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PassPMR - 02 Acquired Brain Injury > 2- Consciousness & Prognosis > Flashcards

2- Consciousness & Prognosis Flashcards

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1
Q

What is consciousness? 🔑🔑

What are the three structures involved in consciousness?

Mention the system that is responsible for consciousness state

A

CONSCIOUSNESS

State where a patient is cognitively aware and able to interact with internal and external environmental stimuli in a meaningful way

COMPONENTS

  1. RAS (Reticular activating system) cell bodies in midbrain
  2. Thalamus.
  3. Cerebral cortex

MECHANISM

RAS is a network of neurons located in the brain stem that project sensory input into the cortex via thalamus and extrathalamic pathway which help us respond to the world around us and interpret incoming information. So RAS controls our consciousness, attention, arousal level, sleep and waking and fight-or-flight responses.

ERABI Module 1 pg18

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2
Q

Mention disorders of consciousness

List 4 descriptive features of patient who is Comatose 🔑🔑

List 4 descriptive features of patient who is Vegetative State 🔑🔑

List 6 descriptive features of patient who is Minimally Conscious State 🔑🔑

A

COMA

  1. Patient’s eyes remain closed, patient is not awake, lack of sleep wake cycles on EEG
  2. No awareness of self or environment
  3. No spontaneous purposeful movement or ability to discretely localize noxious stimuli.
  4. No evidence of language comprehension or expression

VEGETATIVE STATE

  1. Patient’s eyes are opened, patient is awake, evidence of sleep wake cycles on EEG
  2. No awareness of self or environment
  3. No perceivable evidence of purposeful behavior
  4. Presence of a sudden verbal or auditory non-specific response

MINIMALLY CONSCIOUS STATE

  1. Evidence of self or environmental awareness.
  2. Reproducible (or sustained) purposeful behaviors.
  3. Simple command following
  4. Comprehensive verbalization
  5. Gestural or verbal yes/no responses
  6. Smooth pursuit tracking
  7. Visual fixation
  8. Emotional or motor behaviors with specific stimuli (Smiling or getting angry)

Cuccurollo 4th Edition Chapter 2 TBI pg60-62

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3
Q

When patient is considered off Minimally Conscious State? 3 Marks 🔑🔑

A

💡 She communicate, follows the command and use her control system

  1. Reliable use of a communication system
  2. Consistent command following
  3. Functional object use

Cuccurollo 4th Edition Chapter 2 TBI pg62

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4
Q

When do you diagnose patient with persistence or permanent vegetative state? 🔑🔑

A

Cuccurollo 4th Editio Chapter 2 pg61

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5
Q

TBI patient with GCS of 8.

What else would like to examine to determine the severity of his injury?

What to examinations would you preform as prognostic indicators?

A

ANSWER 1

  1. Pupillary responses (CN 2 afferent 3 efferent)
  2. Corneal responses (CN 5 afferent 7 efferent)
  3. Oculocephalic reflexes “Doll’s eye” (CN 8): Central eye indicate abnormal response.
  4. Caloric Testing (CN 8): Away from hot, closer to cold, otherwise consider it negative response.
  5. Gag reflex (CN 9,10)

ANSWER 2

  1. Glabellar reflex: Orbicularis oculi contraction on percussion of the glabella
  2. Pupillary light reflex
  3. Oculovestibular reflex: “Doll’s eye” maneuver: horizontal → moving head forward from side to side or vertical → moving head up and down
  4. Oculocardiac reflex: Bradycardia induced by increasing pressure on the eyeball

Cuccurollo 4th Edition Chatper 2 TBI pg65

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6
Q

Describe the basic levels of consciousness, from full alertness to deep coma.

A

💡 ALOSC

  1. Alertness: awake and fully aware of normal external and internal stimuli.
  2. Lethargy: not fully alert and tends to drift off to sleep when not actively stimulated.
  3. Obtundation: difficult to arouse, and when aroused, is confusional.
  4. Stupor and semicoma: respond only to persistent and vigorous stimulation.
  5. Coma: completely unarousable and remain with their eyes closed.

