(2) TBI: Overview / Disorders of Consciousness Flashcards
Mild Brain injury is defined by…
- Brief (<30 min) or no LOC
- nausea, vomiting, dizziness, lethargy, interrupted recall
- GCS score 13-15
Moderate brain injury is defined by…
- Unconscious up to 24 hours
- Neuro signs of brain trauma including contusion or bleeding and may have focal findings on EEG or CT scan
- GCS score 9-12
Severe Brain injury is defined by…
- LOC greater than 24 hours
- GCS score 3-8
Neurobehavioral Sequelae of Brain injury…
Restlessness and Agitation
Emotional Lability – (disinhibition)
Confabulation
Diminished Insight (judgment and safety)
Impulsivity
Poor Initiation
Reduced Frustration Tolerance
Flat Affect
Depression
Anxiety
Paranoia
Personality Change
Physical / Cognitive Sequelae of Brain Injury
Motor impairment (coordination, balance, spasticity)
Sensory Loss (vision, touch, hearing, smell)
Sleep Disturbance (insomnia, fatigue)
Medical Complications
Sexual Dysfunction
Dizziness / BPPV
Memory (remote or recent)
Attention / concentration
Reduced cognitive flexibility (perseveration, judgement, safety)
Changes in Language
Changes in visuospatial skills
Heterotrophic Ossification
Sensory Changes Brain Injury Sequelae
Proprioception - inability to feel where a body part is in relation to rest of body or things around them
Vision– hemianopsia and hemi-sensory imercaeption
Apraxia (ideational and ideomotor)
Dysphasia
Bowel and bladder changes
What is hemianopsia?
blindness in half of visual field of each eye
what is hemisensory imperception?
visual input from one side of body is not consistently recognized or attended to
What is the difference between ideational and ideomotor apraxia?
Ideational: inability to plan movements related to interaction with objects, due to lost perception of the objects purpose
Ideomotor: inability to translate an idea into motion; no loss of ability to perform an action automatically, but the action cannot be performed upon request
What are the 4 basic assessment Scales
Glascow Coma Scale
Ranchos Los Amigos Scale
Orientation Log
Agitated Behavior Scale
The glascow coma scale is most often performed in…
what does a higher score mean?
acute care
higher score = higher performance, better prognosis
Which level of Ranchos Los Amigos?
Continuous absence of observable change of eye opening
Rancho I: Coma
Which level of Ranchos Los Amigos?
State of wakefulness without awareness of self or environment
patient has sleep-wake cycles and a range of reflexive and spontaneous behaviors
Rancho II: Unresponsive Wakefulness Syndrome, Vegetative
Which level of Ranchos Los Amigos?
Purposeful responses, (squeezing hand on command), correctly demonstrative use of object
Command following may be inconsistent
Rancho III: Minimally conscious, localized response
Which level of Ranchos Los Amigos?
Confused, disoriented, restless, agitated
unaware of current situation
limited ability to correct inappropriate actions or behaviors
*Unable to lay down new memories or learn from mistakes / no new learning
Rancho IV: Confused-Agitated
Which level of Ranchos Los Amigos?
Generally non agitated, but may have episodes of agitation if overstimulated (fatigue, environment)
Confused and inappropriate
short attention span (+- 5 mins)
Confabulation, perseveration, wandering
no new learning
Rancho V: Confused-Inappropriate
Which level of Ranchos Los Amigos?
Can start to learn basic skills again, but impaired memory
Difficulty with changes to routine
Attending to tasks up to 30 mins
Benefits from goal-oriented behavior, needs cueing to complete tasks
Some awareness of self and others
Rancho VI: Confused-Appropriate
Which level of Ranchos Los Amigos?
Robot-like
Usually oriented, confusion has mostly cleared
improved short term memory and awareness of situation, but lacks full insight
decreased judgement and problem solving
beginning community interaction
Rancho VII: Automatic-Appropriate
Which level of Ranchos Los Amigos?
Fully alert and oriented
learns new skills and may or may not need supervision
independent in community
Rancho VIII: Purposeful-Appropriate
Which assessment scale was developed to measure orientation to time, place, and circumstance in a rehab population?
O-Log
How many Q’s are on O-Log?
How does the scoring work?
10 questions
3: spontaneous correct answer
2: cued
1: multiple choice selection (recognition format)
0: spontaneous, cued, and recognition do not generate a correct response
What is fully oriented/max score on O Log?
30
What is post-traumatic amnesia?
when can you clear PTA
- state of confusion immediately after TBI in which the pt is disoriented and unable to remember events that occur after the injury
- once a score is above 25/30 for two consecutive days on O-Log
How often do you use ABS?
rated for every 30 mins
completed by all disciplines at least once/session if needed
ABS
What is a normal, mild, mod, and severe score?
<21
22-28
29-35
>35
ABS scoring
1- behavior not present
2- behavior present to mild degree; doesn’t interfere with session
3- behavior present to mod degree; pt benefits from external cueing
4- behavior present to extreme degree; pt does not benefit from external cueing
Which DOC?
