Functioning
Describe attention. What are things to look out for (5)?
- ¡Eye contact
- ¡Sustained Attention
- ¡Selective Attention
- ¡Attention Switching
- ¡Oriented x1: Oriented to Self (Person)
- ¡Oriented x2: Oriented to Person and to Place
- ¡Oriented x3: Oriented to Person, Place and Time (month, year)
- ¡Oriented x4: Oriented to Person, Place, time and reason for injury
What aspects of memory are tested?
- ¡Immediate Memory
- ¡Short-term memory - story after a few minutes
- ¡Procedural Memory
- ¡Episodic memory
Describe executive functioning. What is it controlled by? What does this system allow? What is it responsible for?
- ¡Controlled by prefrontal cortex
- ¡The system that allows you to act in a way that is different than your “automatic”
- ¡Judgment- ability to evaluate situations, actions, priorities
- ¡Predicting consequences
- ¡Inhibition, self-regulation, “filter”
- ¡Modification of plans
Desribe blast injuries as they relate to hearing. Who has more symptoms? Normal hearing? Where are they diagnosed?
- ¡Blast exposed patients report more symptoms than non-blast exposed patients
- ¡Blast patients often are in normal range for hearing threshold, but are changed from before the blast.
- ¡30% of ear related injuries after blast are diagnosed in theater. Presence of ear-related injury is highly correlated to TBI.
- ¡11% of blast exposed have new onset hearing loss and 6% new onset tinnitus Dougherty et al.
- ¡Number of blast exposures does not impact hearing outcomes
What are other behaviors associated with TBI?
- ¡Agnosia, lack of insight/awareness
- ¡Emotional Disregulation
- ¡Lack of initiation
- ¡Central Auditory Processing disorder
How might a TBI patient be overstimulated?
¡Sensitivity to lights
¡Sensitivity to Sounds
Describe a coma? How long does unconsciousness have to last for? Can patient be awakened? What is their sleep/wake cycle?
- ¡Unconsciousness lasting at least 6 hours
- ¡Patient can not be awakened by any sensory stimulation including pain
- ¡No sleep/wake cycle
Describe a vegetative state. What are movements? Will they respond to stimuli? Is response generalized? What is PVS?
- ¡A patient is minimally arousible. Movements are automatic/reflexive and do not reflect cortical involvement or cognition
- ¡May respond inconsistently to stimuli
- ¡Turn toward stimuli
- ¡Follow moving object
- ¡Response may be generalized and not specific to stimuli
- ¡When a “vegetative state” last longer than 4 weeks it is considered a “Persistent Vegetative State”
Describe a minimally conscious state. How does a patient respond? What does this reflect?
¡Patient responds inconsistently in a way that reflects cognition/cortical involvement
- ¡Answers simple yes/no questions
- ¡Follows simple commands
What are Rancho Levels?
- ¡Developed in 1979 at Rancho Los Amigos Hospital in California, expanded in 2000
- ¡8 (or 10) levels that represent typical pattern of recovery from TBI
- ¡Patients may progress from one level to the next and later revert to a previous level when over stimulated or fatigued
Describe Rancho Level 1. What do they respond to?
¡NO RESPONSE/ TOTAL ASSISTANCE
¡A person at this level will:
¡not respond to sounds, sights, touch or movement.
Describ Rancho Level 2. What do they respond to? How quickly do they respond? What may responses include?
- ¡GENERALIZED RESPONSE- Total Assistance
- ¡A person at this level will:
- ¡begin to respond to sounds, sights, touch or movement;
- ¡respond slowly, inconsistently, or after a delay;
- ¡responds in the same way to what he hears, sees or feels. Responses may include chewing, sweating, breathing faster, moaning, moving, and/or increasing blood pressure.
describe Rancho Level 3. How often are they awake? How do they react? How quickly? What do they begin to recognize? What might they follow? What might they answer?
¡LOCALIZED RESPONSE- TOTAL ASSISTANCE
- ¡A person at this level will:
- ¡be awake on and off during the day;
- ¡make more movements than before;
- ¡react more specifically to what he sees, hears, or feels. For example, he may turn towards a sound, withdraw from pain, and attempt to watch a person move around the room;
- ¡react slowly and inconsistently;
- ¡begin to recognize family and friends;
- ¡follow some simple directions such as "Look at me" or "squeeze my hand";
- ¡begin to respond inconsistently to simple questions with "yes" and "no" head nods.
