TBI Rehab - Bernert Flashcards
Incidence of brain injury annually
1.7 million people
TBI is a contributing factor to _____% of all 1.injury related deaths in the US.
2. ______ patients have lifelong disability
- 30.5%
2. >3.1 million
Total indirect and medical cost associated with TBI in 2010?
76.5 billion
Top 5 causes of BI (in order with percentage)
- Falls 35.2%
- MVCs 17.3%
- Assault 10%
- Struck by/against 16.5%
- other
_____ is the leading cause of TBI related death. Highest rates for which age group?
MVC; 20-24 yoa
TBI Model systems:
- ___% male, ____% female
- Average age at injury?
- Describe the bimodal distribution
- 74% male, 26% female
- 40 yoa
- Ages 0-4 (falls) 15-19 (MVC) >65yoa (falls)
Increasing age increases probability of poor outcome (especially after 60)
Adults >74 yoa have highest rates of TBI related hospitalization and death
with regard to survey sent to KYians in 2004:
1. what % had memory problems after injury?
2. depression
3. anxiety
need for professional services following injury?
- 24.2%
- 20.5%
- 23.3%
- 6%
Seat belts reduce risk of serious injury by ___%, death by ____%
Helmets reduce risk of death in crash by ____% and head injury by ____%
50; 45%
42; 69%
Define primary brain injury
disruption of brain tissue, directly caused by the event.
5 types of primary brain injury
shear rotational percussion acceleration/deceleration penetrating
describe pathophysiology behind primary injury
Impact depolarization (potassium release) leads to cortical disruption and vascular injury. Causes hemorrhage and axonal injury
DAI:
- Dynamic stretch of ____
- Mechanical failure of _____
- Triggers for: ______
- INterrupts ____ transport
- ultimately leads to axonal ______. _____ formation
- axons
- microtubules
- progressive disassembly of the microtubules
- axonal transport
- axonal swelling and degeration (bulb formation)
____ is the most common cause of immediate LOC and severe disability after TBI
Aiffuse axonal injury
Define the 3 grades of DAI
- Scattered axonal retraction balls in parasagittal white matter of cerebral hemisphere. (brief LOC)
- Above plus focal lesions in the corpus callosum (coma of duration, recover process unclear)
- Grade 2 plus focal lesions in the dorsolateral rostral brain stem (immediate coma with posturing, incomplete recovery)
Describe the 5 components associated with axonal swelling and degeneration (reversible cytoskeletal damage)
- secondary axotomy
- Ca Load/excess after stretch
- membrane depolarization
- transmitter release
- “retraction balls”
8 types of secondary brain injury
Ischemia (Hypoxemia, Hypotension, IC Hypertension- Hypoperfusion) Cerebral Edema Herniation Hydrocephalus Infection Fever Hyperglycemia Seizures
describe secondary brain injury on a molecular level
Excitotoxicity ( Glutamate release – injured membranes, depolarized neurons)
Neuronal Cell Necrosis & Apoptosis
Deaffferentation – Cell Dysfunction – Cell Death
7 influences on head injury outcomes
Age
Drugs
Preexisting Disease
Psychosocial status- Family Functioning & Support
Genetic Makeup: Apolipoproteine E4 Allele
- Associated with poorer outcome and larger brain lesions
Education/ IQ-
Coping Style- Non productive coping (worry, , wishful thinking, self blame, substance use associated with postinjury anxiety and depression, lower psychosocial functioning
In acute care brain injury ____ greatly
increases mortality and morbidity
Early Hypoxemia
define hypoxemia.
What improves outcomes in TBI patients with hypoxemia
Apnea or Cyanosis in the field or Oxygen saturation (SaO2) < 90%/ Pa02< 60mm Hg
Intubation of unconscious and unresponsive TBI
patient improves outcome
Hypotension in TBI patients: (2)
Define Hypotension
Doubles mortality, increased morbidity
one single episode of SBP <90mmHg in adults
GCS in TBI patients: Perform after \_\_\_\_ and before \_\_\_\_ Mild TBI: Mod TBI: Severe TBI:
Should do ____ exams.
Change in GCS > ___ is significant prognosticator
After resuscitation, before administering paralytics. 13-15: mild 9-12 moderate 3-8 severe Serial exams >2 change is significant
Hyperventilation prior to ICP monitoring
Reserved for
transtentorial herniation
HPV to pC02 = 30-35 mmHg
20 breaths per minute for adults
ICP management in acute phase BI
ICP:
CPP:
Medical Management:
Keep ICP < 20
Keep CPP > 60
Nutrition in TBI Begin within: By day 7 \_\_\_\_\_\_% of Basal energy expediture in non-paralyzed patient. \_\_\_\_ % in peds \_\_\_\_\_% in multitrauma \_\_\_\_% in paralyzed pateint
72 hours 140% non-paralyzed 160% peds 250% multitrauma (15-20% of calories = protein) 100%
Define post TBI seizures (timewise)
Immediate seizure – first 24 h
Early Seizure – first 7 days
Late seizure – after 7 days
Routine Seizure Prophylaxis
1 week
Prevention of Early Seizures
Phenytoin versus Depakote
6 prognostic indicators of TBI
Initial Glasgow Coma Scale Age Presence of prior brain injury Injury severity Duration of Coma Duration of Post-traumatic Amnesia
Initial GCS best if within 24h of resuscitation: Prognostic precentages: GCS 3-4: 5-7: 8-10: 11 and greater:
GCS 3-4 – death or Vegetative State 87% GCS 5-7 – Death or Vegetative State 53% Moderate recovery 34% GCS 8-10 – moderate or good recovery 68% GCS – 11 moderate or good recovery 87%
With regard to age and TBI
_____ do better.
if > ______: worse outcomes
% good outcome vs mortality in >60 years and <40 years.
