Brain Injury

Question 1

Highest risk for TBIs with 0-4 years old

Answer 1

• Large heads compared to rest of body with weak necks/poor motor control so fall a lot

Question 2

Highest risk for 15-19 year olds

Answer 2

• Body is too strong/mature for their brais (frontal lobe not fully developed)

Question 3

Highest risk for older adults

Answer 3

Falls

Question 4

Most common causes of TBIS

Answer 4

1. Falls
2. Unknown/other
3. MVA
4. Struck by motor vehicle

Question 5

Mild brain injury

Answer 5

• GCS >/= 13
• Known as a concussion
• Symptoms improve over 1-3 months

Question 6

Moderate brain injury

Answer 6

• GCS 9-12

- Loss of consciousness followed by few days/weeks of confusion

Question 7

Severe brain injury

Answer 7

• GCS </=8

Question 8

Primary brain injuries

Answer 8

1. Skull fracture
2. Contusions
3. Hematoma/Hemorrhage
4. Lacerations
5. Diffuse axonal injuries

Question 9

Secondary damage

Answer 9

1. Influx of Ca2+
2. Efflux of K+
3. Reduced magnesium related to decreased energy metabolism and correlated with neurological deficits
4. Rise in oxygen free radicals causing secondary to cell death and damage
   5 .Cerebral edema
5. Intracranial hematoma
6. Cerebral hypoxia and ischemia
7. Brain herniation
8. Increased intracranial pressure

Question 10

Evaluation of a Coma

Answer 10

• Eye movements (pupillary light, conjugate eye movement, VOR, Doll’s head, Caloric response)
• Movement patterns
• Breathing patterns
• Glasgow coma scale
• Coma recovery scale
• Rancho Los Amigos Levels of Cognitive Function

Question 11

Cheyne-Stokes

Answer 11

• Periods of hyperventilation alternating with periods of apnea
• Caused by damage to cortex

Question 12

Central Neurogenic Hyperventilation

Answer 12

• Continuous, regular, rapid respirations/consistent hyperventilation
• Damage to midbrain and upper pons

Question 13

Apneustic Respiration

Answer 13

• Prolonged inspiration with pause before expiration, has period of apnea
• Caused by damage to lower pons

Question 14

Ataxia respirations

Answer 14

• Chaotic with irregular phases; normally leads to cessation of breathing
• Damage to medulla

Question 15

Glasgow Coma Scale

Answer 15

• Uses eye movement, motor response, and verbalization to score coma

Question 16

Coma recovery scale

Answer 16

• Identifies different levels of consciousness (coma, vegetative state, persistive vegetative state, minimally conscious state, brain death)

Question 17

Rancho Los Amigos Levels of Cognitive Function

Answer 17

• 8 levels with more detailed descriptions and a more functional scale

Question 18

Consciousness

Answer 18

• Complete and normal content of consciousness depends on many systems (Memory, emotion, drive, language, executive function, arousal systems, sensory processing)
• Depends on awake and awareness

Question 19

Coma

Answer 19

• A state of unarousable unresponsiveness in which there is no evidence of self-awareness or environmental awareness
• Not awake or aware
• Absence of spontaneous eye opening
• No sleep wake cycles
• Behavior is limited to reflexive activity indicating failure of reticular activating system and integrated cortical activity
• Eyes continuously closed
• Purposeful responses to environmental stimulation cannot be elicited
• No evidence of discrete localized responses
• No evidence of language comprehension or expression

Question 20

Vegetative State

Answer 20

• Awake but not aware
• The recovery of eye opening with continued absence of observable signs of cognitively mediated behavior signals transition to VS
• AAN 3 diagnostic criteria (all must be met): 1. No evidence of sustained, reproducible purposeful or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; 2. No evidence of language comprehension or expression; 3. Intermittent wakefulness manifested by presence of sleep/wake cycles (periodic eye opening)
• May experience sleep-wake cycles or may be constant state of wakefulness
• Can exhibit some behaviors that can be seen as partial consciousness: grinding teeth, swallow, smile, crying, grunting, moaning, screaming, orienting behavior

Question 21

Permanent vegetative state v. persistent vegetative state

Answer 21

1 year; 4 weeks

Question 22

Minimally conscious state

Answer 22

• Awake with fluctuating awareness
• Clear and reproducible evidence of one of the four categories: 1. Follow simple commands; 2. Gestures or verbalizes yes/no; 3. Intelligible verbalization; 4. Movement or affective behavior that occur in response to environmental stimulation that are not reflexive (crying, smiling, laughter, gestures, vocalization, reaching for objects, visual pursuit, sustained fixation)

Question 23

Brain death

Answer 23

• No clinical evidence of brain function upon physical examination
• No response to pain
• No cranial nerve reflexes
• No pupillary response (fixed pupils)
• No oculocephalic reflex (Doll’s Head)
• No corneal reflex
• No caloric reflex test
• No spontaneous respirations
• Flat EEG (not necessary in US to certify brain death)
• Confirmed by exam of 2 independent physicians
• 2 EEG’s, 24 hours apart
• Must be differentiated from conditions where recovery may be possible
• Barbiturate intoxication, alcohol intoxication, sedative overdose, hypothermia, hypoglycemia, coma, or chronic vegetative states
• This will be when patient is on life support and harvest organs
• Only difference between brain dead and dead is your heart is beating

Question 24

Treatment Guidelines for Reducing Brain Edema

Answer 24

• A more direct approach to monitoring and managing increased intracranial pressure and maintaining steady perfusion of brain tissue
• Use of intracranial pressure monitors in ventricles
• Ability to tap off cerebrospinal fluid (CSF) if pressure rises to dangerous levels
• Normal intracranial pressure (ICP) is 7-10 mmHg
• If ICP rises above 20 mmHg then shunt is put in place
• ICP > 25 mmHg is life threatening (above 60 mmHg, uniformly lethal)
• Maintain BP (systolic BP > 90 mmHg) for adequate perfusion of tissue
• Cerebral perfusion pressure (CPP) maintained > 70 mmHg
• CPP = mean arterial pressure – ICP
• MAP = [(2 * diastolic) + systolic]/3
• Treatment has significant effect on outcome
• In cases where acute, elevated ICP cannot be lowered sufficiently, hyperventilation, barbiturates, and diuretics may be used judiciously in combination with ICP management

Question 25

Factors of Prognosis (better vs. worse)

Answer 25

• Damage is focal vs. diffuse
• Damage is superficial vs. deep
• Damage is unilateral vs. bilateral
• Score on 24 hour GCS is better than 8
• Loss of consciousness (LOC) is less than 2 weeks
• Post-traumatic amnesia (PTA) is less than 2 months
• Anterograde – how much people can remember since accident
• There was a lucid interval prior to LOC (less chance of DAI)
• No secondary injury like brain herniation or ischemia
• Younger than 40 years old
• Premorbid psychosocial factors (drug/alcohol free)

Question 26

PTA

Answer 26

• Anterograde episodic amnesia
• Cannot recall events since trauma
• Associated with confusional state
• Length of PTA is a standard measure of severity of injury
• Length of PTA is correlated with length of LOC