TBI Flashcards
What is a TBI caused by?
Bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain
How many TBI hospitalizations in 2018?
> 223,000
What percent of HS students report >= 1 concussion within past 12 mo
15%
Male or females more likely to be hospitalized for TBI?
Males 2x risk and 3x more likely to die
What were the Mech of Inj for TBI 2017?
49% Unintentional Falls
24% Motor Vehicle Crash
Which group (age) is effected the most?
People 75+ w/32% total hospitalization and 28% of deaths
Leading cause of TBI-related death?
Firearm-related suicide
What is a concern w/TBI and older adults?
Misdiagnosed as dementia
When should you check older adults for TBI?
- Falls or fall related injury (hip fx)
- MVC
- On anticoagulants or antiplatelet medication
What are the health disparities in Racial/ethinic groups with TBI?
- American Indian/Alaskan Natives higher risk
- Non-hispanic Black and Hispanic Pts less likely follow up
- Poorer outcomes overall
Homelessness and TBI
- 2-4x more likely to have hx of TBI
- <=10x as likely for moderate/severe TBI
What percent of people in jail/correctional facilities have a TBI
At least 46% but hard to know specifics
What are the health disparities in
- Rural Areas
- Low income w/o insurance
- Rural: more likely to die
- Low income: less access to care and rehab, more likely to die
What can you do to prevent a TBI?
1) Wear seatbelts
2) Avoid Drunk Driving
3) Wear helmets (Bike, sports)
4) Older adults -> review meds
5) Older adults -> annual eye exam
6) Safe areas for children to play w/proper childproofing (window guards and safety railings at stairs)
List (4) types of injury to cause TBI
- External Forces
- Severe acceleration and Deceleration of the head
- Blast Injuries
- Penetrating Objects
What is a
- closed head injury
- open head injury
- Closed: An injury without a skull fracture
- Open: An injury w/skull fx
Define:
- coup injury
- countrecoup injury
- Coup: Occurs at the site of injury
- Countrecoup: Occurs at a distance from the site of injury from hitting the inside of the skull
What is Diffuse Axonal Injury (DAI?)
“Shaken baby syndrome” - brain injury caused by shearing among the axons from accel and decel forces
Where does damage often occure with Diffuse Axonal Injury (DAI)?
Corpus callosum, BG, BS, and cerebellum
What is the most common type of primary lesion in brain trauma?
Diffuse Axonal Injury (DAI)
What occurs in a blast injury?
There is an overpressure wave (High Pressure gas away) and then another pressure wave to cause second overpressure wave (from drop in pressure creating relative vacuum in other direction) that will hit the head
List two Penetrating Trauma Injury Types
High velocity
Low velocity
What is a high velocity penetrating trauma injury?
TBI from bullets or shrapnel that directly damage the tissue it comes in contact with and can also cause damage remote to the injury from shock waves of impact
What is a low velocity penetrating trauma injury?
TBI from sticks or sharp toys - causes damage directly to the tissues they come in contact with
Define contusion
Bruise or bleeding on the brain
that can occur anywhere, but occipital lobe most vulnerable and CN II, VIII, III, IV and VI
What is an epidural hematoma or hemorrhage
Occurs where there is tearing of the meningeal vessels and fluid collects between the skull and dura, often associated with a skull fracture
When does Subdural Hematoma (SDH) occur and where?
Accel/Decel injuries and the bridging veins to superior sagittal sinus are torn
What are secondary Injuries caused by?
Lack of O2 in the brain
What leads to Increased Intracranial Pressure? (ICP)
Swelling of the brain tissue itself or hemorrhaging within the brain
List some primary injuries of the brain
- Contusions
- Epidural hematomas or hemorrhages
- Subdural hematomas (SDH)
- Diffuse axonal injuries (DAI)
- Penetrating Injuries
- Blast injuries
List some secondary injuries of the brain
- ICP (increased intracranial pressure)
- Cerebral hypoxia or ischemia
- Intracranial hemorrhage
- Electrolyte or acid-base imbalance
- Infections
- Seizures from pressure or scarring
What is an example of a diffuse injury?
SDH because it is happening underneath the dura and the skull is only so big
What is midline shift?
When the midline of the brain is no longer in the middle - indicative that there is more damage than just at the site of injury
What is acute hydrocephalus
Blood accumulates in the ventricles leading to ventricular expansion and increased pressure on brain tissue
What is Increased ICP associated with?