Children/ young Adults
Age > 40 worse outcome
> 60 years good outcome 2 %/ mortality 79%
< 40 years good outcome 38%/ mortality 33%
Controlled for severity
If coma lasts > ______: rarely good recovery
Coma > 2 weeks – rarely good recovery
Definition of Post traumatic amnesia
Disorientation to time, place and person, confusion, diminished memory and reduced capabilities for attending and responding to environmental cues
Almost always recall name
Episodic Memory not stored
Basic Orientation Information not stored
Assessment with Goat
What is the post-TBI PTA O-log
10 questions
0-30 points possible
Each item is scored from 0 to 3
3=spontaneous and correct response
2=spontaneous response is lacking, but correct response with a logical cue (e.g. to identify place, cue “This is a place where doctors and nurses work”)
1=spontaneous and cued responses are incorrect, but correct response when provided if given choices to recognize (e.g. to identify the month, provide three months from which to choose)
0=spontaneous, logical cue and recognition cue approaches don’t cause a correct response
Domain specific scores can be generated – place (3 items), time (5 items), situation (2 items)
Scoresheet provides a graph to plot serial assessments over time
PTA emergence tested by
Considered “emerged” when:
GOAT - long list of orientation questions
Clearance: GOAT Score> 75 on (2) 3 occasions
on consecutive days
TBI scale according to PTA length of time:
___ mild
___ Moderate
___ Severe
___ Very severe and recovery will take months
___ Very severe and recovery will take years
___ Very severe and recovery could be life long disability.
Up to 1 hour - The injury is very mild in severity and full recovery is expected. The patient may experience a few minor post-concussive symptoms (e.g. headaches, dizziness).
1 – 24 hours - The injury is moderate in severity and full recovery is expected. The patient may experience some minor post-concussive symptoms (e.g. headaches, dizziness).
1 – 7 days - The injury is severe, and recovery may take weeks to months. The patient may be able to return to work, but may be less capable than before the injury.
1 – 2 weeks - The injury is very severe, and recovery is likely to take many months. The patient is likely to experience long-lasting cognitive effects such as decreased verbal and non-verbal intelligence as well as decreased performance on visual tests. Patients should, however, still be able to return to work.
2 – 12 weeks - The injury is very severe, and recovery is likely to take a year or more. The patient is likely to exhibit permanent deficits in memory and cognitive function, and the patient is unlikely to to able to return to work.
12+ weeks - injury is very severe and accompanied by significant disabilities that will require long-term rehabilitation and management. The patient is unlikely to be able to return to work.
Describe the rancho levels
Level I: No response to pain, touch, sound or sight.Level II: Generalized reflex response to pain.Level III: Localized response. Blinks to strong light, turns toward/away from sound, responds to physical discomfort, inconsistent response to commands.Level IV: Confused/Agitated. Alert, very active, aggressive or bizarre behaviors, performs motor activities but behavior is non-purposeful, extremely short attention span.Level V: Confused/Non-agitated. Gross attention to environment, highly distractible, requires continual redirection, difficulty learning new tasks, agitated by too much stimulation. May engage in social conversation but with inappropriate verbalizations.Level VI: Confused/Appropriate. Inconsistent orientation to time and place, retention span/recent memory impaired, begins to recall past, consistently follows simple directions, goal-directed behavior with assistance.Level VII: Automatic/Appropriate. Performs daily routine in highly familiar environment in a non-confused but automatic robot-like manner. Skills noticeably deteriorate in unfamiliar environment. Lacks realistic planning for own future.Level VIII: Purposeful/Appropriate.Level IX: Purposeful, Appropriate: Stand-By Assistance on Request.Level X: Purposeful, Appropriate: Modified Independent.
3 Criteria for DOC
Coma
Vegetative State - eye opening
Minimally Conscious State - voluntary behavior
Once form of communcation has emerged – emerged
Define coma (6)
Loss of spontaneous or stimulus-induced arousal
No sleep-wake cycle
No purposeful motor activity
No response to command
No receptive or expressive language ability
No awareness
Define vegetative state: (8)
1 No purposeful motor activity 2No response to command 3No receptive or expressive language ability 4No awareness 5Sleep-wake cycle 6Spontaneous or stimulus-induced arousal 7Postures or withdraws to noxious stimulus 8Occasional non-purposeful movement
