TBI (Part 1) Flashcards
1
Q
Central Tentorial Herniation
A
- location:
- midbrain and pons
- RAS
- Effects:
- decerebrate rigidity
- coma
2
Q
Tonsilar Herniation
A
- Location:
- cerebellar tonsils
- RAS
- indirect activation pathways
- vasomotor center
- Effects:
- neck p! & stiffness, Cerebellar sx
- coma
- flaccidity
- altered pulse, RR, BP
3
Q
Vascular Changes: Hemorrhage
A
- occurs at the poles: inf. frontal and temporal
hemotoma:
- epidural: skull and dura (caused by trauma)
- subdural: under dura (caused by trauma)
- subarachnoid: between brain and dura
- intracerebral
4
Q
Vascular Changes: Hypoxia/hypotension
A
- poor perfusion to brain when unconscious
- watershed sx
- areas most affected by anoxia:
- hippocampus
- basal ganglia
- cerebrum
5
Q
Neurochemical changes
A
- inflammatory response
- increase in release of excitatory NT (glutamate)
- inc. ion channel leakage —> inc. CSF and swelling
- membrane depolarization—> non-selective Ca channel gates open —> cell death
- release of free radical and cytokines
6
Q
TBI Evaluation Procedure
A
-
7
Q
Glasgow Coma Scale
A
- measures levels of consciousness
- eye opening: 1-4
- motor response : 1-6
- verbal response: 1-5
- score range 3-15
8
Q
Acute Management of TBI
A
- determine severity
- prevent secondary damage
- look out for:
- edema
- inc ICP
- bleeding
- hypotension
9
Q
Neuroimaging for TBI
A
- head CT (if unconscious > 2min)
- monitor intracranial pressure/perfusion
- surgical intervention
- seizure prophylaxis
10
Q
ICP Monitoring
A
- monitoring through extra ventricular drain, subdural bolt, fibroptic catheter
- 5-19mmHG = normal
- 20mmHG - 40 mmHG= correlated with neurological dysfunction
- 40-60 mmHG = 6x high risk of death
- > 60mmHG = death
11
Q
Managing Elevated ICP
A
- changes in position: elevate HoB
- medication: sedation, barbiturates
- MD induces coma
- hypothermia
- osmotherapy
- surgical decompression
12
Q
ICP & Central Perfusion Pressure (CPP)
A
- mean arterial pressure (MAP) = average pressure during one cardiac cycle
- Central Perfusion Pressure (CPP) = difference between mean MAP and venous back pressure
- 60-80 mmHg = normal CPP
13
Q
Neurosurgery
A
- Goals:
- releases pressure
- evacuate blood
- remove derby
- surgery
- craniotomy (skull flap is replaced)
- burr holes
- cranectomy
14
Q
Dysautonomia
A
- paroxysmal sympathetic hyperactivity (sympathetic storming)
- inc. HR, RR, BP
- diaphoresis
- hyperthermia
- hypertonia
- teeth grinding
15
Q
Other Acute Care Considerations
A
- oral care
- integumentary care
- GI issues
- endocrine issues
- MSK
- stabilize/immobilize fx
- contracture prevention
16
Q
Other Neurological Involvement
A
- undx SCI
- peripheral or plexus injuries
- CRPS
- Seizures
- CSF leas via nose or ears
- inc’d seizure risks
17
Q
Neuromuscular Impairments in TBI
A
- motor control impairments
- hemiparesis
- abnormal tone
- decorticate (abnormal flexion posturing)
- decerebate (extension posturing)
- somatosensory impairments
- impaired postural control
18
Q
Cognitive Impairments in TBI
A
- impaired consciousness
- decreased attention/concentration
- impaired executive function
- memory impairments
- difficulty learning new things
19
Q
Behavioral Impairments in TBI
A
- Agitation
- inflexibility
- impulsivity
- disinhibition
- emotional lability
- irritability
20
Q
post traumatic amnesia (PTA)
A
- Unable to form new memories
- Assess my neurophysiologist every day
- Date, time, place, situation
A prognostic indicator
21
Q
Rancho Los Amigos levels of cognitive function
A
- Used to identify…
- Cognitive level
- Track changes over time
- Develop an advanced the plan of care
- May be used as admission criteria to rehab units
- Does NOT predict long-term outcomes
22
Q
ranchos los amigos cognitive function scale levels
A
- Level I: no response
- Level II: generalize response
