exam 2 Flashcards
seatbelt + airbag
prevention of TBI
81%
wearing a motorcycle helmet
prevention of TBI
67%
what % of motorcyclists who dies were speeding
40%
TBI
- caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain
- either closed or open head injury
- neurological injury can occur due to TBI -> focal brain damage at the site of injury widespread brain damage due to diffuse axonal injury, ischemia, or other secondary effects
ABI
- brain damage caused by other etiologies
- those like near-drowning, brain infections, congenital heart defects, chemotherapy and radiation, and drug overdose
- associated with loss of oxygen & widespread disruption of cell functioning
- brain tumors, ruptured arteriovenous malformations, and strokes
- more focal lesions
- those like near-drowning, brain infections, congenital heart defects, chemotherapy and radiation, and drug overdose
TBI demographics
- below 5 years
- 15-24 years
-
75+ years (or 65+)
- survival rate and age have an inverse relationship.
- males higher incidence
- about 1/2 of all pediatric TBI are from falls
- motor vehicle accidents are a large %
- shaken baby syndrome
- sports/recreational activities
- those with previous tbi are 3x as likely to have another tbi
blast injury
- cavitation effect: negative pressure at the point opposite impact drops below vapor pressure level, causing intra and extracellular fluid to convert to a gaseous form
penetrating injury
- an object (eg bullet) penetrates the skull, possibly carrying debris into the brain
- if brainstem: high mortality rate
- KEY: if patient survives initial injury, prognosis is surprisingly good
closed head
acceleration/decceleration
nonacceleration
impression trauma
acceleration/deceleration: linear velocity
- brain moves along linear path
- KEY: coup, contrecoup
acceleration/deceleration: angular acceleration
- brain rotates at an angle
- lacerations, shearing of axonal connections
- KEY: diffuse axonal injury
non-acceleration: ellipsoidal deformation
- caused by a slow-moving object which deforms skull from oval to circular
- KEY: brain tissue moves outward from center
- stretching, tearing of central structures
impression trauma
damage going in and damage coming out (carrying debris)
personal orientation spheres that may be disturbed by TBI:
- person
- time
- place
- circumstance
cognitive stall
- common for TBI patients to improve after injury at a slower rate than typically developing peers
- particularly executive functioning can recover more slowly
diff between restorative and compensatory approaches to treatment
- restorative: based on notion that neuronal growth (which results from improvement in function) is associated with repetitive exercise of neuronal circuits
- ‘muscle building approach’—repetitive exercises and drilling
- compensatory: concedes that certain functions can’t be recovered, so the goal is to develop strategies to circumvent the impaired functions
- this view of cognitive rehabilitation implies that restoration and compensatory strategies are distinct phases of the rehabilitation continuum. First we do restorative treatment and then we implement compensatory strategies where needed.
pediatric TBI: aspects of cognition negatively affected by TBI
- working memory
- attention
- declarative memory
- social cognition
- executive functioning
pediatric tbi recovery
- occurs in context of development
- influenced by the child’s environment
- nature and extent depends on the age at the injury (due to plasticity)
tbi in adolescents vs pediatric
adolescents:
- respond more like adults do
- diffuse axonal injury
- focal contusions
pediatric
- more likely to have diffuse cerebral edema
- does not affect syntax or morphology
primary and secondary TBI damage
primary:
- focal and diffuse lesions
secondary:
- the changes that evolve over a period of hours to days after the primary brain injury
secondary TBI damage
- hemorrhage
- intracranial pressure
- might restrict cerebral blood flow
- hypoxic & ischemic
- hypoxia: lack of oxygen to brain tissue
- seizures:
- many patients have seizures within 24 hrs of TBI
- neurochemical alteration:
- injured neurons due to the TBI might secrete damaging cytokines
simple partial
seizure
- remain conscious.
