TBI Flashcards
What age demographics are most likely to sustain a TBI?
- Children ages 0 to 4 years
- young adults ages 15-24 years
- adults 65 years and older
- incidence is greater in males in all age groups
What are the parameters for loss of consciousness, alteration of consciousness, post traumatic amnesia, GCS score, and neuroimaging for a mild TBI?
loss of consciousness = 0-30min alteration of consciousness = brief < 24hrs post traumatic amnesia = 0-1d GCS score = 13-15 neuroimaging = normal
What are the parameters for loss of consciousness, alteration of consciousness, post traumatic amnesia, GCS score, and neuroimaging for a moderate TBI?
loss of consciousness = 30min - 24hrs alteration of consciousness = >24hrs post traumatic amnesia = 2-7d GCS score = 9-12 neuroimaging = normal or abnormal
What are the parameters for loss of consciousness, alteration of consciousness, post traumatic amnesia, GCS score, and neuroimaging for a severe TBI?
loss of consciousness = >24hrs alteration of consciousness = >24hrs post traumatic amnesia = >7d GCS score = 3-8 neuroimaging = normal or abnormal
What classifies as an open vs closed TBI?
Open = penetrating injury, dura compromised
Closed = non penetrating, dura uncompromised
primary issues of head trauma?
- Skull fracture
- Contusions of gray matter - coup or contrecoup (may lead to 2* issues)
- Diffuse white matter (axonal) damage
- Hematom
secondary issues of head trauma?
- Anoxia
- Ischemia
- Swelling/Increased intracranial pressure (ICP)
What kind of skull fx can occur?
- Linear
- Depressed
- Compound - breaks off
What are signs of a basilar fracture?
- Raccoon eyes – always bilaterally, bleeding at base of skull
- Battle’s sign – bruising behind ear; middle of the base fracture
What are features of an orbital fracture?
- eye socket
- unilateral bruising (usually)
- sometimes called a ”blowout” fracture
Severing of axons because of shearing forces caused by rapid rotational and acceleration/ deceleration movement; Sudden loss of consciousness - May be prolonged and cause coma; Main mechanism of injury in those with moderate or severe TBI; High mortality rate; Widespread microscopic damage (Often there are minimal findings on initial CT and MRI)
Diffuse white matter (axonal) damage
- see more decerebrate posturing - worst prognosis
What type of hematoma?
- Tear in the meningeal artery between skull and dura
- Usually from a focused blow to the head
- Fixed and dilated pupil on same side
- Emergency surgery
- Best prognosis if treated early
Acute epidural
What type of hematoma?
- Venous rupture between dura and the arachnoid
- High frequency of seizures
- Emergency surgery
- Poor prognosis
- High mortality rate
Acute subdural
What type of hematoma?
- Any location in the brain
- Arteries and veins
- Neurological deficits
- Poor prognosis
- High mortality rate
Intracerebral hematoma
- in the brain itself
- sx of a stroke, looks like hemorrhagic stroke
What does the following series of events cause?
- Starts with anoxia
- Leads to ischemic tissue damage
- Leads to body responding by compensatory vasodilation
- Leads to increased swelling and increased ICP resulting in anoxia
Secondary issues
- Cell death results from a chain of cellular events
- Develop over hours and days
What is normal ICP? When does it cause neurological damage and death?
Normal ICP is 5-20 mm Hg
20-40 mm Hg = may contribute to brain damage
> 40 mm Hg = neurological damage and death
- as it climbs over 20, something has to be done; may remove portion of skull if medication does not work
- may be monitored by ventriculostomy
What are clinical manifestations of ICP?
- Headache
- nausea
- drowsiness
- weakness
- papilledema
What causes brainstem damage?
Downward pressure on foramen magnum
- Caused from swelling and increased ICP
- cranial nerve damage occurs with injuries to base of the skull where the nerves emerge directly from brainstem
What. can cause internal carotid artery damage?
- Gunshot wounds
- Blows to the neck
- Injuries to face
- Cervical hyperextension
What. can cause vertebral artery damage?
- severe cervical hyperextension
2. severe cervical rotation
What is the purpose of a neuro exam in a TBI?
- Determine severity
- Determine baseline of injury in order to detect deterioration
- Categorize injury
- Help with prognosis
What are the components of a neuro exam in a TBI?
- Eye assessment
- Posturing
- Vocalization
- PROM and tone
- Active movement - Purposeful or nonpurposeful?
- Reaction to tactile/painful stimulation
- Clinical Rating Scales
What are you looking at during an eye assessment?
- Size and symmetry of pupils
- Response to light
- Tracking in response to auditory or visual stimulation
- Dysconjugate - asymmetry, inability to turn eyes together in the same direction
What’s the purpose of medications for TBIs?
- Decrease ICP
- Hypertension
- Anti-Seizure
- Muscle spasticity
- Behavioral and cognitive functions
What categories does the Glasgow coma rating scale assess for scores?
