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OTA 200 - Phys Rehab Conditions > TBI > Flashcards

TBI Flashcards

1
Q

DAI

A

Diffuse Axonal Injury (DAI) = More damage across brain than at point of blow (focal injury). Prototypical lesions caused by rapid deceleration. Different densities in the brain rotate at different speeds, causing shearing/tearing across the brain, affecting nerves. Severity of DAI measured by depth/length of coma and associated signs such as pupillary abnormalities.

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2
Q

Primary Axotomy vs. Axonal Dysfunction

A

Primary Axotomy = complete disruption of the nerve

Axonal Dysfunction = structural integrity of nerve remains intact but there is loss of ability to transmit normally along neuronal pathways.

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3
Q

Focal Brain Injury

A

Caused by direct blow to head after collision with external object or a fall, penetrating injury from a weapon, or collision of brain with inner tables of skull. Bones of face/skull may not be fractured. Falls with focal brain injury include intracerebral and brain surface contusions. Areas below the point of collision can also have contusions.

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4
Q

Coup vs. Contrecoup

A 
Coup = directly injured area
Contrecoup = site of indirect injury
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5
Q

CTE

A

Chronic Traumatic Encephalopathy (CTE) = progressive DEGENERATIVE disease with repetitive brain trauma, incl symptomatic concussions and subconcussive hits to head with no symptoms. Prevalent in contact sports (football). May show signs of dementia years after trauma. Use of baseline tests such as imPACT (Immediate Post-Concussion Assessment and Cognitive Testing) can assess cog impairment, but there is no test to detect CTE in living people (only in autopsy).

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6
Q

Decorticate vs. Decerebrate Posturing

A

These are common positions displayed by comatose individuals due to rigidity (presence of increased resistance to passive movement).

Decorticate Rigidity = (FLEXED) upper extremities in spastic flexed position with internal rotation/adduction. LEs are in spastic extended position and internally rotated/adducted. Results from damage to cerebral hemispheres, particularly internal capsules, causing interruption in corticospinal tracts (emerge from cortex and send voluntary motor msgs to extremities).

Decerebrate Rigidity = (EXTENDED) both UE and LE are positioned in spastic extension, adduction, and internal rotation. Wrists/fingers flexed, ankles plantarflexed with inverted feet, trunk extended, head retracted. Occurs as result of damage to brainstem and extrapyramidal tracts (send involuntary motor msgs from brainstem to extremities). These individuals have poorer prognosis than decorticate posture.

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7
Q

Glasgow Coma Scale

A

This is a tool medical staff use when a TBI patient arrives in the ED. Measures patient’s neurological status. Five outcomes: dead, vegetative, severely disabled, moderately disabled, and good recovery. Scored on severity of injury based on eye opening (1-4), best motor response (1-6), and best verbal response (1-5), for a total of 3 to 15. 3-5=potentially fatal; 8+=high chance of recovery.

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8
Q

ICP

A

Intracranial Pressure (ICP): must be lowered if exceeding 20-25 mm Hg

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9
Q

Treatments of high ICP (Intracranial Pressure)

A
  • Mannitol
  • High-dose barbiturate therapy
  • Ventriculostomy (drainage of CSF)
  • Crainiectomy (removal of portions of skull to allow for brain swelling); “bone flap”
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10
Q

Primary vs. Secondary Brain Injury

A

PRIMARY damage: Occurring at the moment of impact: localized contusions (brain slides and strikes skull, found under area of depressed fractures/point of injury); or diffuse axonal injury (shearing occurs betw different brain components).

SECONDARY damage: Occurring in days/weeks after injury: Intracranial hematoma; Cerebral edema-increased intracranial pressure; Hydrocephalus (may need shunting); or Seizures (extremely common).

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11
Q

Vegetative State

A

Wakefulness without awareness. 1) No awareness of self/environment or interaction with others; 2) No sustained, reproducible or voluntary behavioral responses to stimuli; 3) No language comprehension/expression; 4) Sleep/wake cycles of variable length; 5) ability to regulate temp, breathing, circulation to permit survival with routine nursing care; 6) incontinence; 7) variably preserved cranial nerve/spinal reflexes.

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12
Q

Minimally Conscious State (MCS)

A

May reach MCS after vegetative state (rare after 12 mo after TBI). Shows definite behavioral awareness of self, environment, or both. Demonstrates one more more: 1) ability to follow commands; 2) gestural/verbal yes/no responses, 3) intelligible verbalizations; 4) purposeful movement/affective responses to stimuli. Can be assessed with coma scales, or sensory stimulation tests.

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13
Q

Post Traumatic Amnesia (PTA)

A

Length of time from injury to moment when individual regains ongoing memory of daily events. Duration of PTA correlated with outcome (longer is associated with poorer long-term cognitive/motor abilities and decreased ability to return to work/school). A landmark in TBI recovery; single best measurable predictor of functional outcome.

