TBI LECTURE Flashcards
length of stay for acute and IP Rehab
acute 18
IP rehab 21 days
early med management for TBI
- OPEN AIRWAY
positioning
provide O2
endotracheal tube
tracheostomy
provide vent support - VITAL SIGNS, FLUID REPLACEMENT
- NEURO CHECKS 15-30 MIN (no sleep!!!)
Glasgow coma scale
-used at accident scene, ER, acute care
-used as predictor of outcome
-used in research
-high inter-rater reliability
-total score 3-15
minimum score for GCS
3, highest 15!
may be separate into 3 sections (eye opening, best motor response, verbal response V-T MEANS CAN’T BE SCORED DUE TO TRACH)
total score 3-8 for GCS
severe! (90% defined as coma)
44% of ED ADMIT
limitations of GCS
-pre-existing cond (like language)
-aphasia
-alcohol/meds
-other injuries (like jaw crushed)
what is mod injury for GCS
9-12
what is mild injury for GCS
13-15
41% of people admitted
local brain injury is defined as
TBI localized to site of impact on skull
Diffuse brain injury
widely scattered shearing of axons (head bounced back and forth!)
HIGH VELOCITY LIKE CAR, SKII
secondary insults can cause more injury than primary true or false
true
ABOVE ___ MMHG ICP IS CONTRAINDICATION FOR PT
20 mmHg
____ mmHg causes neurologic dysfunction
2-40 mmHg
normal while lying down
0-10 mmHg
__mmHg almost always results in death
60
intracranial infections can happen due to
fx of skull
gunshot wound
open brain injury!!!!
for cerebral arterial vasospasms, velocities over 100 means
NO OOB ACTIVITIES!
JUST SUPINE EXERCISES
hydrocephalus
CSF on the brain
due to:
-foramina blocked by brain herniation
-or ventricles can push onto brain surrounding it
secondary insults in TBI
-intracranial infection
-cerebral arterial vasospasm
-hydrocephalus
-post-traumatic epilepsy
-brain edema
arterial hypoxemia
*breathing centers depressed
-present in 1/3 of pts in ER
arterial hypotension
seldom produced by TBI
alone
-fx of bones, organs, etc
anemia
blood loss from injury
Hyponatremia
(serum sodium levels)
hypoxia and ischemic brain damage
most commonly seen in hippocampus, BG, scattered sites of cerebral cortex, cerebellum
what are two ways to evacuate a hematoma surgically?
craniotomy: less severe
craniectomy: often leaves skull flap off, HELMET, go back for surgery months later
what is a ventriculostomy
insertion of a device to measure ICP, requires burr hole usually of frontal bone
thin catheter tube going through frontal bone…External ventricular drain OR bolt which measures only!
everytime patient moves, what should happen with EVD?
must be re-leveled!
MUST BE CLAMPED
metabolic care of TBI
-in dwelling catheter
-serum electrolytes
-artificial feedings once bowel sounds return
POPS
26 items in 5 categories
-domestic life
-major life activities
-transportation
-interpersonal interactions and relationships
-community, recreational and civic life
__% of individuals require some level of supervision at __ year post op
__% require some supervision __ years post op
37% at 1 year
31% 2 years post op
Rancho Los Amigos Levels of Cog Functioning Scale
- NO RESPONSE (coma)
- Generalized response (limited, inconsistent, non-purposeful, often to pain only)
- localized response
(purposeful responses, MAY follow simple commands, may focus on presented objects ***PULL AWAY TO PAIN
WHAT COMA SCALE distinguishes Rancho II vs III?
JFK! more sensitive than GCS and Rancho
-MINIMALLY CONSCIOUS STATE RANCHO III
-frequent misdiagnosis without JFK, HUGE implications for DC placement from acute care
post-traumatic amnesia (PTA)
period of time from accident to time patient starts to have on going short term memory
What test is used to determine when patient progresses out of PTA?
GOAT galveston orientation and amnesia test
must have 3 consec scores of over 75 to be out of PTA
Rancho Level 4
confused, agitated
Heightened state of activity; confusion, disorientation; aggressive behavior; unable to do self-care; unaware of present events; agitation appears related to internal confusion.
what are causes of agitation?
-fronto-orbital
anterior temporal loves
sylvian fissure
-temporal lobe seizures
-diffuse axonal injuries, esp corpus callosum, dorsolateral columns of midbrain
-secondary effects of hypoxia, compression, neurohormonal effects
premorbid personality
causes of agitation
environment: sensory overload or deprivation
reversible factors: seizures, sleep disturbances, electrolytes, meds, nutrition
agitated behavior scale
observational tool
Observational tool to assess the extent of agitation during acute phase of recovery from TBI
14 item instrument
Minimum score of 14, maximum of 56
Each item rated 1 (not present) to 4 (present to extreme degree)
MOSS attention rating scale
Observational tool to measure attention-related behaviors after TBI
22 items
Scores range 22-110
Includes phrases with both good and impaired attention
Higher score = better attention
Appropriate for moderate to severe brain injury
RANCHO LEVEL 5
confused, inappropriate, non-agitated
Appears alert; responds to commands; distractible; does not concentrate on task; verbally inappropriate, does not learn new information.
RANCHO LEVEL 6
confused, appropriate (still in PTA)
Good directed behavior, needs cueing; can relearn old skills (ADL); serious memory problems; some awareness of self and others.
RANCHO LEVEL 7
automatic, appropriate
Robot-like appropriate behavior with minimal confusion; shallow recall; poor insight into condition; initiates tasks but needs structure; poor judgment, problem-solving and planning skills
RANCHO LEVEL 8
- Purposeful, appropriate.
Alert, oriented; recalls and integrates past events; learns new activities and can continue without supervision; cognitively independent in living skills; capable of driving; defects in stress tolerance, judgment, abstract reasoning persist; many function at reduced levels in society.
