TBI

Question 1

What is DAI?

Answer 1

disruption/teraing of axons and small blood vessels from shear-strain of angular acceleration

• results in neuronal death and petechial hemorrahges
• tearing/stretching disrupts ability to send signals

Question 2

Can you see DAI on imaging?

Answer 2

sometimes; with severe cases you should be able to

Question 3

When you see DAI when reviewing a patient’s chart, what should you automatically be thinking about outcomes for this pt?

Answer 3

usually longer recovery process/more difficult prognosis

- may have more global deficits

Question 4

What separates the cerebral tissue from the cerebellum?

Answer 4

tentorium cerebelli (extension of dura)

Question 5

Describe an uncal herniation.

Answer 5

temporal lobe leaks below the tentorum cerebelli and puts pressure on midbrain

Question 6

Mass effect is often due to what?

Answer 6

damaged area of brain results in swelling/edema/blood, which increases ICP and causes surrounding tissue to get pushed and displaced
- can lead to a herniation of brain tissue (uncal, central, tonsillar)

Question 7

Describe a central herniation.

Answer 7

midbrain tissue moves down centrally between two tentorium

• can be a worsening uncal herniation
• symptoms: poor eye control

Question 8

What is the falx cerebri?

Answer 8

Dura mater that separates the L from R hemisphere

Question 9

Describe a tonsillar herniation.

Answer 9

cerebellar tonsils push down through the foramen magnum onto the brain stem/spinal cord

AKA chiari malformation

Question 10

What types of focal injury (primary injury) can occur in TBI? (4)

Answer 10

1) DAI
2) hematoma, contusion, laceration
3) coup/contracoup injury
4) closed/open injury (with skull fracture)

Question 11

What CN is damaged when the brain rubs over the cribiform plate during TBI?

Answer 11

CN 1

Question 12

Which hematoma is more associated with skull fracture and has a lucidity period, so you need to be sure to wake them every hour?

Answer 12

epidural hematoma

• occurs outside of the dura
• has the potential to really press in on structures inside brain if it keeps getting bigger so need to wake every hour

Question 13

Where do subdural hematomas occur?

Answer 13

between pia-arachnoid mater and dura

Question 14

Onset of symptoms are slower but continue to get worse, with no period of lucidity with what type of hematoma?

Answer 14

subdural hematoma

Question 15

Why does secondary brain damage occur, through what processes? What does this look like?

Answer 15

cascade of biochemical/cellular processes

• ischemia (from compromised cerebral circulation), endogenous cell damage, exogenous cerebral damage
• mass release of damaging neurotranmitters
• concussion (LOC with poor RAS function of brainstem)

Question 16

What does the GCS measure? (3)

Answer 16

1) verbal response
2) motor response
3) eye movement

Question 17

With a temporal lobe brain injury, what might you expect to see?

Answer 17

• hearing issues, poor ability to localize sound
• impaired learning/memory
• no new learning
• fluent aphasia

Question 18

Your patient has visual-spatial issues, tactile agnosia, and impaired taste on the contralateral tongue side. What lobe could be affected d/t his brain injury?

Answer 18

parietal (issues with taste, perceptual function, sensory interpretation)

*tactile agnosia -> agraphesthesia, loss of 2 point descrim, extinction, astereognosis (object in hand)

Question 19

With a patient with frontal lobe damage from TBI, what could you expect to see upon evaluation?

Answer 19

• contralateral paresis/paralysis (more in distal limbs/face)
• apraxia
• lost motor plans
• loss of bilateral postural control
• nonfluent aphasia (brocha’s)
• unstable emotions/ behaviors
• difficulty concentrating

Question 20

If a patient has post-traumatic amnesia for 6 days, what classification of TBI would she receive? (mild/mod/severe)

Answer 20

moderate

<1 day = mild
1- <7 days = mod
7> days = severe

Question 21

You’re performing a chart review on a patient with a GCS of 18. What does this mean?

Answer 21

FAKE cause GCS only goes from 1-15

Question 22

You’re performing a chart review on a patient with a GCS of 8. What level of impairment can you infer for the patient?

Answer 22

severe tbi

severe = <9
mod = 9-12
mild = 13-15

Question 23

What’s the first thing you’ll see when a patient is coming out of a coma?

Answer 23

return of sleep/wake cycles and normalization of vegetative functions (respiration, digestion, BP/HR control)

Question 24

Describe recovery from a coma, in basic terms.

Answer 24

1) begin to have sleep/wake, vegetative function
2) some demonstration of awareness, intermittent
3) confused; no new memories, hyper/hypoarousal
4) confusion clearing, some memories, limited insight, social problems
5) increasing independence though cognitive difficulties still (problem solving, reasoning) and social problems/mood swings

• pt can plateau at any time or regress when experiencing stress

Question 25

What symptoms might lead you to think that a patient has increased cranial pressure?

Answer 25

• intense headache
• vomiting
• increased BP, slower pulse
• Cheyne-stokes breathing
• pupillary changes (unequal, lack of response)
• progressed impairment of motor fxn
• altered consciousness
• seizure activity

Question 26

Poor volitional movement ability as well as paresis/paralysis are more commonly seen in what types of TBI?

Answer 26

front lobe damage

- recall prefrontal cortex (motor)

Question 27

What is sympathetic storming? What do pts look like with this?

Answer 27

stress response (increase in circulating corticoids/catecholamines) from hypothalamic stimulation of the SNS

• pt will generally exhibit minimal alertness/awareness, and reflexive motor response to stim

Question 28

For decreased response levels (LOCF I-III), what are PT goals?

*LOCF = ranchos levels of cognitive functioning

Answer 28

• preserve skin integrity
• prevent contractures through splinting, positioning, ROM
• maintain respiratory status (postural drainage, compression)
• promote early return of FMS: upright positioning for improved arousal, body alignment

Question 29

Your patient is a rancho V; what are going to be your PT management strategies?

Answer 29

1) provide structure, prevent overstimulation
2) provide consistency throughout team; clear feedback
3) engage in task-specific training
4) frequent orientation tasks (time, person, place, task)
5) emphasize safety, calm/controlled behavior (relaxation techniques)

this is moderate-level recovery: LOCF 4-6

Question 30

Your patient is a rancho VIII; what are your treatment goals going to consist of?

Answer 30

• weaning from controlled environments
• involve pt in decision making/planning
• prepare for community reentry with behavioral/cognitive/emotional reintegration
• enhance motor learning and promote fxnal tasks (ADL/IADL) in real life enviro
• encourage active lifestyle/cardio training
• improve postural control/symmetry/balance

Question 31

Reiterate the rancho levels.

Answer 31

1-3 = decreased response levels
4-6 = agitated, confused
7-8 = emerging independence, difficulty with cog skills, higher level balance/motor planning issues

Question 32

Your patient has occulomotor nerve palsy, with accompanied hemiplegia. What does this look like, and what could be going on?

Answer 32

3rd nerve palsy: eye in “down and in” position
- not reactive to light

d/t uncal hernation

Question 33

What is a chiari malformation?

Answer 33

slippage of cerebellar tonsils through the foramen magnum onto the spinal cord