Describe Rancho Level 4
CONFUSED AND AGITATED- MAXIMAL ASSISTANCE
- ¡A person at this level may:
- ¡be very confused and frightened;
- ¡not understand what he feels or what is happening around him;
- ¡overreact to what he sees, hears, or feels by hitting, screaming, using abusive language, or thrashing about. This is because of the confusion;
- ¡be restrained so he doesn't hurt himself;
- ¡be highly focused on his basic needs; ie., eating, relieving pain, going back to bed, going to the bathroom, or going home;
- ¡may not understand that people are trying to help him;
- ¡not pay attention or be able to concentrate for a few seconds;
- ¡have difficulty following directions;
- ¡recognize family/friends some of the time;
- ¡with help, be able to do simple routine activities such as feeding himself, dressing or talking.
Describe Rancho Level 5
CONFUSED AND INAPPROPRIATE- Maximal Assistance
- ¡A person at this level may:
- ¡be able to pay attention for only a few minutes;
- ¡be confused and have difficulty making sense of hings outside himself;
- ¡not know the date, where he is or why he is in the hospital;
- ¡not be able to start or complete everyday activities, such as brushing his teeth, even when physically able. He may need step-by-step instructions;
- ¡become overloaded and restless when tired or when there are too many people around; have a very poor memory, he will remember past events from before the accident better than his daily routine or information he has been told since the injury;
- ¡try to fill in gaps in memory by making things up; (confabulation)
- ¡may get stuck on an idea or activity (perseveration) and need help switching to the next part of the activity;
- ¡focus on basic needs such as eating, relieving pain, going back to bed, going to the bathroom, or going home.
Describe Rancho Level 6
CONFUSED AND APPROPRIATE- Moderate Assistance
- ¡A person at this level may:
- ¡be somewhat confused because of memory and thinking problems, he will remember the main points from a conversation, but forget and confuse the details. For example, he may remember he had visitors in the morning, but forget what they talked about;
- ¡follow a schedule with some assistance, but becomes confused by changes in the routine;
- ¡know the month and year, unless there is a severe memory problem;
- ¡pay attention for about 30 minutes, but has trouble concentrating when it is noisy or when the activity involves many steps. For example, at an intersection, he may be unable to step off the curb, watch for cars, watch the traffic light, walk, and talk at the same time;
- ¡brush his teeth, get dressed, feed himself etc., with help;
- ¡know when he needs to use the bathroom;
- ¡do or say things too fast, without thinking first;
- ¡know that he is hospitalized because of an injury, but will not understand all of the problems he is having;
- ¡be more aware of physical problems than thinking problems;
- ¡associate his problems with being in the hospital and think that he will be fine as soon as he goes home.
Descibe Rancho Level 7
¡AUTOMATIC AND APPROPRIATE- Minimal Assistance
A person at this level may:
¡follow a set schedule;
¡be able to do routine self care without help, if physically able. For example, he can dress or feed himself independently; have problems in new situations and may become frustrated or act without thinking first;
¡have problems planning, starting, and following through with activities;
¡have trouble paying attention in distracting or stressful situations. For example, family gatherings, work, school, church, or sports events;
¡not realize how his thinking and memory problems may affect future plans and goals. Therefore, he may expect to return to his previous lifestyle or work;
¡continue to need supervision because of decreased safety awareness and judgment. He still does not fully understand the impact of his physical or thinking problems;
¡think slower in stressful situations;
¡be inflexible or rigid, and he may seem stubborn. However, his behaviors are related to his brain injury;
¡be able to talk about doing something, but will have problems actually doing it.
Describe Rancho Level 8
¡PURPOSEFUL AND APPROPRIATE- Supervision Level Assistance
- A person at this level may:
- ¡realize that he has a problem in his thinking and memory;
- ¡begin to compensate for his problems;
- ¡be more flexible and less rigid in his thinking. For example, he may be able to come up with several solutions to a problem;
- ¡be ready for driving or job training evaluation;
- ¡be able to learn new things at a slower rate;
- ¡still become overloaded with difficult, stressful or emergency situations;
- ¡show poor judgment in new situations and may require assistance;
- ¡need some guidance to make decisions;
- ¡have thinking problems that may not be noticeable to people who did not know the person before the injury
- Good insight into difficulties