Neuromuscular TBI, mTBI, PCS Flashcards
What are the leading causes of TBI?
- Falls 32%
- Motor Vehicle accidents 19%
- Struck by or against an object 18%
- Assault 10%
What are the causes of brain injury between the ages of 5-65?
The most common cause of TBI between 5-65yrs is Motor Vehicle Accidents (MVA)
What are the causes of brain injury between the ages of 5 and over 65?
The most common cause of TBI between 5 and over 65 yrs is falls
What are the ages for children and adolescents that are at highest risk for TBI?
Children 0-4
Adolescents 15-19
What is the Etiology of TBI?
It can either be Open Head Injury or Closed Head Injury
What is the Pathophysiology of TBI?
Primary Brain injury-damage occurs at the moment of impact, they may exhibit:
- Focal Brain Injury
–Coup-contrecoup injury
–Polar Brain Injury - Blast Injury
- Diffuse Axonal Injury (DAI)
With TBI, what is a Focal Brain Injury?
Coup-Contrecoup Vs Polar Brain injuries.
These injuries occur at the site of impact. Damage may take the form of a contusion or laceration or both.
- Coup-contrecoup: If the brain is hit hard enough, the brain will bounce and make contact with the skull at the opposite site of the local brain damage. (Coup=the injury that occurs within the first point of contact. Contrecoup= the injury on the opposite side)
- Polar Brain injury: Occurs in response to an acceleration, deceleration as well as rotational forces (Common in head on collisions), the frontal and temporal lobes are most susceptible to injury
With TBI, what are Blast Injuries?
Defined as an explosive device that may detonate and a transient shockwave is produced and causes the brain damage.
- Result from the direct effect of blast overpressure on the brain
- Secondary injury results from the shrapnel and other objects being hurled at the individual
- Tertiary injury the patient is being pushed or flung backwards and hitting an object
With TBI, What is Diffuse Axonal Injury (DAI)?
These occur in response to acceleration, deceleration as well as rotation and occur in conjunction with focal and polar brain injuries
With Diffuse Axonal Injury, What is the affect of rapid movement of the brain within the skull? What happens if the damage is severe?
This causes widespread stretching and tearing of the neuronal axons within the myelin sheath. This is labeled as the patient having subcortical white matter shearing.
- If the injury is severe, damage will extend to the brainstem and lead to coma and abnormal posturing
- Not usually evident on CT or MRI, if the pt. is exhibiting DAI, this is found during the neurological exam
With TBI, what are secondary Brain Damage?
These occur within minutes to hours after injury, this involves Intracranial Hematomas (Intracranial pressure occurs and blood accumulates leading to a shifting and compression of brain structures leading to secondary brain damage)
- Other types of secondary brain damage include herniations, Hypoxic-ischemic injury, Post-traumatic epilepsy/seizures, and intracranial infection
What are the different types of hematomas that may occur with secondary brain damage?
- Epidural Hematoma: where blood accumulates on the top of the dura, usually associated with medial meningeal artery damage
- Subdural Hematoma: where venous blood accumulates beneath the dura, common in the elderly related to brain shrinking and the individual having excessive movement of the brain that can occur in a fall or an MVA.
- Intracerebral Hematoma: An intrinsic cerebral arterial blood that accumulates within the brain, usually the most deadly type of hematoma because of the location
With secondary brain damage, what are herniations and the different types?
Herniation: where the brain starts pushing through the foramen magnum, the different types of herniations are:
- Uncal
- Central
- Tonsillar
What is the Medical Management for TBI?
- Neuroimaging: CT and MRI
- Restoration of vital function and prevention of secondary brain damage is top priority
- Glasgow Coma Scale (GCS) is used to determine severity of injury
- ICP is monitored via a catheter into the brain
One of the medical management for TBI is the monitoring of ICP. What is normal ICP and when is it a red flag or a danger?
- Normal ICP is 4-15 mmHG
- After TBI, 15-20 mmHG is expected
- > 25mmHG is a Red Flag and measures will be taken to reduce the pressure
- Danger >40mmHG because impaired blood flow to the brain can cause secondary injury
If ICP goes above 20mmHG notify the nurses &/or doctor and modify intervention
If ICP goes above 30mmHG immediately STOP all interventions and notify nurses and doctors
What is the Sequlae of TBI?
Neuromuscular Impairments
Cognitive Impairments
Neurobehavioral Impairments
With the Sequlae, what are common impairments with Neuromuscular Impairments?
- Paresis
- Abnormal Tone
- Motor Function
- Postural Control
With the Sequlae, what are common impairments with Cognitive Impairments?
- Arousal Level
- Attention
- Concentration
- Memory
- Learning
- Executive functions
With the Sequlae, what are common impairments with Neurobehavioral Impairments?
