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PassPMR - 02 Acquired Brain Injury > 3- Neurological Complications > Flashcards

3- Neurological Complications Flashcards

1
Q

List 5 most common affected cranial nerves in TBI and how do they present. πŸ”‘πŸ”‘

A

Olfactory nerve (CN I)

  • Anosmia, apparent loss of taste and CSF rhinorrhea.
  • Result in decrease in appetite, weight loss
  • Sense of smell can warn one of potential dangers such as hazardous chemicals or fire.

Optic nerve (CN II)

  • Complete blindness - Blurring of vision - Homonymous hemianopsia.
  • Examine: funduscopic examination - visual field - visual acuity - pupillary reflex

Vestibulocochlear nerve (CN VIII)

  • Loss of hearing
  • Postural vertigo and nystagmus

EOM (CN IV > CN III > CN VI)

  • Diplopia - loss of the pupillary response (β€œblown pupil”) may signify uncal herniation.

Facial nerve (CN VII)

  1. Tactile sensation to the parts of the external ear
  2. Taste sensation to the anterior two-thirds of the tongue
  3. Muscles of facial expression
  4. Salivary and lacrimal glands
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2
Q

What are 6 characteristics of frontal lobe dysfunction? πŸ”‘πŸ”‘

A

πŸ’‘ Like ACA infarction, which is Acquired brain injury.

  1. Impaired concentration and executive function
  2. Lack of inhibition (socially inappropriate anger, agitation, aggression).
  3. Depression.
  4. Non-fluent aphasia (Broca or TCM)
  5. Gait apraxia
  6. Motor abnormalities (contralateral spastic paralysis legs > arms).
  7. Apathy/abulia (lack of initiation).
  8. Release of primitive reflexes (palmomental, suck, snout, rooting, glabellar).
  9. Incontinence bowel and bladder.
  10. Frontal eye field involvement – deviation of the eyes to the ipsilateral side

Adams and Victors principles of neurology, 2005, pg 395.

Clinical neurology 5th edition 2002. pg 13.

ERABI case study; http://www.abiebr.com/set/case-study-7/71-frontal-lobe-dysfunction.

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3
Q

Plantar Reflex (Babinski) Equivalents πŸ”‘πŸ”‘ MOCK

A
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4
Q

Fig. 43.2 (3 marks) πŸ”‘πŸ”‘

A

Blue: Crescent-shaped subdural hematoma

Red: Lens-shaped epidural hematoma

Green: Subarachnoid hemorrhage within the sulci

Braddom 6th Edition Chapter 43 TBI pg927

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5
Q

List 4 complications of sub-arachnoid hemorrhage.

A

Just like stroke with bleeding inside raising ICP

  1. Sudden, transient LOC
  2. Focal neurologic deficits include CN3 or CN6 palsy
  3. Hemiparesis
  4. Aphasia (dominant hemisphere)
  5. Seizures/epilepsy.
  6. Vasospasm (secondary ischemia).
  7. Hydrocephalus
  8. Increase ICP
  9. Brain herniation

Cuccurollo 4th Edition Chapter 1 Stroke pg18

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6
Q

Canadian Head CT Rule 5 marks πŸ”‘

A
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7
Q

List 4 Advantages to use CT & MRI in TBI patient

A

ADVANTAGES OF CT

  1. Rapid, reliable & convenience
  2. Relatively low cost
  3. Detects facial and skull fractures
  4. Detect mass lesions requiring immediate surgical intervention.

DISADVANTAGES OF CT

  1. Poor in identifying nonhemorrhagic lesions
  2. Poor corelation with neurological outcome

ADVANTAGES OR MRI

  1. Good for non Hge lesions
  2. Defining the lesions and extent of injury
  3. Guiding treatment options
  4. Prognostication of lesions in small structures such as the brainstem and for DAI.

DISADVANTAGES OR MRI

  1. Time consuming (45 vs. 5 minutes)
  2. Does not really affect early decision-making
  3. Foreign bodies or implanted devices maybe inside the patient

Cuccurollo 4th Edition Chapter 2 TBI pg71

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8
Q

Uncal herniation Location & List 5 sings πŸ”‘πŸ”‘

A

LOCATION

Medial Temporal Lobe

SIGNS

1- Stretching of the CN 3 (oculomotor nerve)

Ipsilateral fixed pupil dilation, ptosis, and ophthalmoplegia

2- Ipsilateral hemiparesis

Pressure on the corticospinal tract located in the contralateral crus cerebri

3- Contralateral hemiparesis

Pressure on the precentral motor cortex or the internal capsule

4- Reduced consciousness

5- Central hyperventilation (Cheyne-stokes respirations)

6- Bilateral decerebration

Cuccurollo 4th Edition Chapter 2 TBI pg74

Greenberg textbook, pg 161-162.

