Paediatric TBI Flashcards
What GCS scores characterise TBI severity?
13-15 = mild
9-12 = moderate
<8 = severe
What changes to the verbal scale of GCS are applied for children?
Aged based.
0-23 months: smiles, coos, orientated to sound/ cries but consolable/persistent
cries/grunts/no verbal response
2-5 yrs: app words/inapprop words/cries/grunts/no verbal response
> 5 yrs: orientated/confused/inapprop words/incomprehensible sounds/no verbal
response
PTAs of what indicate TBI severity
<24 hours = mild
1-6 days = moderate
1-4 weeks = severe
> 4 weeks = extremely severe
How does the pathophysiology of moderate TBI differ in children?
- Children are less likely to suffer mass legions, including haematoma and contusions
- Children are more likely to sustain skull fractures and secondary injuries such as brain swelling, raised intracranial pressure, hypoxia and diffuse axonal injury
- physical issues often resolve in short term
- cognitive and behavioural difficulties are common and likely to impact on participation and progress
- considerable variation between cognitive and behavioural outcomes that reflect the contribution of multiple factors
What are some factors that impact outcome?
- biological insult (nature and severity, dose response effect)
- development of child (age at injury)
- time since onset (acute phase vs chronic, post injury)
- reserve/resilience (pre-injury factors, mental health, family stress and functioning, school and social supports)
May interact to product double hazard effect
Is IQ post injury a good indicator of general functioning?
No. IQ can remain in low - average range following moderate - severe TBI.
TBI IQ profile is not identified
What strategies can be implemented to manage fatigue post TBI?
- graded return to school
- rest breaks
- activity scheduling
What cognitive areas are commonly effected in TBI?
Processing speed, attention, learning and memory, exec function
Outline the effects of TBI on processing speed
- PS sensitive to TBI due to the associated effects of diffuse axonal injury/white matter shearing
- recovery occurs in the first 12 months but can be a persistent deficit of a severe or very severe TBI
- can manifest as slow speech rate or slowed work rate
- can become overwhelmed by the rate at which material is presented and therefore miss out on new learning opportunities
Outline the effects of TBI on attention
- selective attention develops at younger ages, hence is more vulnerable if injury is sustained in early development
- complex attention like shifting and divided attention develop at later ages
- attention issues independent of PS effects may manifest as only being able to take in limited amounts of information at one time, and might miss out on new information, find it hard to complete tasks independently, and keep track of all cues to make sense of social situations
Outline the effects of TBI on executive function
- reflects vulnerability of prefrontal cortex and its networks in TBI
- cognitive deficits may include idea generation, problem solving, flexible thinking, planning and org, self monitoring and initiation
- behavioural deficits may include poor self regulation, flexibility and shifting
- deficits may not be expressed until the child reaches the age when the skills mature in typically developing children (impaired acquisition, not skill loss)
Outline the effects of TBI on new learning and memory
- commonly reported by children and families following TBI
- Reflects that memory is a higher order skills reliant on many underlying processes
- children post TBI may have poor encoding and learning, including an inability to take in amounts of information and slow/inconsistent learning
Outline the psychological and psychiatric outcomes following TBI
- high incidence of new psychiatric disturbance following TBI, which is related to injury severity
- secondary ADHD is most common (up to 48%)
- mood and anxiety disorders
- PTSD
- Personality change due to medical condition
- ODD
- CD
What are the child vs family issues and responses in the subacute (recovery/adjustment) stage following moderate to severe TBI
Child:
- intensive rehab; adjustment of acute disability
- fatigue and irritability
- social isolation
Family:
- Adjusting to changes in child
- denial of child’s disability
- balancing needs of injured child and family
- practical issues (financial and employment)
- stress of following through on rehab procedures
What are the child vs family issues and responses in the chronic (acceptance) stage following moderate to severe TBI
Child:
- Adjustment to residual physical and cognitive disability
- social rejection and isolation
- feelings of loss and frustration
- depression
Family:
- practical issues: organising education resources, managing family changes
- accepting residual disabilities of the child and adjusting expectations
- managing behavioural and physical problems
