TBI Flashcards
diffuse axonal injury
- damage to axons
* s/s LOC, increased ICP, decerebrate or decorticate posture, global cerebral edema
shaken baby syndrome
- example of a diffuse axonal injury
1) blood vessels that lead from the brain to the dura membrane are the most susceptible to tearing since the subdural space between the brain and the skull is greater for babies. Such hemorrhaging is what doctors detect in CAT scans
2) nerves inside the brain may sever. If this happens, the brain will swell, cutting off oxygen to the brain. In surviving babies, blindness and brain damage may also occur
3) the brain stem is where vital sensors are located, if is is severed or damaged the baby will experience respiratory problems and vomitting
4) the optic nerve is often damaged which causes retinal bleeding
Hypoxemia
severe lack of O2 (can cause TBI)
Decerebrate posturing
Decerebrate posture results from damage to the upper brain stem. In this posture, the arms are adducted and extended with the wrists pronated and the fingers flexed. The legs are stiffly extended, with PF of the feet.
*more serious than decorticate
Decorticate posturing
decorticate posture results from damage to one or both corticospinal tracts. In this posture the arms are adducted and flexed, with the wrists and fingers flexed on the chest. The legs are stiffly extended and IR, with PF of the feet.
Ptosis
drooping eyelid
Components of ICP
skull= closed box, total adult volume=1900 ml
3 Volume Components:
•brain tissue 9 (intra/extracellular fluids) 78%
• blood 12%
•cerebrospinal fluid 10%
Normal ICP
- lateral recumbent (side-lying) ICP= 60-150 mm H2O
* 30° elevation of the head, ICP= 0-15 mm H2O
Epilepsy/ Post traumatic seizures
O’Sullivan 7th: 821
Clonic and tonic phases
GCS factors
Indicates whether or not someone is in a coma as well as severity of head injury Factors: • eye opening •verbal response •best motor
GCS: eye opening
Eye Opening: 1 = no response 2= to pain 3= to speech 4= spontaneous
GCS: verbal response
Verbal Response: 1= no response 2= incomprehensible sounds 3= inappropriate words 4= confused conversation 5= oriented
GCS: best motor
Best Motor:
1= no response
2= extensor response (decerebrate posturing, UE and LE extension)
3= flexor response (UE flexion, LE extension)
4= withdrawal
5= localized
6= follows commands
GCS: numerical range classifications
3 or less= coma
0-8= severe head injury
9-12= moderate head injury
13-15=mild head injury
Other factors with head injury
- LOC
- PTA (post-traumatic amnesia)
- AOC (alteration of consciousness)
- Neuroimaging
Mild TBI
LOC: •less than 30 minutes PTA: •0-1 days AOC: •less than 24 hours Neuroimaging: •normal *13-15 GCS
Moderate TBI
LOC: •more than 30 minutes to 24 hours PTA: •more than 1 day but less than 7 days AOC: •more than 24 hours Neuroimaging: •may be normal or abnormal *GCS 9-12
Severe TBI
LOC: • more than 24 hours PTA: • more than 7 days AOC: • more than 24 hours Neuroimaging: • may be normal or abnormal *GCS 0-8
from mild to severe TBI
LOC: • < 30 minutes= mild TBI • > 30 minutes to 24 hours= mod TBI • > 24 hours= severe TBI PTA: post-traumatic amnesia • 0-1 days= mild TBI • more than 1 day but less than 7 days= mod TBI • > 7 days= severe TBI AOC: alteration of consciousness • < 24 hours= mild TBI • >24 hours= moderate or severe TBI Neuroimaging: • normal= mild TBI • may be normal or abnormal= moderate to severe TBI GCS: •3= coma •0-8= mild TBI •9-12= moderate TBI •13-15= severe TBI
Ranchos Los Amigos levels:
I. No response II. Generalized response III. Localized response IV. Confused agitated V. Confused inappropriate VI. Confused appropriate VII. Automatic-appropriate VIII. Purposeful appropriate
Ranchos Los Amigos levels: I. No response
Patient appears to be in a deep sleep and is completely unresponsive to any stimuli:
*GCS= 3
TX: PROM
Ranchos Los Amigos levels: II. Generalized response
Patient reacts inconsistently and nonpurposefully to stimuli in a non-specific manner. Responses are limited and often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and/or vocalization
TX: stages I, II, and III
sensory input, PROM, and positioning. Maybe rolling
Ranchos Los Amigos levels: III. Localized response
Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as closing eyes or squeezing hand in an inconsistent, delayed manner.
TX: stages I, II, and III
sensory input, PROM, and positioning. For stage III definitely rolling and attempt tilt table and OOB to chair.
Ranchos Los Amigos levels: IV. Confused agitated
Patient is in a heightened state of activity, confused and agitated. Behavior is bizarre and non-purposeful relative to immediate environment. Does not discriminate among persons or objects; is unable to cooperate directly with treatment efforts. Verbalizations are incoherent and/or inappropriate to the environment; confabulation may be present. Gross attention to environment is very brief; selective attention is often nonexistent. Patient lacks short and long term recall.
