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OSCE Neuro Remediation > TBI > Flashcards

TBI Flashcards

1
Q

What are the levels of injury on the glascow coma scale?

A
  • Mild injury = 13-15 pts
  • Mod injury= 9-12 pts
  • Severe = less than 9
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2
Q

What factor influences outcome?

A

Pre morbid state (decreased outcomes associated with previoius injury)

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3
Q

What are the types of of Primary injury?

A
  • Local
  • Coup-countercoup
  • Polar damage
  • Diffuse axonal injury
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4
Q

What are the types of local injury?

A
  • Laceration
  • Clot
  • Contusion
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5
Q

What is coup-countercoup?

A

Blow to the skull on one side that causes brain to shift and be damaged on the opposite side:

  • Skull pushes brain at same time as it accelerates
  • on the opposited side there is momentary vacuum
  • When skull stops accelerating vacuum collapses and brain hits skull
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6
Q

What is polar damage?

A

Result of an accel/decel injury and most commonly hits the frontal and temporal poles. Ocassionally occipital

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7
Q

What is damamged in DAI? and what are the levels of severity?

A
  • Widely scattered shearing damage to axons
  • Severity:
    • Mild: little defecit
    • Mod: wider areal of subcortical matter
    • Severe: extends down and in to midbrain and brainstem (coma with posturing and autonomic dysfuntion
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8
Q

What are types of secondary injury?

A
  • Hypoxemic Ischemic Injury-Brain tissue shifted as a result of swelling
  • Intractranial hematoma- forms post injury due to cont. bleeding
  • Increased ICP (normal <10 mmHg)
  • Autodestructive Cellular phenomena (Cell suicide)
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9
Q

What is arterial hypoxemia?

A

A form of HII that results in much wider damage from anything shutting off O2 in the brain (MI, airway obstruction, arrythmia, PE)

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10
Q

What are the 2 scenarios for intracranial hematoma?

A
  • “Talk and Die”- pt has as period of lucidity then loses consciousness and ultimately dies (due to space occupying lesion)
  • Person in coma and has no lucid period-bleeding can go undetected which results in death
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11
Q

what are the 3 types of brain herniations?

A

Uncal, Central, Tonsillar

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12
Q

Characteristics of Uncal herniation

A
  • Location: Tentorial notch, midbrain
  • Cause: mass lesion in temporal lobe or middle fossa
  • Structures involved: Hippocampal gyrus and uncus, occulomotor nerve, cerebral peduncle, midbrain ascending reticular activating system, PCA
  • Clinical effects: Paresis of nerve 3, hemiparesis, coma, homonymous hemianopsia
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13
Q

Characteristics of Central herniations

A
  • Location: same as uncal
  • Cause: mass lesion in frontal, paretiel, or occipital lobe; progression of uncal
  • Structures involved: midbrain, pons (causes decerebate rigidity); ascend. retic. activat. syst (coma)
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14
Q

Characterstics of Tonsillar:

A
  • Location: Foramen magnum, medulla
  • Cause: mass lesion in posterior fossa, Progression of central herniation
  • Structures involved: Cerebellar tonsils (neck pain and stiffnes), Indirect activation pathways (flaccidity), ascend retic. activat. syst (coma), Vasomotor centers (alters pulse, BP, respiration)
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15
Q

What is ACP? How is it treated?

A

Increase in excitatory neurotransmitters (glutamate) due to activation of calcium dependant enzymes that destroy more tissue. Treat: cooling; hyperbaric O2, free radical scavengers

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16
Q

How is a TBI medically managed?

A
  • Monitor TBI
  • check values (>25 mmHg usually requires intervention; <20 for 24 hrs discont. monitoring)
  • Prevent increasing ICP (avoid dependent posns)
  • Meds (check interaction with therapy)
    • can increase spasticity and decrease patient willingness to particpate
17
Q

What are impairments associated with TBI?

A
  • Cognitive Deficits
  • neuromusclar deficits
  • Visual deficits
  • Perceptual Deficits
  • Swallowing deficits
  • Behavioral Disinhibition
  • Commuincation Deficits
  • Cognitive impairments
  • Behavioral Impairments
18
Q

What constitutes a coma?

A

8 or lower on GCS. (if can open eyes and has sleep wake cycles, but cannot obey commands = vegetative)

19
Q

What is post traumatic amnesia?

A

Time between injury and when patient begins to remember ongoing events

20
Q

What are behavioral deficits?

A

Sexual disinhibition, emotional disinhibition, aggressive disinhibition, apathy, depression, low tolerances for frustration

Remember that behavior problems are a result of damage, not personal

21
Q

What are indirect impairments?

