Mod/Severe TBI Flashcards
Traumatic Brain Injury
injury to the brain due to the application of an external physical force or rapid acceleration/deceleration forces that results in impairments in cognitive, emotional, behavioral and physical functioning
What age range is the highest risk factor for a TBI?
18-25 years
What is the single larges indirect cause?
Alcohol abuse
GCS
13-15 - ?
9-12- ?
3-8- ?
13-15= mild
9-12= moderate
3-8= severe
Post Traumatic Amnesia
inability to create new memories
Post Traumatic Amnesia
Lasting <24 hours
Mild
Post Traumatic Amnesia
Lasting 1-7 days
moderate
Post Traumatic Amnesia
Lasting >7 days
severe
> 2 weeks PTA prognosis is ___
less optimistic
If a patient has persistent PTA what is that termed
amnestic syndrome
Survivors of _____ traumatic brain injury constitute a small percentage of the total group of TBI survivors, but they account for the majority of those who receive acute TBI rehab
severe
Vast majority of TBIs are mild 80%
whats the survival percentage?
100%
about 10 percent of TBIs are moderate what is the survival percentage
93%
About 10 percent of TBIs are severe
what is the survival percentage?
43%
Prognosis for TBI is highly variable and depends on several factors what are some of the most important (5)
- initial severity of injury
- age - very young and very old poor prognosis
- CT abnormalities
- Concomitant injuries- SCI with TBI
- Length of post traumatic amnesia
Types of primary brain injuries (6)
- concussion
- Diffuse axonal injury- stretching shearing
- anoxic/hypoxic brain injury- lack of blood flow to brain
- Contusion- brain bruise
- Laceration
- Hemorrhage- internal bleed
Types of secondary brain injuries (8)
- Increased intra cranial pressure
- Cerebral edema
- Hypotension
- Vasospasm
- Failure of auto-regulation
- Hypoxia
- Excitoxicity
- productioN of free radicals
What is normal intracranial pressure
0-15
Two types of brain injuries?
Diffuse and Focal
What are the types of diffuse brain injuries?
- Concussion
- Diffuse Axonal Injury
- Anoxic/hypoxic brain Injury
- metabolically active areas
-hippocampus, cerebellar, basal ganglia
What are the types of focal brain injures?
- Contusion
- Laceration
- Hemorrhage
-epidural hematoma
-subdural hematoma
-subarachnoid hemorrhage
-intracerebral hematoma
What does closed brain injury mean?
closed means the skull is intact
Coup-contre coup is an example of what type of brain injurY
Closed
What does an open brain injury mean?
open injury means the skull is fractured or broken
this could be due to impact, explosion, projectiles and gunshot wounds
Which is more sensitive MRI or CT in terms of TBI
MRI is more sensitive
CT can show acute, blood, bone, edema- shows active bleed and cracked skull
epidural Hemorrhage/hematoma
location
type of bleed
cause
treatment
subjective
epidural hemorrhage/hematoma
Location: between skull and dura
Arterial bleeding- fast
Cause: laceration of the middle meningeal artery from temporal fracture- blow to head
Treatment: surgery
subjective: headache im going to sleep it off
clear mentally before they rapidly become unclear
Ex: pt seems okay but after ski accident they dont wake up
Subdural Hemorrhage/hematoma
location
type of bleed
cause
treatment
Location: between the dura mater and brain surface
Bleed: venous slow bleed
Cause: can occur with minimal force in the elderly and chronic alcoholics
Treatment: may require surgical evacuation if causing mass effect or worsening symptoms
What is the main difference between epidural hematoma and a subdural hematoma
epidural- arterial blood fast
subdural- venous blood slow
Subarachnoid hemorrhage
location
type of bleed
cause
treatment
subarachnoid hemorrhage- only considered a stroke if it happens spontaneously
location: bleed directly in the brain parenchyma
Blood: arterial blood fast
Cause: gun shot wound, fall, due to a burst aneurysm
Contusion
location
cause
contusion: occurs from the brain impacting the skull
-brain moving over the sharp edge in the skull
often considered a brain bruise
Cortical areas overlying basal skull structures are particularly vulnerable
inferior frontal lobes, anterior and medial temporal lobes, ventral brainstem
Explain Diffuse Axonal Injury
widespread stretching of axons caused by rotation of the brain around its axis and the differential effect of rotational and acceleration/deceleration forces. may be better described as multifocal
Does a Diffuse Axonal injury involve white or gray matter
white matter throughout the brain, deeper structures such as corpus callosum and brainstem indicate higher severity
Explain anoxic or hypoxic injury
consider oxygenation status in the field
mechanism of trauma ie: asphyxiation, drowing, anaphylaxis
What are poor prognostic factors related to lab values
hypotension SBP <90 bpm
Hypoxia PaO2 <60 mm Hg apnea or cyanosis in field
Intracranial pressure
normal <15mmhg
if >20 mmHg mortality 50-60%
______volume in one area of the brain _______ volume in another area
increased volume in one area of the brain decreased volume in another area
When unable to auto-regulate pressure, ICP _____.
