5: Traumatic Brain Injury Flashcards
What age group has the highest numbers/rates of TBI related hospitalizations and deaths?
ages 75+
What are 6 causes of TBI?
1) falls
2) struck by/against events
3) motor vehicle/traffic crashes
4) assaults
5) intentional self-harm
6) blast related injuries
What is the leading cause of TBI-related deaths by age:
1) 65+
2) 25-64
3) 5-24
4) 0-4
1) falls
2) intentional self-harm
3) motor vehicle crashes
4) assaults
What about of TBI pts admitted to hospitals are intoxicated?
about half
What are the 3 most common causes of TBI sustained by intoxicated adults? Most to least
1) MVAs
2) falls
3) assaults
What are 4 factors that can increase risk for TBI?
1) SES
2) participation in high risk sports
3) history of TBI
4) incarceration
What is the most common cause of TBI with military?
blast injuries
Why is it hard to identify TBI/concussion in military individuals? (3)
1) may have occurred simultaneously with other life threatening issues
2) solider may have other issues present (depression, PTSD, etc)
3) blast injuries may not result in outward signs of injury
What are 4 potential mechanism dynamics?
1) primary blast
2) secondary blast
3) tertiary blast
4) quaternary blast
What mechanism dynamic is this: instantaneous increase in atmospheric pressure that impacts air and fluid filled cavities of the body
primary blast
What mechanism dynamic is this: objects placed in motion by the blast hitting the service member (wood, glass, metal)
secondary blast
What mechanism dynamic is this: service member being placed in motion by the blast
tertiary blast
What mechanism dynamic is this: other injuries from the blast such as burns, crush injuries, toxic fumes
quaternary blast
What are the 2 types of TBI?
1) penetrating
2) non-penetrating
What type of brain damage did Phineas Gage have?
left frontal lobe
High velocity penetrating brain injury
gun shot wound
What are results of a GSW? (3)
1) destroys tissue on both sides
2) diffuse bleeding/tissue disruption
3) increased risk of inflection bone fragments, hair, and skin
What are 3 low velocity penetrating brain injuries?
1) shrapnel
2) depressed skull fracture
3) knife
What are 4 results of low velocity penetrating brain injury?
1) less often fatal
2) can fracture vs. perforate
3) penetrates the skull and carries foreign material in
4) tissue destruction more focal in the site of injury
What are secondary results of low velocity penetrating brain injury?
1) infection
2) bleeding
3) fluctuating blood pressure
4) increased intracranial pressure (brain swelling and hydrocephalus)
What is a non-penetrating brain injury?
closed head injury
meninges remain intact and foreign substances do not enter the brain
What are the 2 types of closed head injuries?
1) nonacceleration injuries
2) acceleration injuries
What is a non-acceleration injury?
produced when head is struck by a moving object
Compare nonacceleration to accelaration injuries
less severe TBI with nonacceleration
What are the 2 consequences of a nonacceleration injury?
1) deformation of the skull
2) localized damage to the meninges and brain cortex at the point of impact (impression trauma)
What is an acceleration/deceleration injury?
TBI caused by sudden acceleration or deceleration of the head, the brain and brain stem resulting in diffuse damage caused by their movement within the skull
What are 2 common causes of acceleration/deceleration injuries?
1) MVA
2) falls from heights
What are 2 common causes of acceleration/deceleration injuries?
1) MVA
2) falls from heights
What are 2 types of acceleration/deceleration injuries?
1) linear acceleration injuries
2) angular acceleration injuries
What do linear acceleration injuries cause?
stretching and tearing
What do angular acceleration injuries?
shearing and twisting
What is a coup injury?
brain injury at the point of impact
What is a contre-coup injury?
injury to the brain at the side opposite of the initial impact, caused by brain moving and hitting inside the skull
Coup and contrecoup injuries cause:
1) focal damage to meninges and blood vessels coursing through the space
2) contusions - particularly in frontal and posterior regions
3) stretching, tearing of axons subcortically
The coup and contrecoup injury damage is sometimes called ____________ ________ and occurs as a consequence of:
translational trauma
linear acceleration and deceleration
Translational trauma is more likely to occur in the _______ or _____ of the head vs. the _____. Why?
front or back
side
epidural space is greater in front and back so increased risk for movement
What CNs are likely to be damages with acceleration injuries? and how?
