TBI Intro

Question 1

Patient population of typical TBI

Answer 1

• Children and older adults (>75 YO)
• Males > females
• Race: American Indian/Alaskan Native, Black, Hispanic population
• Service members/veterans
• Homeless
• Incarcerated
• Domestic abuse survivors
• Rural area dwellings

Question 2

The MOST common cause of TBI?

Answer 2

FALLS
(MVA/MVC, acts of violence and sports)

Question 3

Children will most likely suffer a TBI due to:

Answer 3

fall, abuse

Question 4

Adolescents & young adults will most likely suffer a TBI due to:

Answer 4

falls, assault, MVA

Question 5

Open TBI

Answer 5

penetrating wound, skull fracture, meningeal compromise

Question 6

Closed TBI

Answer 6

no skull fracture, only cortical tissue, meninges remain intact

Question 7

Focal injury

Answer 7

localized to area under site of impact or site opposite to site of impact.

Question 8

Types of Focal TBIs

Answer 8

1. Hematomas
2. Hemorrhage
3. Contusion
4. Coup-contrecoup injuries

Question 9

Common sites of focal injuries.

Answer 9

Anterior-inferior temporal lobes, prefrontal lobes

Question 10

Which type of TBI often have stroke-like presentation.

Answer 10

Focal TBI

Question 11

Your patient was struck in the head and had a brief syncope episode then regained consciousness. Later on they suddenly went unconscious. What type or TBI are you suspecting and what is the potential treatment?

Answer 11

Epidural hematoma, craniotomies and hematoma evacuation

Question 12

Your elderly patient fell and hit their head. EMS was called and the patient refused transport. They did not loose consciousness. Now it is the next morning and they are not waking up. What kind of TBI do you expect they have and what is the treatment?

Answer 12

subdural hematoma, smaller clots will be reabsorbed by the body, larger clots will require surgical removal.

Question 13

What is the most life threatening type of TBI and a common sequela?

Answer 13

Subarachnoid hemorrhage (SAH), vasospasm

Question 14

A common sequela of intracerebral hemorrhage includes

Answer 14

seizures

Question 15

Coup lesion

Answer 15

contusion on the same size of the brain as the impact.

Question 16

Contrecoup lesion

Answer 16

surface hemorrhages on the opposite side of the brain trauma as a result of deceleration

Question 17

Which is associated with more damage, coup or countercoup damage?

Answer 17

Contrecoup

Question 18

Most common structures involved with coup-contrecoup injuries include:

Answer 18

anterior poles, underside of temporal and frontal lobes

Question 19

A diffuse axonal injury is:

Answer 19

widespread shearing and retraction of damaged axons resulting in traumatic micro-bleeds

Question 20

Diffuse axonal injury are associated with significant neurological involvement and a poor prognosis. They most commonly result from damage where?

Answer 20

corpus callosum
basal ganglia
brainstem
cerebellum

Question 21

T/F secondary brain damage post-TBI occurs much like a stroke via apoptosis and/or necrosis.

Answer 21

False, TBI secondary damage only occurs through apoptosis

Question 22

Why is increased ICP more dangerous when associated with secondary brain damage compared to primary?

Answer 22

Associated with higher rates of herniation and death

Question 23

The areas most vulnerable to anoxic/hypoxic brain injuries include

Answer 23

-Hippocampus
-Cerebellum
-Basal Ganglia

Question 23

Primary cause of anoxic or hypoxic brain injuries?

Answer 23

cardiac arrest (also, CO2, toxicity, near drowning, severe bleeding = systemic hypotension)

Question 24

Primary blast injuries

Answer 24

direct effect of blast overpressure on organs

Question 25

What type of blast injury results in diffuse brain damage?

Answer 25

primary

Question 26

Secondary and Tertiary blast injuries are characterized by:

Answer 26

2ND: shrapnel 3RD: direct blow to head

Question 27

Imaging in the acute management stage of a TBI consists of:

Answer 27

MRI/CT, PET, EEG

Question 28

Acute medical management of TBI includes

Answer 28

↓ BP/ICP/IC bleeding/body temp/infection rate/seizure risk

Question 29

If a patient is in induced hypothermia to decrease ICP, are they a candidate for PT?

Answer 29

NO

Question 30

The primary acute TBI concern

Answer 30

Increased ICP

Question 31

Abnormal ICP Value

Answer 31

≥20 mmHg (NOT PT CANDIDATE)

Question 32

Your pt ICP has been steady around 15 mmHg. Are they a candidate for PT?

Answer 32

Yes, but proceed carefully avoiding interventions that increase ICP.

Question 33

Activities that increase ICP

Answer 33

* Percussion + vibration * Fully supine or Trendelenburg * Cervical flexion * Valsalva * Exertional activities (quick elevation HOB, supine>sit)

Question 34

S&S of ICP

Answer 34

↓ responsiveness ↓ consciousness - Seizures - Severe HA - Vomiting - Irritability - Papilledema, pupillary changes, impaired eye movement - Speech changes - Posturing *Cushing's Triad: ↑ BP/↓ HR, irregular RR

Question 35

Treatment of ICP

Answer 35

Careful monitoring Pharmacological agents Ventricular peritoneal shunt

Question 36

When can you mobilize a patient who has post-TBI seizures? a. ≥24 hours seizure free b. 24-48 hours seizure free c. ≥ 72 hours seizure free d. 24-72 hours seizure free

Answer 36

a. ≥24 hours seizure free

Question 37

Common S&S of seizure

Answer 37

- focal/diffuse twitching, jerking, stiffening -potential LOC -Absent staring, "zoned out"

Question 38

Paroxysmal Autonomic Instability and Dystonia (PAID)

Answer 38

severe medical instability, overdrive of nervous system ("Sympathetic Storming")

Question 39

GCS associated with PAID

Answer 39

3-8

Question 40

Medical management of PAID

Answer 40

Symptom management (CNS depressant meds) "ride the storm out"

Question 41

Patients are at an increased morbidity risk with PAID...

Answer 41

w/o management/appropriate treatment

Question 42

S&S Paid:

Answer 42

Tachypnea Tachycardia Fever (hyperthermia) HTN Diaphoresis Rigidity +/- decorticate posturing / *decerebrate posturing Agitation

Question 43

How do symptoms of PAID present

Answer 43

Cyclicly, at least one cycle/day ~3h long

Question 44

T/F Decorticate posturing is associated with PAID syndrome d/t damage above red nucleus

Answer 44

False, decerebriate posturing is associated with the sympathetic involvement lower in the brainstem.

Question 45

What posturing is associated with damage in relation to the red nucleus

Answer 45

Above: decorticate Below: decerebrate

Question 46

Polytrauma TBI patient's have an increased risk of

Answer 46

Heterotopic ossification most common in large joints

Question 47

It is 8 weeks post-TBI for your patient. They also suffered from multiple fractures d/t an MVC. They are now complaining of knee pain and decreased ROM. You also note erythema, pain with movement, selling and warmth. When you are assessing how will you differentiate between a DVT and HO?

Answer 47

End feel! (DVT: empty or normal end feel, HO: hard end feel)

Question 48

HO PT Treatment

Answer 48

PROM and stretching to maintain ROM and prevent further complications.