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9
Q

When is ET intubation indicated? One caution?

A

ET intubation

  • Comatosed GCS ≀ 9

Benefits

  1. Desaturation to maintain oxygenation
  2. Airway protection is indicated in patients with GCS <9
  3. Correction of hypoxia

Caution

  • Cervical spine injury (avoiding neck manipulation/hard cervical collars) in patients with severe TBI or those with a high index of suspicion for spine trauma.

Cuccurollo 4th Edition Chapter 2 TBI

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10
Q

List 4 Indication for surgical management in TBI & 2 surgical options πŸ”‘πŸ”‘

A

Indication

  1. Penetrating injury
  2. Compound depressed skull fracture
  3. Epidural hematoma > 30 cc in volume (1 oz)
  4. Subdural hematoma > 1cm thickness (1 cm)
  5. Focal contusion or intracerebral hemorrhage
  6. Midline shift > 5mm.

Surgical operations

  1. Craniotomy
  2. Emergency Burr Hole

Cuccurollo 4th Edition Chapter 2 TBI pg73

Brain injury medicine textbook pg 272-273.

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11
Q

List 4 preventive measures to be implemented in newly admitted TBI πŸ”‘πŸ”‘

A
  1. Manage bowel and bladder function
  2. Maintain nutrition
  3. Maintain skin integrity
  4. Control spasticity
  5. Prevent contractures

Cuccurollo 4th Edition Chapter 2 TBI pg61

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12
Q

What are the different time frame of epilepsy/seizure post TBI?πŸ”‘πŸ”‘ EXAM 2021

A

CLASSIFICATION

1. Immediate Post Traumatic Seizure (Immediate PTS)

Single or recurrent seizure after TBI within the first 24 hours post-injury

Treat for 7 days

2. Early Post Traumatic Seizure (Early PTS)

Occurs within the first week (24 hours to 7 days) β†’ Treat for 1 year

3. Late Post Traumatic Seizure (Late PTS) or Post Traumatic Epilepsy (PTE)

Occurs after the first week β†’ Treat for 2+ years

STATUS EPILIPTICUS

  • More than 5 minutes of continuous seizure activity
  • Two or more seizures, without full recovery of consciousness between seizures.

Cuccorollo 4th Edition Chapter 2 TBI pg74

ERABI Module 7 pg3 & pg9

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13
Q

List 6 risk factors for late post-traumatic seizures after TBI (late seizures).πŸ”‘πŸ”‘ EXAM 2021

A
  1. Prolonged coma or PTA (>24 hours): 35%
  2. Depressed skull fracture: 3% to 70%
  3. Penetrating head injury: 33% to 50%
  4. Intracranial hematoma: 25% to 30%
  5. Early PTS (>24 hours to 7 days): 25%
  6. Age
  7. Presence of foreign bodies
  8. Focal neurological deficits (aphasia, hemiplegia)
  9. Alcohol abuse
  10. Use of TCAs

Cuccurollo 4th Edition Chapter 2 TBI pg75

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14
Q

Why penetrating injuries increase the risk of post-traumatic seizures?

A

They result of abnormal electrophysiological activity in the brain at the site of injury.

ERABI Module 7 pg7

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15
Q

List 6 complications of post-traumatic seizures.πŸ”‘πŸ”‘

A

PATIENT

  1. Accidental injuries
  2. Loss of driving privileges
  3. Status epilepticus
  4. Death

RECOVERY & FUNCTION

  1. Deterioration in functional status
  2. Deterioration in cognitive status
  3. Negative impact on neurological recovery

ERABI Model 7 pg10

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16
Q

TBI patient is seizing, what could be your differential diagnosis?

A

BRAIN

  1. Hydrocephalus
  2. Mass occupying lesions (hemorrhage, abscess)
  3. Encephalitis/meningitis

BODY

  1. Sepsis/fever

ELECTROLYTE

  1. Electrolyte abnormalities (Na, Mg, Ca)
  2. Hypoglycemia

ORGAN FAILURE

  1. Uremia
  2. Hepatic encephalopathy

TOXIC

  1. Alcohol, Cocaine, Ecstasy, Amphetamines
  2. High dose Caffeine
  3. Tricyclic antidepressants
  4. Narcotics

ERABI Module 7 pg11

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17
Q

TBI patient developed first episode of seizure. List 3 investigations to be done.