1) CN 1: Olfactory - stretch or tear
2) CN 3, 4, + 5: extraocular muscles (diplopia)
3) CN 8: tinnitus or vertigo
What are angular acceleration injuries?
blows that strike the head off center propel it at an angle from the direction of the blow and cause the head to rotate away from the blow
Angular acceleration forces are ___________ rather than ________
rotational
linear
Rotational forces are __________ and __________ forces that are concentrated in _________ structures. Mainly in what 4 structures?
twisting and shearing forces
axial
1) midbrain
2) basal ganglia
3) brain stem
4) cerebellum
What is shaken baby syndrome?
the combination of violent shaking and the child’s weak neck muscles cause the child’s head to bounce back and forth, causing diffuse acceleration injuries to the fragile brain tissues
Shearing forces are concentrated at the boundaries between:
They are more severe around major _____ ______ ______ such as (3):
And they can cause:
gray and white matter
white fiber tracts
1) internal capsule
2) corpus callosum
3) brain stem
more severe damageWhat is a diffuse axonal injury caused by?
both linear and angular injury
What is diffuse axonal injury caused by?
linear and angular injury
What is diffuse axonal injury?
damage to nerve cell axons diffusely scattered throughout the brain
Diffuse axonal injury is common with __________________ and is responsible for many of the _________ ________________ and _________________ impairments
TBI
diffuse cognitive and behavioral impairments
When diffuse axonal injury is widespread, what occurs?
vegetative state
sleep wake cycles but no purposeful movement, no talking, no visual activation, preserved brain stem but lots of damage to the cortical and subcortical structures
Diffuse axonal injury is commonly evident in the __________ _________, _________ ____________, and ____________ ____________ _____________.
medial frontal
corpus callosum
superior cerebellar peduncles
Twisting and shearing does not result in _______________ _______________ of axons from their neural cell bodies. What happens instead?
immediate disconnection
the axons stretch, then within 2-3 hours axons swell and then within several hours the axons split
Diffuse axonal injury is a _________ process, meaning what?
diffuse
it affects some regions and not others
What is it called when intact axon terminals adjacent to areas of damage send fibers into the region?
collateral sprouting
The cortical tissues can receive (1)____________ and (2)_______________ as the brain moves in the (3)_______ vault during a TBI.
And the (3) vault is uneven, so the (1) and (2) are concentrated where?
abrasions and lacerations
cranial
frontal lobes and anterior temporal lobes
What is a traumatic hemorrhage?
cuts and bruises on the brain surface and twisting and shearing within the brain causing bleeding (hemorrhage) and blood accumulation (hematomas)
What are the 4 types of traumatic hemorrhages?
1) epidural
2) subdural
3) subarachnoid
4) intracerebral
Where do epidural hematomas occur?
What is the main cause?
between dura mater and the skull
automobile accidents
Epidural hemorrhages can occur where (4) and what are the mortality rates (2)?
1) middle meningeal artery = 85%
2) middle meningeal vein = 15%
3) posterior inferior epidural space
4) frontal and superior epidural space
Where does a subdural hematoma occur?
accumulation of blood between the dura and the arachnoid
Subdural hematomas are _______ as common as epidural. They are often caused by/result in:
twice
shaken baby syndrome
What is the source of a subdural hematoma?
cortical blood vessels
Which type of hematoma is the common consequence of a TBI?
subarachnoid
What are the 5 primary physical consequences of TBI?
1) stretching
2) shearing
3) laceration
4) contusions
5) hemorrhage
What is the secondary consequence of TBI?
brain response to trauma
What are the 3 types of secondary consequences of TBI/brain responses to trauma?
1) cerebral edema
2) traumatic hydrocephalus
3) ischemic brain damage
What is cerebral edema?
fluid accumulation between brain and skull within ventricles or brain tissue, that develops around the primary site of lesions
What is traumatic hydrocephalus?
swelling of brain tissues that compresses passages where CSF circulates, which puts pressure on ventricle walls and compresses brain structures and elevates intracranial pressure
What are the 4 most deadly consequences of TBI?
1) cerebral edema
2) traumatic hydrocephalus
3) hemorrhage
4) herniation
What is herniation?
when cerebral structures are pushed around rigid partitions in the cranial vault or extrude through cranial orifices
What is ischemia?
lack of oxygen to brain tissues
What are 4 results of ischemic brain damage?
