L14 Severe TBI Flashcards
TBI Causes
falls
assaults
MVA
sports
gun shot
workplace
child abuse
domestic violence
military
Non-traumatic brain injury
stroke
infection
electric shock
seizure
tumor
toxic exposure
metabolic disorers
poisoning
cardiac arrest
drowning
drug overdose
TBI Definition
disruption in normal function of brain that can be caused by bump, blow, jolt to head or penetrating head injury
Epidemiology of TBI
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
High risk populations for TBI
racial and ethnic minorities
service members, veterans
houseless individuals
correctional and detention facilities
DV survivors
rural areas
Top causes of TBI in US
falls
firearm related suicide
MVA and assaults
Incidence of TBI in sports
limited data sources means that it is currently undetermined
Closed Head Injury
skull not penetrated
focal and diffuse axonal damage
Open Injury
penetrating wound
focal axonal damage
Deceleration Injury
diffuse axonal damage
Coup-Contracoup Injury
Coup = moving object strikes head
Contracoup = head hits stationary object
diffuse axonal damage to opposite poles of the brain
Blast Injury
rapid pressure shock creating kinetic energy that causes deformation of the brain
diffuse axonal damage and higher incidence of PTSD
What lobes are susceptible to damage from external forces?
frontotemporal lobes
Focal Axonal Injury (Primary Brain Injury)
necrotic area is concentrated at the coup with compromised blood supply
lead to impairments based on neuroanatomy of area
Diffuse axonal injury (Primary Brain Injury)
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
Secondary Injury of TBI
- trauma disrupts BBB
- Leukocytes, microglia, and astrocytes produce reactive O2 species
- Causes demyelination of axons and cytoskeletal disruption
causes neurodegeneration, glial scar, cell death
MILD TBI Criteria
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
MODERATE TBI Criteria
Glasgow = 9-12
Loss of consciousness = 30 min - 1 week
Post-traumatic amnesia = >24 hrs, <1 wk
Alteration of mental state = >24h
SEVERE TBI Critera
Glasgow = ≤ 8
Loss of consciousness = > 1 week
Post-traumatic amnesia = > 1 week
Alteration of mental state = >24 h
Fiver year outcomes of persons with TBI
22% died
30% became worse
22% stayed the same
26% improved
Lifetime economic cos of TBI
76.5 billion
Glasgow Coma Scale
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
13-15 Glasgow
mild TBI
patient is awake
presents with confusion, but can follow directions and communicate
9-12 Glasgow
moderate TBI
drowsy or obtunded
can open eyes and localize pain
3-8 Glasgow
Severe TBI
pt is obtunded to comatose
unable to follow directions
decorticate or decerbrate posture
Obtunded
dulled or reduced level of alertness or consciousness
Glasgow scale test areas
eye opening response
best verbal response
better motor response
Decorticate Posture
Closed hands
legs IR
Feet inverted
Arms are adducted and flexed
Decerebrate Posture
head and neck arched
legs straight
toes are PF
arms are extended
hands curled
Decorticate and Decerbrate posturing…
both abnormal responses
indicates lack of cortex motor function
worse prognosis for recovery is cause is not treated immediately
Diagnostic Procedures
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
ER Medical Management of TBI
limit development of secondary brain damage, maintaining airway, replacement of fluid
Early Medical Management of TBI
coma inducing meds to reduce brain O2 demands
diuretics to reduce fluid and intracranial pressure
anti-epileptic meds to prevent seizure
Surgical Intervention for TBI
decompression of injured brain
craniotomy
removal of hematoma
removal of skull fragments
insertion of ICP
external ventricular drain
External ventricular drain
drains CSF from ventricles in real time to external bag
RN has to clamp it before PT
used for TBI, stroke, brain tumor
Normal ICP
4-15 mmHG
Types of ICP Monitors
- Subarachnoid bolt
- Epidural bolt
- EVD
1 + 2 only look at ICP data
3 does data and drains
Disorders of Consciousness Continuum
Brain Death
Coma
Unresponsive Wakefulness (vegetative)
Minimally Consciousness
Post-Traumatic Confusional
Arousal is supported by
brainstem
defined as eye-opening
Awareness is controlled by
cerebral cortex
wide frontoparietal network
known as command following
Consciousness is controlled bu
cerebral cortex, thalamus, brainstem
Recovery from COMA or DOC
consciousness mesocircuits (widespread anatomical connections) facilitate recovery