A
  1. EEG
  2. Prolactin level: ↑ prolactin level confirms true seizure activity, but normal level does not ruleout seizure activity
  3. Brain MRI

Cuccurollo 4th Edition Chapter 2 pg76

ERABI Module 7 pg13

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18
Q

TBI patient developed seizure for one minute 2 hours after injury. What medication you would start and for how long? πŸ”‘πŸ”‘ MOCK

A

πŸ’‘ Important to remember that all anticonvulsants may cause some degree of sedation and cognitive deficits (usually psychomotor slowing).

PROPHYLAXIS

  • Phenytoin, valproic acid (Depakene) or carbamazepine (Tegretol) for 1 week
  • Levetiracetam (Keppra) is as effective as phenytoin

WHEN TO STOP

  • After 1 week, seizure free

RESTART

  • Evidence of late PTS

WHEN TO STOP AGAIN

  • After a 2-year, seizure-free interval

Cuccurollo 4th Edition Chapter 2 TBI pg76 & 78

ERABI Module 7 pg13

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19
Q

Surgical Interventions for the Prevention and Treatment of PTS

A
  1. Surgical excision of PTS focus
  2. Vagus Nerve Stimulator
  3. Deep brain stimulation of the thalamic anterior nucleus

Cuccurollo 4th Edition Chapter 2 TBI pg79

ERABI Module 7 pg16

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20
Q

What lab investigations are required when initiating phenytoin and levetiracetam?

A

πŸ’‘ All medications start with simple admission profile: CBC, RFT, LFT.

Phenytoin:

  1. CBC
  2. BUN/Cr.
  3. Liver enzymes
  4. Phenytoin level

Levetiracetam:

  1. BUN/Cr
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21
Q

What are the side effects of Levetiracetam (keppra)? πŸ”‘πŸ”‘

A

πŸ’‘ Body organs: Brain - cerebellum - eyes - muscle - heart

  1. Lethargy
  2. Fatigue
  3. Weakness
  4. Headache
  5. Somnolence (Drowsiness or Sleepiness)
  6. Dizziness
  7. Depression
  8. Ataxia
  9. Diplopia

https://reference.medscape.com/drug/keppra-spritam-levetiracetam-343013#4

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22
Q

What are the features of phenytoin toxicity? πŸ”‘πŸ”‘

A
  1. Ataxia
  2. Nystagmus
  3. Confusion
  4. Hallucinations
  5. Neuropathy
  6. Movement disorders
  7. SA/AV nodal block
  8. Stevens-Johnson Syndrome

ERABI Module 7 pg19

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23
Q

Why TBI patient develop Ventriculomegaly? 2 marks. πŸ”‘πŸ”‘

A
  1. Cerebral atrophy and focal infarction of brain tissue
  2. CSF absorption limited by blood products, protein, or fibrosis leading to ventricular dilatation

Cuccurollo 4th Edition Chapter 2 TBI pg79

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24
Q

List 3 classical manifestations of hydrocephalus in TBI patient

CT findings and how to manage? πŸ”‘πŸ”‘

Treatment for ↑ ICP

A

Acute:

  1. Headache, nausea, vomiting, and lethargy.
  2. Change in mental status (confusion, drowsiness).

Chronic:

  1. Incontinence
  2. Ataxia/gait disturbance
  3. Dementia.
  4. Worsen or fail to progress adequately.

CT Findings

  1. Periventricular lucency
  2. Sulcal effacement
  3. Uniform ventricular dilation

Treatment

  1. Lumbar puncture
  2. Shunting

Management for ↑ ICP

  1. Avoid flat, supine position; instead, elevate head of bed to 30Β°.
  2. Hyperventilation should be used with caution because it reduces brain tissue PO2.
  3. Hyperosmolar therapy with mannitol
  4. Furosemide/acetazolamide may also be used
  5. Neurosurgical decompression

Cuccurollo 4th Edition Chapter 2 TBI pg79 & Chapter 1 pg23

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25
Q

Define Agitation, List 4 components of Agitation, Lobe location πŸ”‘πŸ”‘

A

Agitation

  • Subtype of delirium occurring during the state of PTA
  • Most commonly occurs with frontotemporal lesions, which coordinate arousal, attention, executive control, memory, and limbic behavioral functions

Characterized by:

  1. Aggression Ω…Ψ΄Ψ§ΨΉΨ± Ψ§Ω„ΨΊΨΆΨ¨ أو Ψ§Ω„ΩƒΨ±Ψ§Ω‡ΩŠΨ© Ψ§Ω„Ψͺي Ψͺ؀دي Ψ₯Ω„Ω‰ Ψ³Ω„ΩˆΩƒ عدائي أو ΨΉΩ†ΩŠΩ
  2. Akathisia Ψ§Ω„Ψ£Ψ±Ω‚ Ψ§Ω„Ψ­Ψ±ΩƒΩŠ
  3. Disinhibition ΨΉΨ―Ω… Ψ§Ω„Ω‚Ψ―Ψ±Ψ© ΨΉΩ„Ω‰ Ω…Ω†ΨΉ Ψ§Ω„Ψ³Ω„ΩˆΩƒ غير Ψ§Ω„Ω„Ψ§Ψ¦Ω‚
  4. Emotional lability ΨͺغييراΨͺ Ω…Ψ¨Ψ§Ω„ΨΊ ΩΩŠΩ‡Ψ§ في Ψ§Ω„Ω…Ψ²Ψ§Ψ¬

Agitation is often accompanied by (same picture + GOAT)

  1. Disorientation
  2. Post-traumatic amnesia (PTA)
  3. Disinhibition
  4. Aggression
  5. Akathisia

Cuccurollo 4th Edition Chapter 2 TBI pg80

ERABI Module 5 pg8

26
Q

List 4 possible differential diagnosis for agitations πŸ”‘πŸ”‘ (OSCE Q) A case of TBI agitation with normal electrolytes – list 6 other causes. What to rule out in patient with agitation?

A
  1. Drug withdrawal
  2. Delirium tremens (DTs)
  3. Infection
  4. Pain
  5. Hypoxia
  6. Seizure disorder

Cuccurollo 4th Edition Chapter 2 TBI pg84

  1. Noxious stimuli (pain).
  2. Environmental (overstimulation).
  3. Medical conditions:
  4. Infections: Systemic, encephalitis, meningitis, abscess, tertiary syphilis.
  5. Endocrine: Hypothyroidism, hypo/hypercortisolism, hyperparathyroidism
  6. Seizures:Ictal or post-ictal
  7. Vascular: Stroke, TIA, hypoperfusion, hypoxemia, SDH, etc.
  8. Medications & drugs
  9. Structural: Hydrocephalus, stroke, intracranial bleed, etc.
  10. Mood disorders.

Flash cards

  1. Severe medical illness
  2. electrolyte disturbance,
  3. anxiety and depression
27
Q

What is the most commonly abused substance following an ABI?

A

Alcohol

ERABI Module 5 pg8

28
Q

What is the normal duration of agitation? πŸ”‘πŸ”‘ (OSCE Q)

A
  • Majority of patients with agitation recover completely in three week to three months.
  • Agitation is considered a normal phase of recovery in acute period (14 days) following a moderate to severe ABI
  • Strongly associated with frontal lobe lesions.

ERABI Module 5 pg8

29
Q

List two assessments for agitation and their results πŸ”‘πŸ”‘

A

πŸ’‘ MMSE 18-23

Agitated Behavior Scale (14-56) β†’ 21,28,35

  • Below 21: normal
  • 22 to 28: mild agitation β†’ non-pharmacologcial measures
  • 29 to 35: moder ate agitation β†’ pharmacological measures
  • 35 to 54: severe agitation β†’ restrain?

Rancho Los Amigos (RLA) Scale

  • Agitation: Level IV Confused and agitated behavior.

Cuccurollo 4th Edition Chapter 2 TBI pg68

Braddom 6th Edition Chapter 43 Traumatic Brain Injury pg930

30
Q

First-Line Interventions for Posttraumatic Agitation πŸ”‘πŸ”‘

A

Environmental Management of Posttraumatic Agitation

  1. Reduce the level of stimulation in the environment
    • Remove noxious stimuli if possible
    • Reduction of lines/direct restraints
    • Scheduled toileting program
    • Place patient in quiet, private room
    • Limit unnecessary sounds and visitors
  2. Protect patient from harming self or others
    • Place patient in a floor bed with padded side panels (Craig bed).
    • Assign 1:1 or 1:2 sitter to observe patient and ensure safety
  3. Reduce patient’s cognitive confusion
    • One person speaking to patient at a time
    • Minimize contact with unfamiliar staff
  4. Tolerate restlessness when possible
    • Allow patient to pace around unit with 1:1 supervision.
    • Allow confused patient to be verbally inappropriate

