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6 Neurological Dysfunction > L14 Severe TBI > Flashcards

L14 Severe TBI Flashcards

1
Q

TBI Causes

A

falls
assaults
MVA
sports
gun shot
workplace
child abuse
domestic violence
military

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2
Q

Non-traumatic brain injury

A

stroke
infection
electric shock
seizure
tumor
toxic exposure
metabolic disorers
poisoning
cardiac arrest
drowning
drug overdose

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3
Q

TBI Definition

A

disruption in normal function of brain that can be caused by bump, blow, jolt to head or penetrating head injury

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4
Q

Epidemiology of TBI

A

214,00 TBI hospitalizations
69,000 TBI deaths

People 75+ had highest number of deaths/hospitalizations

males are 2x more likely to be hospitalized and 3x more likely to die

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5
Q

High risk populations for TBI

A

racial and ethnic minorities
service members, veterans
houseless individuals
correctional and detention facilities
DV survivors
rural areas

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6
Q

Top causes of TBI in US

A

falls
firearm related suicide
MVA and assaults

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7
Q

Incidence of TBI in sports

A

limited data sources means that it is currently undetermined

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8
Q

Closed Head Injury

A

skull not penetrated
focal and diffuse axonal damage

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9
Q

Open Injury

A

penetrating wound
focal axonal damage

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10
Q

Deceleration Injury

A

diffuse axonal damage

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11
Q

Coup-Contracoup Injury

A

Coup = moving object strikes head
Contracoup = head hits stationary object

diffuse axonal damage to opposite poles of the brain

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12
Q

Blast Injury

A

rapid pressure shock creating kinetic energy that causes deformation of the brain

diffuse axonal damage and higher incidence of PTSD

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13
Q

What lobes are susceptible to damage from external forces?

A

frontotemporal lobes

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14
Q

Focal Axonal Injury (Primary Brain Injury)

A

necrotic area is concentrated at the coup with compromised blood supply

lead to impairments based on neuroanatomy of area

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15
Q

Diffuse axonal injury (Primary Brain Injury)

A

non-contact forces of rapid deceleration and acceleration cause shearing and stretching injury in cerebral brain tissues

presents as extensive damage of axons predominantly in subcortical and deep white matter tissue of brain stem and corpus callosum

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16
Q

Secondary Injury of TBI

A
  1. trauma disrupts BBB
  2. Leukocytes, microglia, and astrocytes produce reactive O2 species
  3. Causes demyelination of axons and cytoskeletal disruption

causes neurodegeneration, glial scar, cell death

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17
Q

MILD TBI Criteria

A

Glasgow = 13-15
Loss of consciousness = 30 min or less
Post-traumatic amnesia = less than 24 h
Alteration of mental state = up to 24 h

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18
Q

MODERATE TBI Criteria

A

Glasgow = 9-12
Loss of consciousness = 30 min - 1 week
Post-traumatic amnesia = >24 hrs, <1 wk
Alteration of mental state = >24h

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19
Q

SEVERE TBI Critera

A

Glasgow = ≤ 8
Loss of consciousness = > 1 week
Post-traumatic amnesia = > 1 week
Alteration of mental state = >24 h

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20
Q

Fiver year outcomes of persons with TBI

A

22% died
30% became worse
22% stayed the same
26% improved

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21
Q

Lifetime economic cos of TBI

A

76.5 billion

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22
Q

Glasgow Coma Scale

A

assesses pts depth and duration of impaired consciousness and coma following TBI. Also used acute brain injuries

validity and reliability decrease when given to pts who are intubated or sedated

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23
Q

13-15 Glasgow

A

mild TBI
patient is awake
presents with confusion, but can follow directions and communicate

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24
Q

9-12 Glasgow

A

moderate TBI
drowsy or obtunded
can open eyes and localize pain

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25
Q

3-8 Glasgow

A

Severe TBI
pt is obtunded to comatose
unable to follow directions
decorticate or decerbrate posture

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26
Q

Obtunded

A

dulled or reduced level of alertness or consciousness

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27
Q

Glasgow scale test areas

A

eye opening response
best verbal response
better motor response

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28
Q

Decorticate Posture

A

Closed hands
legs IR
Feet inverted
Arms are adducted and flexed

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29
Q

Decerebrate Posture

A

head and neck arched
legs straight
toes are PF
arms are extended
hands curled

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30
Q

Decorticate and Decerbrate posturing…

A

both abnormal responses
indicates lack of cortex motor function
worse prognosis for recovery is cause is not treated immediately