- Agitation/Aggression
- Disinhibition
- Apathy
- Emotional lability
- Mental Inflexibility
- Impulsivity
- Irritability
- Communication
- Swallowing
With Perceptual and Cognitive Impairments with TBI, what is orientation?
Orientation: Understanding of person (last to lose), place, and time (first to lose)
With perceptual and Cognitive Impairments with TBI, what is memory? Short term vs. Immediate recall vs. Long term memory.
Memory: the ability to store and retrieve information and past experiences
- Short term: Took place a few minutes, hours, or days ago
- Immediate Recall: Recall after a few seconds
- Long-term: Recall of events that occurred years ago
With perceptual and Cognitive Impairments with TBI, What is Lethargy, Obtunded, Stuper, and Coma?
- Lethargy: Altered consciousness in which a person’s level of arousal is diminished; drowsy but able to answer
- Obtunded: Diminished arousal and awareness; difficult to arouse and when aroused is confused
- Stuper: Altered mental status and responsiveness to one’s environment; can only be aroused with vigorous stimuli
- Coma: Unconscious patient, can not be aroused, eyes remain closed, no sleep wake cycles
What are specific cognitive impairments that are unique to TBI?
They deal with the altered levels of consciousness:
- Coma: Arousal state not functioning,No sleep/wake cycle, Not usually permanent
- Vegetative State: Disassociation between wakefulness and awareness, Sleep/wake cycles are present, patient will demo reflexive, non-purposeful responses
- Minimally conscious state (MCS): The patient will now exhibit localization to stimuli and may inconsistently reach for objects
With Rancho Los Amigos (RLA), what are the Levels Of Cognitive Functioning (LOCF)?
I. No response
II. Generalized Response
III. Localized Response
IV. Confused-Agitated
V. Confused-Inappropriate
VI. Confused-Appropriate
VII. Automatic-Appropriate
VIII. Purposeful-Appropriate
The first 3 are severe disorder of consciousness on the Coma Recovery Scale (coma, vegetative, MCS)
With TBI, what are key areas to examine in the acute stage?
- Arousal, attention, cognition-CRS-R, LOCF
- Integumentary Integrity
- Sensory Integrity
- Motor Function
- ROM
- Reflex Integrity
- Ventilation/Gas exchange
What is the Glasgow Coma Scale?
An outcome measure that is used to help determine the severity of injury
What are the 3 components of the Glasgow Coma Scale?
- Eye Opening
- Best Motor Response
- Verbal Response
With the Glasgow Coma scale, What are the scores for Severe brain injury, Moderate Brain injury and Minor Brain injury?
- Severe Brain Injury: Score 3-8 (coma if eye opening is absent)
- Moderate Brain injury: Score 9-12
- Minor Brain Injury: Score 13-15
What is a Concussion? What can cause them? What is the result of a concussion?
- A brain injury induced by biomechanical forces
- Concussion is a functional disturbance, not a structural injury
- Can be caused by a direct blow to the head, neck, face or body and result in neuropathological changes
- Results in a set of clinical symptoms and usually does not involve loss of consciousness
What are the Acute Symptomology for Concussion?
If any ONE or more of the following are present its suspected that a concussion is present and further assessed
1) Symptoms (headache, fogginess, emotional lability)
2) Physical signs (LOC, amnesia, neurological deficit)
3) Balance Impairment (gait, unsteadiness)
4) Behavioral Changes (Irritability)
5) Cognitive Impairment (Slowed Reaction Times)
6) Sleep Disturbance (Insomnia)
S/S may be delayed several hours following a blow to the head and concussion should be viewed as an “evolving injury in the acute stage
What is the Epidemiology of Concussion?
Concussion can occur at any age, from a variety of causes
- Falls (work accidents, older adult)
- MVA (head impact or whiplash)
- Violence (Abuse or explosions/blast)
- Playground injury
- Sports (football, hockey, rugby, soccer, and basketball have the highest incidence)
With the Pathophysiology of Blast-Related Concussion, what are the Primary, Secondary, and Tertiary injuries?
- Primary Injury
–Shock waves from a blast disrupts brain tissue
–Similar to diffuse axonal injury
–More widespread injury - Secondary injury
–Fragments cause penetrating injury - Tertiary Injury
–Blunt trauma from striking solid surface
What is the Pathophysiology of Blunt-Force Concussion?
(Cascade of Events)
Must Know
- Ion channel dysfunction
–Potassium ions rush out of the neurons and destructive calcium and sodium ions rush in - Metabolic Energy Crisis
–Cerebral Glucose demand increased
–Cerebral blood flow decreased - Physiologic axonal stretching
–Microscopic axonal dysfunction (not seen in imaging)
What are some Acute S/S of Concussion
What are the “Sideline” Diagnostic tools for acute concussion?
