Exam 2 TBI Dr. Shappy Flashcards
TBI: Most common age group injured
young males
MOI for SCI
(three motions, four results)
some sort of method of acceleration/deceleration where the brain tissue smashes into the cranium
- Accerleration
- Deceleration
- Rotation
If any of these causes:
- Shearing,
- tearing,
- compression, or
- displacement of brain tissue
some method of trauma
Head doesn’t actually have to hit something, but brain must slosh agains something
brain can rotate into scull
what is a focal injury?
–Area of impact
–Can result in bruising (hematoma), swelling (edema), Slicing/laceration/tearing of brain, coup-contra coup effect.
From Wikipedia:
Focal and diffuse brain injury are ways to classify brain injury: focal injury occurs in a specific location, while diffuse injury occurs over a more widespread area. It is common for both focal and diffuse damage to occur as the result of the same event; many traumatic brain injuries have aspects of both focal and diffuse injury.[1] Focal injuries are commonly associated with an injury in which the head strikes or is struck by an object; diffuse injuries are more often found in acceleration/deceleration injuries, in which the head does not necessarily contact anything, but brain tissue is damaged because tissue types with varying densities accelerate at different rates.[2]
http://en.wikipedia.org/wiki/Focal_and_diffuse_brain_injury
what are three ways to classify a brain injury?
- Focal Injjury
- Diffuse Axonal Injury (DAI)
- Hypoxic Ischemic Injury
what is DAI?
Diffuse Axonal Injury
Diffuse Axonal Injury
–Diffuse damage to neural tissue (axons)
From Wikipedia:
Focal and diffuse brain injury are ways to classify brain injury: focal injury occurs in a specific location, while diffuse injury occurs over a more widespread area. It is common for both focal and diffuse damage to occur as the result of the same event; many traumatic brain injuries have aspects of both focal and diffuse injury.[1] Focal injuries are commonly associated with an injury in which the head strikes or is struck by an object; diffuse injuries are more often found in acceleration/deceleration injuries, in which the head does not necessarily contact anything, but brain tissue is damaged because tissue types with varying densities accelerate at different rates.[2]
http://en.wikipedia.org/wiki/Focal_and_diffuse_brain_injury
what is a hypoxic ischemic injury
•Hypoxic Ischemic Injury
- –Arachnoid damage
- –Other stuff I didn’t get down
From International Brain Injury Association:
Hypoxic-ischemic brain injury is a diagnostic term that encompasses a complex constellation of pathophysiological and molecular injuries to the brain induced by hypoxia, ischemia, cytotoxicity, or combinations of these conditions (Busl and Greer 2010). The typical causes of hypoxic-ischemic brain injury – cardiac arrest, respiratory arrest, near-drowning, near-hanging, and other forms of incomplete suffocation, carbon monoxide and other poisonous gas exposures, and perinatal asphyxia – expose the entire brain to potentially injurious reductions of oxygen (i.e., hypoxia) and/or diminished blood supply (ischemia).
http://www.internationalbrain.org/articles/hypoxicischemic-brain-injury/
which types of TBI have bad outcomes?
DAI & Hypoxic injury = bad outcomes
what is a brain hematoma?
A bleed on the brain
what does Dura Mater man?
Dura Mater = “tough mother”
What can brain hematomas cause?
An increase in intracranial pressure
where are three common places that hematomas can happen in the brain?
- –Epidural
- •above the dura
- –Subdural
- •Below the dura
- –Intracerebral
- •Between hemispheres
what does ICP stand for?
Intracrainial Pressure
what is considered normal ICP (for shappy)?
•Normal ICP 4 to 15 mmHg
what is the goal for Intracranial Pressur eto be able to do rehab?
•Below 20 mmHg- goal
The higher the ICP gets, the ______ the outcome
The higher the Intracranial pressure gets, the worse the outcome
The longer amount of time spend at higher ICP, the ______ the outcome
The longer amount of time spend at higher ICP, the worsethe outcome
What are three things that can be used to manage a high ICP?
