Week 2-TBI

Question 1

Definition of a brain injury?
Severity based on Glasgow scale?

Answer 1

-disruption of brain fxn due to a blow, bump, jolt, or penetrating injury to the head

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

Question 2

Description of a Primary brain injury vs Secondary brain injury

Answer 2

Primary
-brain comes into contact with an object (skull, external object)
-common damaged areas include: frontal lobe of brain, lat/temporal poles)
-from a rapid acceleration/deceleration or rotation
-common areas damaged: brainstem, corpus collosum
-Traumatic axonal injury (widespread tear of axons)

Secondary
-secondary damage/cell death
-From: hypoxia, hypotension, ischemia (lack of brain perfusion), edema (CSF build-up, accumulation of blood in subdural/epidural space), elevated ICP

*Normal ICP
-Supine: .9-16.3
-Standing: 5.9-8.3

Question 3

What’s a coup-contrecoup injury?

Answer 3

-Polar brain damage from opposite poles of the brain damaging one another after these areas bump into the ends of the skull

Question 4

Describe the 3 brain herniations:
-Uncal
-Central
Tonsilar

Answer 4

Uncal: medial part of temporal lobe (Uncas) is squeezed inward and puts pressure on midbrain; CN3 damage (pupillary dilation and lack of pupillary restriction to light)
*MUST have pupil dilation & disruption of consciousness

Central: diencephalon, thalamus, hypothalamus, and ,dial parts of temporal lobes are forced through a notch in the tentorium cerebelli; if not treated, basilar arteries can tear and cause fatal hemorrhage
*Decompression can occur if caught early

Tonsilar
-cerebellar tonsils shift through foramen magnum and cause pressure on medulla and upper cervical cord; cardiac/respiratory dysfunction due to medulla being affected

Question 5

Name a few ways you can help manage an acute TBI

Answer 5

-Stabilize- ortho injuries, hypoxia, hypotension(greatest threat to functional outcomes), hematomas or other masses

-Diagnostic testing- CT, MRI, EKGs

-Manage co-morbidities- fractures, lacerations, lesions

-Prevent/manage complications

Question 6

Potential complications pt can experience within the acute phase of TBI

Answer 6

-Infections (UTI, pneumonia)
-Seizures
-GI issues (ulcers, delta in gastric emptying, regurgitation f feeding tube, nutrition issues, aspiration)
-Respiratory (atelectasis-lung collapse, pneumonia)
-Cardiovascular (HTN, DVT-use compression/low molecular heparin)
-Dermatological (pressure injuries, lesions, abrasions)
-MSK (contractures, heterotrophic ossification)

Question 7

ICP (normal values & other info)

Answer 7

-Normal: .9-16.3
-Strongly associated with morbidity and mortality with high ICP
*medically treat if >20

Question 8

Cerebral Perfusion Pressure (CPP) normal values and other info)

Answer 8

-Normal: 60-80
*CPP<55 = ischemia (will be low with increased ICP or hypotensive)

*Normal MAP: 70-100 ; DPB+1/3(SBP-DBP)= MAP

Question 9

Interventions to help manage ICP

Answer 9

-Bed Positioning (HOB 15-30 degrees to promote venous drainage; hip flex >30 can increase IAP->increase ICP)

-Decrease external stimuli

-Mild hyperventilation (decreases PCO2 to 20-35->vasoconstriction->decreases blood flow to brain->decreases ICP)

-Diuresis (Lasix-takes fluid out of vascular system; Manitol-takes out fluid directly from the brain)

-Sedation (decreases sympathetic tone and movement induced hypertension to prevent cough/valsalva maneuver that could increase ICP; drugs such as lorazepam, diazepam, propofol to decrease ICP)

-Surgery (craniotomy vs craniectomy)

Question 10

Lines/Leads/Tubes: Central venous catheter

Answer 10

-can be multiple lumen, mono, bi, or triple lumen
-within the big vein near the heart
-central line
-administer meds, fluids, nutrients, used to draw blood

Question 11

Lines/Leads/Tubes: CVP monitor

Answer 11

-central venous pressure line
-direct measurement of BP in the R atrium and vena cava
-can mobilize pt with this but needs to be re-calibrated

*no tension on this lone (may cause arrhythmia)

Question 12

Lines/Leads/Tubes: Arterial Line

Answer 12

-goes directly into artery; harder plastic material
- radila, brachial, femoral(permission prio to out of bed/doing hip flexion >40 degrees)
-can be disconnected by nursing; if dislodged, apply immediate pressure