- Glasgow Coma Scale
- Standardized Assessment of Concussion (SAC)
–Scores orientation, immediate memory, concentration, delayed recall. - Standardized Concussion Assessment Tool-5 (SCAT5)
(Designed for use of only qualified first responders and medical professionals)
– >13
–Maddock’s questions, self reported Sx (HA, dizziness, etc.), memory and attention via SAC, balance, coordination, gait tested
Most established and rigorously developed instrument for sideline assessment - Military Acute Concussion Evaluation (MACE)
–Ideally performed 24 hrs of injury
–15 min
–History or injury, symptoms, neuro screen, and short cognitive test
What are risk factors for sport-related concussions?
- Youth (5-18 yrs) account for 65% of sport related concussion. Why…
–Brain developing (axons not well myelinated)
–Less well developed cervcial and shoulder musculature
–Poor technique on the field - Risk is greatest in football, rugby, hockey and soccer players
- Preinjury mood, learning, and attention deficit disorder
- Preinjury migraines
- Females
What are possible reasons that patients might get another concussion?
Physiologic recovery may be slower than patient reported recovery
- ability to dual task is impaired and persist for several weeks post injury despite patient reported recovery of symptoms
What is the Prognosis for concussion?
80-90% of concussions resolve in 7-10 days
- LOC is not a measure of severity unless it last >1min
- Immediate motor phenomena (tonic posturing, convulsions) can occur but are generally benign
- The presence and duration of amnesia does not seem to play a role in determining severity of concussion
What is the Return to Play guidelines for concussion?
- Removed from play if concussion is suspected
- No play on same day of suspected concussion - rest for 24-48 hours
- Athletes should be symptoms free without medications prior to returning to sport
- Prior to returning, athletes should participate in a graduated return to play protocol in which no return of symptoms occur
What is the first step of the Graduated Return to Sport Strategy?
Symptom-limited Activity
- Daily activities that do not provoke symptoms
What is the second step of the Graduated Return to Sport Strategy?
Light aerobic exercise
- Walking or stationary cycling at slow to medium pace, no resistive training
What is the third step of the Graduated Return to Sport Strategy?
Sport-Specific exercise
- Running or skating drills. No head impact activities
What is the fourth step of the Graduated Return to Sport Strategy?
Non-contact training drills
- Harder training drills, e.g, passing drills. May start progressive resistive training
What is the sixth step of the Graduated Return to Sport Strategy?
Return to sport
- Normal Game play
What is the fifth step of the Graduated Return to Sport Strategy?
Full Contact practice
- Following medial clearance, participate in normal training activities
What if the patient does not recover spontaneously? Prolonged recovery is predicted for those with…
- History of previous concussion
- Greater number and severity of acute symptoms
- Acute “one-field” dizziness
- Symptom of fogginess post injury
- Cognitive deficits in the first 3 days
- Females
- History of learning disability
- History of migraines
What is Post Concussion Syndrome?
- > 10-14 days persistent symptoms
- > 4 weeks of persistent symptoms for high school athletes
What are the 4 system clusters of PCS?
- Cognitive
- Mood disruptions
- Sleep alterations
- Somatic symptoms
With the system clusters of PCS, what are common symptoms for Cognitive?
- Concentration, distractible
- Memory deficit
- Cognitive fatigue
With the system clusters of PCS, what are common symptoms for Mood Disruptions?
- Irritable
- Depression
- Anxiety
- Panic
With the system clusters of PCS, what are common symptoms for Sleep Alterations?
- Difficulty falling asleep
- Fragmented sleep
- Excessive sleep
With the system clusters of PCS, what are common symptoms for Somatic Symptoms?
- HA
- Dizziness
- Visual disturbances
- Impaired balance
- nausea
- Light and noise sensitivity
- Cervical pain
What is Secondary Impact Syndrome?
- Occurs when a second injury occurs before the first has resolved
- Diffuse and often catastrophic edema occurs
- Associated with football players
- Highlights the importance of return-to-play
The secondary repeated injury concern is Chronic Traumatic Encephalopathy (CTE), what is this?
Progressive tauopathy (neurodegenerative disorders characterized by the deposition of abnormal tau protein in the brain)
- Generalized atrophy of cerebral cortex
- Frontal and temporal lobe degeneration, hippocampus, limbic
- Progression to widespread axonal dysfunction and loss
What is stage 1 of Symptomology of CTE?
Headache, loss of attention and concentration, irritability
What is stage 2 of Symptomology of CTE?
Depression, explosivity, short term memory loss, increased suicidality
What is stage 3 of Symptomology of CTE?
Executive dysfunction, cognitive impairments
What is stage 4 of Symptomology of CTE?
Dementia, word-finding difficulty, aggregation, gait and speech abnormalities, Parkinsonism may occur in some