TX: behavioral and cognitive strategies, i.e. model calm behavior, closed environment, decrease distractions, treat as an adult, be prepared to re-direct, routine is important, decrease sources of stress and stimulation, provide safe choices, do not expect empathy, don’t expect recall, use activities they can automatically perform.
Ranchos Los Amigos levels: V. Confused inappropriate
Patient is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or fragmented. Demonstrates gross attention to the environment but is highly distractible and lacks ability to focus attention on a specific task. With structure may be able to converse on a social automatic level for short periods of time. Verbalization is often inappropriate and confabulatory. Memory is severely impaired; often shows inappropriate use of objects; may preform previously learned tasks with structure but is unable to learn new information.
TX: same as those used for stage IV. as well as transfers and functional activities, balance, and blocked distributed exercises: alternate between rest and small parts of tasks (keep it simple)
Ranchos Los Amigos levels: VI. Confused appropriate
Patient shows goal-directed behavior but is dependent on external input or direction. Follows simple directions consistently and shows carryover for relearned tasks such as self-care. Responses may be incorrect due to memory problems, but they are appropriate to the situation. Past memories show more depth and detail than recent memory.
TX: transfers, functional activities, balance, gait
Ranchos Los Amigos levels: VII. Automatic-appropriate
Patient appears appropriate and oriented within the hospital and home settings (familiar surroundings); goes through daily routine automatically but frequently robot-like. Patient shows minimal to no confusion and has shallow recall of activities. Shows carryover for new learning but at a decreased rate. With structure is able to initiate social or recreational activities; judgment and planning remains impaired.
TX: higher level balance, speed, coordination, and dual tasks
Ranchos Los Amigos levels: VIII. Purposeful appropriate
Patient is able to recall and integrate past and recent events and is aware of and responsive to environment. Shows carryover for new learning and needs no supervision once activities are learned. May continue to show a decreased ability relative to PLOF. May have decreased abstract reasoning, tolerance for stress, and judgment in emergencies or unusual circumstances.
TX: community reintegration
Early mobilization following TBI
- contraindicated with increased ICP and/or unstable spine
* precautions include- WB restrictions, cardiovascular problems, and autonomic instability
ICP normal values
•5-20 mmHg normal
increased ICP tx
- elevate head to 30°
- avoid head and neck flexion
- hypothermia- cooling blankets, flush with cold saline
Autonomic instability s/s
Tachypnea, tachycardia, hyperthermia
Maintain stability for TBI
- keep ICP normal
- systolic BP above 90
- O2 above 90
Principles of neural plasticity
- Use it or lose it= failure to drive specific brain functions can lead to functional degradation.
- Use it and improve it= training that drives a specific brain function can lead to an enhancement of that function.
- Specificity= the nature of the training experience dictates the nature of the plasticity.
- Repetition matters= induction of plasticity requires sufficient repetition (neuroplastic changes requires certain dosage).
- Intensity matters= Induction of plasticity requires sufficient training intensity.
- Time matters= different forms of plasticity occur at different times during training.
- Salience (the importance/dominance of what you are doing) matters= the training experience must be sufficiently salient to induce plasticity.
- Age matters= training-induced plasticity occurs more readily in younger brains.
- Transference= plasticity in response to one training experience can enhance the acquisition of similar behaviors.
- Interference= plasticity in response to one experience can interfere with the acquisition of other behaviors.
Strategy and clinical application for confused agitated patients (stage IV)
- Consistency
- Expect no carryover
- Model calm behavior
- Expect egocentricity
- Flexibility/Options
- Safety
- Environment
Strategy and clinical application for confused agitated patients: Consistency
- All team members and all family should address inappropriate behaviors in consistent ways.
- The pt should be seen at the same time, by the same person, in the same place, every day
- Provide orientation info (person, time, place) in a non-threatening way. Generally better than challenging the patient to provide it.
Strategy and clinical application for confused agitated patients: Expect no carryover
- Teaching new skills at this level is unrealistic
- Patient may be able to perform automatic tasks
- Use of charts or graphs may be helpful, without such tools the patient is unlikely to be able to recall the previous day’s performance.
Strategy and clinical application for confused agitated patients: Model calm behavior
- The patient is likely to reflect the demeanor of the caregiver
- The patient may not be able to control his or her behavior and may not feel safe
Strategy and clinical application for confused agitated patients: Expect egocentricity
-Patient will not consider other people at this point, will only think of him or herself
Strategy and clinical application for confused agitated patients: Flexibility/Options
- Patient will have a limited attention span so the clinician should have numerous activities planned in order to be able to quickly redirect the patient once they lose interest in a task
- Treat the patient at an age-appropriate level
- Give the patient control by giving simple activity choices
Strategy and clinical application for confused agitated patients: Safety
- Patients at this stage should be in a locked unit of the hospital
Strategy and clinical application for confused agitated patients: Environment
- Initially interventions should be performed in a closed environment
- Progress to a more open environment as the patient improves.
