Lecture 5 - TBI Flashcards
What is more expensive, acute care, or inpatient rehab?
Acute care
Early medical management of a TBI
Establish open airway
check vital signs
fluid replacement
Neuro checks every 15-30 mins
Glasgow Coma Scale:
What does the score range between?
How is it used?
3-15 (worst is 3)
Used at scene of accident, in ER, throughout acute care
used as a predictor of outcome
used in research
What are the 3 components of the glasgow coma scale?
Eye, Verbal, Motor Response
Glasgow coma score meanings:
3-8
9-12
13-15
3-8 Severe injury (defines coma in 90% of cases)
9-12 moderate injury
13-15 mild injury
What are limitations of the glasgow coma scale
Pre-existing conditions
aphasia
alcohol or medications
other injuries (example : jaw injury makes it hard to talk)
Local brain injury vs Diffuse axonal Injury
Local brain injury : localized to the site of impact on skull
Diffuse axonal injury: widely scattered shearing of axons
Intracranial pressure norms:
0-10
10-20
20-40
60
0-10 normal while laying down
10-20 Abnormal
20-40 Contraindication for PT, causes neurological dysfunction
60+ almost always results in death
What can cause an intracranial infection?
Foreign objects in brain from the injury
How can a hemmorhage cause cerebral arterial vasospasm
blood where its not suppose to be irritates the smooth muscle of the vessels and causes vasospasm
Hydrocephalus vs brain edema?
Hydrocephalus : CSF build up where it’s not suppose to be
Brain edema- the brain cells are swollen
What could cause arterial hypoxemia from a TBI
Depressed breathing centers
What could cause arterial hypotension from a TBI
Bleeding elsewhere in the body
How is anemia caused from a TBI?
Hyponatremia?
anemia- bleeding
hyponatermia - sodium loss
Distortion vs midline shift
Distortion is a smaller shift than a midline shift, doesn’t move the whole brain over
What is the difference between hypoxemia and ischemia?
hypoxemia- less oxygen in blood
Ischemia- bloodflow isnt happened
Where is hypoxemic and ischemic brain damage commonly seen?
Hippocampus, basal ganglia, scattered sites of cerebral cortex and cerebellum
What is the difference of a craniotomy vs a craniectomy
Craniotomy - Make a hole to let pressure drain
Craniectomy - remove flap that they’ll put back later
What is a ventriculostomy?
Used to insert a measurement/drain device into the ventricles to measure intracranial pressure
How does an EVD (external ventricular drain) work?
Measures intracranial pressure
Must be kept level with patients head at all times to work
check with nurse before mobilization
an average adult with a TBI in the ICU requires how many calories per day?
3000 kcal atleast
note: articifial feeding once bowel souns return via nasogastric tube, gastrotomy, jujunostomy
Damage to the hypothalamus can cause ________ fever
Neurogenic fever
note: a fever can be signof iritation with a brain herniation and causes increased caloric/metabolic demand of brain
Systemic arterial hypertension can result in blood brain barrier disruption causing more __________
loss of autoregulation of cerebral bloodflow increases blood-brain volume AKA ____________
brain edema
inracranial hypertension
What is the most common side effect related to heart rate stemming from a TBI?
Tachycardia
Participation vs Activity vs Body Structure/function scales
What is the definition of each?
Participation - how well they’re doing socially ability to participate in life
Activity- Measures their overall physical functional abilities (example: how they walk/run)
Body structure/function: Measures more specific things related to their body. example: spasticity
How is the disability rating scale scored?
What does it measure?
0-no disability to 30 - death
It measures PARTICIPATION
What does the CHART (Craig Handicap assessment/reporting technique) measure?
Physical independence
Mobility
Occupation
Social Intregration
Economic Self Sufficiency
Cognitive Independence
Note: it’s also a participation measure
What does the POPS measure (Participation Objective/ Participation subjective)
Measures participation…
26 items in 5 categories
Example: in a typical month how often do you go to the movies?
How important is this to your well being? are you satisified or would you like to be doing more or less?
What are the 4 supervision categories on the supervision rating scale?
Overnight supervision
Part time supervision
Full time indirect supervision
full time direct supervision
When does most improvement on the supervision rating scale happen?
First year
note: overall most recovery for everything happens in first year
What is the UDS-FIM
an ACTIVITY measure
What is HIMAT?
HiLevel Mobility Assessment tool
Activity measure
note: minimum mobility requirement: independent walking 20 meters
Includes walking, running, jumping, stairs…
What is Rancho level 1?