Cuccurollo 4th Edition Chapter 2 TBI pg81 Table 2-11

31
Q

What medications can be used to treat life-threatening aggression following an ABI? πŸ”‘πŸ”‘

What medications can be used to treat non life-threatening aggression following an ABI? πŸ”‘πŸ”‘

Which medications should be minimized in treatment of aggressive/agitated behaviour? πŸ”‘πŸ”‘

A

LIFE THREATENING

1- Short Acting Intramuscular Benzodiazepines

GABA receptor agonists (CNS Depressant)

Lorazepam (Ativan) - Midazolam

S/E May cause paradoxical agitation in the elderly & impaired motor recovery

2- Oral Atypical Antipsychotic

Dopamin 2 receptor antagonist

Quetiapine (Seroquel): Start 50mg bed time or 25mg BID, max 800mg in 3 doses

S/E QT prolongation, Dizziness, Extrapyramidal Sx, Fatigue, Anticholenergic

Risperidone (Risperdal): 0.25mg BID to 2-8 mg/day once daily or divided q12hr

S/E Insomnia, Anxiety, Headache, Agitation, Parkinsonism, Akathisia

NON-LIFE THREATENING

1- Propranolol (420-520mg/day)

S/E Hypotension, Anxiety, Sleepiness, Insomnia

2- Anticonvulsants β†’ pain and sleep

Carbamazepine (Tegretol), Valproic acid (Depakene), Gabapentin (Neurontin)

S/E Sedation, Fatigue, Weight gain, Nausea, Edema

3- TCA: Amitriptyline β†’ mood and sleep

S/E Anticholeregic: Urine retention, constipation, dry eyes and mouth, dizziness

4- Dopamenergic β†’ arousal or attention

Amantadine and Methylphenidate

S/E Hallucinations, Insomnia, Anxiety, Headache, Nausea

TO AVOID

  1. Benzodiazepines
  2. Typical antipsychotic agents (haloperidol)

Cuccurollo 4th Edition Chapter 2 TBI pg82-84

32
Q

You’ve asked to transfer agitated patient. Do you accept him? Why? πŸ”‘πŸ”‘ EXAM

A

We can’t accept the patient

  1. May harm himself
  2. May deteriorate
  3. Will not benefit from rehabilitation at the current state.
33
Q

What is the definition of a restraint? What types of restraints exist? EXTRA BONUS

A

Chemical restraints

Beta blockers, antidepressants, anticonvulsants, psychostimulants, propranolol, neuroleptics, valproic acid, and anti-Parkinson’s agents

Physical restraints

Bed rails, feeding trays, hand tying, chest straps, seat belts, ankle/wrist restraints, and jacket restraints

ERABI Module 5 pg26

34
Q

What is the difference between typical and atypical antipsychotics?πŸ”‘πŸ”‘

A

Atypicals are less likely to cause motor side effects than typicals:

  1. Tardive dyskinesia
  2. Parkinsonism
  3. Dystonia
  4. Akathisia

Cuccurollo 4th Edition Chapter 2 TBI pg82

35
Q

What medications are recommended impaired arousal or attention? πŸ”‘πŸ”‘

What medications are recommended for learning and memory deficits? πŸ”‘πŸ”‘

A

Arousal & Attension

  1. Amantadine: 100 mg orally twice a day, Max dose: 400 mg/day
  2. Methylphenidate: 20 to 30 mg orally in 2 or 3 divided doses, Max dose: 60 mg/day
  3. Bromocriptine

Learning and memory deficits

  1. Donepezil (Aricept): 5-10mg starting dose

ERABI Module 6

36
Q

What cognitive and behavioral changes are commonly seen in TBI?

A

Cognitive

  1. Attention
  2. Memory

Behavioral

  1. Disinhibition (anger - violence)
  2. Impulsive

PMR Secrets 3rd Edition Chapter 53 pg 437 Q18

37
Q

Which neurotransmitter is thought to be highly important for:

  1. Memory 2. Attention 3. Mood 4. Arousal
A
  1. Acetylcholine Ψ²Ω‡Ψ§ΩŠΩ…Ψ±
  2. Norepinephrine Ψ§Ω†ΨͺΨ¨Ψ§Ω‡
  3. Serotonin Ψ³ΨΉΨ§Ψ―Ψ©
  4. Dopamine Ψ§Ψ«Ψ§Ψ±Ψ©
38
Q

List 4 dopaminergic and 2 non-dopaminergic medications to be used in TBI patient. πŸ”‘πŸ”‘

A

πŸ’‘ Amani leaving to the prom for myth to improve mood & memory.