*should be below the transducer

Question 13

Lines/Leads/Tubes: Fecal collection vs Foley catheter

Answer 13

Fecal Collection
-Pouch (adhesive around the anus) vs tube (connected to anus)
-Colostomy (may need to be emptied prior to mobilization; look at gait belt considerations if this is present)

Foley catheter
-drains urine into a bag
-keep below level of bladder
-hook onto pocket or walker when mobilizing pt

Question 14

Lines/Leads/Tubes: Drains

Answer 14

-Jackson-Pratt (JP) drain (hand grenade; closed suction to collect bodily fluids from surgical sites)

-Hemovac (typical after orthopedic surgery; accordion device with one end of tube placed in the surgical site for drainage)

Question 15

Lines/Leads/Tubes: NG tube

Answer 15

-for feeding or attached to wall suction for abdominal decompression
-can be disconnected with permision
-don’t lie pt flat when feeding to help prevent aspiration

*could have 2 types in at same time
-smaller one- usually for feeding
-bigger one- usually for suction

Question 16

Lines/Leads/Tubes: feeding tube

Answer 16

-NG (nasal gastric)
-OG (oral gastric)
-G-tube: PEG (percutaneous endoscopic gastrostomy)
-J-tube (jejunum of small intestine)

*a lock is present if you need to disconnect

Question 17

Lines/Leads/Tubes: Chest tube

Answer 17

-used to drain air/fluid from pleura or medistinal space
-connected to a pleur-evac to maintain lung expansion

*Bubbling: wall suction
*Silent: water seal

Question 18

Lines/Leads/Tubes: Mechanical ventilation

Answer 18

-promotes oxygenation

-controls volume and pressure of air pushed into the lungs (normal breathing is a negative pressure phenomenon, but mechanical ventilation is positive pressure)

-Continuous mandatory ventilation (air volume is constant and there is a mandatory minimum of breaths per minute)

-Supported or intermittent mandatory ventilation (machine set a specific tide volume and adjusts amount of pressure based on pt’s airway resistance and chest compliance)

-Pressure assisted breathing (assisted spontaneous breathing; machine provides pressure support to assist in inspiratory volume)

Question 19

Examples of body structure/function impairments
-Neuromuscular
-Neurobehavioral
-Cognitive

Answer 19

Neuromuscular
-paresis
-abnormal tone/spasticity
-motor fxn
-postural control

Neurobehavioral
-aggression
-disinhibition (Do something w/o thinking about it)
-impulsive
-apathy
-emotional lability (quick changes in mood)

Cognitive
-arousal lvl
-attention
-concentration
-memory
-executive fxns (planning, organizing, time management)

Question 20

Examples of activity limitations

Answer 20

-walking/locomtion
-basic mobility/ADLs
-IADLs

Question 21

Examples of participation restrictions

Answer 21

-vocational
-family role
-community/social role

Question 22

cognition/behavior example deficits

Answer 22

-disorganzied thoughts
-confusion
-inability to adjust communication based on situation/environment
-inability to read social cues
-combativeness

Question 23

Arousal level chart with description of each level (6) in order from highest-lowest

Answer 23

-Alert: awake and attentive

-Lethargic: sluggish/apathetic; drowsy/falls asleep easily; attention difficulty; loud voice needed to keep pt awake

-obtunded: lessened interest in pt’s environment; slowed response to stimulation and requires repeated simulation; often needs loud voice or gentle shake to open eyes

-stupor: greatly dulled or suspended sense of sensibility; absent e of spontaneous mvt; responds only to noxious stimuli then quickly returns to unconsciousness once stimulus stops

-delirium: confusion, disoriented, agitated, hallunication; emerging from coma

-coma: deep unconsciousness for prolonged period of time; can’t be aroused even with noxious stimuli

Question 24

Levels of Consciousness (5)

Answer 24

-Conscious: awake and aware os surroundings

-Minimally Conscious State (MCS): follows simple commands; responds to stimuli inconsistently
-eMCS: demonstrates functional object use/communication; purposeful mvts with environment
-MCS+: behaviors related to language expression and comprehension; command-following, intelligebile verbalization, intentional communication
-MCS-: non reflex mvts (localizes noxious stimuli, visual fixation, localizes objects)

-Unresponsive wakefullness/Vegetative state: preserved arousal (spontaneous eye opening) without awareness; ONLY reflexive behavior