- Intraventricular catheter
- Subural screw
- Epidural sensor
where are five places that a ICP cantheter can be placed? (picture it too)
- Epidulral
- Intraparencyhmal
- Subarachnoid
- Ventricular
- Subdural
List 7 tests that can be done to diagnose a TBI?
- •CT scan
- •MRI
- •PET scan
- •SPECT scan
- •FMRI
- •EEG
- •Neuropsychological testing
what happens to athletes twho get a concussion?
Concussion testing battery baseline
retest before they can return to play after concussion
Free of symptoms counts as day 1 (still might not be exactly where they were before)
why is exercise a risk after someone experiences a TBI?
Exercise increases BP that can increase intracranial pressure
What does PET stand for?
PET = Positron Emission Tomography
What does SPECT stand for?
SPECT = Single Photon Emission Computerized Tomography
Does a mild concussion require imaging?
no
(but I think Dr. Shappy thinks it should)
What does FMRI stand for?
Functional Magnetic Resonance Imaging
(functional MRI)
clinician tells pt to do something and that area lights up on the MRI
see attached picture
what does DAI stand for?
Diffuse Axonal Injury
why is it good to look at any images we can get our hands on in the hospital?
The more we see these images along with symptoms, the more we understand them and we can develop expertise
what does Sequelae mean?
a condition that is the consequence of a previous disease or injury.
What are 11 Sequelae categories of TBI?
- •Neuromuscular Impairments
- •Cognitive
- •Orientation
- •Memory
- •Executive function
- •Behavioral
- •Communication
- •Visual-Perceptual
- •Dysphagia- swallowing
- •Dysarthria- speaking
- •Indirect impairments
what are five deficits in memory that are part of sequelae of TBI?
- –Amnesia
- –Declarative memory
- –Procedural memory
- –Post-traumatic
- –Impaired attention
what are three types of amnesia?
- retrograde amnesia
- antrograde amnesia
- Post-truamatic amnesia
what is regrograde amnesia?
retrograde (can’t remember before a certain time)
what is anterograde amnesia?
antrograde (can’t learn new things)
what is post-traumatic amnesia?
Post-truamatic: the time between injury and when your memory returns
- used as a predictor for prognosis
what is post-traumatic amnesia used as?
used as a predictor for prognosis
what is declarative memory?
Declarative memory: the ability to recall facts and previous events. Language based. can tell you facts and information. (I think they could tell you a procedure even if they can’t do it: like I might be able to tell you the steps of how to do a back handspring, but I cannot do one)
_______
Declarative memory consists of facts and events that can be consciously recalled or “declared.” Also known as explicit memory, it is based on the concept that this type of memory consists of information that can be explicitly stored and retrieved.
Declarative memory differs from procedural memory, which encompasses skills such as the use of objects or movements of the body that are deeply embedded and are performed without being aware.
http://www.livescience.com/43153-declarative-memory.html
what is Precedural memory?
Procedural memory is a part of the long-term memory that is responsible for knowing how to do things, also known as motor skills. As the name implies, procedural memory stores information on how to perform certain procedures, such as walking, talking and riding a bike. Delving into something in your procedural memory does not involve conscious thought.
http://www.livescience.com/43595-procedural-memory.html
what is impaired attention
Impaired attention: Difficulty focusing to facilitate learning. Forget what they are doing mid task.
What can be used to assess cognitive state?
glascow coma scale
Six cognitive states
- Coma
- Vegetative State
- Persistant Vegettative state
- Minimally Conscious
- Stupor
- Obtunded Phase
Vegetative State
eyes open but cannot follow commands or speak, but they may have some sort of cycle of sleep time and awake time. May have some type of reflexive movement
Persistent Vegetative State
From wikipedia
A persistent vegetative state is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. It is a diagnosis of some uncertainty in that it deals with a syndrome. After four weeks in a vegetative state (VS), the patient is classified as in a persistent (or ‘continuing’) vegetative state. This diagnosis is classified as a permanent vegetative state (PVS) some months after a non-traumatic brain injury (3 months in the US, 6 months in the UK, or one year after traumatic injury).