- weakness, numbness, unusual smells/tastes
complex partial
- alters their ability to interact with environment
- eg. walking in circle, smacking lips, fear, uncontrollable laughter, etc
petit mal
- lapses of awareness, staring, brief jerking of the eyelids or facial muscles
- usually begin and end abruptly, lasting only a few seconds
- often so brief they escape detection
- usually begin and end abruptly, lasting only a few seconds
atonic
individual has an abrupt loss of muscle tone producing head drops, loss of posture or sudden collapse
grand mal
- stiffening of the limbs (tonic phase), followed by jerking of the limbs (clonic phase)
- during the tonic phase, breathing may decrease producing cyanosis (blueing) of the lips, nail beds, and face
glasgow coma scale
measures eye opening, verbal response, and motor response
- severe: 3-8
- moderate: 9-12
- mild: 13-15
-if it is more severe it will be a lower number
-if it is less it will be higher
rancho los amigos scale
no general is loco enough to be confused 3x he is automatic and purposeful-appropriate 3x
- I: no response — total assistance
- II: generalized response — total assistance
- III: localized response — total assistance
- IV: confused-agitated — maximal assistance
- V: confused, inappropriate, non-agitated — maximal assistance
- VI: confused-appropriate — moderate assistance
- VII: automatic-appropriate — minimal assistance for daily living skills
- VIII: purposeful-appropriate — stand by assistance
- IX: purposeful-appropriate — stand by assistance on request
- X: purposeful-appropriate — modified independent
FIM scale (functional independence measure)
- total assist (performs less than 25% of task)
- maximal assist (performs 25%-49% of task)
- moderate assist (performs 50%-74% of task)
- minimal assist (performs 75% or more of task)
- supervision (cuing, coaxing, prompting)
- modified independence (extra time, devices)
- complete independence (timely, safeley)
grasp
primitive reflexes
- press object on the palm of the hand
- closure of the hand around object
babinski
primitive reflexes
- scratch the lateral margin of the foot from the heel to the toe
- extension and flaring of the toes
moro (startle)
primitive reflexes
- loud noise
- symmetrical spread of the arms with the fingers extended
tongue thrust
primitive reflexes
- present liquid
- movement of the tongue between/against the upper teeth during swallow
tonic bite
primitive reflexes
- pressure to the gums
- closure of the jaws in a biting motion
RHD characterized by
- perceptual deficits
- attentional deficits
- affective (emotional) deficits
- communication deficits
perceptual deficits
- capgras syndrome
- prosopagnosia
- left neglect
capgras syndrome
belief that family and friends are not real selves, but imposters or doubles
prosopagnosia
inability to recognize familiar faces
left neglect
- copying/pointing to/reading from only the right side
- not a visual problem
makisack-myers edgeness task
- Tx of left neglect
- find specified number of cubes on a board with quadrants
- can increase difficulty by including colors
tompkins & flowers Tx
- Tx of prosodic features
- 3-sentence story, last sentence is a quote by a character
- patient has to read and generate appropriate prosody
oral phase
- food chewed into paste texture
- bolus formed positioned for transport into pharynx
- voluntary
oral transit or transport phase
- begins with the posterior propulsion fo the bolus by the tongue
- bolus is propelled posteriorly in the pharynx
- bolus arrives at the base of the tongue and triggers swallow reflex
- voluntary
pharyngeal phase
- bolus moves through larynx
- larynx rises and laryngeal vestibule closes
- epiglottis inverts to cover airway
- pharynx constricts, esophageal sphincter opens
- involuntary
esophageal phase
- bolus enters the esophagus through the UES and travels to the stomach
- gravity and peristalsis
- involuntary
difference between aspiration and penetration
aspiration:
- food, fluid, or secretions pass the fold and enter the trachea
penetration:
- material enters the larynx but does not pass below the folds
outward symptoms of dysphagia
- self-report of difficulty swallowing
- slowness in eating
- coughing/choking at mealtimes
- gurgly/wet voice
- drooling/leakage at the lips
- residue in the mouth after swallowing
- watery eyes
- history of recurrent pneumonia
- unexplained weight loss
- silent aspiration
clinical swallow assessment (bedside swallow)
steps:
1. observe patient in room (alertness, posture, O2 saturation, ability to follow directions)
2. oral motor exam (labial, lingual, velopharyngeal)
3. graduated food trials (ice chips, thin liquids, thick liquids, pureed food, solids
- advantages: easily accessible materials, more timely, view oral-prep phase
- disadvantages: can’t see the pharyngeal phase*
- or esophageal
- can’t see silent aspiration
fiberoptic endoscopic examination of swallow (FEES)
- video naseoendoscopy
- disadvantage: “white out period” where the image is blocked
modified barium swallow examination:
- videofluoroscopy (moving x-ray)
- radio-opaque barium is used to visualize food movements during swallow
- different types of food and liquid can be visualized
- most in depth
after evaluation: modifying diet
- modifying food textures may be used to:
- help avoid aspiration risk
- improve ease of chewing and managing the bolus
- help improve safety if the patient has cognitive impairments
- solid foods may be pureed, minced, or chopped
- liquids may be thickened
- thing liquids can be hardest to control
- think: would you drink this?