-Persistent vegetative state: when unresponsive wakefulness/VS >4 weeks

-Coma: complete absence of arousal and awareness

Question 25

Sympathetic Storming vs Post traumatic amnesia

Answer 25

-SS: paroxysmal hyperactivity (increase SNS activity); within the first few weeks of brain injury; bouts of increased HR/BP, RR, diaphoresis *Tend to have more severe brain injuries and poorer outcomes -PTA: the time b/w injury and a person's ability to form new memories *BEST clinical predictor of long-term cognitive outcomes

Question 26

Recommended Acute care outcome measures

Answer 26

-Rancho Levels of cognitive functioning -coma recovery scale-revised -agitated behavior scale -moss attention rating scale

Question 27

Description of Glasgow Coma Scale

Answer 27

-used to track progress in ICU setting; help triage pts to proper care team -looks at eye opening, motor response, verbal response -higher score=better prognosis -Scoring: >13: minor brain injury 9-12: moderate brain injury

Question 28

Rancho Levels of cognitive functioning Scale

Answer 28

-used to describe the pt's cognitive/behavioral patterns recovering from brain injury -takes into account pt's consciousness and lvl of assistance pt needs to carry out cognitive and physical functional activities

Question 29

Coma Recovery scale-revised

Answer 29

-used for pts with disorders of consciousness or in a coma with minimal responsiveness -to assess auditory fxn, receptive and expressive language, communication ability, motor fxns, arousal levels Scoring: 0-23 8: detects consciousness >/=10: MCS or eMCS *higher change score within 4 weeks in IRF, predicted likelihood of VS-> MCS/eMCS or MCS to eMCS

Question 30

Agitated Behavior Scale (ABS)

Answer 30

-measure agitation in acute phase of brain injury including aggression, disinhibition, and liability (extreme changes in mood/behavior) -should be administered at different times of the day to help recognize any pt patterns of behavior Scoring -higher score=worse agitation - <21= WNL - 22-28=mild agitation - 29-35=-64 moderate agitation - >35=severe agitation

Question 31

Moss Attention Rating Scale (MARS)

Answer 31

-observational tool for attention related behaviors following brain injury (for at least 2 days; restlessness/distractibility, sustained consistent attention, initiation) -higher score=better attention *usually for IP setting* *indicated for Rancho level >/= 4*

Question 32

Regarding prognosis- positive/negative factors

Answer 32

Positive: -higher IQ/education -early/rapid cognitive/motor improvements -access to services -no prior substance abuse/TBI Negative: -prolonged coma -post-traumatic amnesia -little/no change in Glasgow coma scale in 4 weeks time -+ brain injury findings on MRI

Question 33

Examples of written Prognoses

Answer 33

-this pt has good potential to return to independent functioning in a modified home environment in 5 weeks -it is anticipated that the pt will need 6 weeks I the rehabilitation facility and then continue with him for out-patient therapy -the positive/negative factors effecting her prognosis include...

Question 34

Highly Recommended for: -IP only -OP only -Both settings

Answer 34

IP: Coma recovery Scale & Moss Attention Rating Scale -others: Agitated behavior scale OP: High lvl Mobility Assessment (HiMAT) -others: Balance error scoring scale Both: 6MWT, 10MWT, BBS, Community Balance & Mobility scale, Disability rating scale, Functional Assessment Measure (FAM), MAS, QoL after Brain Injury, Ranchos Levels of Cog. Scale

Question 35

Functional Assessment Scale (FAM)

Answer 35

-to expand upon the FIM to include items more specific to brain injury -different disciplines score items -Measures: Self care, sphincter control, mobility, locomotion, communication, cognitive, psychosocial Score: <65 = risk of long-term unemployment *scored at admission and D/C

Question 36

Disability Rating Scale

Answer 36

-to track recovery of an individual from coma to community following brain injury -recommended to do at 72 hr of rehab admission & 72 hr prior to D/C -measures: consciousness, cognitive ability (NOT FUNCTIONAL; feeding/toileting/grooming), dependence of others, employability *lower score = less disability

Question 37

Balance Error Scoring Scale (BESS)

Answer 37

-to assess postural stabilities for pts with mild head injuries to assist in return to sport -looks at double leg stance (firm/foam surface), single leg stance (firm/foam surface), tandem stance (non-dominant in back; firm/foam surface) WITH each: barefoot & eyes closed 20 sec *count # of errors*