1) injury to cardiac and respiratory systems
2) elevated intracranial pressure
3) cerebral vasospasm
4) decreased auto-regulation of blood pressure/lower blood pressure
Ischemic brain damage is more common in _______ TBI than _____________ or _______
severe
moderate or mild
What is this level of consciousness?
appearance of wakefulness, awareness of the self and environment
alert
What is this level of consciousness?
severe drowsiness requiring moderate stimulation, but drifts back to sleep
lethargy
What is this level of consciousness?
dulled responses to stimuli, sleeps more than normal and drowsiness between sleep states
obtunded
What is this level of consciousness?
eye opening with some visual tracking, inconsistent command following, may gesture
minimally conscious state
What is this level of consciousness?
eye opening, but not responsive to stimuli, has sleep wake cycles
vegetative state
What is this level of consciousness?
sleep like appearance and behaviorally unresponsive to all external stimuli, no sleep wake cycles
coma/unconscious
What is the coma a result of?
widespread cortical/subcortical damage
brainstem process affecting the upper pons and midbrain
What type of lesion won’t cause a coma?
Unless what?
unilateral lesion
unless it affects the bilateral deep structures by mass effect
__________ of a coma is a prognostic indicator
duration
The Glasgow coma scale divides pts into what 3 categories?
1) severe head injury (3-8)
2) moderate head injury (9-12)
3) mild head injury (13-15)
What is post-traumatic amnesia and what is it an indicator of?
time between injury and recovery of continuous memory
severity and fair predictor of outcome
What is the Galveston Orientation and Amnesia Test (GOAT) designed to evaluate? What does it give an estimate to?
orientation to person and place
estimates intervals prior to and after brain injury for which there is no recall
What are 10 categories to assess cognitive and behavioral characteristics?
1) arousal/alertness
2) behavior
3) vocalization
4) attention
5) memory
6) executive ability
7) orientation
8) compensatory strategies
9) pragmatics
10) insight/awareness
What are the 2 least conscious Rancho Los Amigos levels?
1) comatose
2) semi-comatose
What are 6 pt related variables to consider with TBI?
1) age
2) substance abuse
3) intelligence
4) socioeconomic status
5) premorbid personality disorders
6) emotional disturbances
What is the recovery pattern of a CVA? (2)
1) curvilinear - rapid with gradual slowing
2) relationship between initial severity and permanent level of impairment is strong
What is the recovery pattern of TBI? (2)
1) stepwise - little or no change alternate with rapid improvement
2) very difficult to determine permanent level of impairment in first weeks post onset
How is the recovery pattern of a TBI predictable? (3)
1) loss of consciousness
2) return to consciousness
3) oriented/increased appropriateness
What are areas of communication deficits that occur due to TBI? (5)
1) verbal expression
2) comprehension
3) reading
4) writing
5) pragmatics
What are effects of TBI within verbal expression?
1) mutism
2) language of confusion
3) anomia
4) word fluency
5) perseveration
What are effects of comprehension within comprehension? (3)
1) implied meaning
2) understanding the big picture
3) selecting the most important pieces of information
What are effects of pragmatics within pragmatics? (5)
1) turn taking
2) eye contact
3) personal space
4) topic maintenance
5) inappropriate behavior
What are speech related deficits of TBI? (9)
1) dysarthria
2) hypernasality
3) slow rate
4) imprecise consonant production
5) pitch variability
6) decreased breath support
7) abnormal stress patterns
8) decreased loudness variability
9) reduced intelligibility
What are the 5 cognitive deficits of TBI?
1) orientation
2) attention
3) memory
4) executive function
5) awareness
What are 5 effects of TBI within attention?
1) focused
2) sustained
3) selective
4) alternating
5) divided
What are 3 effects of TBI within memory?
1) retrograde or anterograde amnesia
2) working memory
3) short term memory
What are 7 effects of a left CVA?
1) focal damage
2) speech is often relevant
3) syntactic difficulties
4) no disorientation
5) cognitive deficits not typical
6) communication better than demonstrated language skills
7) no significant behavioral/personality changes
What are 8 effects of language of confusions (TBI)?
1) bilateral damage, diffuse
2) typically irrelevant
3) confabulation
4) little or no syntactic difficulties
5) disoriented
6) cognitive deficits
7) communication worse than demonstrated language skills
8) significant behavioral/personality changes
