TBI - 2a Mod-Severe TBI Flashcards
what is an acquired brain injury
any type of brain damage occurring after birth that isn’t hereditary, congenital, degenerative, or induced by birth trauma
what are the top 4 causes for acquired brain injuries
falls
MVA
struck by/against
assault
what age range is the incidence of acquired brain injury highest in
15-24yo
what is the leading cause of TBI in people >65yo
falls
what are 5 risk factors for TBIs
SDOH
- education
- socio-economic
- healthcare access
- resource access
male
age (<4yo, 15-24, >65yo)
substance abuse
previous TBI
- behavior, insight, judgment
what are primary injuries from a TBI (6)
skull fx
contusions
lacerations
hematomas
DAIs
hypoxia
why does having a TBI inc risk for seizures
metabolic and electrical signaling imbalance
what are secondary injuries from a TBI (7)
ischemia
infection
neurochem alterations
sz
edema
inc ICP
brain/brainstem herniation
what are the 3 main types of intracranial hematomas from a TBI
intracerebral
epidural
subdural
what is a common cause of intracerebral hematoma
caused by lacerations - blood flow in brain
what is a common cause of epidural hematoma
tearing of meningeal vessels results in blood collecting b/w skull and dura
what is a common cause of subdural hematoma
accel-decel injuries when bridging veins to superior sagittal sinus are torn and blood accumulates in subdural space
what is the pathophys of a DAI
brain tissues differing in structure and wt experience unequal acceleration, deceleration, or rotation during rapid head movement or impact
- tissue tears and shears
white vs gray matter in a DAI
white matter heavier than gray matter
- gray matter = cell bodies
- white matter = axons
-> see axonal twisting/crushing as white matter accels/decels
what is the location of tissue sheared in a DAI
b/w coup and contrecoup
what is a common MOI for DAIs
high-speed MVA
what specific brain tissues/structures are more susceptible to DAIs (3)
- parasagittal white matter of cerebral cortex
- pontine-mesencephalic junction
- corpus callosum
what is the prognosis for a DAI
worse outcomes
what are the 3 main characteristics to describe a TBI
open vs closed
focal vs diffuse
level of arousal
what are 3 measures to assess status of TBI
CRS-R ->DOC
glasgow coma scale
RLA
what are ex of focal vs diffuse TBIs
focal:
- coup
- coup & contre-coup
- hematoma
diffuse:
- DAI
- anoxic brain injury
what are 5 main definitions for level of arousal
alert
lethargic
delirium
obtunded
stupor/semicoma
characteristics of alert level of arousal
awake, attentive, interactive
characteristics of lethargic level of arousal
drowsy
drifts to sleep when not stim
brief response to stim
poor attention
characteristics of delirium level of arousal
confused
hallucinating
characteristics of obtunded level of arousal
difficult to arouse (aggressive stim)
confused when alert
characteristics of stupor/semicoma level of arousal
not self alerting
responds to vigorous/noxious stim
- ie sternal rub, nail bed
what is a comatose state (DOC)
state of unarousable unresponsiveness in which there is no evidence of self-awareness or environmental awareness
what behavior is seen in a comatose state and what is this indicative of
behavior limited to reflexive activity
failure of reticular activating system (RAS) and integrated cortical activity
what is there no evidence of in a comatose state (6)
awake/aware
sleep wake cycles
spontaneous eye opening
purposeful response to environmental stim
discrete localized responses
evidence of language comprehension/expression
what is a vegetative state (DOC)
awake but not aware
what is the dx criteria for vegetative state of consciousness
must meet all three:
1. no evidence of sustained, reproducible purposeful or voluntary behavioral responses to visual, auditory, tactile, or noxious stim
2. no evidence of language comprehension or expression
3. intermittent wakefulness manifested by presence of sleep/wake cycles (ie periodic eye opening)
what is the main difference between veg and comatose states of consciousness
veg - recovery of eye opening w continued absence of observable signs of cog mediated behavior signals
what behaviors seen in veg state can be construed as arising from partial consciousness
grinding teeth
swallowing
smiling
shedding tears
grunting
moaning
screaming
all w/o apparent external stim or orienting behavior
what is a minimally conscious state (MCS)
minimal but definitive behavioral evidence of self-awareness or environmental awareness
what are characteristics of conscious behaviors exhibited in a MCS
subtle and inconsistent
must be differentiated from random or reflexive
what are 4 ex of dx MCS behaviors
- follow simple commands
- gestures/verbalizes yes/no regardless of accuracy
- intelligible verbalization
- movement/affective behavior occurs in response to environmental stim that are not reflexive
what is the differential between MCS and someone who is emerging
more consistent awareness in emergences
- reliable demonstration of either interactive communcation or functional object use
what are the 3 categories assessed in the GCS
eye opening
motor response
verbal response
mTBI: GCS, LOC length, imaging
GCS >/= 13 (“conscious”)
brief or no LOC
imaging normal
mod TBI: GCS, LOC length, imaging
GCS 9-12
LOC 30min-24hr
imaging prob abnormal
notable characteristic of a GCS >/=9
follows commands
severe TBI: GCS, LOC length, imaging
GCS </= 8
LOC > 24hrs
imaging likely abnormal
what is the purpose of the coma recovery scale (CRS-R)
assist w differential dx, px, assessment and treatment planning in pts w DOC
what are 6 subscale functions scored in the CRS-R
auditory
visual
motor
oromotor
communication
arousal
how are subscales of the CRS-R arranged and the correlating anatomical structures assessed
hierarchically arranged items ranging from reflexive activity (brainstem) to cog-mediated behaviors (cortical processes)
what is CRS-R scoring based on
presence or absence of defined behavioral responses
RLA level 1: response, assistance needed, and main presentation
no response
total assist
comatose
RLA level 2: response, assistance needed, and main presentation
generalized response
total assist
limited, inconsistent, delayed, and identical responses to any stimuli
RLA level 3: response, assistance needed, and main presentation
localized response
total assist
inconsistent but specific responses depending on stim
may follow simple commands
RLA level 4: response, assistance needed, and main presentation
confused-agitated
max assist
active and bizarre behavior w purposeful attempts but not appropriate relative to environment
incoherent, inappropriate verbalizations
RLA level 5: response, assistance needed, and main presentation
confused-inappropriate non-agitated
max assist
consistent follow simple commands
gross attention to environment
w structure, may converse on social/automatic level briefly
RLA level 6: response, assistance needed, and main presentation
confused-appropriate
mod assist
inconsistent orientation
goal-directed behavior
shows carryover to relearned tasks
*memory book - use w max assist
RLA level 7: response, assistance needed, and main presentation
automatic-appropriate
min assist for ADLs
appropriate/oriented in home/hospital setting
min to no confusion
carryover new learning at dec rate
judgment impaired
rec/social activities w structure - poor social skills
RLA level 8: response, assistance needed, and main presentation
purposeful-appropriate
stand-by assist
carryover for new learning and no supervision once activities learned
need supervision for new activities
recall/integrate past and recent events
aware of environment
RLA level 9: response, assistance needed, and main presentation
purposeful, appropriate
stand-by assist on request
independence shifts back and forth
still might need supervision
might still be more irritable than before injury
*assistive memory device
accurately estimate abilities
acknowledge others feelings/needs
self-monitor appropriateness of social interaction
RLA level 10: response, assistance needed, and main presentation
purposeful, appropriate
modified independent
better in tune w limitations
better bandwidth to be more tolerable w social interactions and emotions
