exam 3: severe TBI Flashcards
to be classified as a severe TBI:
- GCS score is:
- Post-traumatic amnesia (PTA) O-log score ____ for _____days
- loss of consciousness:
- 3-8
- < 25 for > 7 days
- > 24 hours
Glasgow Coma Scale includes 3 subdivisions which are ?
a lower score indicates:
eye opening, best motor response, and verbal response
- more severe
unable to remember events on an ongoing basis for a period of time after the traumatic event.
results in confusion and disorientation.
post-traumatic amnesia (PTA)
______ amnesia = loss of events before the injury
_____ amnesia = loss of events after injury
retrograde
anterograde
the Galveston Orientation and Amnesia Test (GOAT) assesses ______ and ______ in patients who have had a _______ ____
PTA and retrograde amnesia (RA) ; severe TBI
a score of ______ on the GOAT = PTA
< 75/100
levels of consciousness:
- complete absense of arousal or awareness
- arousal without awareness
- minimal, reproducible, but inconsistent awareness
- coma
- vegetative state
- minimally conscious state
describe the following Rancho levels:
- I
- II
- III
- no response: patient in deep sleep, unresponsive to any stimuli
- generalized response: patient reacts inconsistently and non-purposefully to stimuli in a non-specifc manner
- localized response: patient reacts specifically but inconsistently to stimuli, may follow simple commands in an inconsistent delayed manner
imaging for TBI
- initially:
- 24-48 hours later:
- CT head
- MRI of brain for higher sensitivity or if CT initially negative
what is one of the more common types of severe TBI and how does it often happen?
Diffuse axonal injuries –> microscopic injury, often misdiagnosed or undiagnosed
most common in the acceleration/deceleration mechanism of injury (high-speed MVAs)
what might you gather from a patient’s history of someone with a severe TBI?
- arousal, consciousness, and behavior limitations (perform in low stim closed environment or rely on family members)
- PLOF and CLOF
- co-morbidities
- consult with RN prior to eval
what are indications that you would not treat the patient?
- ICP >20 mmHg
- MAP < 60mmHg
- CPP <60 mmHg
- SpO2 < 90%
- vent settings too high
- vitals outside treatable limits
what are the 3 appropriate outcome measures to test arousal/attention/cognition in a TBI pt?
- coma recovery scale
- moss attention rating scale
- rancho levels of consciousness scale
Coma recovery scale:
- higher score = ____
- recommended for ______
- increased consciousness
- all disorders of consciousness
MARS:
- measures:
- ________ damage affects attention
- what do you need to be careful of when using this rating scale?
- attention related behaviors after TBI
- frontal lobe
- some items are flipped (positives vs. negatives)
what elements make up a neuromuscular screen for a TBI patient?
- passive motion testing –> tone
- motor exam
- sensory exam
- reflexes
what are the two primary considerations when doing a cardiopulm screen on a TBI patient?
- ICP under 22mmHg (under 20 is ideal)
- CPP between 60-70 mmHg
CPP = MAP-ICP
what do you screen for in a MSK screen?
heterotopic ossification
contracture risk
what is heterotopic ossification?
the abnormal development of bone in areas of soft tissue
HO occurs in _______% of adult patients with TBI
10-20%
early symptoms of HO appear as _________ and can lead to _____
inflammatory
contractures, pressure injuries, impaired mobility
what are the two things you screen for in an integumentary screen with a TBI patient?
wounds (from accident)
pressure ulcers (from immobility)
what do you check in a GI/GU screen in a TBI patient?
foley catheters
fecal management systems
overactive or neurogenic bladder
when examining a patient, you find abnormal posturing, sensorimotor impairment, and synergy patterns present. You forgot to chart review before seeing the patient. Based off their presentation, what are two diagnoses you are debating?
stroke and TBI –> can have similar examination findings!
what are two important considerations when forming interventions for a severe TBI patient?
patient’s available resources (family support, PLOF, CLOF)
attainable goals (DC plan)
what is PTs role in the acute phase with TBI patients?
early mobilization
prevent compensations and learned helplessness
monitor patient’s status and VS
to increase stimulation provide ____ ______ –> what is it? give examples
sensory stimulation: used to increase level of arousal and elicit movement in those with low levels of arousal
- upright interventions
- hand over hand
- auditory
- nail bed pressure
to decrease stimulation limit ____, ____, and ______
touch, sound and visual stimulus
______ and _____ change increase arousal due to the ______ _____ system.
–> to do this, start by ________
vestibular and positional ; reticular activating system
–> raising HOB
the HOB should never be below _____ degrees in a TBI patient for ICP purposes
30 deg
what type of wheelchair is a great option to get a TBI patient upright?
–> why?
tilt-in-space
tilt for pressure relief moving pressure from ischials to sacrum
to prevent contractures and promote function at all major joints, what would be a good intervention?
PROM
what is serial casting?
- joint immobilized at end-range for 2-5 days at a time
- cast is removed and further stretching is performed and new cast is set with new ROM
- repeat until significant gains in ROM are achieved
serial casting does not improve ______ but rather it can improve ____
spasticity
muscle tissue length
what are contraindications of serial casting?
risk of skin breakdown
monitor distal to cast for swelling or circulation problems
explain how positioning can be used as a type of intervention for TBI patients.
- wounds: “turning” schedule, off weight pressure areas
- contractures: influence of hypertonicity (prevent certain positions)
- cardiopulm considerations: BP management and pneumonia prevention
what are some things to teach the family or caregiver how to manage?
stimulation schedule
splinting schedule
PROM
turning schedule
equipment use
bowel/bladder management
body mechanics
what is the most appropriate discharge location from acute care for a TBI patient?
LTACH
*** case study at end of lecture