http://en.wikipedia.org/wiki/Persistent_vegetative_state
coma
a coma is a state that lacks both awareness and wakefulness.
is a state of unconsciousness lasting more than six hours in which a person: cannot be awakened; fails to respond normally to painful stimuli, light, or sound; lacks a normal sleep-wake cycle; and, does not initiate voluntary actions.[1] A person in a state of coma is described as being comatose.
http://en.wikipedia.org/wiki/Coma
Minimally Conscious
: in and out awake/asleep. Improvement now. They will no longer be called persistently vegetative. Evidence of self and environmental awareness. (this is also where family members grab on). Usually more localized response. Can be seen better if we hold out something to them that they want. This is where a lot of pts will be in a TBI unit.
Stupor
: This may be drug induced post TBI. May have brief time of arousal. May be a temporary period or they may persist in a state of stupor.
Obtunded phase
Sleep often. Have delayed reactions or interests. When we arouse them, they are decreased in their alertness.
What category does exectuvie function usually fall into?
Executive function: usually falls into the category of IADLs (Instrumental activities of daily living) = above the most basic levels of function; planning etc.
What are behavioral sequelae of TBI?
Behavioral: could be violent, angry, apathy, frustration, depression, sexual dysfunction, unfiltered comments. Ranchos level 4 contains the sexually inappropriate behaviors. (10 is fully functioning). What do we do for them?
Sequelae of TBI: Communication
Communication, we talked about before
- broca’s vs Wernike’s
- read write
Also ask, is is dysarthria (speaking problem) or is it a language problem (broca’s and wernike’s)
Sequelae of TBI: Inderect impairments
•Indirect impairments
- –Other systems effected by same trauma, etc. or as a result of condition
I think Heterotrophic ossification was given as an example
what is Heterotrophic ossification?
Heterotopic ossification (HO) is the process by which bone tissue forms outside of the skeleton.
http://en.wikipedia.org/wiki/Heterotopic_ossification
what is a craniotomy?
Craniotomy = removal of scull
What is the difference between a craniotomy and craniectomy?
What is the difference between a craniotomy and craniectomy?
Both procedures involve removing a portion of the skull, usually to perform surgery on the brain. The difference is that after a craniotomy the bone is replaced and after a craniectomy the bone is not replaced immediately.
http://www.phoenixchildrens.org/medical-specialties/barrow-neurological-institute/programs-services/neurotrauma/faqs-neurosurgery
why might a craniotomy or craniectomy be performed?
to relieive pressure in the cranium and make room for swelling
where is the bone stored after a craniotomy until it is put back into the cranium?
Store cranium in abdomen until pressure goes down and can put it back in head
Usually in the subcutaneous abdominal wall
what percentage of stored bones “take” when they are replaced into the head?
about 70%
What is a cranioplasty?
Cranioplasty is a surgical repair of a defect or deformity of a skull.
Prognosis and goal setting: who should be invovled?
Prognosis and Goal Setting: Familiarity with outcomes reasearch for which three areas (name the areas)
- –Severity of Injury
- –Duration of Coma
- –Length of Post Traumatic Amnesia
what are two types of pts that the FIM can be used for for prognosis and as an evaluation meausre?
Stroke patienst
TBI patients
what outcome measure could we use for prognosis in a pt that could be in a coma?
Glascow-coma
Medical Managment of TBI: Emergency Management (3)
- –Cardiovascular
- –Respiratory
- –Vital signs
Medical Managment of TBI: Patient Stable(3)
- –Neurologic evaluation
- –Surgical evacuation
- –ICP
Medical Managment of TBI: oncomitant Injuries (8)
- –Long bone or other fractures
- –Soft tissue wounds
- –Neurologic problems
- –GI issues
- –Genitourinary issues
- –Respiratory
- –Cardiovascular
- –Dermatological
Rehab Perspective: What are goals based on?
focused on the location is the patient going to at discharge
Rehab Perspective: what are five places a patient might be getting discharged to?