- Level III: localized response
- Level IV: confused and agitated
- Level V: confused and inappropriate
- Level VI: confused and appropriate
- Level VII: automatic appropriate
- Level VIII: purposeful appropriate
23
Q
RLCFS: Level I-III
A
- Level I: no response to stimuli
- Level II: inconsistent, limited response
- No specifics
- vocal; changes in heart rate, blood pressure, sweating; gross motor body movements
- Level III: inconsistent but relevant
- response to simple task and pain
24
Q
RLCFS: Levels IV-V
A
- Level IV: aggressive driven by confusion
- Decreased attention; behavior isn’t purposeful
- Heightened state of activity
- Memory (long and short term) impaired
- Level V: increased distractibility, unable to learn new material
- verbal (confabulatory); simple task
25
Q
RLCFS: Levels VI-VIII
A
- Level VI: goal oriented; follow simple consistently
- Can follow a schedule; poor insight
- Level VII: out of post traumatic amnesia; fall schedule
- New learning with extra time; unable to recall every daily detail
- Level VIII: (I) at home; recalls past with current experience
- May have difficulty with problem-solving; stress management; abstract reasoning
26
Q
Severity of TBI
A
GCS | PTA | LOC
Mild | 13-15 | < 1 day | 0-30 min
Mod | 9-12 | > 1 to >7 days | > 30 min to 24 hrs
Severe | 13-15 | < 7day | > 24 hrs
27
Q
TBI Prognostic Indicators
A
- age: 5-30 years old (+)
- 0 to 4 years old = 62% mortality within first year
- Older adults = longer rehab; slower coverage; increased cognitive impairment at discharge
- Coma/PTA: >1 month = 50% of getting out
- PTA length is best indicator of long-term outcomes and memory impairment
- Have increased risk of cognitive decline later in life
28
Q
Cardiopulmonary: Ventilation
A
- ventilator/ tracheostomy placement
29
Q
TBI Classification
A
- Primary injury
- Blast injury
- Secondary injury
- Goal is to figure out which category the patient is in and how that patient will present*
30
Q
DAI Grading Scale
A
- Grade I = microscopic level evidence in cortex
- Grade II = grade I + corpus callosum
- Grade III = grade II + brainstem lesion
31
Q
Sub falcons Herniation
A
- Location
- Frontal/parietal brain extends under flax cerebri
- effects:
- Compresses ACA with hemiparesis
- LE > UE
32
Q
Infection
A
- ex:
- encephalitis (subdural/epidural)
- meningitus (membrane around brain)
- abscess (within brain)
- pneumonia
- integumentary infection
- other sites
- tubes: IV, catheters, ventilators, ICP monitor
33
Q
Common Locations of DAI
A
- Discrete areas
- parasagittal white matter of cerebral cortex,
- corpus callosum
- brainstem: Pontine mesencephalic Junction
34
Q
Diffuse Axonal Injury
A
- Occurs during acceleration- deceleration
- Microscopic injury of the white matter axons related to sheer/stretch/tensile strain
- Axons twist and tear at the gray and white matter junction
- Common and high speed motor vehicle accidents and sports
- Leads to wallerian type axonal degeneration
35
Q
Common Points of Injury
A
- Interior tempural poles
- Frontal poles
- Lateral and inferior temporal Cortices
- Orbital frontal cortices
-coup-contra coup injury (slide 19)
36
Q
Primary Injuries
A
- Direct trauma to the parenchyma
- Brain tissue comes in contact with an object (skull, bullet, sharp object)
- Rapid acceleration/deceleration of brain
- Diffuse axonal injury
- Tissue tearing
- Intracerebral hemorrhage
37
Q
TBI Pathology
A
- Brain damage results from
- External forces;
- rapid acceleration/deceleration forces;
- blast waves from explosion
38
Q
Leading Causes for each age group
A
- Falls
- 55% = children (0 to 14 years old)
- 81% = older adults (65+)
- MVA
- 15 to 55 yrs old
39
Q
Causes of TBI
A
- Falls = 40%
- Unintentional struck by or against an object = 17%
- Motor vehicle accident = 14%
- Assault = 10%
- Unknown/other