when unable to auto-regulate pressure ICP increases
What two pressures need to me monitored in a patient with a TBI
Intracranial pressure- 0-15 mmhg
Cerebral perfusion pressure- 60-100mmhg
What is Cerebral Perfusion pressure and how do you measure it
pressure at which the brain tissue is being perfused
MAP-ICP=CPP
intracranial pressure can cause ____ shift and herniation
midline shift
How can you measure intracranial pressure?
use of a monitoring device- a bolt monitor
surgery- decompression, debridement, bone flap
early management to decrease brain metabolism
paralytics
barbiturates
hypothermia
What do paralytics do in early management to decrease brain metabolism
act at neuromuscular junction decreasing stimulation
shut down body to shut down demand on the brain
What do barbiturates do in early management to decrease brain metabolism
decrease metabolic rate
undesirable side effects (sedate)
does hypothermia decrease or increase metabolic rate of the brain
decrease
Occipital contusions can impact what?
visual processing difficulties or cortical blindness
Motor cortex injury can impact what
contralateral paresis or paralysis
Brain stem injury can result in what
disruption in cardiac and respiratory function
Cranial nerve damage
1. lack of smell
2. blindness
3. depth perception problems and diplopia
4. swallowing problems
- CN I olfactory
- CN II optic
- CN III, IV, VI oculomotor, trochlear, abducens
- IX hypoglossal
Frontal lobe injury- neurobehavioral issues
may be due to whole brain trauma or injury to frontal lobe
What medication can be taken to regulate mood
amantadine
What medication can be taken to increase stimulate brain activity
ritalin
dopamine agonist
provigil
What is heterotopic ossification and what are the risk factors
pain decreased ROM, edema
Risk factors: whole body trauma, immobility, spasticity, long bone fractures, prolonged coma
What is the treatment for HO
NSAIDs, ROM
What are two other complications to TBI?
intracranial infection- especially with open TBI
seizures- especially with open TBI and hemorrhagic injuries
How are post traumatic seizures classified?
<24 hours from time of injury
1-7 days from time of injury
>7 days from time of injury
classified by the time since injury
1. immediate
2. early
3. late
During the first 2 years after injury individuals are ___X greater risk of siezure
3x
If epilepsy develops, medications are needed for ____
life
____ is the #1 cause of death in children over 1 y.o.
trauma
areas of brain do not function in _____, especially in young children
isolation
_______: responsible for 56% of severe injuries in infants and 90% of severe injuries in 1-4 yrs old
abusive head trauma
_____: responsible for 39% of injuries under 14 years old and leading cause of injury under 4 years old
falls
______: responsible for 66% of injuries in adolescents and 20% in young children
MVC
Explain shaken baby syndrome: non- accidental trauma
acute and chronic subdural hemorrhages
intraparenchymal injury
retinal hemorrhages
multiple fracture of ribs/long bones
various stages of healing
children have _____ head with ___necks
larger heads with weaker necks
there is less _____ and higher brain water in children
myelin
_____ can go to deeper parts of the brain in children
forces can go to deeper parts of the brain
Medical intervention in the PICU
neurobehavioral therapy
establish day- night cycle
sensory stimulation
maintain familiar routine, objects, surroundings
What medications improve arousal
dopamine agonist
amantadine
provigil
ritalin
What medications decrease agitation/sedation
benxodiazepine
14-23% of pediatric TBI survivors have
Heterotopic ossification
HO presents early with what signs in children
warmth, erythema, decreased ROM
What happens in a child less than <7 years of age with diffuse brain injuries
- less physical development infrastructure for recovery to build upon
- injury alters subsequent development of the brain
- They are more likey to have cognitive and social difficulties long term
Seizures
an episode of neurologic neurologic dysfunction caused by an abnormal imbalance of excitatory and inhibitory neurotransmitters neuronal activity that results in a sudden change in behavior, sensory perception or motor activity
How long do seizures last?
finite and brief rarely last longer than 30-90sec
Can seizures cause transient brain impairment or LOC
yes
If the underlying cause for seizure is eliminated the seizure will stop true/false
true
in _____ individuals seizures occur unpredictably at any time and without any relationship to activities
most
in ____ individuals seizures are provoked by specific stimuli such as flashing lights or a flickering television
some
What is Ictus or ictal
period in which the seizure occurs
Post ictal
period after seizure ends but before patient has returned to his or her baseline mental status
Status Epilepticus (SE) is common in people who have a known cause such as
tumor, CNS infection, drug abuse
can status epilepticus be fatal
yes
What are four potential causes of acute seizures?