Question 38

QoL after brian injury

Answer 38

- to assess health related QoL following brain injury using a questionnaire

Question 39

Community Integration Questionnaire

Answer 39

-assess community interactions and social role in individuals following brain injury *higher score=better

Question 40

Ranchos Level 1 -description & some interventions

Answer 40

-No response, Total assist -coma; likely in ICU and on ventilator; no response to stimuli -Interventions (aimed to increase pt stimulus response): stimulate the 5 senses (auditory-radio, tv, voice; gustatory- sweet, sour, salty applied to gums/teeth; olfactory- various scents under nose; tactile- vibrations, textures; kinesthetic- PROM, early mobilization) -multiple short sessions

Question 41

Ranchos lvl 2 -description & some interventions

Answer 41

Generalized Response: total assistance -Vegetative state (spontaneous eye opening, or upon stimulation) w/o awareness; ONLY reflexive behaviors; slow/minimal stimuli responses -Interventions -continue sensory stimulation program from lvl 1; continue to elicit responses

Question 42

Ranchos lvl 3 -description & some interventions

Answer 42

Localized Response: total assistance -Minimal conscious state (minimal but inconsistent behavioral signs of awareness) -longer awake periods; no verbalizations; may grab at tubes/pull away from pain; can follow 1-step commands; won't remember info Interventions: -use of 1-step commands, allow additional time for responses, allow for rest, adapt w/c for positioning and mobility; talking to person at eye lvl

Question 43

Ranchos lvl 4 -description & some interventions

Answer 43

Confused Agitated: Maximal assistance -agitated (hitting behavior, cursing, yelling); restless; unable to reason; may confabulate (make up stories) Interventions: -provide calm atmosphere; limit distractions, don't force activities; when pt is upset you should attempt to change topic/re-direct convo; use of automatic activities (walking, standing up) *DON'T EXPECT CARRYOVER* *Keep activities simple* *highly structured environment is needed* Overall goal: prevent reconditioning, maintain/increase ROM, improve stimulus response

Question 44

Ranchos lvl 5 -description & some interventions

Answer 44

Confused, inappropriate, Non agitated: max assistance -max structure needed for basic tasks; need for step by step instructions -not fully Oriented; wakefulness with awareness -can perform previously learned tasks (eat, dress) -poor problem-solving (doesn't recognize errors) -preservation is common (focused on 1 thing) Interventions -repeat instructions several times -work on orientation (memory planner) -gentle correction of misinformation -increase minutes of participation -consistent schedule (do activities the same way each time)

Question 45

Ranchos lvl 6 -description & some interventions

Answer 45

Confused, Appropriate Moderate Assistance -memory evident but still requires assistance -self-centered behavior -insight into some deficits they have -focal injury deficits (L or R sided weakness; comprehension issues; word-finding problems) Interventions -work on problems solving -start allowing pt to be more responsible in things (stretches, exercise routine -functional activities -continue to practice familiar tasks with corrections pen

Question 46

Ranchos lvl 7 -description & some interventions

Answer 46

Automatic, Appropriate: min assistance -consistent day to day memory & orientation -unable to recognize consequences -overestimate their abilities and may not know why they can't do things -continued socially inappropriate behaviors Interventions -facilitate organization and execution of activities with minimal supervision -increase endurance -job training skills -family education to recognize and understand limitations/disabilities

Question 47

Ranchos lvl 8 -description & some interventions

Answer 47

Purposeful, appropriate: standby assist -can fxn in most social situations -may return to school/work -able to acknowledge impairments (be mindful of depression) -much greater independence but still some cognitive deficits Interventions -reminders to use compensatory strategies for memory -community re-intergration (support groups, vocational rehab) -high reps to increase neuroplasticity -aerobic conditioning (high intensity gait training)

Question 48

Ranchos lv 9 -description & some interventions

Answer 48

Purposeful, appropriate: standby assist on request -aware of need for occasional assistance -able to shift attention b/e activities - able to think about consequences Interventions -community reintegration and QoL important factors -functional training (dual-task; high lvl mobility and interaction with environment (walk backwards, run, skip, stairs); high lvl balance training)

Question 49

Ranchos lvl 10 -description & some interventions

Answer 49

Purposeful, appropriate: modified independent -independent in activities within their physical capabilities (may still have paresis) -independently using compensatory strategies -some activities may still take more time for processing Interventions -address physical deficits -address endurance deficits (high intensity gait training to increase walk speed/distance for example)