The Mental Status Examination in Neurology p30

Braddom 6th Edition Chapter 1 Physical History & Examination pg7

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7
Q

You have been asked to assess a patient who was involved in a car accident in ER. When you examine the patient, you noticed that he is able to open his eyes spontaneously but seems to be confused and disoriented and pulls the examiner’s hand away when pinched. What is his Glasgow Coma Scale? 🔑🔑 EXAM

A

E4 V4 M5 total 13

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8
Q

List 3 main prognostic indicators 🔑🔑 EXAM 2021

List 3 severities of TBI

What is the best acute predictor of outcome? 🔑🔑

Coma & Post-traumatic Amnesia Duration and relation to recovery and disability🔑

A

💡 Memory Aid:

  • GCS: 8 - 9 - 13
  • Coma: 1/4 Hour - 1/4 Day - 2 Days - 2 Weeks - 4 Weeks
  • PTA: 1 Hour - 1 Day - 1 Week - 2 Months - 3 Months

Best acute predictor of outcome:

  • Motor response, particularly 2 weeks postinjury

Good Recovery

  • Coma lasts <2 weeks
  • PTA lasts <2 months.

Poor Recovery

  • Coma lasts >4 weeks
  • PTA lasts >3 months.

Cuccurollo 4th Edition Chapter 2 pg65

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9
Q

Define period and end of PTA? 🔑🔑 When does patient emerge from PTA? what does it indicate?

A

Period of PTA

Defined as the number of days beginning at the end of the coma to the time the patient attains the first of two successive GOAT scores ≥75

End of PTA

Defined as the date when the patient scores 75 or higher in the GOAT for 2 consecutive days

Resolution of PTA

Clinically corresponds to the period when coding daily activities and events in the working memory

Cuccurollo 4th Edition Chatper 2 TBI pg65

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10
Q

How can PTA duration affect the prognosis?

A

Before 1 Week, full recovery

  • 1 Day fast full recovery
  • 1+ Days slow full recovery
  • 1 Week, very slow recovery

After 1 Week, disability starts

  • 1-2 Weeks, prolonged recovery with mild disability
  • 2-4 Weeks, very prolonged recovery with permanent disability
  • 4+ Weeks, significant disability

Cuccurollo 4th Edition Chapter 2 TBI pg66 Table 2-4 Classification of PTA

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11
Q

How to assess for PTA for newly admitted TBI patient? why it’s important?🔑🔑 OSCE

A

INDICATION

To be used in agitated patient as patient may not emerge from PTA

TESTING PTA

  1. Galveston Orientation and Amnesia Test (GOAT)
    • Normal >75/100
    • Boarderline 66-75/100
    • Impaired <66/100
  2. Orientation Log (O–Log)
    • 25/30

QUESTIONS (GOAT)

  1. Time: Day / Month / Year & Time
  2. Place: Date, transportation, reason
  3. Person: Name, DoB, Address
  4. Pre & Post Memory
    • Memory before the injury (retrograde amnesia)
    • Memory after the injury (antrograde amnesia)

Cuccurollo 4th Edition Chapter 2 TBI pg65-66

ERABI Model 1 pg22

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12
Q

5 Domains of Post-traumatic Amnesia (PTA)

A

💡 CAD & 2 amnesias

  1. Confusion
  2. Agitation and delusions
  3. Disorientation
  4. Retrograde amnesia
  5. Inability to store new memories

ERABI Model 2

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13
Q

How does Post-traumatic Amnesia (PTA) patient look alike? Bonus Question

A
  1. Patient doesn’t remember his daily activities.
  2. He can’t think ahead.
  3. He goes robotically from place to place and from task to task as directed by her therapists.
  4. If he’s able to speak, he asks the same questions repeatedly because he can’t remember the answers.

Google

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14
Q

What is working memory? What are the parts of working memory? (Extra Bonus Question)

A

Working memory

  • Brain system that provides the temporary storage of information that can be held in mind and used in the execution of cognitive tasks

Examples

  • Keeping a person’s address in mind while being given directions.
  • Dialing a telephone number that you were just told.
  • Calculating the total bill of your groceries as you are shopping (mental math)

Components

  1. Phonological loop - Access to verbal information or sounds.
  2. Visuospatial sketchpad - Manipulating visual images.
  3. Episodic Buffer - limited capacity storage system responsible for integrating information from several sources to create a unified memory, sometimes referred to as a single ‘episode’
  4. Executive control system - Controlling, monitoring and regulating information needed for reasoning and problem solving.
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15
Q

List 5 negative (poor) prognostic factors in TBI outcome🔑 🔑

A

ANSWER 1

MAJOR FACTORS “TBI SEVERITY”

  1. Length of coma (LOC) > 2 Days
  2. Post Traumatic Amnesia (TPA) > 1 Week
  3. Initial CGS < 9
  4. Motor response 2 weeks post injury (most important)
  5. Old Age

OTHERS

  1. Injury etiology
  2. Injury severity
  3. Prior brain injury
  4. Sex
  5. Medical commodities

BRAIN STEM REFLEXES

  1. Decerebrate posture
  2. Abnormal Caloric testing
  3. Abnormal Oculocephalic Test (Doll‘s eye sign)
  4. Fixed dilated pupils