restoration of excitatory neurotransmission along subcortical and cortical pathways
Stages of recovery of consciousness
- Wakefulness
- Awareness, Arousal, Attention
- Perception and Recognition
- Speed of Info Processing
- Memory
- Reasoning and Problem-Solving
- Executive Functioning
CP of Diffuse Axonal Injury
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
Rancho of Cognitive Functioning Scale
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
Rancho 1
“no response”
individual appears to be in a deep sleep and is unresponsive to any stimuli
total assist
Rancho 2
“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
Rancho 3
“localized response”
individual responds specifically but inconsistently to direct stimulus
responses are directly related to type of stimulus
may follow simple commands
total assist
Rancho 4
“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
Rancho 5
“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
Rancho 6
“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
Rancho 7
“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
Rancho 8
“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
Rancho 9
“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
Rancho 10
“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
Coma is equal to
Rancho 1
Vegetative state is equal to
Rancho 2
Minimally Consciousness State is equal to
Rancho 3
Post traumatic confusional state is equal to
rancho 4
Contraindications of PT for TBI
worsening or new neuro signs
unstable vital signs
EVD without orders from MD
Precautions for PT with TBI
surgical –helmet, icp
neck immobilized until spine is imaged
PT Exam includes
brief systems review
mobility assessment
impairments
outcome measures
Level of Consciousness Tests
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
Level of Attention Tests
need to have attention before you can test cognition and executive function
at least beyond rancho 3
Cognition and Executive Function Tests
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
Coma Recovery Scale Revised
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
Coma Recovery Scale Scores
higher score indicates transition to higher arousal states
scored from 0-23
> 10 = minimally conscious state (rancho 3)
Rancho 1 PT Interventions
ongoing PT is not appropriate
could see pt for 1-2 visits for family education on PROM and when PT will be provided
Rancho 2-3 Interventions
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
Monitor and document for Rancho 2-3
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
Progression/Regression for Rancho 2-3
slowly increase amount of time you provide sensory stimulation, amount of time spent sitting up (especially for ADLs), multiple sensory stimulation
What causes Agitation?
- pathophysiological = neural injury leads to disinhibition of behaviors
- behavioral = certain people
- unmet basic needs
- environmental vulnerability or stressors
PT Treatment Causes of Agitation
Too frequent feedback
Task overload
retention testing
premature test to self-monitor
contrived treatment
delay in assistance
Warning Signs of Agitation
restlessness
decreased visual contact
decreased verbal output
increased loudness of voice
increased distractibility
negative self-deprecating comments
chewing
What to do if pt becomes agitated
- remove them from stimuli or change stimuli
- call a code gray
- Avoid escalation
- Remove yourself from the situation
- use restraints
some pts may use agitation to avoid PT. try to take note of patterns and change motivators
Agitated Behavior Scale
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
Measures on ABS
- short attention span
- impulsive
- uncooperative
- violent
- explosive anger
- rocking, rubbing
- pulling at tubes/restraints/ivs
- wandering from treatment
- restlessness, pacing
- rapid, loud, excessive talking
- repetitive behaviors
- sudden changes of mood
- excessive crying or laughter
- self-abusiveness
Rancho 4 PT treatment
- Functional training using handling and neuro facilitation
- Impairment based interventions (ROM, MMT, cognitive)
- Assess for ADs, orthotics
- Family Education on red flags and overstimulation
Tips for PTs with Rancho 4
- Find good motivator for pt like family, tasks
- Select interventions that maintain safety without agitating pt
- Keep restraints on so they can be latched quickly
- Use ADs or equipment
- Handoff to other staff