Eye Opening = spontaneous> to speech> to pain> no response
Motor Response = Follows motor commands> localizes> withdraws> abnormal flexion> abnormal extension> no response
Verbal Response = oriented> confused conversation> inappropriate words> incomprehensible sounds> no response
Assists with prognostic assessment and treatment planning; 23 items, 6 subscales addressing:
Auditory
, Visual
, Motor
, Oromotor/Verbal
, Communication
, Arousal
- takes 30 mins to administer, cut off scores for vegetative state, minimally conscious, and emerging from minimally conscious
Coma recovery scale
What are the Ranchos Los Amigos Levels of Cognitive Recovery? assesses typical cognitive behavioral recovery
I No response: Needs total assistance
II Generalized response: Needs total assistance
III Localized response: Needs total assistance
IV Confused – agitated: Needs maximal assistance
V Confused – inappropriate: Needs maximal assistance
VI Confused – appropriate: Needs mod assistance
VII Automatic – appropriate: Needs min assistance
VIII Purposeful – appropriate: needs SBA
Damage to this area of the brain results in:
- loss of movement
- repetition of single thought
- unable to focus on a task
- mood swings, irritability, impulsiveness
- changes in social behavior and personality
- difficulty with problem solving
- difficulty with language; can’t get words out (aphasia)
frontal lobe
Damage to this area of the brain results in:
- difficulty distinguishing L from R
- lack of awareness or neglect of certain body parts
- difficulty with eye-hand coordination
- problems with reading, writing, naming
- difficulty with math
parietal lobe
Damage to this area of the brain results in:
- defects in vision or blind spots
- blurred vision
- visual illusions/ hallucinations
- difficulty reading and writing
occipital lobe
Damage to this area of the brain results in:
- difficulty understanding language and speaking
- difficulty recognizing faces
- difficulty IDing/ naming objects
- problems with ST and LT memory
- changes in sexual behavior
- increased aggressive behavior
temporal lobe
Damage to this area of the brain results in:
- difficulty coordinating fine movements
- difficulty walking
- tremors
- dizziness
- slurred speech
cerebellup
Damage to this area of the brain results in:
- changes in breathing
- difficulty swallowing food and water
- problems with balance and movement
- dizziness and nausea
brainstem
what is worse? decorticate or decerebrate?
decerebrate rigidity
- Corticate – corticospinal damage
- Cerebrate – brainstem damage
What are cognitive impairments associated with mild TBI (concussion)?
- Irritable, distractible
- Difficulty with reading and memory
- Symptoms of headache, fatigue, dizziness
- Changes in personality
- Emotional changes
Level of consciousness:
- Drowsy, fall asleep easily
- Decreased alertness, delayed reactions
- Once aroused, responds appropriately
obtunded/ lethargy
Level of consciousness:
- Near-unconsciousness
- Aroused briefly by verbal, visual, or painful stimuli
- Slowed motor or moaning responses to stimuli
Stupor
Level of consciousness:
- Not awake and not aware
- “Unarousable unresponsiveness”
- No sleep-awake cycle “deep sleep”
coma
Level of consciousness:
- Intact eye opening and sleep-awake cycles but not able to speak or obey commands
- Called a persistent vegetative state if >1 year
vegetative state
Whats the difference between retrograde and post-traumatic (anterograde) amnesia?
Anterograde – time between injury and memories returning, can’t form new memories, used in diagnosing severity
Retrograde – period before injury
What are the communication impairments often present in TBI?
Normally no aphasia but issues are related to cognitive impairments
- Disorganized
- Word retrieval difficulties
- Socially inappropriate language
- Difficulty reading social cues
What are the behavioral impairments often present in TBI?
- Agitation
- Anger/Aggression
- Denial
- Depression
- Egocentrism
- Excessive Talking
- Impulsivity
- Inability to Initiate
- Irritability
- Lability
- Memory
- Obsessional Behavior
- Paranoia
- Social Inappropriateness
What are strategies for agitated patients?
- Model calm and controlled behavior
- Redirect when necessary
- Be consistent with daily routine
- Be flexible and vary activity to avoid boredom
- Schedule short frequent breaks
- Give options to patient so they feel more in control
- Do not teach a new complex skill
- Do not overstimulate
- Always be aware of safety
What are some general strategies for working with pts with TBI?
- BE PATIENT
- Establish an open, trusting relationship
- Remember anger is often a spontaneous act
- Assist pt. in verbalizing what they may be feeling
- Seek professional help for suicidal statements
- Give consistent feedback and praise
- Set clear boundaries
- Do not feel obligated to respond to all statements
- End conversation at a set amount of time
- Teach “stop, think, and then act”
- Break tasks into small steps
- Don’t argue with paranoid thoughts
- Directly confront inappropriate behavior
What are techniques to address memory loss?
- Use compensation skills - Lists, calendars, reminders, alarms, etc
- Give information in writing
- Use repetition
- Periodically “check in” with pt. during treatment - “Explain what I just said” or “Review what we have been working on”
What are pre injury prognostic indicators?
Education level
Age - neuroplasticity
What are post-injury prognostic indicators?
- Type of injury
- Initial GCS score
- Pupil reactivity
- Other injuries along with TBI
- Duration of coma
6 Duration of amnesia