ERABI Module 1 Table 1.2 & Module 2 pg 7

ANSWER 2

  1. Age > 75
  2. Violence
  3. Military Blast Injury
  4. High-speed vehicular crashes (multiple injuries)
  5. Child abuse (shaken baby syndrome)
  6. TBI with hemorrhagic shock

Braddom 6th Edition Chapter 43 TBI

ANSWER 3

  1. Age: young children (<5 years old) and older adults (>65 years old) have greater mortality.
  2. Rate of early recovery
  3. Pupillary reaction to light: reactive pupils after TBI achieve moderate disability to good recovery
  4. Time: Most recovery usually occurs within the first 6 months postinjury.
  5. Post coma use of phenytoin: Long-term use of phenytoin has been reported to have adverse cognitive effects
  6. Decorticate posturing is a more positive prognostic indicator than decerebrate posturing or flaccid muscle tone

Cuccurollo 4th Edition Chapter 2 TBI pg66

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16
Q

Name 4 outcome measures by which you can follow a TBI patient 🔑

A

GLOBAL & FUNCTIONAL

  1. Functional Independence Measure (FIM)
  2. Barthel Index (BI)
  3. Disability Rating Scale (DRS)
  4. Berg (Balance) Scale: Score ≤45 indicates an increased risk of falling

AMNESIA

  1. Galveston Orientation and Amnesia Test (GOAT)
  2. Orientation Log (O–Log)

AGITATION

  • Rancho Los Amigos Scale (RLAS)

Stage 4 = Confused, Agitation

Stage 5 = Confused, Non Agitated

Stage 6 = Confused, Appropriate

  • Agitation Behavioral Scale (ABS)

< 21 = Low agitation

22-28 = Mildly agitated → Environmental measures

29-35 = Moderately agitated → Environmental measures

36-56 = Severely agitated → Pharmacological measures

17
Q

List 4 Pupillary findings correlate with poor outcomes 🔑🔑

A
  1. Bilateral fixed dilated pupils (CN 3)
  2. Loss of pupillary reaction to light (CN 2 → 3)
  3. Loss of corneal reflex (CN 5 → 7)
  4. Loss of oculocephalic reflexes (CN 8)
  5. Gaze deviations to the ipsilateral side
18
Q

List 4 Parameters of ImPACT Trial for TBI severity.

A
  1. I = Injury severity
  2. P = Pupillary reactions
  3. A = Age
  4. CT = Midline shift
19
Q

Shaken baby syndrome (SBS) Triad

A
20
Q

Age is poor prognostic and risk factor in ABI for couple reasons

A
  1. Less neuronal plasticity
  2. Decreased balance and syncopal episodes → Falls
  3. Fragile bridging veins → SDH
  4. On anticoagulant → Higher risk of bleeding
21
Q

Decorticate vs Decerebrate Posturing. What is the clinical significance? 🔑🔑

A

Decorticate

  1. Flexion of the upper limbs (elbows bent to the core, heart)
  2. Extension of the lower limbs

Decerebrate

  1. Opisthotonus: spasm of the muscles causing backward arching of the head, neck, and spine.
  2. Clenched jaws
  3. Stiff, extended limbs internal rotation of arms
  4. Ankle plantar flexion

Decerebrate posturing is worse and indicates significant brain stem (midbrain) damages.

22
Q

Acute complaints after mTBI typically fall into three symptom clusters 🔑

A

💡 Mental - Mood - Somatic

  1. Cognitive: difficulties with attention, speed of information processing, and memory
  2. Affective: irritability, depression, anxiety
  3. Somatic: headache, dizziness, insomnia, fatigue, sensory impairments

DeLisa 5th Edition Chapter 24 TBI pg587

23
Q

What Are The 5 Domains of Post-traumatic Amnesia (PTA)?

A
  1. Confusion
  2. Agitation and delusions
  3. Disorientation
  4. Retrograde amnesia
  5. Inability to store new memories

ERABI Model 2

24
Q

List 4 Pupillary findings correlate with poor outcomes 🔑

A
  1. Bilateral fixed dilated pupils (CN 3)
  2. Loss of pupillary reaction to light (CN 2 → 3)
  3. Loss of corneal reflex (CN 5 → 7)
  4. Abnormal oculocephalic reflexes “Doll’s eye” (CN 8)
  5. Abnormal caloric Testing (CN 8)

PassPMR - 02 Acquired Brain Injury (6 decks)

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