TBI Flashcards
Causes of acquire brain injuries-7
- strokes
- Tumors
- anoxia
- hypoxia
- toxins
- Degenerative disease
- near drowing
Definition of TBI
NOT DEGENERATIVE OR CONGENITAL
- caused by external physical force
- alteration in brain function caused by an external force
Outcomes of TBI depend on 5
immediate damage cumulative effects pre-morbid substance abuse interpersonal relationships and work history
Open Vs Close brain injuries
OPEN:
- penetrating types of wounds
- gunshot, knife
- skull is either fractured or displaced
- brain injury follows path of object entry and exit
- risk of infection increased from open wound and hair, fragments
Closed:
- impact to the head but the skull does not fracture or displace
- brain tissue damaged and dura remains intact
Contusion
- bruising on the surface of the brain
- small blood vessels on the surface hemorrhage
Coup vs CounterCoup
Coup:
- same side of brain where impact is
Counter:
- opp side of trauma
- acceleration can cause further vessel occlusion and edema formation
Epidural Hematomas
- between dura mater and skull
- seen with MVA blow to head and side of skull fracture
- Arterial Hematoma
Signs:
- unconsciousness and then alert&lucid
- immediate surgical intervention needed
Subdural Hematoma
- venous hematoma
- rupture of cortical bridging of veins
- between dura and arachnoid
- common in older adults who fall
- slow to build up and detect
signs:
- resemble CVA and flucuate
Small clots can be reabsorbed vs. large need to be removed
Subarachnoid hematoma
space below arachnoid and above the pia mater
- associated with cerebral aneurysm
- -but can be caused by skull fx
Diffuse Anoxal injury
- common
- usually from shaking brain back and forth
Symptoms of Diffuse Anoxal Injury
disorientation or confusion headache nausea or vomit drowsiness or fatigue trouble sleeping sleeping longer than normal LOB or dizziness
Concussion
most common
can be caused by open or closed injury
momentary loss of consciousness and reflexes
repeated concussion leads to CTE
Symptoms of concussion
dizziness disorientation blurred vision difficulty concentrating altered sleep patterns nausea headache LOB amnesia
3 types of secondary problems
*cerebral damage occurs in result to initial injury
1. Increased ICP
2 anoxic injuries
3. postraumatic epilepsy
Increased ICP
- skull is rigid and does not expand to accommodate edema
- leads to compression of brain tissue, decreased perfusion of blood and possible herniation
Treatment: monitor, drugs, shunt
S&S of increased ICP
decreased responsiveness impaired consciousness severe headache vomiting irritability papilledema changes in vital signs--increased BP and decreased HR
normal ICP range
5-10mmHg—> above 20 is abnormal
anoxic injuries
brain tissue demands 20% of bodys O2 intake to maintain proper o2 sats and metabolic functions
- cardiac arrest most frequent cause
- causes diffuse damage within brain tissue
What areas of the brain are vulnerable from anoxic injuries
hippocampus
cerebellum
basal ganglia
Post traumatic Epilepsy
- at increased risk after TBI
- open injury: subdural hematoma->older adults
- vestibular stimulation is contraindicated
what triggers a seizure
stress poor nutrition electrolyte imbalance missed meds flickering lights infection lack of sleep fever anger worry fear
what do you do if a pt. has a seizure
bring them to lowest safe level
do not put anything in mouth
protect them from hitting head but do not restrain
flip on side if they are starting to vomit
medications for seizures
Phenytoin
phenobarbital
carbamazepine
**also used to control behavior
Glasgow Coma Scale
- used in ER to assess the individuals level of arousal and function of cerebral cortex
- TYPICALLY: 3-4 scores do not make it
- most powerful predictor of prognosis and outcome of TBI
Mild TBI
- GCS of 13 or higher
- LOC less than 20 minutes
- normal CT
- awake when arriving to hospital
- may present dazed, confused
- c/o headache or fatigue
Moderate TBI
GCS 9-12
- confused and unable to answer questions
- most have permanent physical, cognitive and behavioral deficits
Severe TBI
GCS of 3-8
individual is in coma
permanent functional and cognitive impairments
7 manifestations of TBI
decreased level of consciousness cognitive deficits motor deficits sensory deficits communication deficits behavioral deficits associated problems
Definition of Coma
decreased level of awareness
state of unconsciousness
presents with:
eyes remain closed
unable to initiate voluntary activity
sleep/wake cycle not present
vegetative state
person who demonstrates a return of brain stem functions
- respiration
- digestion
- BP control
no sleep/wake cycle
may experience arousal and spontaneous eye opening
pain responses may be evident
unaware of external and internal needs
persistent vegetative
been in this state for a year or longer with no improvements in neurological status
arousal
regulated by RAS
awareness
consciousness of int/ext env. stimuli
consciousness
state of being aware
stupor
condition of general unresponsiveness
obtundity
people who sleep a great deal of the time
when aroused demonstrate disinterest in env. and slow to respond to sensory stim.