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31
Q

Diagnostic Procedures

A

urgent exam by ed team
neck immobilization
CT scan to look for fx, hemorrhage, edema

once medically stable, MRI to look for more detailed injury

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32
Q

ER Medical Management of TBI

A

limit development of secondary brain damage, maintaining airway, replacement of fluid

33
Q

Early Medical Management of TBI

A

coma inducing meds to reduce brain O2 demands

diuretics to reduce fluid and intracranial pressure

anti-epileptic meds to prevent seizure

34
Q

Surgical Intervention for TBI

A

decompression of injured brain
craniotomy
removal of hematoma
removal of skull fragments
insertion of ICP
external ventricular drain

35
Q

External ventricular drain

A

drains CSF from ventricles in real time to external bag
RN has to clamp it before PT
used for TBI, stroke, brain tumor

36
Q

Normal ICP

A

4-15 mmHG

37
Q

Types of ICP Monitors

A
  1. Subarachnoid bolt
  2. Epidural bolt
  3. EVD

1 + 2 only look at ICP data
3 does data and drains

38
Q

Disorders of Consciousness Continuum

A

Brain Death
Coma
Unresponsive Wakefulness (vegetative)
Minimally Consciousness
Post-Traumatic Confusional

39
Q

Arousal is supported by

A

brainstem
defined as eye-opening

40
Q

Awareness is controlled by

A

cerebral cortex
wide frontoparietal network

known as command following

41
Q

Consciousness is controlled bu

A

cerebral cortex, thalamus, brainstem

42
Q

Recovery from COMA or DOC

A

consciousness mesocircuits (widespread anatomical connections) facilitate recovery

restoration of excitatory neurotransmission along subcortical and cortical pathways

43
Q

Stages of recovery of consciousness

A
  1. Wakefulness
  2. Awareness, Arousal, Attention
  3. Perception and Recognition
  4. Speed of Info Processing
  5. Memory
  6. Reasoning and Problem-Solving
  7. Executive Functioning
44
Q

CP of Diffuse Axonal Injury

A

altered level of consciousness due to disruption of circuits between brainstem and cortex

can have many impairments because of large volume of axonal damage in cortex and brainstem

45
Q

Rancho of Cognitive Functioning Scale

A

used by brain injury HCP
measures individual’s recovery over time after brain injury

recovery can plateau at any level and pt can fluctuate between stages

46
Q

Rancho 1

A

“no response”

individual appears to be in a deep sleep and is unresponsive to any stimuli

total assist

47
Q

Rancho 2

A

“generalized response”

individual reacts inconsistently, delayed, and non-purposefully to stimuli

limited responses that may include gross motor, vocalization, physiologic changes. Deep pain causes response

Total assist

48
Q

Rancho 3

A

“localized response”

individual responds specifically but inconsistently to direct stimulus

responses are directly related to type of stimulus

may follow simple commands

total assist

49
Q

Rancho 4

A

“confused agitated”
-heightened state of activity
-decreased ability to process info
-behavior is not related to environment
-common hostility and attempts to climb out of bed
-may perform actions but not upon request at times

max assist

50
Q

Rancho 5

A

“confused inappropriate”
-appears alert and responds to simple commands consistently
-agitation is out of proportion, relates to stimuli
-inappropriate responses and high distractibility
-impaired memory
-requires assistance for self-care

max assist

51
Q

Rancho 6

A

“confused appropriate”
-goal-directed behavior
-needs external input
-response to discomfort is appropriate
-simple commands
-carry-over for relearned activities
-orientation is inconsistent
-awareness of self and others is increased

mod assist

52
Q

Rancho 7

A

“automatic appropriate”
-acts appropriately
-robot like
-poor recall of activities done
-absent to minimal confusion
-lacks insight
-poor judgement and problem solving
-unrealistic future plans
-can begin to initiate tasks or social activities with schedule

min assist routine ADLs

53
Q

Rancho 8

A

“Purposeful appropriate”
-alert and oriented
-able to recall and integrate past events
-aware and responsive to surroundings
-independence at home and community
-carryover for new learning
-doesn’t need supervision for learned activities
-social/emotional/cognitive not at prior to injury level

stand by assist

54
Q

Rancho 9

A

“purposeful appropriate”
-can shift between different tasks and complete independently
-aware of impairments
-compensatory strategies
-cannot independently anticipate secondary impairment obstacles
-w/assistance can understand consequences
-w/assistance can understand emotional needs of others
-depression, frustration