Dopaminergic β†’ Alterness, Arousal

  1. Amantadineβ€”increases EXOGENOUS dopamine
  2. Levadopa/carbidopaβ€”increases EXOGENOUS dopamine
  3. Bromocriptineβ€”increases ENDOGENOUS dopamine
  4. Methylphenidateβ€”blocks reuptake of dopamine and norepinephrine

Non-Dopaminergic

  1. Antidepressants (TCA, SSRI, SNRI) for Mood & Sleep
  2. Anticholinesterase: Donepezil (Aricept) for Memory & Attention

Cuccurollo 4th Edition Chapter 2 TBI pg62 & 93

39
Q

What is Executive functions? Location in brain.

A

Executive functions

  • Complex processes, such as goal setting and execution, decision making, human adjustment, problem solving, and long-term planning.

Location

  • Prefrontal cortex (medial prefrontal network & dorsolateral prefrontal network)

ERABI Module 2 pg7

40
Q

List 2 test for cognitive function and their figures πŸ”‘πŸ”‘

A
  1. Montreal Cognitive Assessment (MoCA)
    • ≀25 out of 30 indicates impairment
  2. Mini-Mental State Examination (MMSE) β€œABS is 21,28,35”
    • 18-23 mild cognitive impairment
    • 0-17 severe cognitive impairment

ERABI Module 2 pg11

41
Q

Intervention for Attention, Concentration and Information Processing Speed.

A

Non-Pharmacological

  1. Dual-Task Interventions
  2. Computer-based programs and virtual reality
  3. Goal Management Training

Pharmacological

  1. Methylphenidate twice a day with a total daily dosage of 20-30mg, max 60mg per day
42
Q

What pharmacological interventions are recommended for the remediation of executive function following an ABI?

A

None. Unfortunately, there are no pharmacological interventions which have consistently shown improvement of executive function in the ABI literature.

ERABI Module 2 pg26

43
Q

How to deal with schooling after TBI? πŸ”‘πŸ”‘ (OSCE Teenager with mTBI)

A
  1. Frequent breaks
  2. Reduced workload
  3. Modified assignments
  4. Additional time to complete assignments
  5. Preferential seating in the classroom
  6. Reduced auditory stimulation
  7. Reduced visual stimulation.
44
Q

What are the three stages of memory?

A
  1. Encoding
    • Integration of hearing, vision, verbals, and personal experiences and information through cognitive mechanisms
  2. Consolidation
    • Creating interactions between the cortex, the limbic system, more specifically the hippocampus
  3. Retrieval
    • Process of accessing these memories through either recognition or recall.

ERABI Model 2 pg5

45
Q

List 4 brain structures involved in memory. πŸ”‘πŸ”‘

A
  1. Mammillary body (general memory).
  2. Fornix (carries signals from hippocampus to mammillary bodies and septal nuclei).
  3. Hippocampus (spatial learning, declarative learning, explicit memory).
  4. Dentate gyrus (new memory formation).
  5. Parahippocampal gyrus (spatial memory).
  6. Amygdala (emotional memory).

Wikipedia, http://en.wikipedia.org/wiki/Limbic_system

46
Q

What are the only two pharmacological interventions supported by the ABI literature for learning and memory deficits? What are their recommended daily dosages? πŸ”‘πŸ”‘

A
  1. Donepezil (Aricept), 5-10 mg/day
  2. Rivastigmine, starting dosage of 1.5 mg/day, maintenance at 3-6 mg/day.

ERABI Module 2 pg25

47
Q

Intervention for Learning and Memory πŸ”‘

A

NON-PHARMACOLOGICAL:

Internal

  1. Verbal and visual cuing
  2. Visual imagery.
  3. Self-imagination
  4. Self-talk
  5. Memory training: learning to β€˜chunk’ information, memory games, mnemonics.
  6. Repeated Practice
  7. Retrieval Practice

External

  1. Memory aids: computer, pager, diaries, agendas, calendars, family members, photos.

PHARMACOLOGICAL:

  1. Donepezil (Aricept)
  2. Physostigmine: memory in men with TBI.
  3. Improve attention: Amantadine, methylphenidate.

EBRSR module 12 pg 34; ERABI module 12 pg 96; ERABI Module 2 pg23

48
Q

Mention 3 Anxiety Disorder associated with post-ABI

A
  1. Generalized anxiety disorder (GAD)
  2. Obsessive compulsive disorder (OCD)
  3. Post-traumatic stress disorder (PTSD)

ERABI Module 3

49
Q

List 2 assessment tools help in diagnosis for mood and behavioral disorders following an ABI?

