TBI Flashcards
What is DAI?
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
Can you see DAI on imaging?
sometimes; with severe cases you should be able to
When you see DAI when reviewing a patient’s chart, what should you automatically be thinking about outcomes for this pt?
usually longer recovery process/more difficult prognosis
- may have more global deficits
What separates the cerebral tissue from the cerebellum?
tentorium cerebelli (extension of dura)
Describe an uncal herniation.
temporal lobe leaks below the tentorum cerebelli and puts pressure on midbrain
Mass effect is often due to what?
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)
Describe a central herniation.
midbrain tissue moves down centrally between two tentorium
- can be a worsening uncal herniation
- symptoms: poor eye control
What is the falx cerebri?
Dura mater that separates the L from R hemisphere
Describe a tonsillar herniation.
cerebellar tonsils push down through the foramen magnum onto the brain stem/spinal cord
AKA chiari malformation
What types of focal injury (primary injury) can occur in TBI? (4)
1) DAI
2) hematoma, contusion, laceration
3) coup/contracoup injury
4) closed/open injury (with skull fracture)
What CN is damaged when the brain rubs over the cribiform plate during TBI?
CN 1
Which hematoma is more associated with skull fracture and has a lucidity period, so you need to be sure to wake them every hour?
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
Where do subdural hematomas occur?
between pia-arachnoid mater and dura
Onset of symptoms are slower but continue to get worse, with no period of lucidity with what type of hematoma?
subdural hematoma
Why does secondary brain damage occur, through what processes? What does this look like?
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)
What does the GCS measure? (3)
1) verbal response
2) motor response
3) eye movement
With a temporal lobe brain injury, what might you expect to see?
- hearing issues, poor ability to localize sound
- impaired learning/memory
- no new learning
- fluent aphasia
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?
parietal (issues with taste, perceptual function, sensory interpretation)
*tactile agnosia -> agraphesthesia, loss of 2 point descrim, extinction, astereognosis (object in hand)
With a patient with frontal lobe damage from TBI, what could you expect to see upon evaluation?
- 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
If a patient has post-traumatic amnesia for 6 days, what classification of TBI would she receive? (mild/mod/severe)
moderate
<1 day = mild
1- <7 days = mod
7> days = severe
You’re performing a chart review on a patient with a GCS of 18. What does this mean?
FAKE cause GCS only goes from 1-15
You’re performing a chart review on a patient with a GCS of 8. What level of impairment can you infer for the patient?
severe tbi
severe = <9 mod = 9-12 mild = 13-15
What’s the first thing you’ll see when a patient is coming out of a coma?
return of sleep/wake cycles and normalization of vegetative functions (respiration, digestion, BP/HR control)
Describe recovery from a coma, in basic terms.
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
What symptoms might lead you to think that a patient has increased cranial pressure?
- 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
Poor volitional movement ability as well as paresis/paralysis are more commonly seen in what types of TBI?
front lobe damage
- recall prefrontal cortex (motor)
What is sympathetic storming? What do pts look like with this?
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
For decreased response levels (LOCF I-III), what are PT goals?
*LOCF = ranchos levels of cognitive functioning
- 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
Your patient is a rancho V; what are going to be your PT management strategies?
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
Your patient is a rancho VIII; what are your treatment goals going to consist of?
- 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
Reiterate the rancho levels.
1-3 = decreased response levels 4-6 = agitated, confused 7-8 = emerging independence, difficulty with cog skills, higher level balance/motor planning issues
Your patient has occulomotor nerve palsy, with accompanied hemiplegia. What does this look like, and what could be going on?
3rd nerve palsy: eye in “down and in” position
- not reactive to light
d/t uncal hernation
What is a chiari malformation?
slippage of cerebellar tonsils through the foramen magnum onto the spinal cord