(2nd injury)
Poorer outcomes and higher mortality
How does the Glasgow Coma Scale delineate a: Mild TBI - score - Loss of consciousness - Posttraumatic amnesia - Associated S/S - Potential Outcome
13-15 No LOC 0-1 day Post-traum. amnesia Vomiting, dizziness, lethargy, mem loss --> High likelihood of survival
How does the Glasgow Coma Scale delineate a: Moderate TBI - score - Loss of consciousness - Posttraumatic amnesia - Associated S/S - Potential Outcome
9-12 LOC of 30 min - 24 hr PT Amnesia: >1-<=7 days Signs of trauma, contusions, and/or bleeding on imaging --> Good survival w/some LT Disability
How does the Glasgow Coma Scale delineate a: Severe TBI - score - Loss of consciousness - Posttraumatic amnesia - Associated S/S - Potential Outcome
3-8
LOC > 24 hours
PT Amnesia: >7 days
No obvious sleep/wake cycles, trauma on neuroimaging
–> poor likelihood of survival and high likelihood of LT Disability
What does the glasgow coma scale asses?
Function of BS and Cerebrum
- Eye opening
- Best motor response
- Verbal Response
Initial MGT: Pre-hospital
- O2
- BP
- Cognitive function (Use GCS)
- Pupillary function
- Signs of brain herniation
What is the goal of MGT in the ER
Resuscitation and prevention of secondary injury
What things should be done in the ER for TBI
- CT scan
- NeuroSx Eval
- GCS if not done in field
- Airway protection and ventilation
- Monitor cerebral profusion pressure (CPP) and BP
- Fluid MGT
- Hyperosmolar therapy
- Sedation
- Prophylaxis of infection, DVT, seizures, hypothermia
Surgical Interventions for TBI
- ICP monitor and/or extra-ventricular drain (EVD) placement
- Burr Holes (subdural hematoma evacuation)
- Craniotomy
- Decompressive craniectomy (remove portion of skull to relieve pressure)
What is a craniotomy
Sx intervention for TBI where the skull is opened to evacuate bleeding, commonly of the fronto-temporo-parietal)
What can you do pharmacologically for TBI
- Decrease ICP
- Control BP and CPP (cerebral profusion pressure )
- Decrease intracranial bleeding
- Control seizures
- Prevent brain cell death
- Prevent infection
- Affect behaviour and cognitive functions
- Affect motor function
What other injuries are common with TBI
- Other organs (cardiac, pulmonary, liver, bowel)
- Fx (limbs, spinal, facial)
- Ligament damage (often not noted or treated until after healing of other injuries)
- Other Sx repairs
What are the categories of Consequences of TBI
Cognitive
Physiological
Behavioral
What are physiological consequences of TBI
Dysautonomia Motor Sensory Perceptual Disorders of consciousness
What are cognitive consequences of TBI
Memory problems
Attention disorders
Impaired abstract reasoning
Apathy/lack of initiation
What are behavioural consequences of TBI
Labile Aggressive/agitated/irritable Euphoric Inappropriate behaviour Perseveration Impulsive
What is impacted with a ___ Lesion:
- Frontal
Judgement Reasoning Concentration Executive function behaviour Impulse control Voluntary motor function Expressive aphasia
What is impacted with a ___ Lesion:
- Temporal
Senses Receptive aphasia Learning Memory Conversation Artistic expression
What is impacted with a ___ Lesion:
- Occipital
Vision and visual reflexes
What is impacted with a ___ Lesion:
- Cerebellum
Fine motor movement
Balance
Coordination
What is impacted with a ___ Lesion:
- BS
CN Functions
Cardiac
Respiratory and motor functions
Wakefulness
List the Clinical Features of TBI
- Disorders of consciousness
- ANS changes
- Motor, sensory, perceptual, and functional changes
- Cognitive, personality, and behavioural changes
- Other (Infections, contractures, skin breakdown, pulmonary problems, etc)
List 4 disorders of consciousness
Impaired arousal and consciousness
Coma
Vegetative State//Unconscious Wakefulness Syndrome
Minimally Conscious State
What is impaired arousal and consciousness
Direct damage to systems regulating arousal and awareness
Indirect damage to systematic neural connections
What is Coma
Loss of sleep-wake cycles on EEG and lack of interaction with the environment
What is a Vegetative State//Unconscious Wakefulness Syndrome
No signs of consciousness after their eyes are open - no evidence that they are processing stimuli
What does Vegetative State//Unconscious Wakefulness Syndrome come from
Diffuse cerebral hypoxia or severe diffuse white matter impact damage
What is Minimally Conscious State
No longer comatose or vegetative, but they can still display significant deficits
ANS Changes
Variabilities HR and RR IBS Elevated Temp BP Changes Excessive sweating, salivation, tearing, and sebum secretion Dilated pupils Vomiting Anxiety, panic disorder, and PTSD
Why do ANS Changes occur
ANS Dysfunction occurs due to connections between frontal cortex and the ANS
What is a sympathetic storm
Tachycardic, BP rises, pupils dilate, often becomes diaphoretic/sweaty
What severity TBI is likely to have sympathetic storms?
