TBI: pathology, classification, exam, outcomes measures Flashcards
1
Q
What is the #1 cause of TBIs
A
Unintentional falls
2
Q
Caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain.
A
Traumatic brain injury
Mild– a brief change in mental status or consciousness
Severe– an extended period of unconsciousness or amnesia after the injury
3
Q
Type of TBIs caused by direct contact
A
Concussion
contusion (coup/contrecoup)
hematoma (epidural, intracerebral, subarachnoid)
4
Q
Type of TBIs caused by penetrating injury
A
invasive injury to neuronal and vasculature tissue
5
Q
Type of TBIs caused by acceleration/deceleration
A
concussion
hematoma (subdural)
diffuse axonal injury
6
Q
Type of TBIs caused by blast injury
A
Diffuse axonal injury
7
Q
Type of TBIs caused by heart attack, near drowning (acquired brain injuries)
A
anoxia (the absence of oxygen)
hypoxia (inadequate oxygen to tissues)
8
Q
contusion
A
Swollen brain tissue where there is vascular and tissue damage
- can be a response to the brain moving around in the skull (same side = coup; opposite side from contact = contrecoup)
- identified on CT; appears as hemorrhagic lesion
- differentiated from hematoma in that blood is intermixed with brain tissue
9
Q
Hematoma
A
Damage to major blood vessels in the head or heavy bleeding into or around the brain
- epidural: bleeding between skull and dura
- Subdural: bleeding between dura and arachnoid
- subarachnoid/intracerebellar: bleeding within the brain
10
Q
Diffuse axonal injuries
A
Torsion or shearing of long axons
- greater likelihood of disruption of white matter tracts: corpus callosum, internal capsule, brainstem, cerebellar peduncles
- axonal injury not always diffuse
- interruptions of axonal transport and axonal swellings
- not identified on CT and sometimes on MRI
11
Q
Blast injuries
A
Primary: occur following high order over-pressurization shock wave moving through the body, affects gas-filled organs such as lungs, GI tract, middle ear, etc.
Secondary: caused by bomb fragments and other objects propelled by an explosion resulting in penetrating injuries
Tertiary: result from the blast wind throwing the victim and include bone fractures and amputation
Quaternary: include injuries not included in the first three (burns, crush injuries, and respiratory injuries)
12
Q
What are the typical intracranial pressure values?
A
10-15 mm Hg in supine
-10 mm Hg in standing
Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure (MAP) - Intracranial Pressure (IP)
13
Q
What can result from excess intracranial pressure?
A
papilledema, herniation, brain tissue damage, stroke, etc.
Signs: decreased pulse rate, change in consciousness, agitation, coma
14
Q
What is Cushing’s Triad?
A
Three primary signs that often indicate increased intracranial pressure: increased Systolic BP decreased pulse decreased respiration *opposite of shock symptoms*
15
Q
Glasgow Coma Scale: eye opening response scoring
A
Spontaneous: open before stimulus- 4 pts
To verbal stimuli (spoken or shouted request)- 3 pts
to pressure (finger tip stimulus)- 2 pts
No opening at any time, no interfering factor- 1 pt
Non-testable: closed by local factor- NT
16
Q
Glasgow Coma Scale: verbal response scoring
A
Oriented: correctly gives names/place/date- 5 pts
Confused conversation, but coherent- 4 pts
Words: intelligible but inappropriate- 3 pts
Sounds: incomprehensible, moans/groans- 2 pts
No response, no interfering factor- 1 pt
non-testable: closed by local factor- NT
17
Q
Glasgow Coma Scale: motor response
A
Obeys commands for movement- 6 pts
Purposeful movements to stimulus- 5 pts
Withdraws in response to pain- 4 pts
Flexion response to pain (decorticate)- 3 pts
Extension response to pain (decerebrate)- 2 pts
No response, no interfering factor- 1 pt
Non-testable: closed by local factor- NT
18
Q
Abnormal flexion response to stimulus
A
slow stereotyped arm across chest forearm rotates thumb clenched leg extends
19
Q
Normal flexion response to stimulus
A
rapid
variable
