final exam mild TBI Flashcards by Demond Fleming

do you need to have a bleed or positive imaging to have a severe or moderate TBI?

no!

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traumatic injury that affects the brain induced by biomechanical forces transmitted to the head by a direct blow to or forces exerted on the body but that does not result in an extended period of unconsciousness, amnesia, or other significant neurological signs indicative of a more severe brain injury

concussion aka mild TBI

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a combination of what 5 things differentiates the state of a TBI?

LOC
AOC
GCS
imaging
PTA

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mild, moderate or severe TBI?
- LOC: 0-30 minutes
- AOC: brief-24 hours
- PTA: 0-1 day
- GCS: 13-15
- neuroimaging: normal

mild TBI

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mild, moderate or severe TBI?
- LOC: >30 minutes and < 24 hours
- AOC: > 24 hours
- PTA: > 1 and < 7 days
- GCS: 9-12
- neuroimaging: normal or abnormal

moderate

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what are the 3 major categories on the Glasgow Coma Scale?

eye opening
best motor response
verbal response

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which Rancho level?
No response. deep sleep, unresponsive

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which Rancho level?
Generalize response. inconsistent, non-purposeful response to stimuli

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which Rancho level?
localized response. inconsistent localized response to a stimulus

III

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which settings will you most likely see Rancho levels I-III?

ICU and LTACH

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which Rancho level?
Heightened state of activity, non-purposeful, confused, hard to learn

IV: confused agitated

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which Rancho level?
can follow simple commands inconsistently, minimal attention, inappropriate verbalizations

V: confused inappropriate

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which Rancho level?
can show goal directed behavior, but need external cuing, follows simple directions consistently, some learning

VI: confused appropriate

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which levels are more related to mild TBI stages?

Rancho VII: automatic appropriate - can get through daily activities, but robotically and needs routine
VIII: purposeful appropriate - responsive to environment, has carryover for new learning

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what is post-traumatic amnesia (PTA)?
- what do you measure it with?

duration of memory loss post injury
measured with: O Log and Galvaston orientation and amnesia test (GOAT)

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what’s the most likely reason an older person would be hospitalized from a TBI?

falls

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what are the two main mechanism of injury for mTBI?

blow to head –> direct trauma
forces exerted on the body –> pressure, movement of the brain inside a closed system

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can you get a concussion without hitting your head?

yes
Coup/contrecoup forces (acceleration/deceleration)
example: whiplash
injury to cells or structure itself. sagittal, frontal, rotational, angular

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what are the 5 subtypes of concussion?

anxiety/mood
cognitive
migraine -> headache is the first highest symptom
ocular
vestibular –> dizziness is 2nd highest symptom

what are 2 other under represented subtypes?

cervical
sleep disturbances

is concussion an isolated problem or is it electrical and metabolic problems too?

electrical and metabolic
can affect multiple systems

depolarization leads to:

glutamate influx
increased Na and Ca2+
decreased potassium (K+)
decreased cerebral blood flow –> this impacts the function of mitochondria

decreased cerebral blood flow leads to:

energy crisis
decreased ability to produce ATP –> we need to bring more O2 to the area

there is decreased ATP due to (3)

lack of glucose
decreased mitochondria function
decreased cerebral blood flow and oxygen

if the force was applied in the sagittal plane, what structures are involved?

frontal lobe - functional execution occipital lobe - vision brainstem area - CN involvement

if the force was applied in the frontal plane, what structures are involved?

temporal parietal lobe - strength, sensation, speech

TRUE OR FALSE. sheer forces and rotational injuries would not happen with mild TBI?

false - both can also be involved

it takes ____ days to recover from metabolic cascade. ___% resolved in 1 week symptom resolution for collegiate athletes is ____ days. why?

7-10 days 60% 28 days - have higher return to function

if symptoms do not resolve in 1-3 months what could be the case?

PCS - post concussion syndrome

diagnosis for PCS: cognitive deficits in attention and memory AND at least 3 of the following symptoms:

fatigue sleep disturbance dizziness irritability affective disturbance apathy or personality changes that persist 3+ months

what three things do you need to make sure to ask in your subjective history for mTBI?

mechanism of injury baseline levels (any history of concussion) questions surrounding subtypes

in order to conduct a more efficient screening of mTBI, what is one thing you should work to identify?

the subtype of concussion

what are the 4 major categories to eval concussion per the CPG?

cervical/MSK vestibular/oculomotor autonomic/exertional tolerance motor function: balance and gait

vestibular/oculomotor exam should include:

ocular alignment smooth pursuits saccades vergence and accommodation gaze stability dynamic visual acuity visual motion sensitivity vertigo caused by BPPV light-headedness due to orthostatic hypotension

balance/gait exam should include:

static and dynamic balance motor coordination and control dual/multitasking tests

what are 4 outcome measures specific to concussion

SCAT 6 (sports concussion assessment tool) HiMAT (high level mobility assessment tool) BCTT (buffalo concussion treadmill test) BESS (balance error scoring system)

how should you base your interventions for concussion?

specific to subtype and individual CPG within symptom tolerance --> you CAN push them too hard & make them worse

which subtype is there best evidence for?

vestibular-ocular subtype consider head turns with vestibular rehab --> slow these down to 1Hz due to MOI

what are things you need to educate your patient on post-concussion?

self management of symptoms importance of relative rest importance of sleep gradual progressive return to activities with pacing strategies signs and symptoms that warrant further follow up care POC and expected time to recovery

what are two things PTs need to factor in when making interventions for concussion?

irritability of patient Self-management ability of the patient

in the past, we were told not to sleep after a concussion. why? what are we told is best now?

past: don't sleep bc we are worried about brain bleeds now: relative rest, NOT strict rest. strict rest prolongs recovery

what is stimulation schedules? why is this found to be the best now?

scheduled times with decreased stimulation (can sleep, don't have to) followed by times with stimulation (light activity) we still need sleep, just not all day and don't stay up all night

what are return to sport protocol rules?

must have full 24 hours between each stage --> this is why it often takes ~ 1 week to return post-concussion must be completely symptom free to move to next stage need physician approval to initiate protocol, initiate full contact, & return to competition

what are the 6 stages that must be met to return to sport?

1. back to regular activity - recovery 2. back to light aerobic activity - increase heart rate 3. moderate activity - add movement 4. heavy, non-contact activity - exercise, coordination, cognitive load 5. practice and full contact - restore confidence and assess functional skills by coaching staff 6. competition

who is part of the healthcare team with concussion?

PT SLP OT Athletic trainer Physician Neuropsychologist

what settings will concussion show up in?

sports --> on field military outpatient (ortho, neuro, geriatrics, peds, sports) ED acute care acute rehab (secondary injuries most likely)