S/S of muld TBI/post concussive syndrome
1) Headache
2) Nausea
3) Dizziness
4) Poor balance
5) Fatigue
6) Difficulty sleeping
7) Eyestrain
8) Visual difficulties
9) Feeling confused or foggy
10) Frustration
11) Light sensitivity (photophobia)
12) Noise sensitivity (phonophobia)
13) Difficulty hearing (vestibular issues)
14) Irritable
15) More emotional
16) Difficulty concentrating and remembering
return to school and sports
- can return to school when no s/s after 30-45 minutes of concentration.
- can return to sports with gradual buildup. Every time symptoms occur have one day of rest then regress to level achieved pre symptoms.
Antispasmodics
- Meds: Soma, Parafon Forte, Flexeril, Diazapam/Valium, Robaxin, Norflex/Norgesic
- Function: Relax skeletal muscle and decreases muscle spasm.
- Adverse effects: drowsiness, dizziness, dry mouth
Antispastics
- Meds: Baclofen/Lioresal, Dantrolene Sodium/ Dantrium, Diazapam/Valium, Zanaflex)
- Function: Relax skeletal muscle and decreases muscle spasm.
- Adverse effects: drowsiness, dizziness, confusion, weakness
Anticonvulsants
- Meds: Tegretol, Klonopin, Valium, Phenobarbitol/ Luminal, Dilantin)
- Function: Controls seizures. Acts as a generalized CNS depressant.
- Adverse effects: drowsiness, ataxia, sedation
ICP cont…
Patient’s neck should be stabilized with a cervical collar and the head elevated 30° to protect the spine from instability and avoid an increase in ICP. Elevated ICP can be treated with the use of sedating meds, moderate head up positioning (30°), osmotherapy, hypothermia, surgical decompression, and barbiturates. If elevated ICP cannot be treated successfully, inducing a pharmacological coma or surgical decompression may be necessary.
Effects of dysautonomia of the sympathetic system
Elevated sympathetic nervous system activity occurs as a normal response to trauma; following TBI, this response may become overactive. Increased sympathetic activity results in increased heart rate, RR, and BP; diaphoresis; and hyperthermia. Other symptoms of dysautonomia include decerebrate and decorticate posturing, hypertonia, and teeth grinding. The term paroxysmal sympathetic hyperactivity (also known as sympathetic storming) accurately describes this phenomenon (occurs in 8%=33% of TBI ICU patients).
Coma
the arousal system is not working, the patient’s eyes are closed, there are no sleep-wake cycles, and the patient is ventilator dependent. There is no auditory or visual function, and no cognitive or communicative function. Abnormal motor and postural reflexes may be present. A coma is usually not permanent. Patients may become brain dead, enter a vegetative or minimally conscious state, or go onto full recovery.
Vegetative state (unresponsive wakefulness)
in this state there is dissociation between wakefulness and awareness. The higher CNS centers are not integrated with the brain stem. The brain stem manages the basic cardiac, respiratory, and other vegetative functions, and the patient can be weaned off the ventilator. Sleep/wake cycles are present. The eyes may be open, though awareness of surroundings is absent. Patients may startle to visual or auditory stimuli and briefly orient to sound or visual stimuli. Meaningful cognitive and communication function is absent. Reflexive smiling/crying may be present. A withdrawal response to noxious stimuli is present. Although patients in a vegetative state may appear to have purposeful movement they are merely reflexive in response to external stimuli. Movement will not be reproducible.
Stupor
an unresponsive state from which the patient can be aroused briefly with vigorous, repeated sensory stimulation.
Obtunded
The patient in an obtunded state sleeps often and when aroused exhibits decreased alertness and interest in the environment and delayed reactions.
Heterotopic ossification
• common side effect of TBI
•abnormal growth of bone in the non-skeletal tissues including muscle, tendons, or other soft tissues. will eventually show up on x-rays
s/s: redness, swelling, decreased ROM
Serial casting
Fiberglass casting material is wrapped around the limb. May be used to maintain or improve ROM, often used for plantarflexor or biceps contractures. Casts applied to increase ROM are changed approx. every 2-5 days and replaced with a new one to further challenge and increase ROM. Precautions should be taken in applying this hard cast to patients who are aggressive.
Mental practices
Easier Methods:
•Blocked: repeating the same thing over and over, used for early learning.
•Distributed: more rest than practice
•Extrinsic Feedback: verbal and tactile extrinsic (augmented) feedback
Advanced Methods:
•Random: different tasks, later learning and retention
•Massed: more practice than rest
•Intrinsic feedback: self feedback, proprioceptive