- –Acute care hospital
- –Nursing home or long-term care facility
- –Sub-acute rehabilitation or Skilled Nursing Facility (SNF)
- –Acute rehabilitation
- –Community settings
Name the people that may be part of an Interdiciplinary Team necessary for treating TBI (10 main)
- •Patient and Family
- •Physician’s
- –Neurologist
- –Physiatrist
- •Speech-language Pathologist
- •Occupational Therapist
- •Physical Therapy
- •Rehabilitation Nurse
- –NP, RN, LPN, CNA
- •Case Manager/Team Coordinator
- •Medical Social Worker
- •Neuropsychologist
- •Other
- –Respiratory Therapy
- –Recreational Therapist
what can you use Glascow Coma scale on?
It can be used with anything that could cause pt to be in a coma
At what ranchos levels would you probably want to use the Glasgow-Coma scale too?
Definately levels I and II
possibly level III
At what level on the Rancho scale could you start using the FIM-FAM?
Probably Ranchos level IV
What guides prognosis and goal setting?
The interdiciplinary team gets together and evaluates scores on outcome measures.
All the sequele are potential things to evaluate
Where do PTs come in during medical management of SCI?
After the emergency is managed and pateint is stable
We do our own neuro eval, check ICP, etc.
What should we be sure to consider when doing an eval on a SCI pt?
Be sure to consider discharge on the eval (what is their outcome going to be)
In answering the question, “What setting will be appropriate for them at discharge?” how helpful would the glasgow-coma scale be? the racho scale?
What setting will be appropriate for them at discharge
Difficult to answer if we are using coma scale
Easier to answer if rancho level above III
What would be an example of a pt that we will send to SNF at discharge instead of a Rehab Center?
-SNF: older more frail person who cannot tolerate as much rehab time each day
what are signs that a rehab center is a good discharge destination for a patient?
-Usually will be headed in good direction to tolerate 3 hrs of rehab/day (the amount of PT they can tolerate is usually a good indicator)
who is usually the head fo the rehab hospital?
a Physiatrist (an MD)
- Similar to a “hospitalist” in the acute setting
- Hospitalist is in an acute care hospital setting
what are the different types of rehab nurses? (list in order of education)
- NP = Nurse Practitioner
- RN = Registered Nurse
- LPN = Liscenced Practical Nurse
- CNA = Certified Nursing Assistant
Details about CNA
Helps pt go to batheroom, etc.
Could be your best freind
Is overseen by RN or LPN
Do not need a degree (must go to an intensive course)
Details on LPN
Usually has associates degree
Primarily responsible for drugs
does wound care
supervises CNA
details about RN
Usually has bachelors degree
Primarily responsible for drugs
(possibly responsible fo same things as LPN, but I did not write that down)
Details on NP
masters level degree
Responsibilities are a lot like a Physicians Assistant
must be a Registered Nurse prior to becoming a NP
details on Casem Manager/Team Coordinator
- Could be social worker
- Could be other
- Responsible for insurance stuff
- Coordinating DC
Details on the Medical Social Worker
Medical Social worker (a more specific type of social worker)
- Could be Something besides the case worker
- Could be more working on home care
Details on the neuropsychologist
Neuropsychologist should understand neural disease process better
-More often role is filled by a regular psychologist
Details on Recreational Therapist
Recreational Therapist
- Bad part of rec therapy is that they are not reimbursed, so they are usually only in outstanding rehab centers
- They do great things that are more fun
What does IRF-PAI stand for?
Inpatient Rehabilitation Facility
Patient Assessment Instrument
Levels of Consciousness Again (all the way to alert)
- Alert
- Lethargic (bringman: pt may fall asleep during eval)
- Obtunded (bringman: pt may fall asleep during transfers): Seep often. Delayed reaction or reduced interests
- Stupor: Brief time of arousal
- Minimally Consicous: barely not in vegetative state. localized response. may respond to something held out to them.
- Vegetatie state: eyes open but cannot follow commands (may have wake/sleep cycle)
- Persistant Vegetative State (3 months?)
- Coma: state that lacks both awareness and wakefullness