A
  1. Patient Health Questionnaire (PHQ9)
  2. Hospital Anxiety and Depression Scale
50
Q

What pharmacological interventions are recommended for the treatment of anxiety following an ABI?

A

SSRIs (Prozac, Cipralex), are the only pharmacological intervention recommended for the treatment of anxiety following an ABI.

ERABI Module 5 pg23

51
Q

How is fatigue defined? How is it classified? πŸ”‘πŸ”‘

A

Fatigue

  • Feelings of physical and/or mental exhaustion during or after usual activities
  • Feelings of inadequate energy to begin activities.

ERABI Module 13 pg4 & pg8

52
Q

TBI patient in the clinic c/o fatigue.
Take history of fatigue and manage it πŸ”‘πŸ”‘
OSCE Dr. Nasser

A

Sign & Symptoms of Fatigue

  1. PHYSICAL
    • Lack of energy, weakness, or light headedness
    • Yawning
    • Nodding off or head drooping
  2. MENTAL
    • Difficulty concentrating
    • Making mistakes on well-practiced tasks
    • Forgetfulness
    • Difficulty thinking clearly
    • Poor decision makine
  3. PSYCHOLOGICAL
    • Lack of motivation
    • Irritable

Causes of Fatigue (Table)

OSCE was RLS & Management

1) Iron correction 2) Dopaminergic agents, Anticonvulsants, Benzodiazepines

ERABI Module 13 Fatigue

53
Q

Management of Fatigue πŸ”‘πŸ”‘ List 6 elements of sleep hygiene include πŸ”‘πŸ”‘

A

Non-Pharma

  1. Conserving energy and pacing: Prioritize their commitments & plan important activities when they feel they are at their best
  2. Exercise: Start with aerobic exercise for cardiovascular health, general well-being, emotional and immune system functioning.
  3. Sleep hygiene
  4. Cognitive Behavioural Therapy (CBT)
  5. Lifestyle management: Adaptive coping, goal management, healthy diet and self care for emotional, physical, and mental health
  6. Light Therapy: expose to a short wavelength light (430-475 nm; blue wavelength light) upon awakening to alter melatonin production and secretion leading to increased daytime alertness and earlier onset of evening sleep

Sleep Hygiene

  1. Going to bed and getting up at the same time every day, including weekends
  2. Avoiding naps, or taking naps for no longer than 20 minutes if necessary
  3. Avoiding caffeine, alcohol and nicotine
  4. Regular exercise
  5. Avoiding heavy exercise and heavy meals for several hours before bedtime
  6. Keeping bedroom quiet, dark, and at a comfortable temperature
  7. Keeping stress and work out of the bedroom
  8. No TV or computer while in bed
  9. If unable to sleep, don’t lie in bed; get up and do a relaxing activity for a short while

Pharma (Dopamenergic)

  1. Methylphenidate
  2. Modafinil

ERABI Module 13 pg13 & Module 7

54
Q

List 4 causes of poor sleep in TBI πŸ”‘πŸ”‘

A
  1. Pain
  2. Irritability
  3. Anxiety
  4. Obstructive sleep apnea
  5. Restless leg syndrome β†’ OSCE station
  6. Trauma damaging reticular activating system (RAS) affecting sleep-awake cycle
  7. Fatigue

DeLisa 5th Edition Chapter 24 TBI pg595

PMR Secrets 3rd Edition Chapter 53 TBI pg437

55
Q

What are the three most common sleep disorders following an ABI?

A
  1. Insomnia
  2. Sleep apnea
  3. Hypersomnia

ERABI Module 13 pg17

56
Q

Patient with poor sleep quality. What would the adverse effect on rehab sessions?

A
  1. Easily distracted and unable to focus on more than one task at a time
  2. Rapid mental fatigue and may require frequent breaks
  3. Complain of fatigue or frequently ask to return to their room or bed
  4. Rest-seeking behaviors such as excessive time in bed, frequent naps, and inactivity
  5. Asleep mid-task during a therapy session or require frequent cues to remain awake
  6. Alterations in circadian rhythms, sleep patterns, and sleep quality.
57
Q

List some methods to improve sleep quality πŸ”‘πŸ”‘

A

Non-Pharma

  1. Sleep restriction (fewer naps during the day)
  2. Sleep hygiene (turning off television or other sources of stimulation near bedtime)
  3. Relaxation Strategies (warm footbath)
  4. Lifestyle Management Strategies
  5. Cognitive Behavioural Therapy
  6. Regular Exercise
  7. Light Therapy
  8. Blood draws could be rescheduled to maximize uninterrupted sleep.
  9. Alterations in therapy schedule may improve arousal and provide rest breaks at times of day when arousal is low.