arm away from body
20
Q
Head injury classification via GCS
A
3-8–severe
9-12– moderate
13-15– mild
21
Q
classification of TBI severity: loss of consciousness (LOC)
A
0-30 min– mild
> 30 min and < 24 hrs– moderate
> 24 hrs– severe
22
Q
classification of TBI severity: alteration of consciousness/ mental state (AOC)
A
up to 24 hrs– mild
> 24 hrs; severity based on other criteria– moderate or severe
23
Q
classification of TBI severity: post-traumatic amnesia (PTA)
A
0-1 day– mild
>1 day and < 7 days– moderate
> 7 days– severe
24
Q
classification of TBI severity: Glasgow Coma Scale (best available scores in first 24 hrs)
A
13-15– mild
9-12– moderate
< 9– severe
25
Coma
unconscious and no sleep wake cycles; may have reflexive movement
26
Persistent Vegetative state
unconscious, but have sleep wake cycles;
withdraws to noxious stimuli;
occasional non-purposeful movement;
brief orientation to sound or an object
27
Minimally conscious state
partially conscious
localize noxious stimulus and sound
inconsistent following commands
28
Stupor
general unresponsiveness
| require repeated stimuli
29
obtunded
reduced alertness
| slow to respond to stimuli
30
Delirium
disoriented
| fearful and misinterpret stimuli
31
Ranchos Los Amigos Scale for cognitive function
L1: no response (total assist): unconscious/comatose; no reaction to stimuli
L2: generalized response (total assist): reaction inconsistent/without purpose
L3: localized response (total assist): more specific reaction, i.e. may turn head in direction of voice
L4: confused/agitated (max assist): active; bizarre behavior; may react in hostile manner secondary to confusion
L5: confused, inappropriate non-agitated (max assist): less agitated/more consistent but still confused/inappropriate
L6: confused, appropriate (mod assist): context-appropriate, goal-directed responses, requires direction
L7: automatic, appropriate (min assist for ADLs): follow routine, but judgement/problem-solving impaired
L8: purposeful, appropriate (stand by assist): oriented, independent with familiar tasks, may need assistance to manage routines and planning of daily personal, household, community, work and leisure activities
L9: purposeful, appropriate (stand by assist on request): independent with tasks for longer period, may still request assistance for routines
L10: purposeful, appropriate (Mod. independent): able to handle multiple tasks simultaneously, accurately estimates abilities and independently adjusts to tasks demands
32
Differential diagnosis for mild TBI vs. concussion
mTBI requires traumatically induced physiological disruption of brain function, as manifest by at least on of the following:
- any period of loss of consciousness
- any loss of memory for events immediately before or after accident
- any alteration in mental state at the time of the accident
- focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following;
- loss of consciousness of approx. 30 min or less
- after 30 min an initial GCS of 13-15
- post-traumatic amnesia not greater than 24 hr.
33
Concussion
recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness (LOC). (American Academy of neurology)
34
Sports Related Concussion
- may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
- typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously.
- in some cases, signs and symptoms evolve over a number of minutes to hours.
- acute and clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury
35
Signs and symptoms of concussion/mTBI
Thinking/remembering: difficulty thinking clearly, feeling slowed down, difficulty concentrating, difficulty remembering new info
Physical: headache, fuzzy/blurry vision, nausea/vomiting (early), dizziness, sensitivity to noise or light, balance issues, feeling tired, having no energy
Emotional/mood: irritability, sadness, more emotional, nervousness or anxiety
Sleep: sleeping more than usual, sleeping less than usual, trouble falling asleep
36
what is the problem with the ImPACT test?