4 weeks+ = significant long-term disability.

Measured by Galveston Orientation and Amnesia Test (GOAT) or the Orientation Log.

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14
Q

Rancho Los Amigos Levels of Cognitive Functioning (RLA)

A

Descriptive measurement of 8 (to 10) levels of awareness and cognitive function. Progression through the levels is typical, but some may skip levels (typically level IV, agitated/confused).

Level I: no response
Level II: generalized response (reflexes)
Level III: localized response (ie follow light)
Level IV: confused, agitated (alert but confused)
Level V: confused, inappropriate, nonagitated
Level VI: confused, appropriate (attend to 30 min task)
Level VII: automatic, appropriate (new learning occurs)
Level VIII: purposeful and appropriate (up to 1 hr task)
*Level IX: purposeful, appropriate (SBA on request)
*Level X: purposeful, appropriate (modified independent)
*(Used at some out-client facilities to identify higher functioning clients)

Remember:
Level 1-3 = total assistance needed
Level 4-6 = confused; difficulty learning
Level 7-8 = automatic/purposeful; ability to learn
Level 9-10 = higher functioning

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15
Q

Effects of TBI

A

Effects can include impairments related to:
• thinking or memory
• movement
• sensation (e.g., vision or hearing)
• emotional functioning (e.g., personality changes, depression)

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16
Q

Cerebrum

A

Main body portion of brain.

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17
Q

Cerebellum

A

Part of brain below the cerebrum and toward the back.

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18
Q

Brain Stem

A

Portion of brain directly connected to spinal cord. “Anchors” the brain.

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19
Q

Frontal Lobe

A

Commonly injured; judgment, reasoning, motivation (executive functions)

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20
Q

Temporal Lobe

A

Common to be injured; memories, ability to think

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21
Q

Occipital Lobe

A

Visual, sub-serve other functions of brain

22
Q

Central Sulcus

A

(Includes precentral and postcentral gyrus) = movement, initiating movement, receiving info from limbs (feeling)

23
Q

Subcortical Layer of Brain

A

Movement modification; smooth movement (connected to spinal cord)

24
Q

Epidural Hematoma (EDH)

A

Type of focal hemorrhage associated with skull fractures in adults with disruption of integrity of meningeal arteries. Bleeds fast! Occurs adjacent to blow. May initially be alert after blow, but increasing pressure as hemotoma develops betw skull and dura causes secondary injury/rapid deterioration in mental/physical status. Must be promptly recognized and have neurosurgical treatment. Slightly easier hematoma to manage.

25
Q

Subdural Hematoma (SDH)

A

Type of focal hemorrhage that occurs betw dura and brain surface through tearing of bridging veins. Slower hemorrhage than EDH because venous bleeding is more gradual than arterial. Can occur as frequently on opposite side from blow. Tend to spread around entire hemisphere or in posterior fossa. Acute SDH=diagnosed w/in 48 hr. Subacute SDH=w/in 2-14 days. Chronic SDH=may have occurred before arrival at hospital w/changing mental status (progressive decline since injury). When these get bad, they are harder to manage/emergency!

26
Q

Intracerebral Hemorrhage (ICH)

A

A focal injury with missile wounds within the brain’s tissue, common after falls and assaults. Appear on follow-up CT scans within first week after TBI. Most severe type of hemorrhage, as it’s in the brain tissue itself!

27
Q

Subarachnoid Hemorrhage (SAH) and Intraventricular Hemorrhage (IVH)

A

Multifocal/diffuse injuries that occur when the pia or arachnoid is torn (closer to brain; more detrimental). SAH caused by trauma or rupture of an aneurysm. Large IVH can block flow of CSF and cause hydrocephalus. **Importance in evaluating for ruptured aneurysm causing brain dysfunction! May require fast surgical intervention.

28
Q

Post-Traumatic Seizures (PTS)

A

Occur as secondary brain injury after TBI. Classified as :
• Immediate (occur during 1st 24 hr.)
• Early (occur during first 7 days)
• Late (occur after first 7 days)

Treated/prevented with prophylactic anticonvulsants within first week only.

29
Q

Sequelae

A 
Symptoms of a disease/injury. With TBI, common sequelae are:
• sleep/mood disorders
• pain
• hydrocephalus
• heterotopic ossification 
• endocrinopathies (hormone imbalances)
30
Q

Heterotopic Ossification

A

Presence of bone in soft tissue where bone normally does not exist. Can occur after TBI.

31
Q

Factors Affecting Progression Along Continuum of Consciousness

A
  • Age
  • Previous health status
  • Severity of injury
  • Methods of medical, therapeutic, and environmental mgmt
32
Q

Areas Affected by TBI

A

1) Physical status
2) Cognitive status
3) Visual status
4) Perceptual status
5) Psychosocial factors
6) Behavioral status

33
Q

Modified Ashworth Scale

A

Assessment of muscle tone, scored on scale of 0 to 4.

