Test 3: Severe TBI

Question 1

what is severe TBI

Answer 1

most significant

Low GCS level

low level arousal

high need for medical management

Question 2

GCS for severe TBI

Answer 2

<9

3-8

Question 3

loss of consciousness for severe TBI

Answer 3

> 24 hours

Question 4

O-log score for severe TBI

Answer 4

<25 for 7 days

Post Traumatic Amnesia (PTA) >7 days

Question 5

what is post traumatic amnesia

Answer 5

unable to remember events on ongoing basis for period of time after traumatic event

results in confusion and disorientation

measured with orientation log (O-log) or Galveston Orientation and Amnesia Test (GOAT)

Question 6

what is retro grade vs antero grade amnesia

Answer 6

loss for events before injury or after injury respectively

common with PTA

pts tend to never recover the memories of the accident possibly due to events never being encoded/stored

Question 7

scores on goat and O-log that indicate post traumatic amnesia

Answer 7

o-log <25/30 for >7 days

GOAT <75/100 for >7days

may not be able to participate in instrument based on medical stability and level of consciousness

Question 8

describe the Galveston Orientation and Amnesia Test

Answer 8

assesses PTA and retrograde amnesia in pts who had severe TBI

measures orientation to person, place, and time

measures memory for events preceding and following the injury

<75 = PTA

<66 = impaired

Question 9

coma vs vegetative state vs minimally conscious

Answer 9

coma = complete absence of arousal and awareness

vegetative = arousal without awareness

minimally conscious = minimal, reproducible, but inconsistent awareness

Question 10

describe Ranchos levels I-III

Answer 10

I - no response: pt in deep sleep, unresponsive to any stimuli

II- generalized response: pt reacts inconsistently and non-purposefully to stimuli in non-specific manner

III - localized response: pt reacts specifically but inconsistently to stimuli; may follow simple commands in an inconsistent delayed manner

Question 11

imaging for diagnosing severe TBI

Answer 11

head CT initially

MRI of brain 24-48 hours later for higher sensitivity or if CT initially negative

Question 12

describe TBI MOI: axonal diffuse axonal injuries

Answer 12

one of more common types of TBI

most common with acceleration/deceleration mechanism of injury (i.e. high speed MVA)

disrupts parasagittal white matter, corpus callosum, and pontine mesencephalic junction

microscopic injury; often undetected on imaging

Question 13

what info do you want from history and interview of a pt with severe TBI

Answer 13

arousal, consciousness, and behavior limit:
- rely on chart/family/team members
- pt interview in low stimulation closed environment

PLOF vs CLOF

co-morbidities

medical status; may be dynamic; consult pts primary RN prior to eval

Question 14

chart review contraindications

Answer 14

ICP > 20mmHg

MAP<60 mmHg

CPP<60mmHg

SpO2<90%

any other labs out of treatable limits

vent settings too high

vitals outside of treatable limits

Question 15

outcome measures for cognitive review of severe TBI pts

Answer 15

coma recovery scale- revised (CRS-R)

Moss Attention Rating Scale

Rancho Levels of Consciousness Scale

Question 16

scores for CRS-R that indicate severe injury

Answer 16

score range from 0-23

higher score = increased consciousness

lower score = WORSE

Question 17

rating for MARS

Answer 17

attention related behaviors

frontal lobe damage affects attention

22 items

5 pt rating scale

higher scores = better attention

Question 18

3 body structure and function systems involved in TBI

Answer 18

neuromuscular

cognitive

neurobehavioral

Question 19

neuromuscular review for TBI

Answer 19

PROM testing - postureing/tone
motor exam
sensory exam
reflexes
- babinski
- hoffman
- DTRs
- clonus

Question 20

what would you look at/screen for cardiopulmonary system

Answer 20

vitals

ventilator settings

ICP - try for below 22 mmHg; below 20 is ideal

CPP (cerebral perfusion pressure) - try for between 60-70mmHg
- CPP = MAP-ICP
- MAP = (1/3SBP) + (2/3 DBP)

Question 21

MSK screen with TBI pt

Answer 21

screen for heterotopic ossification

contracture risk
- need slint?
- serial casting?

Question 22

what is heterotopic ossification

Answer 22

abnormal development of bone (osteogenesis) in areas of soft tissue

pt with hypertonicity at risk; restricts motion

unknown etiology

clinically significance HO in 10-20% TBI pts

most often at hip and knee

can lead to contractures, pressure injuries, impaired mobility, and compromised ability to perform ADLs

Question 23

early S&S of HO

Answer 23

swelling
joint pain
muscle pain
decreased ROM
redness
local warmth
possible low grade fever

Question 24

management of HO

Answer 24

pharmacological management
PT for ROM maintenance
sx for severe limitations
careful with PROM; dont want to cause trauma
surgical excision when HO causes extreme limits

Question 25

integumentary screen

Answer 25

wounds - primary from accident pressure ulcers - secondary injuries due to prolonged bedrest and immobility

Question 26

GI/GU items you want to screen

Answer 26

foley catheters fecal management systems overactive or neurogenic bladder

Question 27

important considerations for TBI exam

Answer 27

spasticity/tone - synergy patterns/abnormal tone - decorticate or decerebrate rigidity sensorimotor impairments postural stability in sitting/standing - upright interventions can improve arousal functional mobility - FIM - synergy patterns present gait (if appropriate) - synergy patterns present

Question 28

team members who may be involved with TBI

Answer 28

neurosurgery neurology internal medicine nursing pharmacy social work care management social work care management OT SLP physical medicine and rehab (PMR) RT PT

Question 29

examples of interventions for severe TBI

Answer 29

arousal management upright postural stability wheelchair seating passive ROM positioning caregiver edu

Question 30

ways to increase stimulation with TBI pt

Answer 30

pharmacologically = Amantadine sensory stimulaiton - increase LOC and elicit movement in those with low levels of arousal stimulate reticular activating system others - auditory - hand over hand - nail bed pressure - temp change - sternal rub - vestibular stim - upright intervention

Question 31

ways to decrease stimulation with TBI pt

Answer 31

limit touch, sound, visual stimulus create stimulation schedule

Question 32

how to introduce upright interventions for arousal

Answer 32

if stable/no contraindications start with raising HOB - chair position in bed - TBI HOB should not be less than 30 deg for ICP purposes monitor EVD - consult RN may consider sitting EOB if minimally conscious

Question 33

describe a tilt in space wheelchair and its benefits/cons

Answer 33

great for getting pt upright can tilt for pressure relief moving pressure form ischials to sacrum need mechanical lift to get them in chair. caregiver needed to transfer pt and chair need specialized cushion for protection

Question 34

what is serial casting

Answer 34

joint immobilized at end range for 2-5 days at a time cast removed and further stretching is performed and new cast is set with new ROM repeat process until significant ROM gains achieved

Question 35

indications for serial casting

Answer 35

often used for PFs or bicep contractures long term soft tissue changes due to spastic posturing no evidence that it improves spasticity only that it can improve muscle tissue length

Question 36

contraindications for serial casting

Answer 36

risk of skin breakdown (pressure ulcer) or pt hurting themself with cast monitor limb distal to cast for signs of swelling or circulatory problems

Question 37

important things to consider when providing caregiver education and training

Answer 37

stimulation schedule splinting schedule PROM pressure injury prevention bowel/bladder management body mechanics DC planning/prognosis equipment usage - lifts - hospital bed - WC - feeding equipment - assistive technology - cushion management