Pharma

  1. Melatonin 0.5-1mg night time up to 5-10mg
  2. Tricyclic antidepressants: Amytriptalin 25mg night time
  3. Modafinil 100-200mg morning to improve circadian rhythm

ERABI Module 7

58
Q

How do you approach and manage sleeping disorder in any patient? Management of Insomnia, Restless legs syndrome (RLS) and Sleep apnea πŸ”‘πŸ”‘

A

INSOMNIA

β‰₯3 nights per week for β‰₯3 months

Causes: - Advanced age - Psychological factors - Lifestyle behaviours - sleep apnea

Medications: Psychostimulants, anticonvulsants, antidepressants

Medical: Growth hormone deficiency, hyperthyroidism

Treatment

  1. CBT
  2. Sleep hygiene
  3. Regular exercise
  4. Avoid caffeine, other CNS stimulants
  5. Melatonin
  6. Tricyclic antidepressants

CIRCADIAN RYTHM

Causes: Lifestyle habits - Advanced age - Environment or occupation

Medications: CNS depressants or stimulants

Treatment

  1. Sleep hygiene
  2. Light therapy

RESTLESS LEG SYNDROME

β‰₯ 3 months and occurring β‰₯3 nights per week

Causes: akathisia, periphral neuropathy, iron deficiency

Medications: antihistamines, dopamine antagonists such as anti-emetics or antipsychotics, lithium, antidepressants such as SSRIs and TCAs, substances (caffeine)

Treatment

  1. Iron supplementation
  2. Avoid caffeine, nicotine, alcohol
  3. Exercise program
  4. Dopamine agonists
  5. Gabapentin

SLEEP APNEA

β‰₯15 obstructions per hour of sleep.

Causes: central sleep apnea, obstructive sleep apnea, obesity hypoventilation syndrome, and sleep-related hypoventilation

Others: Excess weight - Chronic nasal congestion - Smoking - Diabetes - Asthma - Hypertension

Treatment

  1. Morning modafinil
  2. CPAP
  3. Sleep specialist refferal

HYPEROSMIA

Medications: CNS depressants, opioids or other pain medications, anticonvulsants, anti-emetics, antihistamines, antidepressants, anxiolytics, beta-blockers, anti-spasticity medications, muscle relaxants

Others: hypothyroidism - sleep apnea

Treatment

  1. Modafinil
  2. Re-evaluate contributory medications

ERABI Module 13 pg25

59
Q

Common signs and symptoms of depression following an Acquired Brain Injury. πŸ”‘πŸ”‘

A

At least 2 of the following core for the last two weeks:

  1. Depressed mood: feeling low, sad, or hopeless
  2. Lethargy: reduced energy/ increased fatiguability
  3. Anhedonia/loss of pleasure and interest

In addition:

  1. Ideas of guilt, unworthiness and failure
  2. Disturbances in sleep
  3. Diminished appetite.
  4. Thoughts of death or suicide.
  5. Difficulty concentrating.
  6. Social withdrawal.

ERABI Model 5

  1. Reduced self-esteem and self-confidence
  2. Bleak and pessimistic view of the future

ICD 10

60
Q

Pharmacological treatments which have been shown to be effective in the treatment of depression specifically in those with an ABI.

A

πŸ’‘ We want to increase both dopamin and seratonin.

  1. Methylphenidate (Dopamenergic)
  2. Citalopram (SSRI): start at 10mg, and increase to a daily dose of 20-40mg.

ERABI Module 5 pg21

61
Q

Types of Post-traumatic Seizure (PTS) πŸ”‘πŸ”‘

A

πŸ’‘ Majority of PTS are simple partial

  1. Partial seizure
    • Simple partial, preserved consciousness
    • Complex partial, impaired consciousness
  2. Generalized seizure
    • Grand mal or tonic–clonic

Cuccorollo 4th Edition Chapter 2 TBI pg74

ERABI Module 7 pg3 & pg9

62
Q

Incidence of post traumatic seizure? πŸ”‘

PassPMR - 02 Acquired Brain Injury (6 decks)

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