Moderate to severe TBIs
List some motor deficits seen in TBI
- Paralysis or paresis
- CN injury
- Impaired coordination
- Abnormal reflexes
- Abnormal tone
- Poor balance
- Loss of bowel or bladder control
List some sensory and perceptual deficits
Impaired proprioception, touch, stereognosis
- hypersensitivity to light or noise
- impaired hearing and vision
Numbness and tingling, dizziness or vertigo
- Sensory selection and weighting deficits
- Visual-spatial abnormalities
- Agnosia and apraxia
List some communication deficits
Aphasia
Dysarthria
Impaired auditory and reading comprehension
Impaired social communication
Cognitive Changes
Temporary or permanent disorders of intellectual function Memory Loss Impaired attention span Concentration problems Confusion Changes in motivation Loss of executive function Impaired problem-solving skills Lack of intiation Lack of reasoning Poor abstract reasoning
List the behavioural changes
Agitation/Aggression/Irritability Substance Abuse/Behaviours that lead to legal consequences Apathy Depression Anxiety PTSD OCD Psychosis Suicidal ideation and attempts, suicide
What is capacity
What you measure in the clinical environment
What is performance
How the patient does in their own environment
What are some activity deficits
Impaired Fun. Mobility Balance ADLs Gait Stairs
What are some participation deficits
Return to community
Return to work
Driving
Family and social roles
Define retrograde amnesia
Unable to recall events that occured during the period immediately preceding the event
Define PTA (posttraumatic amnesia)
Time b/t the event and the point at which memory is restored - duration assoc w/severity of injury
Define anterograde memory
Ability to form new memories
What are the factors we look at for a prognosis
GCS Age Health disparities CT Scan Abnormalities PTA Duration
T or F: It takes an interdisciplinary team to care for a TBI Pt
True
What is the RLA Levels of Cognitive Functioning (LOCF)
An eval tool that is used to describe stages of recovery seen after a brain injury - Pts can start anywhere and progress at any rate through the levels
What is Level 1 of RLA LOCF
No response
- Comatose w/o response to stimuli
What is Level 2 of RLA LOCF
Generalized Response
- Opens eyes, some sleep/wake cycle, Patient inconsistently and non-purposefully reacts to stimuli.
What is Level 3 of RLA LOCF
Localized Response
- Reacts specifically but inconsistently to stimuli.
May follow simple commands in an inconsistent and delayed manner
What is Level 4 of RLA LOCF
Confused, Agitated Response
- Confused and frightened w/overreactions and restlessness
- Highly focused on basic needs
- Short attention span
- Can do simple routine activities w/help and has difficulty following directions
What do you do w/Levels 1,2,3 of RLA LOCF
- Explain in a normal tone w/clear and concise commands.