- altering texture and thickness does NOT guarantee swallow safety
after evaluation: nasogastric tube
- nurse usually insertis tube via nose, pharynx, into the esophagus
- delivers liquified nutrients
- usually short-term option
- increased reflux risk
indirect treatment:
indirect treatment:
- exercising muscle groups used in swallowing or by practicing neuromuscular elements in swallow without using food
- ex. shaker exercise:
- client lies on back, elevates head to see their feed for 1 minute, then 1 minute of rest
- ex. shaker exercise:
direct treatment:
- actually change swallow physiology as food or liquid is utilized
- generally not provided if patient is aspirating
-shaker exercise don’t know unless he talked about it in class
what is mechanical dysphagia?
structural change caused by surgery to remove tumor (such as laryngectomy, hemilaryngectomy etc.); may involve the tongue or larynx
what is triggered to protect the airway form the intrusion of food, liquid, or secretions?
cough reflex
ICP (intracranial pressure)
- hemorrhage, edema, or CSF can cause increased ICP
- increased ICP can restrict cerebral blood flow
- | severity | ICP in mmHg |
| typical | 5-15 |
| mild | 16-20 |
| moderate | 21-30 |
| severe | 31-40 |
| very severe (often fatal) | 40+ |
minimally conscious state
a condition in which there is minimal but definitive evidence of self- or environmental awareness
why treat dysphagia?
🍎 maintain adequate nutrition
📈 increase recovery
🫁 decrease risk of aspiration pneumonia, which may
🏥 lengthen hospital stay
😷 weaken an already sick patient
⚰️result in death
swallow reflex
- a sequential series of actions to:
1. protect the airway and
2. propel food into the esophagus - hyoid bone moves anteriorly, epiglottis inverts, larynx elevates, the laryngeal vestibule collapses and breathing temporarily stops
- constrictor muscles move the food through the pharynx as the upper esophageal sphincter relaxes and allows the food to enter the esophagus
gag reflex
- triggered by touching pharyngeal wall
- often also based of tongue, velum
- not predictive of swallowing function
cough reflex
- triggered by material in the larynx
- forceful exhalation, vocal fold approximation
- protects the airway against intrusion
- neuro damage can prevent this reflex
neurological dysphagia
-
brain damage impacts control of movements
- stroke, tbi, or degenerative disease
- could cause weakness, slowed contraction, or discoordination
- impaired sensory feedback
neurologic dysphagia phases
oral and oral transit phases
- poor chewing, bolus formation
- weakness prevents bolus propulsion
- residue in the mouth
- premature spilling of liquids into pharynx
- thin liquids are most difficult for them
pharyngeal phase
- difficulty triggering swallow
- insufficient laryngeal elevation, closure
- weakened pharyngeal peristalsis
- pooling of residue — subsequent aspiration
esophageal phase
- seldom seriously affected
esophageal diverticulum
bulging or pouch caused by weakness in the esophageal wall
mechanical dysphagia phases
oral and oral transit phases
- difficulty forming, moving bolus
- may need to change food textures
pharyngeal phase
- airway protection may be compromised
- scarring may reduce mobility
esophageal phase
- physical constriction or blockage
- unlike neurological which doesn’t have issues
how do we treat dysphagia
diet, postural changes, exercise, and alternative feeding options
behavioral treatments — postural adjustments
chin down — helps protect airway
chin up — uses gravity to move bolus
head tilt — tips bolus toward stronger side
head turn — can close off weaker side of pharynx
npo
- some patients must be npo
- aspiration of all texture types
- minimally responsive
- recent oral/pharyngeal surgery
nasogastric tube (NG tube)
- nurse usually inserts tube via nose, pharynx, into the esophagus
- delivers liquified nutrients to stomach
- usually short-term option
- causes irritation, ulcerations
- increased reflux risk
PEG feeding (percutaneous endoscopic gastrostomy)
- attachment remains on abdominal wall
- allows long term feeding
-be REALLY clean around them
non-enteral feeding
- bypasses digestive tract
- nutrients delivered to bloodstream