0 = No increase in muscle tone
1 = Slight increase with catch/release in flex/ext
1+ = Slight increase with catch
2 = More marked increase, affected part(s) easily moved
3 = Considerable increase, passive movement difficult
4 = Affected part(s) rigid in flex/ext
34
Q

Factors that can affect muscle tone

A
  • Position
  • Volitional movement
  • Medication
  • Infection
  • Menstruation
  • Illness
  • Pain
  • Environmental factors (ie: temp)
  • Emotional state
35
Q

Physical Status Factors that can be affected with TBI

A

1) Rigidity (decorticate, decerebrate, motor, etc.)
2) Muscle tone/spasticity
3) Primitive reflexes
4) Muscle weakness
5) Decreased functional endurance
6) Ataxia (incoordination, impaired sitting/standing balance)
7) Postural deficits
8) Limitations in joint movement
9) Sensation
10) Integration of total body movements (difficulty reaching, performing ADLs)
11) Dysphagia
12) Self-Feeding (due to cognitive and motor issues)

36
Q

Cognitive Status Factors that can be affected with TBI

A

1) Attention/concentration
2) Memory
3) Initiation/termination
4) Safety awareness/judgment
5) Processing of information
6) Executive functions/Abstract thought
7) Generalization

37
Q

Psychosocial Factors that can be affected with TBI

A

1) Self-concept
2) Social roles
3) Independent living status
4) Dealing with loss
5) Affective changes (mood)

38
Q

Mechanisms of TBI:

A
  • Car accident
  • Stabbing/Penetrating injury
  • Blunt trauma (blow)
  • Deceleration injury (brain is hit and then moves)
39
Q

Closed vs. Open Head Injury

A

Closed injury: head is not open (skull can be fractured, but not open)

Open injury: exposed/penetrated brain

40
Q

Clinical Signs/Symptoms seen in TBI

A

1) Decerebrate Rigidity
2) Decorticate Rigidity
3) Bruxism
4) Spasticity/Clonus
5) Rigidity and Bradykinesia; Parkinsonism
6) Torticollis
7) Myoclonus
8) Tremor
9) Dystonia
10) Athetosis
11) Chorea
12) Hemiballismus/Ballismus
13) Tics
14) Pseudobulbar Athetoid Syndrome

41
Q

Bruxism

A

Symptom of TBI. Persistent jaw clenching, grinding teeth (may disclocate/sublux jaw)

42
Q

Bradykinesia/Parkinsonism

A

Symptom of TBI. Velocity-independent resistance; lead pipe/cogwheel types of rigidity; worse when awake.

43
Q

Torticollis

A

Symptom of TBI. Dystonic posture of neck, spasticity and/or contracture of sternocleidomastoid, splenius muscles

44
Q

Myoclonus

A

Symptom of TBI. Abrupt, shocklike involuntary jerks in large (limb) or small muscles when asleep or awake.

45
Q

Dystonia

A

Symptom of TBI. Dynamic contraction/relaxation of muscles with slow, writhing or repetitive twisting movements or sustained contortions; usually distal limb(s).

46
Q

Athetosis

A

Symptom of TBI. Slow, sinuous movements of the face, tongue, or limbs.

47
Q

Chorea

A

Symptom of TBI. Involuntary, dancelike/jerky movements without rhythmic pattern; distal.

48
Q

Hemiballismus/Ballismus

A

Symptom of TBI. Sudden irregular flinging movements starting in hip/shoulder, occasionally facial or oral with/without rotator component; worse with arousal/excitement; absent in sleep.

49
Q

Pseudobulbar Athetoid Syndrome

A

Symptom of TBI. Postural dystonia with fragmentary athetosis, with/without bradykinesia; often preserved intellect/personality.

50
Q

Pronator Drift

A

Assessment for motor response/weakness. Helps to detect mild upper limb weakness in a patient who’s awake and able to follow directions. Ask the patient to close the eyes, then to stretch out both arms in the appropriate position: Flex the shoulder joint to 90 degrees (45 degrees, if supine) and fully extend the elbow joint. The palms should be facing up (supinated). The patient should maintain this position for 20 to 30 seconds. Observe both arms. If the motor pathway is intact, the arms should remain in this position equally. Patients with a slight weakness in one arm won’t be able to keep the affected arm raised, and ultimately the palm may begin to pronate (palm facing down).

51
Q

Levels of Brain Injuries

A

MILD = Brief/no LOC; vomiting; dizziness; memory loss

MODERATE = Unconscious up to 24 hr; signs of brain trauma; contusions/bleeding; signs of injury on neuroimaging

SEVERE = Unconscious exceeding 24 hr (coma); no sleep/wake cycle during LOC; signs of injury on neuroimaging.

52
Q

Clonus

A

Spasticity.

OTA 200 - Phys Rehab Conditions (12 decks)

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