inconsistent results
has high error rates
can be easily misled by neurological factors unrelated to concussion
37
Components of the Sports Concussion Assessment Tool (SCAT5)
```
Immediate/on-field assessment:
-red flags
-observable signs
-memory assessment
-GCS
-cervical spine assessment
Off-Field assessment
```
38
Components of the Vestibular/Ocular-motor screening (VOMS) for concussion/mTBI
```
Smooth pursuits
Saccades
Convergence
Visual motion sensitivity
VOR
Score for headaches, dizziness, nausea, fogginess on 1-10 scale
```
39
Components of Cervical Exam for concussion/mTBI
ROM
| Pain with palpation/isometric contraction
40
Components of visual exam for concussion/mTBI
Extra-ocular movements (smooth pursuit, saccades, convergence)
VOR
Dynamic visual acuity (Head movements @ 2 Hz. > 3 line change = + test)
41
Components of post-traumatic vertigo (BPPV) exam for concussion/mTBI
Canal testing: posterior, anterior, lateral, multiple canal involvement
42
Components of balance exam for concussion/mTBI
Balance Error Scoring System (BESS):
-recommended for sideline screening
-very similar to mCTSIB but may be better for higher level patient/athlete
Sensory Organization Testing via Modified Clinical Test of Sensory Integration and Balance (mCTSIB):
-good psychometric properties
-better for wide range or non-athlete patient
43
What is the prognosis for a concussion/mTBI?
-neuropsychological deficits are present during the first 2-weeks after mTBI
-less agreement on when deficits resolve (> 6mo)
-young children may not be able to report symptoms: look for behavior changes, excess crying, vomiting, loss of new skills
Older adults:
-brain atrophy may result in more severe injury due to coup/contre-coup action.
-symptoms of mTBI often attributed to other co-morbidities (stroke, syncope, seizure, dehydration, dementia, etc)
-on average, experience higher morbidity and mortality, slower recovery, and worse functional, cognitive and psychosocial outcomes than younger individuals.
44
Age-related issues for a concussion/mTBI
-young children may not be able to report symptoms: look for behavior changes, excess crying, vomiting, loss of new skills
Older adults:
-brain atrophy may result in more severe injury due to coup/contre-coup action.
-symptoms of mTBI often attributed to other co-morbidities (stroke, syncope, seizure, dehydration, dementia, etc)
-on average, experience higher morbidity and mortality, slower recovery, and worse functional, cognitive and psychosocial outcomes than younger individuals.
45
Who is involved in intervention/management of mTBIs
```
neuropsychologist
physician (PCP, Sports Med, Neuro, Ortho, Psych, PM & R)
PT
OT
Behavior Neuro-optometry
Athletic Trainer
```
46
Active Rehab principles for mTBI
Rest 24-48 hrs post-concussion
start light activity as tolerable after that period; adolescent athletes that rested 5 days had slower recovery
for post-concussive syndrome:
-graded cardiovascular exercise
-treatment of symptoms: cervical/headache, vestibular, ocular motor
47
Questions to guide the examination for mTBI
```
PIP:
-usually participation restriction or activity limitation
-may be impairment (dizziness, headache, balance, visual deficits, sensitivity to sensory stimulation, feeling mentally slow or foggy)
Non PIP:
-arousal
-cognition
Precautions/contraindications:
-elevated ICP
-seizure disorder
-autonomic abnormalities: HR, RR, BP
```
48
sympathetic storming
uncontrolled activation of the sympathetic nervous system
clinical presentation:
- temperature of 38.5* C (101.3 F)
- hypertension
- HR > or = 130 bpm
- Respiratory rate > or = 40 breaths per minute
- agitation
- diaphoresis
- dystonia
49
Review of integumentary system
ask about: skin integrity
burns or lacerations (blast injuries/MVA)
sites of prolonged pressure
50
review of cardiopulmonary system
```
ask about: lung function and fatigue
pneumothorax
physical fatigue
cognitive fatigue
-changes to auto-regulatory center may impact physiological function
```
51
review of musculoskeletal system
ask about: joint motion and injury
heterotopic ossification (calcium deposits in joint)
fractures or amputation
AROM w/ overpressure
-presence of ho or contracture will impact movement
-management: NSAIDS, biphosphonates, radiation therapy
52
review of neuromuscular system
```
ask about: seizures, vision, dizziness, balance, swallowing, cognition, sleep, changes in neurologic impairments
-seizure disorders
-cranial nerve integrity
-cognitive impairment
-concussion
-undiagnosed change in neurologic status
Cranial nerve test, VOMS, & BESS
-mechanism may suggest cranial nerve impairment (particularly CN VIII); postural control systems may be impaired
```
53
review of neuromuscular system
ask about: emotional stability
- mood swings
- anxiety
- depression
- temper/outbursts
54
Questions to determine immediate referral
```
headaches that worsen
presence of seizures
focal neuro signs (numbness, weakness)
drowsy/can't be aroused
repeated vomiting
slurred speech
can't recognizer people/places
increasing confusion/irritability
neck pain
unusual behavior change
change in state of consciousness
```
55
Common patient-identified problems
difficulty...