- Tell them who you are and orient them
- Calm environment w/rest periods
- Bring in favorite objects
Managing Level 4 of RLA LOCF
- Stage where most Pts begin IPR
- Avoid overstimulation and encourage breaks
- Provide structure and allow as much mvmt as is safe
What is Level 5 of RLA LOCF
Confused, Inappropriate, not agitated
- Alert and able to respond to simple commands fairly consistently
- Highly distractible & w/o structure non-purposeful
- Wander off and try to go home
What is Level 6 of RLA LOCF
Confused, appropriate response
- Show goal directed behaviour but still dependent on external direction
- Follows schedule with some assistance
What is Level 7 of RLA LOCF
Automatic, Appropriate Response
- Follows schedule & does routine activ w/o help
- Superficial awareness of but lack insights into own condition
- Shows carry-over for new learning at a decreased rate
Managing Level 5 of RLA LOCF
- Repeat w/short and simple commands
- Re-orient Pt at start and end of session
- Help Pt get organized
Managing Level 6 of RLA LOCF
- Repeat things as needed
- Discuss what happened during day to work on memory
- Help person w/starting and continuing activities
- Encourage Participation in all therapies
What is Level 8 of RLA LOCF
Purposeful and Appropriate Response
- Realize they have cognitive deficits
- Alert and Oriented
- Shows carry-over of new learning
- May have poor judgements
Management of Level of VII and VIII
- Allow them to be as independent as possible
- Monitor level of distractions
- Decrease barriers to isolation
What can we do as PT to monitor agitation
Modify environment to decrease stimuli
Avoid restraints
Stay calm
Do not leave Pt alone
T or F: A Pt can take meds for agitation
True! Beta blockers
How long does agitation typically last
<= 14 days, could be longer in some cases
What are some examples of restless behaviours
Rocking
Pacing
Fidgeting
Sliding back and forth in WC
What are behaviours of poor attention span
- Distraction during meal times or toileting
- Poor participation in therapy
What are some examples of impulsive behaviour
Pt drinks water when NPO
Forgets to lock WC
Stands up to walk to bathroom w/o walker
How to help Pt w/Impulsivity
- Use strategy with a Pt and verbally review the steps for each activity at the start
- Have Pt think about how to complete the task before starting it
What to do about Pt Disinhibition
- Remain calm and provide concrete feedback
- Identify issue as “self-control”
- Avoid emotional responses
What to do about Pt Perseveration
Allow Pt time to disengage from one activity before proceeding to the next
- Lots of structure
- Cue to redirect away
Define confabulation
Unconscious filling in of gaps in memory with fabricated facts and experiences - Pt believes these to be real
What to do about confabulation in Pt
Low function: Ignore it
High function: Provide nonthreatening feedback on inaccuracy of memory; then, redirect
What does decreased insight look like in a Pt
- Overestimation of their abilities
- Inability to self-reflect
What to do about apathy in a Pt
- Have treatment target choices and acknowledge accomplishments
- Do not present yes/no choices
- Ask what Pt wants to do
What to do about lack of initiation in a Pt
- VC at beginning of movement using same cue for each step
What medications might be used to help with behaviour management
- Psychostimulants
- Antidepressants
- AntiPD meds
- Anticonvulsants
- Meds for sleep/wake cycle promotion
T or F: A concussion is a mild brain injury
True
What types of symptoms can you see for a Concussion?
Cognitive
Physical
Emotional
Sleep
When do symptoms typically occur with a concussion
Begin w/in first 7-10 days and go away w/in 3 months
What symptoms are common of Post-concussive syndrome
Headache
Dizziness
Difficulty w/concentration and memory
List the subtypes of concussions
Ocular Cervical Vestibular Cognitive/Fatigue Anxiety/Mood Post-traumatic Migraine
What do you see w/ocular concussion
Visual issues
What do you see w/cervical concussion
MSK - C-Spine stiffness and pain, headaches
What do you see w/vestibular concussion
Dizziness; issues w/sensory system weighting
What do you see w/Cognitive/Fatigue concussion
Overwhelmed by busy environments; feel better in am worse in pm; fatigued and low energy but trouble sleeping at night
What do you see w/Anxiety/mood concussion
Overwhelmed by busy environments; feel better in am worse in pm; fatigued and low energy but trouble sleeping at night; Feelings of anxiety
What do you see w/Post traumatic migraine concussion
Severe H/A esp in morning
Nausea
Photophobia and phonophobia
Sleep disturbances
What is Chronic Traumatic Encephalopathy (CTE)
Brain degeneration likely caused by repeated head trauma
Symptoms develop over years post-head trauma
List the types of Nontraumatic Brain Injury
Infections
Tumors
Metabolic Causes
What are causes of infectious NTBI
Bacteria, Viruses, Parasites, Prions, Abscesses
Define Encephalopathy
Brain disease, damage, or malfunction
What can cause a hypoxic/anoxic brain injury
Cardiac Arrest
Prolonged Seizures
Prolonged Asthma Attacks
COPD Exacerbations
What are symptoms of hypoxic/anoxic brain injury
Lethargy altered mental state Tremors Altered Breathing Patterns Coma
What causes Toxic/Metabolic Encephalopathy
Metabolic Disorders (Ketoacidosis)
Toxic Chemicals (mercury, lead, ammonia)
Severe ETOH use
Uremia in kidney failure