Pt has range of reflexive and spontaneous behaviors which may include…
chewing/ teeth grinding…
grasp reflex
startle response (aud/visual)
facial movements
shedding tears/laughing (not in response to anything)
Generalized arousal response to painful stimuli (respiration, grimace, groan)
Localization to sound (head or eyes orient)
Rancho II Unresponsive wakefulness syndrome
Which DOC?
Pt has inconsistent but reproducible signs of consciousness which may include…
sustained fixation in resp to visual stimuli ( > 2 sec)
localization to noxious stimuli (must locate and make contact with stimulated body part 2/4 trials)
smiling, laughing, crying in resp to emotional stimuli
gestural or verbal yes/no response (regardless of accuracy)
object localization/recognition/manipulation
Rancho III Minimally Conscious State
Emergence to full consciousness requires…
What are two outcome measures?
correct yes/no responses (verbal or gestural) to 6/6 basic situational orientation or autobiographical questions on two consecutive evaluations
Individualized quantitative behavioral assessment (IQBA)
JFK Coma recovery scale – revised JFK or CRS-R
How many items does JFK have?
What are the 6 subscales?
23 items
auditory, visual, motor, oral motor, communication, arousal functions
Scoring for JFK
0-severe vegetative state
23 normal functioning
overall score doesn’t associate with a level, but can be used to track change
Disability Rating Scale
Items?
Categories?
Scale? Max min score?
What does the test measure?
What does a lower score mean?
8 items, 4 categoies, 30 point scale
0-no disability
29- extreme vegetative state
measures cognitive and functional disability
less = less disabilty
Braden Scale is used for…
lower scores mean…
min/max score
risk of skin breakdown/pressure ulcer
lower score = higher risk of breakdown
min score = 6
max score = 23
FIST (function in sitting test)
items, ordinal scale (what do the numbers mean)
14 items
ordinal scale (0-4)
4= independent
0-dependent
FLACC Behavioral Pain Assessment Scale
What do the letters stand for?
What is this assessment for?
face, legs, activity, cry, consolability
pts not able to verbalize pain
Decerebrate vs Decorticate
Decerebrate (lots of Es –extended)
- damage to upper brain stem, UE: adduction and IR shoulder, elbow extension, forearm pronation, finger flexion; LE: ext and IR at hip, ext knee, plantar flexion feet, abd/hyperext toes
Decorticate
- Damage to one or both corticospinal tracts, UE: adduction and IR shoulder, flexion elbow,, wrist and fingers; LE: ext and IR hip, ext knee, PF feet abducted/hyperext toes
Treatment plan and goal setting for DOC
1. start with…and work towards…
2. _________ which include….
3. _________ in prone, supine and seated
- Start with seated static posture and work towards gait
- Developmental positions: (monitor BP, RR, HR) SL, prone, quadruped, tall kneeling
- Stretching (seated–edge of mat vs wheelchair)
Facilitation for DOC means….
examples:
to encourage or make possible
- verbal request: ask them to do it before you help!
- change communication
- change environment
- physically encourage
- assist as much as NEEDED
Treatment plan and goal setting for DOC (continued)
Upright postures (tilt table, standing frame, robotic assist vs body weight support)
FES
Positioning and pressure reliefs
Ther. Taping
Med management
External bracing, splints, casting
Vestibular input
Adjunct treatments (recreational, music, pets, aquatics)
Location changes/outdoors
Appropriate rest breaks
What are some medical complications associated with DOC
Hydrocephalus, syndrome of trephined, autonomic storming, seizures, hypertonicity/spasticity, HO, contractures
What is hydrocephalus and observation/intervention?
- abnormal accumulation of CSF on the brain
- bulging defect (convexity), obtuned, fever, slow/stagnant progress, change in functional or clinical presentation, change in continence status***
- medical management such as surgical placement of shunt
what is syndrome of trephined
observation?
treatment?
symptoms of overactive shunt (opp. of hydrocephalus)
- sunken- in syndrome (concavity)
- med managment, supine, trendelenburg, freq. rest breaks
what is autonomic storming
observation?
treatment?
- acute disorders of sympathetic function that result in alterations of body temperature, blood pressure, heart rate, respiratory rate, sweating, and muscle tone.
- sweating, posturing, hypertension, tachycardia, HA, facial flushing, fever
- positioning, remove tight clothing, fan/cool air (medical: hydration, meds –beta blockers, pain)
Seizures
observation?
treatment?
- partial (simple, complex) vs generalized (absent, myoclonic, atonic)
tell med team, time episode, roll onto their side and protect head
Hypertonicity/spasticity
observations?
treatment?
- difficulty w movement actively and or passively
- med managment, casting, WB, stretching
HO
observations?
treatment?
- hard, rigit end feel w painful palpation
- pain managment, surgery 1+ yrs post event, NO aggressive stretching
Contractures
observations?
treatment?
hard/rigit end feel
botox, serial casting, surgical tendon release, splinting, positioning instructions
(medical management: amantdine, baclofen, botox, tendon release, trach decannulation, tube feed, bowel bladder program, sleep/wake cycle
Aspects to DOC programming
- created for families of pts with DOC
- 3 week program with spec goals
- caregiver training checklist
- IQBA to determine level and emergence
Aspects to DOC programming
- created for families of pts with DOC
- 3 week program with spec goals
- caregiver training checklist
- IQBA to determine level and emergence (1x daily, all disciplines)
