13) TBI Flashcards
TBI
Caused by a bump, blow, or jolt to the head or penetrating head injury that disrupts normal fxn of the brain
Who is more at risk for TBI?
Males
Risk factors for hospitalization/death post-TBI
- Male
- Age
- Previous TBI
- Drugs & alcohol use
Primary Injury
Occurs at the moment of impact
Focal Injury
Occurs at moment of impact
Diffuse Injury
Widespread brain tissue damage
2° Injury
Triggered by primary injury, causing even more brain damage
What does 2° injury cause?
- Inflammation
- Cell receptor-mediated dysfxn
- Free-radical & oxidative damage
- Ca2+/Ion-mediated Damage
- Cerebral Edema
Contusion
Bruising
Coup Injury
At site of impact
Contre Coup Injury
Injury to the opposite side
Diffuse Axonal Injury
Shearing, tensile stress, & widespread injury
Open Head Injury
Skull Fx
Epidural Bleeding
Bleeding btwn the skull & dura; Caused by a blow to the head
What can epidural bleeding cause?
High ICP & brain shift
Why do epidural bleeds progress so quickly?
Bc the bleeding is usually arterial
What is the 1st sx of epidural bleed?
Fixed/dilated pupil on ipsilateral side bc of CN3 compression
What region of the brain is the most common place for epidural bleeds to occur & why?
Temporal region bc the temporal bones are the most commonly fx’ed
Tx for Epidural Bleed
Evacuation via burr hole or craniotomy
What gives a more favorable prognosis for epidural bleed?
If pt was conscious immediately after injury
Subdural Bleeding
Venous bleeding btwn the dura & brain
What determines the severity of a subdural bleed?
Speed of Onset
True or False: Sx’s of subdural bleed can appear immediately or be delayed.
True
Who are subdural bleeds most common in?
Very young & elderly
Tx for Subdural Bleed
Craniotomy w/dural incision
Subarachnoid Bleeding
Bleeding into the subarachnoid space bc of a ruptured blood vessel or severe blow to the head
Sx’s of Subarachnoid Bleed
- Severe HA
- Vomiting
- Confusion
- Altered Consciousness
- Sometimes seizures
What are the most common complications of subarachnoid hemorrhage?
Hydrocephalus, Seizure, & Re
Intraparenchymal Hemorrhage
Bleeding into the brain tissue
What is the most common cause of intraparencyhmal hemorrhage?
Non-traumatic mechanisms
What can intraparenchymal hemorrhages cause?
HIgh ICP & fatal herniations
Intraventricular Hemorrhage
Bleeding into the ventricles
What is intraventricular hemorrhage associated w/?
SAH & IPH
Subfalcine Herniation
Compression of pericallosal arteries, which causes HA & contralateral leg weakness
Transtentorial Hernia
Compression of PCA & CN3 causing:
- CN3 paresis
- Ipsilateral dilated pupil
- Abn EOM’s
- Contralateral hemiparesis
Tonsilar Hernia
Compresses pons & medulla & causes obtundation
What are the 2° mechinisms of injury associated w/TBI?
- Acidosis
- Cerebral edema
- Hypoxia
- Hypotension
- Hypercapnia
- Incr ICP
- Ischemia
Level 1 LOC
Coma; No eye opening, no sleep/wake cycle, & no response to stimuli
Level 2 LOC
Vegetative State; Have sleep/wake cycle, but no purposeful responses
- Means brainstem fxn is intact but cortical fxn is severly impaired
- Pt has general response to noxious stimuli
- Complex reflexes may be present
Level 3 LOC
Minimally conscious state; Inconsistent purposeful responses (Level 3)
Minimally conscious state (Level 3 LOC)
Inconsistent, but clearly discernible behavioral evidence of consciousness
- Pt will have localized response to stimuli
- Pt can inconsistantly follow 1 or 2-step motor commands
When is pt said to have “emerged” from a minimally conscious state?
- When they can use 2 different objects on 2 consecutive days
- Ability to answer 6/6 visual or auditory situational questions
Favorable Prognostic Indicators
- Initial GCS >5
- Pupillary response
- Younger age
- Limited trauma
- Short duration of PTA
- Low injury severity
- Higher intelligence
- Higher education level
Unfavorable Prognostic Indicators
- Midline shift
- Repeat injury
- Anoxia
- Mass lesion
- High ICP
- Hypotension
- Premorbid distability
- Poor work hx
- Hx of violence, drug, or alcohol use
What outcome measures are used to asses TBI outcomes?
- Brain Injury Awareness Questionnaire
- Coma/Near Coma Scale
- Community Integration Questionnaire
- Disability Rating Scale
- JFK Coma Recovery Scale
- Fxnl Independence Measure
- GCS
Acute care TBI management
- Early mobes in ICU
- PROM/Contracture management
- Positioning for skin integrity
- Behavior management
- Ongoing monitoring for 2° complications
2° complications of TBI
- Agitation
- Physiological shifts
What causes TBI-related agitation?
Damage to the frontal & temporal lobes
What kinds of meds are given to TBI pt’s?
- Anti-epileptics
- Dopamine agonists
- Anti-depressants
- Anti-psychotics
- Beta-blockers
Spasticity
Motor disorder characterized by a velocity-dependent incr in tonic stretch reflexes w/exaggerated DTR bc of UMN involvement, loss of descending inhibitory control from the reticulospinal tract, & overactive vestibulospinal tracts
Management for spasticity
- WB
- Stretching
- Serial casting
- Splinting
- Botox
- Oral meds
- Baclofen
Sx’s of Seizures
- Uncontrolled movements
- Unresponsiveness/Staring
- Chewing movements
- Hallucinations
- Sudden fatigue or dizziness
- Language changes
- High fever
- Loss of sleep/extreme fatigue
Side effects of anti-epileptic drugs
- Sleepiness
- Balance deficits
- Lightheadedness
- Dizziiness
- Trembling
- Double vision
- Confusion
What causes post-traumatic hydrocephalus?
- Overproduction of CSF
- CSF blockage
- Insufficient CSF absorption
True or False: Pt’s w/hydrocephalus can have either normal or high ICP.
True
Is a non-communicating hyrocephalus classified as communicating or non-communicating?
Non-communicating
Actue Post-Traumatic Hydrocephalus
Coma & focal neurological deficits
How will a pt w/chronic Post-Traumatic Hydrocephalus present?
Gradual decline in fxnl status or failure to improve
Who usually picks up on chronic post-traumatic hydrocephalus?
PT’s
What are the 3 cardinal signs of post-traumatic hydrocephalus?
1) Progressive gait disorder
2) Impaired cognition
3) Urinary incontinence
Sx’s of non-communicating hydrocephalus
Papilledema & cognitive changes
Management of hydrocephalus
Shunt placement & rehab
Concussion
Traumatically induced physiological disruption of brain fxn manifested by LOC, loss of memory for events right before/after the accident, altered mental state, or focal neurological deficits
How does concussion present?
Constellation of varied physical, cognitive, emotional, & sleep-related sx’s
Tx for Concussion
- Rest
- Rehab
- Cervical strengthening
- HA management
- Balance
- Vestibular Therapy
- Vision therapy
- Psychotherapy
- Sx-based meds
Why has there been an incr incidence of concussion?
Bc of incr youth sports participation
Consequences of concussion
- Predispostion for more concussions
- Cognitive slowing
- Early-onset alzheimers
- 2nd Impact Syndrpme
- Chronic Traumatic Encephalopathy
How long does it take for most concussions to resolve?
1wk
Do pt’s w/post-concussion syndrome return to baseline fxn?
No