delirium
disorientation, fear, misperception of sens. stim
clouding of consciousness
state in which a person is confused, distracted and has poor memory
Cognitive deficits
dysfunction can include: disorientation, poor attention span, loss of memory, poor orginizational and reasoning skills and inability to control emotional response
affect ability to learn new skills
motor deficits
*when unconscious pt unable to initiate active movement
abnormal posture are frequently seen from brain stem injury
Decerebrate Rigidity
LE: Hip add Hip IR Knee ext PF supintation
UE: Shoulder ext and IR
elbow ext
pronation
wrist/fingers flex
what causes decerebrate rigidity
severing of the neuroaxis in midbrain region
Pons medulla and SC remain functional
decorticate rigidity
UE: shoulder flex, add, IR Elbow flex pronation wrist flex
LE:
extension
what causes decorticate rigidity
dysfunction above the level of the red nucleus
between basal nuclei and thalamus
sensory deficits
loss of sense of smell
impairment or absence of tactile or kinesthetic sensations
visual deficits
perceptual and proprioceptive deficits
communication deficits
initially lost or severely impaired
decreased awareness of env. can limit opportunities for interaction
may not be able to initiate communication because of abnormal tone or posturing
behavioral deficits
- most enduring and socially disabling deficits
- can exhibit neuroses, pychoses, sexual disinhibition, apathy, irritability, agression, low frustration tolgerance
associated problems
- 70% of TBI pts. will have other injuries
- may make care and rehab
Early intervention goals of PT for TBI
- increase pt. level of arousal
- preventing development of secondary impairments
- improving pt. function
- provide pt. and family with education
**avg. length of stay in hospital is 2 weeks
position of pts.
- supine-facilitate extensor tone and tonic labyrinthine
- sidelying or semi-prone: reduce influence of tonic labyrinthine refelx
- UE: abd and ER to inhibit abnormal tone
- Position out of decebrate or decorticate postures
- contractures occur quickly
reflex inhibiting postures
static then progressing to active movements
superimposed on static positions
heterotopic ossification
abnormal bone formation in soft tissues and muscles
presents with loss of ROM, pain, swelling and erythema
no effective treatment
DRUGS: NSAIDS
ways to increase patients awareness
important even with coma pts.
assume pt. can hear you and undestand
explain what youre doing all the time
orient pt. x4 and converse with pt. & family
RLA 1-3 characteristics
decreased level of responsiveness
little interaction with env.
RLA 1-3 goals and outcomes
- physical function and alertness increased
- risk of secondary impairments reduced
- motor control improved
- effects of tone managed
- postural control improves
- tolerance of activities and positions increased
- joint integrity and mobility improved or remain functional
- education of family and caregivers
RLA 1-3 intervention
-prevent indirect impairments
-proper positioning both in bed and sitting
-turn every 2 hrs.
recline w/c or tilt in space
-postural drainage, percussion and vibration
-ROM and orthotics to prevent contractures
RLA 1-3 improving arousal
short sessions-15 to 30 mins avoid over stim normal toone and meaningful topics of auditory photographs-visual 10-15 sec of olfactory swabs low freq vibration or stroke/rub with wash cloth rolling and neck rolling
RLA 1-3 monitoring
HR BP RR Diaphoresis Facial grimicing changes in posture head turning vocalization
1-3 RLA managing effects of tone and spasticity
positioning
rom
orthotics
inhibitory tech.
