Traumatic brain injury Flashcards

Question

GCS limitations

Answer 1

External factors which alter the patient's level of consciousness interfere with the scale's ability to accurately reflect the severity of a traumatic brain injury, e.g. metabolic disturbances Verbal response invalid patients who cannot speak (intubated / tracheostomy) Orbital trauma may make eye opening impossible Spinal cord injury invalidates the motor scale for the limbs (unless patient is obeying commands – then use tongue)

Answer 2

Always check neurological observations in nursing notes before assessing your patient with TBI If fully sedated, pupils assessment only. Abnormal pupil response → warrants medical or neurosurgical intervention, may contraindicate physiotherapy management GCS scores are important as patient emerges from sedation Once sedation is weaned, progress as tolerated: Respiratory: ventilator weaning – deep breathing, active cough Active / active assisted exercise – Letto, therapist or family-assisted Introduce anti-gravity activity, sitting over edge of bed, standing, sitting out Positioning for pressure relief, minimise contracture risk

Answer 3

``` According to GCS: 13 – 15: Mild 9 – 12: Moderate 3 – 8: Severe According to duration of post-traumatic amnesia – length of time from injury to restoration of continuous memory, period of confused state: < 1 hour: Mild 1 – 24 hours: Moderate > 24 hours: Severe ```

Answer 4

Herniation or ischaemia → Brain stem death | Systemic complications – respiratory, cardiovascular

Answer 5

Irreversible structural brain damage, incompatible with life Criteria: Diagnosis compatible with brain stem death Outrule other causes of reduced brain stem activity (barbituates, sedatives, hypothermia, endocrine) Pupillary response absent Corneal reflex absent Vestibulo-ocular reflex absent Gag reflex absent Motor response absent No spontaneous respiratory effort (movement and ABGs)

Answer 6

Severe bilateral hemisphere damage may result in a state in which the patient has no apparent awareness of themselves or their environment. Important to distinguish from “locked-in syndrome” Periods of eye-opening and closing may occur, suggesting sleep-wake cycles, and there may be spontaneous movements of face, trunk or limbs, but the patient does not communicate or interact with others in any way. Becomes “permanent” when irreversibility can be established with a high degree of certainty, e.g. 12 months after TBI. One month after trauma, up to 33% of patients will show improvement in the subsequent year. ``` Multidisciplinary management RAMP Principles: Maintain and Prevent Liaise with OT regarding seating Tone management: splinting, passive exercise (active / passive cycle ergometer – Letto), positioning (see Lecture 6) Family involvement NRH “SMART” programme Sensory stimulation ```

Answer 7

Post-traumatic amnesia (PTA) is the time after a period of unconsciousness when the injured person is conscious and awake, but is behaving or talking in a bizarre or uncharacteristic manner PTA = cannot remember injury or time afterwards Symptoms of PTA include confusion, agitation, distress or anxiety Uncharacteristic behaviours may include violence or aggression, both physical and verbal, swearing, shouting and disinhibition If the person is mobile, difficulties may be experienced in preventing wandering Increased risk of falls and orthopaedic complications

Answer 8

``` resp tone and ROM strength mobility / function balance cerebellum vestibular pain ```

Answer 9

PTA / cognitive impairment: focus, concentration, attention will be poor → not the time for task-specific training, intense practice of difficult motor skills Don’t expect the patient to remember exercises or instructions at first Engage in automatic tasks that patient understands and can see a point to it, e.g. walking, cycling, even football (with handling belt) Carefully choose the amount of stimulation: quiet times in the physio gym, time with visitors / family Be mindful of safety awareness, educate team and family Motor learning: practice, practice, practice

Answer 10

Irish pathway: acute hospital → neurosurgical unit → acute hospital → specialist rehabilitation (NRH) → long term care or home. People with TBI can have significant unmet rehabilitation needs Rehabilitation improves outcomes and saves costs (Turner-Stokes et al, 2016) TBI should be conceptualised as a chronic health condition (Wilson et al, 2017) Similar to SCI, plan for long-term mitigation of effects of physical inactivity

Answer 11

Sufferers of TBI have a reduced life expectancy, even after surviving the acute injury Diminished mobility is known to be a powerful predictor of increased mortality for patients with TBI, spinal cord injury, and many other conditions (Shavelle et al, 2001) Recovery of ambulation post TBI (Katz et al, 2004) 82% of patients who achieved independent ambulation did so at 2 months post injury 95% were independently mobile at 3 months For the remainder, only 9% recovered ambulation if they had not already done so at 3-4 months Shavelle et al (2001): Standardised mortality ratios in TBI survivors – 16.4 in immobile survivors, 4.5 in survivors with impaired mobility (mobilised >20ft +/- assistance), 1.5 in those able to climb stairs independently.

Answer 12

Seizure occurrence is a recognized complication of TBI Associated with poorer functional outcome after TBI (Asikainen et al, 1998) The reported overall incidence of late PTS or PTE has a range of 13–50%, depending on the population studied and the follow-up time Highest incidence noted in studies of war veterans, who have the highest incidence of penetrating TBI (Englander et al., 2003) Can experience either early or late onset post-traumatic epilepsy or seizure activity

Answer 13

May include some or all of the following after a known blow to the head: symptoms: somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and/or emotional symptoms (e.g. lability) physical signs (e.g. loss of consciousness, amnesia) behavioral changes (e.g. irritablity) cognitive impairment (e.g. slowed reaction times) sleep disturbance (e.g. drowsiness).

Answer 14

Topical issue in sports (see “Concussion” movie), but it has a long history…. Martland (1928) first investigated the association of chronic progressive neuro-degeneration from observation of boxers, when the term “punch drunk syndrome” was first used to describe a progressive dementing disorder in participants of the sport TBI in a number of other sports, such as American Football, can result in increased rates of late-life cognitive impairment (Guskiewicz et al., 2005) History of just a single TBI is a risk factor for the later development of clinical syndromes of cognitive impairment such as Alzheimer’s Disease (Fleminger et al, 2003)

Traumatic brain injury Flashcards

(38 cards)