- metabolic
- drug induced
- illness
- neurologic
Epilepsy
refers to recurrent seizures from known or unknown causes
Epilepsy affects how many americans?
3 million
What are 4 common risk factors for seizures?
- developmental disability
- head trauma
- stroke hx
- family hx seizures
Febrile convulsions are the most common seizure disorder during _____ and have excellent prognosis
Childhood
workup is still warranted because there is a possibility of an underlying acute infectious disease such as sepsis or bacterial meningitis
What are 4 prenatal and perinatal factors?
- hypoxia-ischemia
- congenital infection
- inborn errors of metabolism
- prematurity
What are 3 postnatal conditions?
- CNS infections
- head trauma
- Hypoxic-ischemic encephalopathy
What is the greatest concern in instances when the individual has a seizure during eating
asphyxia
What are the two types of seizures?
Focal onset
Generalized onset
Explain Focal onset
abnormal electrical discharge clearly begins in one specific part of the brain
Explain generalized onset
abnormal electrical activity is wide-spread throughout the brain very early in the seizure
During focal seizures awareness can be retained if awareness is not retained it is called ____
focal dyscognitive seizure
motor symptoms (jerking) or sensory symptoms (paresthesias or tingling) that spread to different parts of the body
focal seizure
Psychotic responses to seizure activity include illusions hallucinations a sudden sense of fear is common
focal seizure
person appears dazed and confused with random walking, mumbling, head turning or pulling at clothes
lasts 45- 90 sec and is followed by confusion and disorientation lasting several more minutes
focal seizure- focal dsycognitive seizure
consist of the sudden cessation of ongoing conscious activity with only minor convulsive muscular activity or loss of postural control
absence seizure
absence seizure typically occur in children and frequently disappear by adolescence
true
sudden brief, single or repetitive muscle contractions involving one body part or the entire body
myoclonic- generalized seizure
manifestations include a sudden LOC, generalized rigidity and rapid generalized jerking movement
with recovery individuals may c/o headache, muscle soreness, mental dulling, lack of energy or mood changes
bilateral convulsive seizure with tonic and/or clonic
generalized seizure
a brief losses of consciousness and postural tone not associated with tonic muscular contractions
the seizures are often called drop attacks
they occur most often in children with diffuse encephalopathies and are characterized by sudden loss of muscle tone that may result in falls with injury
atonic seizures- generalized
An anticonvulsant is used as an add-on drug for individuals with refractory complex partial and secondary generalized tonic-clonic seizures
gabapentin (neurontin)
drug acts at voltage-sensitive sodium channels to stabilize neuronal membranes and inhibit neuronal release, particularly of glutamate
lamictal
blocking voltage dependent sodium channels
topamax
blocking reuptake of neuroinhibitory transmitter GABA into neuronal and glial cells
gabitril
seizure med
keppra
brain injury med
depakote
what does a vagal nerve stimulator do?
can be provided through an implantable pulse generator
by stimulating the left vagal nucleus an inhibitory projection influences the entire cerebral cortex
vagal nerve stimulation has been reported to result in 50% reduction in seizure
What do you do when someone is having a seizure?
call out help or push code button
secure the patient
help the patient be seated or catch the patient if you are physically able to and ease them to the ground
clear the space around them and place a pillow behind the head
attempt a careful log roll of the patient to one side to clear secretions or vomit
What do you not do during a seizure
put anything in the patients mouth during a seizure this can cause broken teeth aspiration, injury
hold down the patient
ED may not be necessary when?
if the patient has know epilepsy and they have quickly returned to their cognitive baseline
no physical injury was sustained that needs additional evaluation
the fall with seizure onset was witnessed
no neck pain, concussion, vomiting or new neurological deficits
What does a PT need to know regarding exercise
hx of seizure diagnosis
medication
patient education
seizure triggers
type and frequency of seizures
refer if signs of depression are present
for a new diagnosis of seizure what should the person do
activity restrictions for the first 2-3 months
recs for safe activity
medical treatment must be initiated and monitored
side effects of seizure medication
slowed congition
altered reaction time
nystagmus
ataxia
dysarthria
nausea
irritability
skin rash
Colorado a doctor is ____ required to report that a person has a seizure disorder to the DMV
not
