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Neuro 2 > TBI Arousal, Cog, and DOC > Flashcards

TBI Arousal, Cog, and DOC Flashcards

1
Q

Cognition based Outcome Measures

A
  1. GOAT
  2. O-Log
  3. Moss Attention Scale
  4. Agitated Behavior Scale
  5. Rancho Los Amigos levels of cognition recovery: revised
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2
Q

how many levels are there to the Rancho?

A

10

first 3 are disorders of consiousness (DOC)

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3
Q

describe RLAS Level 1

A

No response: Total Assistance

complete absence of observable change in behavior when presented w/any type of stimuli

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4
Q

describe RLAS Level 2

A

Generalized Response: Total Assistance

demos generalized reflex response to noxious stimuli

  • responds to repeated auditory stimuli with increased/decreased generalized activity
  • responds to external stimuli w/physiologic changes generalized gross body movement and/or not purposeful vocalization
  • responses may be sig delayed
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5
Q

describe RLAS Level 3

A

Localized Response: Total Assistance

  1. demos withdraw or vocalization to painful stimuli
  2. turns toward or away from auditory stimuli
  3. blinks when strong light crosses visual field
  4. follows moving obj passed within visual fields
  5. responds inconsistently to simple commands
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6
Q

match the RLAS level to DOC

A
  1. Coma → Level 1
  2. Vegetative State → Level 2
  3. Minimally Conscious State → Level 3
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7
Q

what is consciousness?

A

process of knowing including wakefullness + awareness

discrimination between, and selection of, relevant info, acquisition of info, understanding and retention, and the expression and application of knowledge in the appropriate situation

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8
Q

describe the DOC level coma

A

Level 1 → no response: total assistance

  1. complete failure of arousal system
  2. no spontaneous eye opening
  3. unable to be awakened by application of vigorous sensory stimulation
  4. all behavioral responses consist entirely of reflex activity
  5. loss of both reticular and cortex function
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9
Q

how long do comas last?

A

rarely longer than 2-4 weeks

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10
Q

describe vegetative state

A

Level 2 → generalized response: total assistance

  1. complete absence of behavioral evidence for self or environmental awareness
  2. can still spontaneously be aroused via stimulus
    • eyes open (spontaneously)
  3. +Sleep/wake cycles on EEG
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11
Q

what is a persistent vegetative state?

A

VS for at least 1 year

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12
Q

describe minimally conscious state

A

RLAS Level 3

a condition of severely altered consciousness in which minimal but definite behavioral evidence of self or environmental awareness is demonstrated

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13
Q

list the diagnostic criteria for MCS

A

one or more of the following:

  1. simple command-following
  2. gestural or verbal yes/no response (regardless of accuracy)
  3. intelligible verbalization
  4. movements or affective behaviors that occur due to relevant stimuli and are not reflexive
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14
Q

give some examples of contingent motor and affective responses

A
  1. crying, smiling, or laughing produced by the linguistic or visual content of emotional but not neural stimuli
  2. vocalizations or gestures that occur in direct response to verbal prompts
  3. reaching for objs with clear relationship between obj location and direction of reach
  4. touching/holding obj in a manner that accommodates size and shape of the obj
  5. visual pursuit or sustained fixation in response to a moving or salient stimuli
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15
Q

why do we care about distinguishing between VS and MCS?

A

Prognosis difference is HUGE

much more favorable for MCS

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16
Q

what are the criteria for emergence from MCS?

A
  1. Functional interactive communication
    • via any modality

OR

  1. Functional use of two different objects
    • behavioral evidence for obj discrimination
17
Q

Outcome measures for DOC

A
  1. JFK CRS-R
  2. DOCS
18
Q

what is the purpose of the CRS-R?

A

measure recovery from comatose through recovery state (RLAS 1-3)

19
Q

describe the CRS-R

A
  1. Interdisciplinary outcome measure
  2. 6 function scale
    • arousal
    • auditory
    • visual
    • motor
    • oromotor
    • communication
20
Q

what is unique about the CRS-R?

A
  1. only outcome measure that directly incoorporates the exisiting diagnostic criteria for coma, VS and MCS
  2. makes it much less likely to misdiagnosis level
  3. typically done multiple times a day by multiple providers
21
Q

describe the prognostic utility of the CSR-R

A
  1. visual tracking is important in outcome prediction
  2. Scores over intial 4 weeks correlate strongly with functional outcome at 1 year
    • better than compared to GCS
  3. doesn’t appear to have a temporal cut off when consciousness can/cannot return
    • probability drops quickly and continuously the longer it takes
22
Q

why is visual tracking an important score on the CRS-R?

A

among pts with VS, 73% of those with visual tracking recovered consciousness within first 12 month postinjury

vs

45% of pts who did not demo visual tracking recovered consciousness within first 12 months postinjury

23
Q

What is the DOCS?

A

(Disorders of Consciousness Scale)

bedside test that measures neurobehavioral functioning during coma recovery

24
Q

what does the DOCS do?

A
  1. evaluates a pt as they are brought through a series of test stimuli by modalities
    • scored as → no response, generalized response, localized response
25
Q

how is the DOCS helpful clinically?

A

can be better at evaluating the effects of an intervention

26
Q

list some modalities used in the DOCS

A
  1. Social knowledge
  2. Taste, swallow
  3. Olfaction
  4. Proprioception/Vestibular
  5. Tactile
  6. Auditory
  7. Visual
  8. Obj recognition, obj tracking
  9. facial recognition, tracking
27
Q

what is the main goal of DOC rehab?

A

multiple CRS-R evaluations performed throughout interdisciplinary team each day

28
Q

what does DOC rehab look like?

A
  1. Positioning
    • may include developmental positioning
  2. Tone Managment
    • ROM maintenance
  3. Sensory Stimulation (in addition to CRS-R)
    • stim schedules
  4. equipment prescription
  5. family training
  6. family education
29
Q

what is developmental positioning?

A
  1. works to put pts in hierarchal progression of positions to mimic how we progress from an infant to a walking toddler
    • this is an attempt to functionally activate specific muscle groups
30
Q

what is the purpose of stim schedules during DOC rehab?

A
  1. to manage the amount of stimulation the pt is receiving
  2. monitor results from different types of stimuli
    • changes in resting tone
    • changes in RR, HR as indicator of pt’s tolerance to stimulation
31
Q

what may be included in family education during DOC rehab?

A
  1. positioning
  2. splinting
  3. (over) stimulation
  4. stretching program
  5. reinforcement of DOC info
32
Q

while the pt is still in the VS or MCS state, what does goal setting look like?

A

Can make goals based on:

  1. Cognition
  2. Impairment levels
  3. Overall mobility considerations
33
Q

what is the most commonly used outcome measure in the DOC population?

Neuro 2 (30 decks)

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