stand by assist on request

55
Q

Rancho 10

A

“purposeful, appropriate”
-multitask with assistance
-memory retention
-independently anticipates obstacles from secondary impairments
-takes corrective actions
-requires more time or compensatory strategies
-intermittent depression and frustration
-can interact appropriately with others

modified independent

56
Q

Coma is equal to

A

Rancho 1

57
Q

Vegetative state is equal to

A

Rancho 2

58
Q

Minimally Consciousness State is equal to

A

Rancho 3

59
Q

Post traumatic confusional state is equal to

A

rancho 4

60
Q

Contraindications of PT for TBI

A

worsening or new neuro signs
unstable vital signs
EVD without orders from MD

61
Q

Precautions for PT with TBI

A

surgical –helmet, icp
neck immobilized until spine is imaged

62
Q

PT Exam includes

A

brief systems review
mobility assessment
impairments
outcome measures

63
Q

Level of Consciousness Tests

A

pts in rancho 1-3 = focus of your exam

document level of alertness with specific statement of what the patient did in response to particular stimuli

64
Q

Level of Attention Tests

A

need to have attention before you can test cognition and executive function

at least beyond rancho 3

65
Q

Cognition and Executive Function Tests

A

may be ready for exam in rancho 4, but if agitated may need to wait until rancho 5

involves orientation, memory, ability to follow directions, judgement, visuospatial processing

66
Q

Coma Recovery Scale Revised

A

6 sub-scales comprised of hierarchically arranged items reflecting brainstem, subcortical, cortically mediated behaviors

lowest item on each subscale represents reflexive activity while highest item represents cognitively mediated behaviors

67
Q

Coma Recovery Scale Scores

A

higher score indicates transition to higher arousal states

scored from 0-23

> 10 = minimally conscious state (rancho 3)

68
Q

Rancho 1 PT Interventions

A

ongoing PT is not appropriate

could see pt for 1-2 visits for family education on PROM and when PT will be provided

69
Q

Rancho 2-3 Interventions

A

pts need to move

position changes like PROM to AAROM, sitting at EOB with 2-3 person assist

positioning devices to prevent loss of ROM and skin

sensory stimulation (auditory, tactile, visual)

family education

70
Q

Monitor and document for Rancho 2-3

A

skin integrity
joint ROM
opening of eyes
verbal response
non-verbal responses
amount of time they can tolerate activities before closing eyes or getting agitated

71
Q

Progression/Regression for Rancho 2-3

A

slowly increase amount of time you provide sensory stimulation, amount of time spent sitting up (especially for ADLs), multiple sensory stimulation

72
Q

What causes Agitation?

A
  1. pathophysiological = neural injury leads to disinhibition of behaviors
  2. behavioral = certain people
  3. unmet basic needs
  4. environmental vulnerability or stressors
73
Q

PT Treatment Causes of Agitation

A

Too frequent feedback
Task overload
retention testing
premature test to self-monitor
contrived treatment
delay in assistance

74
Q

Warning Signs of Agitation

A

restlessness
decreased visual contact
decreased verbal output
increased loudness of voice
increased distractibility
negative self-deprecating comments
chewing

75
Q

What to do if pt becomes agitated

A
  1. remove them from stimuli or change stimuli
  2. call a code gray
  3. Avoid escalation
  4. Remove yourself from the situation
  5. use restraints

some pts may use agitation to avoid PT. try to take note of patterns and change motivators

76
Q

Agitated Behavior Scale

A

useful for pts with TBI, alzheimer’s, stroke

used to monitor agitation through recovery or throughout the day

14 behavior items, scored from 1 (absent) to 4 (extreme)

total score is used to assess agitation, with higher scores meaning that agitation is worse

77
Q

Measures on ABS

A
  1. short attention span
  2. impulsive
  3. uncooperative
  4. violent
  5. explosive anger
  6. rocking, rubbing
  7. pulling at tubes/restraints/ivs
  8. wandering from treatment
  9. restlessness, pacing
  10. rapid, loud, excessive talking
  11. repetitive behaviors
  12. sudden changes of mood
  13. excessive crying or laughter
  14. self-abusiveness
78
Q

Rancho 4 PT treatment

A
  1. Functional training using handling and neuro facilitation
  2. Impairment based interventions (ROM, MMT, cognitive)
  3. Assess for ADs, orthotics
  4. Family Education on red flags and overstimulation
79
Q

Tips for PTs with Rancho 4

A
  1. Find good motivator for pt like family, tasks
  2. Select interventions that maintain safety without agitating pt
  3. Keep restraints on so they can be latched quickly
  4. Use ADs or equipment
  5. Handoff to other staff

6 Neurological Dysfunction (16 decks)

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