RLA 4
confused
agitated
goals for RLA 4
pt. edurance improved joint mobility and integrity maintained risk of 2ndary impairments decreased increase tolerance of activities pt family educated on dx, prognosis, pt outcomes
RLA 4 INTERVENTION
utilize same therapist, time and place of tx expect no carry over model calm behavior redirect provide options expect egocentricity
RLA 4 PT. FAMILY EDUCATION
difficult to provide education directly at this level
pt. does not have control of behavior
entering this stage is good because it indicates improvement
aggressive behaviors are usually short-lived
keep consistency
RLA 5&6
confused but no longer agitated
simple commands improved
improved carry over
RLA 5&6 GOALS AND OUTCOMES
performance of fun. mobility and ADL skills increased
gait, mobility and balance improves
motor control, postural control increase
risk of 2ndary impairments reduced
strength and endurance increased
safety with fun mobility & ADL skills improved
pt. fam education
tolerance of activities increased
RLA 5&6 INTERVENTION
ROM exercise & task
physical conditioning
focal lesions: balance and ataxia
RLA 5&6 2 TREATMENTS STRATEGIES
- Compensatory
- improve functional skills by compensating for the lost ability - Restorative
- locomotive training via BW support and treadmill
- constraint induced movement therapy for UE function
RLA 5&6 INTERVENTION CONSIDERATIONS
maintain structure emphasize safety simple instructions short term goals: -gradual increased in the number of reps&exercise time practice should be distributed -sufficient rest periods to minimize physical and mental fatigue extrinsic feedback
RLA 5&6 FAMILY EDUCATION
emphasize safety awareness ed
family should learn to assit pt. with fun mobility
fam should learn to assist pt. with strength &ROM
fam should be aware of methods to enhance decision making skills and safety
RLA 7&8 CHARACTERISTICS
cognitive and emotional deficits are usually greater than the physical deficits
RLA 7&8 GOALS AND OUTCOMES
pt.& fam education
safety of pt. & family is improved
ability to perform physical tasks related to ADL skills, community, work integration and leisure is improved
motor control, balance and postural control increased
Strength & endurance increased
level of supervision and assistance for task performance is decreased
RLA 7&8 INTERVENTIONS
ROM exercise and functional tasks
physical conditioning
ADL and IADL training - pt. integrating cognitive, physical and emotional skills necessary to function in community
RLA 7&8 PATIENT AND FAMILY EDUCATION
pt. should be educated how to best compensate for residual impairments and disabilities
pt. and family should contact local support group
RLA level 1 characteristics
NO RESPONSE; TOTAL ASSIST
-complete absence of change in behavior when stimuli presented
RLA Level 2 Characteristics
GENERALIZED RESPONSE; TOTAL ASSIST
- reflex response to painful stimuli
- response to repeated auditory stimuli
- response to ext. stimuli with gross body movement or vocalization
RLA 3 Characteristics
LOCALIZED RESPONSE;TOTAL ASSIST
- withdrawal or vocalization to pain stim
- head turns with auditory stim
- follows objects with eyes
- responds to discomfort
RLA 4 Characteristics
CONFUSED/AGITATED; MAX ASSIST
- alert and heightened state of activity
- purposeful attempts to remove tubes and restraints
- non purposeful movements of divided attention
- may cry or scream to stimulus
- unable to cooperate with treatment
- mood swings for no apparent reason
- incoherent verbalization
RLA 5 Characteristics
CONFUSED, INAPPROPRIATE NON AGITATED;MAX ASSIST
- Alert not agitated
- not oriented to person, place or time
- may be able to perform learned tasks with cues
- simple commands can be followed but random
- able to converse on social, level for brief periods of time with cues
RLA Level 6 Characteristics
CONFUSED, APPROPRIATE; MOD ASSIST
- inconsistently oriented
- able to attend to familiar tasks for 30 minutes
- able to use assistive memory aide with max assist
- mod assist to problem solve
- unaware of impairments
- verbal expressions are appropriate
RLA Level 7 characteristics
AUTOMATIC, APPROPRIATE; MIN ASSIST
- consistently oriented
- min supervision with new learning and with safety in routine at home and community
- overestimates abilities
- unable to recognize inappropriate social-interaction behavior
- unaware of others needs and feelings
RLA Level 8 characteristics
PURPOSEFUL, APPROPRIATE; STAND BY ASSIST
- consistently oriented
- independently attends and completes task for 1 hour
- uses assitive memory devices to recall schedule
- thinks about consequences
- aware and acknowledges impairments
- over or under estimates abilities
- able to recognize inappropriate social interactions
- self centered and uncharacteristically independent/dependent
Locked in Syndrome
rare neurological disorder that results after TBI
- complete paralysis of all voluntary muscles except those that control eye movement
- pt. remains conscious and possesses cognitive function but is unable to move