No response
What is Rancho level 2?
Generalized Response
non-purposeful responses, often to pain only
What is Rancho level 3?
Localized response
purposeful responses, can follow simple commands or focus on object.
What is rancho level 4?
Confused Agitated
What is rancho level 5?
Confused, inappropriate, non-agitated
appears alert, verbally inappropriate, unable to learn new information
What is rancho level 6
Confused, Appropriate
good directed behavior, can relearn old skills, serious memory problems, has self awareness
What is Rancho level 7?
Automatic Appropriate
Robot-like appropriate behavior with minimal confusion
poor insight into condition, poor judgement and problem solving
What is rancho level 8?
Purposeful Appropriate
Alert/oriented can recall and integrate past events
cogntitively independent
many function at reduced levels in society at this level
How is mild traumatic brain injury defined?
By atleast one of these:
Any period of loss of conciousness
any loss of memory
any change in meental state at time of accident
focal neuro deficits
What is the JFK Coma/near coma scale?
scale used to monitor alertness for patients in a coma/PVS
more sensitive than glassgow and rancho
shows emergence from coma/PVS to a minimally concious state
What is the average duration of unconciousness after a traumatic brain injury
7.87 days
Most have under 1 day though. (46%)
25% have between 2-7 days of unconciousness
How will TBI patients typically present?
Lots of tubes
asleep or awake
high risk for skin breakdown
unstable vital signs
increased risk of seizures
NPO (nothing by mouth)
Extreme levels of hypertonicity
How will a patient in a coma appear?
no eye opening (even spontaneously), nor movements or vocalization
How long does a coma usually last?
Not more than 2 weeks
How will a patient in a persistent vegetative state appear?
Can have eyes open, move spontaneously, but unable to follow commands or speak, they will have sleep/wake cycles
How long can a persistent vegetative state last for
indefinitely
How is the JFK coma scale scored?
0 is worst, 23 is best
What are the categories of the JFK coma scale?
auditory, visual, motor, oromotor/verbal, communication, and arousal.
What is post traumatic amnesia PTA
Period of time from the accident to the time a patient starts having ongoing short term memory
patients will often not remember the accident or the events immediately preceding it
How long does PTA usually last?
Generally lasts 3-4 times the length of unconciousness
so if you were unconcious for 24 hours you wouldnt remember 3-4 days
What is the average duration of PTA (post traumatic amnesia)
23 days
What is the galveston orientation and amnesia scale?
How is it scored?
Used to determine when a patient is progressing out of PTA
Must have 3 consecutive scores of 75+ to be out of PTA
Causes of agitation
Actual site of injury:
Slyvian Fissure
Temporal Lobe
Diffuse axonal injury Esp of corpus callosum and dorsolateral columns of midbrain
secondary effects of hypoxia and compression, neuro hormones
Or pre-morbid personality
Environment (sensory overload or deprevation)
What are reversable factors of agitation?
Seizures
Sleep disturbances
Electrolytes
Medication
Nutrition
How can physical therapy help patients with agitation
get them up and walking and change enviroments
What scale measures agitation from a TBI?
Agitated behavior scale
minimum score of 14, max of 56
higher score = more agitation
What scale measures attention after a TBI
Moss Attention Scale
Scores 22-110
Higher score = better attention
not appropriate for patients in PVS or coma
What is the classification for a mild traumatic brain injury?
Traumatic induced disruption of brain manifested by atleast one of these:
Any period of LOC
Any memory loss
any change in mental state at time of accident
Focal neuro deficits (transient or lasting)
In order to have a MILD traumatic brain injury, the severity should not exceed:
LOC greater than 30 mins
After 30 mins they must score no less than 13-15 on the Glassgow coma scale
Symptoms of mild TBI are not commonly reported initially but ______________
what is the most common reported symptom?
Surface later and last 1 year or more
headaches
What are symptoms of a mild TBI
Physical: Headache, dizziness, balance, sleep disturbances, fatigue, tinnitis, diplopia,
Cognitive: attention, concentration, perception, memory, executive functions
Behavioral: irritability, disinhibition, emotional lability
How long is the period of rapid recovery after a TBI?
What happens after?
Most recovery happens in 1 year at inpatient rehab
activity and participation levels tend to plateau between 1-2 years post injury
What should you say and not say when working with TBI patients and families
dont: “I know just how you feel”
DO: show empathy, be mindful w/ words
educate and reinterate
provide resources
remind them of loved ones progress