A
  • contractures (hand, wrist,PF)
  • decreased endurance
  • DVTs
  • Mobility deficits
  • Pneumonia
  • Heterotopic ossification (development of bone tissue within soft tissue of unknow cause), confirmed by x-ray; typically in elbow or hip flexors; avoid agressive stretching)
22
Q

What are major areas requiring intervention?

A
  • Increase level of consciousness
  • Avoid seconday impairments
  • Posturing and tone issues
  • Maintaining joint integrity
  • Increasing intolerance of positions and activities
  • Family education
23
Q

What is the purpose of sensory stimulation?

A

To increase the LOC through multi-system sensory input in the RAS

24
Q

What are purposes of positioning?

A
  • Decrease posturing and thereby possibly reduce ICP
  • Decrease tone
  • Reduce risk of contractures
  • Prevent skin breakdown
25
Q

What are major areas of concerns for contractures?

A
  • Ankles (PF)
  • Toes (flexor tone)
  • Elbows, wrist fingers
26
Q

What is a contraindication for ROM of TBI pts?

A

DVTs

27
Q

What are Levels I and II of RLA? How does PT interact?

A

Level 1 = no response; Level 2= generalized response

  • Talk to patient in a normal conversational manner (hearing is the first to come back; don’t talk about medical condition in the room)
  • Provide appropriate stimulation (Alternate periods of time with noise for about 15 minutes)
  • Change pts position
28
Q

what is level III? How do you interact?

A

Level 3 =Localized response

  • Continue in normal conversation tones. Talk about their interests
  • Use simple 1-part directions. Use 1 or 2 short sentences
  • Reallize attention span is very short
  • Encourage verbalizing (except if on vent)
  • Provide orientation for the patient
  • Remember rest periods
  • Don’t expet pt to remember recent events
  • Provide visual helps
29
Q

what is level IV? how do you interact?

A

Level 4 = confused/agitated

  • Remember agitation is not personal (major concern is pt safety: avoid contacts to which pt responds negatively, don’t react with anger, don’t stay alone with pt if you feel uncomfortable, produce a calm environment, pt will not remember the way they acted)
  • short, simple directions. allow for delayed responses. talk slow
  • Don’t expect pt to remember instructions (attention span < 2 min)
  • Provide orienting information frequently
  • Prepare pt for tasks
  • pick tasks pt can complete
  • Treat pt as adult
30
Q

What is level V? how to interact?

A

Level 5 = confused/inappropriate/nonagitated

  • pt will perform automatic tasks but supervised
  • pt still in PTA and can’t remember recent events and attention span is 2-3 min for single task. provide ways to support memory
  • Use gentle cues to orient patient
  • one-step directions, simple words
  • attention span is 20-30 min for varied tasks
  • agitation is caused by too much pressure placed on them
  • if pt becomes agitated: rest period, change task, calmly ask pt to relax
31
Q

What is level VI? how to interact?

A

Level 6 = confused/ appropriate

  • pt not fully out of PTA, but beginning to remember some new information. recall of past is shallow and inconsistent ( can reduce cueing and start a journal)
  • 2-step directions and normal language (be concrete and specific; don’t use sarcasm or humor- they won’t get it)
  • pt needs a lot emotional support
  • pt can take responsiblity for perfomance of basic daily tasks w/o supv
  • pt may acknowledge his or her physical and memory impairments
32
Q

What is level VII? how to interact?

A

Level VII = automatic/appropriate

  • normal conversation; 2-3 step directions
  • pt will literally interpret what you say (won’t get subtle humor)
  • Expect general day-to day carryover (frequently discuss events to encourage recall; pt can use a memory notebook)
  • Encourage pt to resume responsiblity for daily routine (ADLs, getting to and from therapy sessions)
  • Expect denial of future implications of disablilites (pt will feel normal)
  • Design tasks or situations so that pt can control emotional expression (Behav. Mod)
33
Q

What is level VIII? how to interact?

A

Level VII= purposeful/appropriate

  • use normal conversation, complex commands
  • pt will still take things literally, but will understand with explanation
  • detailed carryover of daily events (pt should continue to use notebook; memory deficits may be permanent)
  • pt will carry out daily responsiblities independently
  • pt will make long range plans and goals
    • will incorporate present physical and mental abilities and limitations in future planning
    • pt and staff should engage in mutual planning. consider pt premorbid state
    • pt tolerance for frustration increased (emotional control still not as good as before, help pt avoid situations that cause anger and stress)

OSCE Neuro Remediation (5 decks)

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