swallowing
orienting to environment
looking
56
common impairments related to difficulty swallowing
```
difficulty...
with lip closure (drooling)-- CN VII
chewing-- CN V
moving bolus posteriorly-- CN VII (retention of food between cheeks and gums); CN XII (retention of food in mouth)
initiating swallow-- CN IX and X
```
57
simple orientation is spontaneous recall of...
date, time, city, kind of place, name of hospital, event, deficits
58
higher level orientation with cognitive process...
able to repeat address of an unknown person
count backwards from 20
state months in reverse order
estimate 30 seconds without clock
59
atypical orientation response...
```
required logical cueing (that was yesterday so today msut be...)
requires options (is it this or that?)
requires phonemic cueing (it's Frrr...)
inaccurate despite cueing
inappropriate response
unable to respond
```
60
Pursuit eye movements
able to smoothly follow a target 3 ft away across midline in both horizontal and vertical direction at a speed of 1 foot per second
atypical response:
jerky, requires saccadic correction, induce dizziness or HA
61
Saccades
able to move accurately and quickly between two targets that are both 30 degrees from midline
Atypical:
over/undershoot requiring a correction, induce dizziness or HA
62
convergence
able to keep a target in focus when bringing a target from arms length to 6 cm from the nose with both eyes moving medially
insufficiency:
asymmetry in medial eye movement (outward deviation of one eye), blurriness, dizziness or HA
63
Vestibulo-ocular reflex
able to stabilize vision with head movement of at least 20 degrees at a speed of rotation at 180/minute (3/second)
impaired:
saccadic correction, blurriness, dizziness or HA
64
Common impairments that interfere with activities
```
coordination
perception
somatosensation
force generation
flexibility
```
65
Coma recovery scale- revised
measures arousal
23 items, 6 subscales addressing auditory, visual, motor, oromotor, communication and arousal functions.
lowest item on each subscale = reflexive activity
highest item on each = cognitively-mediated behaviors
66
Moss Attention Rating Scale (MARS)
Measures attention
| 22 items, scored on 5-point Likert scale
67
Agitated Behavior Scale
```
measures agitation
1 = absent
2 = present to a slight degree
3 = present to a moderate degree
4 = present to an extreme degree
```
68
Cognitive TUG
dual task TUG, requiring the person to count backward by threes from a randomly selected number between 20-100 while completing the movement task
69
TBI EDGE: Activity level measures
functional assessment measure: adds cognitive items to FIM
Disability rating scale: responsiveness and ADLs
Community balance and mobility scale: standing and walking item
6-minute walk test
10-meter walk test
Berg Balance Scale
70
Functional assessment measure (FAM)
12 items added to the 18 items of the FIM:
swallowing, car transfer, community access, reading, writing, speech intelligibility, emotional status, adjustability to limitations, employability, orientation, attention, safety judgement
71
Disability Rating Scale
evaluates 8 areas of function in 4 categories
- consciousness
- cognitive ability
- dependence on others
- employability
72
Community Balance and Mobility Scale (CB&M)
Detects high level balance and mobility deficits based on tasks commonly encountered in community environments
73
TBI EDGE: participation level measures
Community integration questionnaire: quantifies independence with independence in the community
Dizziness Handicap Inventory: quantifies dizziness symptoms with activities
Quality of Life after Brain Injury
74
Community Integration Questionnaire
3 domains:
home integration
social integration
75
Dizziness Handicap inventory
```
3 domains:
functional
emotional
physical
question examples:
does looking up increase your pain?
because of your problem, do you feel frustrated?
does walking down
```
76
Quality of Life after Brain Injury
comprehensive questionnaire with 37 items covering six dimensions of HRQoL after TBI
Domains include cognition, self, daily life & autonomy, social relationships, emotions, physical problems
