Test 3: Severe TBI Flashcards
what is severe TBI
most significant
Low GCS level
low level arousal
high need for medical management
GCS for severe TBI
<9
3-8
loss of consciousness for severe TBI
> 24 hours
O-log score for severe TBI
<25 for 7 days
Post Traumatic Amnesia (PTA) >7 days
what is post traumatic amnesia
unable to remember events on ongoing basis for period of time after traumatic event
results in confusion and disorientation
measured with orientation log (O-log) or Galveston Orientation and Amnesia Test (GOAT)
what is retro grade vs antero grade amnesia
loss for events before injury or after injury respectively
common with PTA
pts tend to never recover the memories of the accident possibly due to events never being encoded/stored
scores on goat and O-log that indicate post traumatic amnesia
o-log <25/30 for >7 days
GOAT <75/100 for >7days
may not be able to participate in instrument based on medical stability and level of consciousness
describe the Galveston Orientation and Amnesia Test
assesses PTA and retrograde amnesia in pts who had severe TBI
measures orientation to person, place, and time
measures memory for events preceding and following the injury
<75 = PTA
<66 = impaired
coma vs vegetative state vs minimally conscious
coma = complete absence of arousal and awareness
vegetative = arousal without awareness
minimally conscious = minimal, reproducible, but inconsistent awareness
describe Ranchos levels I-III
I - no response: pt in deep sleep, unresponsive to any stimuli
II- generalized response: pt reacts inconsistently and non-purposefully to stimuli in non-specific manner
III - localized response: pt reacts specifically but inconsistently to stimuli; may follow simple commands in an inconsistent delayed manner
imaging for diagnosing severe TBI
head CT initially
MRI of brain 24-48 hours later for higher sensitivity or if CT initially negative
describe TBI MOI: axonal diffuse axonal injuries
one of more common types of TBI
most common with acceleration/deceleration mechanism of injury (i.e. high speed MVA)
disrupts parasagittal white matter, corpus callosum, and pontine mesencephalic junction
microscopic injury; often undetected on imaging
what info do you want from history and interview of a pt with severe TBI
arousal, consciousness, and behavior limit:
- rely on chart/family/team members
- pt interview in low stimulation closed environment
PLOF vs CLOF
co-morbidities
medical status; may be dynamic; consult pts primary RN prior to eval
chart review contraindications
ICP > 20mmHg
MAP<60 mmHg
CPP<60mmHg
SpO2<90%
any other labs out of treatable limits
vent settings too high
vitals outside of treatable limits
outcome measures for cognitive review of severe TBI pts
coma recovery scale- revised (CRS-R)
Moss Attention Rating Scale
Rancho Levels of Consciousness Scale
scores for CRS-R that indicate severe injury
score range from 0-23
higher score = increased consciousness
lower score = WORSE
rating for MARS
attention related behaviors
frontal lobe damage affects attention
22 items
5 pt rating scale
higher scores = better attention
3 body structure and function systems involved in TBI
neuromuscular
cognitive
neurobehavioral
neuromuscular review for TBI
PROM testing - postureing/tone
motor exam
sensory exam
reflexes
- babinski
- hoffman
- DTRs
- clonus
what would you look at/screen for cardiopulmonary system
vitals
ventilator settings
ICP - try for below 22 mmHg; below 20 is ideal
CPP (cerebral perfusion pressure) - try for between 60-70mmHg
- CPP = MAP-ICP
- MAP = (1/3SBP) + (2/3 DBP)
MSK screen with TBI pt
screen for heterotopic ossification
contracture risk
- need slint?
- serial casting?
what is heterotopic ossification
abnormal development of bone (osteogenesis) in areas of soft tissue
pt with hypertonicity at risk; restricts motion
unknown etiology
clinically significance HO in 10-20% TBI pts
most often at hip and knee
can lead to contractures, pressure injuries, impaired mobility, and compromised ability to perform ADLs
early S&S of HO
swelling
joint pain
muscle pain
decreased ROM
redness
local warmth
possible low grade fever
management of HO
pharmacological management
PT for ROM maintenance
sx for severe limitations
careful with PROM; dont want to cause trauma
surgical excision when HO causes extreme limits
integumentary screen
wounds - primary from accident
pressure ulcers - secondary injuries due to prolonged bedrest and immobility
GI/GU items you want to screen
foley catheters
fecal management systems
overactive or neurogenic bladder
important considerations for TBI exam
spasticity/tone
- synergy patterns/abnormal tone
- decorticate or decerebrate rigidity
sensorimotor impairments
postural stability in sitting/standing
- upright interventions can improve arousal
functional mobility
- FIM
- synergy patterns present
gait (if appropriate)
- synergy patterns present
team members who may be involved with TBI
neurosurgery
neurology
internal medicine
nursing
pharmacy
social work
care management
social work
care management
OT
SLP
physical medicine and rehab (PMR)
RT
PT
examples of interventions for severe TBI
arousal management
upright
postural stability
wheelchair seating
passive ROM
positioning
caregiver edu
ways to increase stimulation with TBI pt
pharmacologically = Amantadine
sensory stimulaiton - increase LOC and elicit movement in those with low levels of arousal
stimulate reticular activating system
others
- auditory
- hand over hand
- nail bed pressure
- temp change
- sternal rub
- vestibular stim
- upright intervention
ways to decrease stimulation with TBI pt
limit touch, sound, visual stimulus
create stimulation schedule
how to introduce upright interventions for arousal
if stable/no contraindications
start with raising HOB
- chair position in bed
- TBI HOB should not be less than 30 deg for ICP purposes
monitor EVD
- consult RN
may consider sitting EOB if minimally conscious
describe a tilt in space wheelchair and its benefits/cons
great for getting pt upright
can tilt for pressure relief moving pressure form ischials to sacrum
need mechanical lift to get them in chair. caregiver needed to transfer pt and chair
need specialized cushion for protection
what is serial casting
joint immobilized at end range for 2-5 days at a time
cast removed and further stretching is performed and new cast is set with new ROM
repeat process until significant ROM gains achieved
indications for serial casting
often used for PFs or bicep contractures long term soft tissue changes due to spastic posturing
no evidence that it improves spasticity only that it can improve muscle tissue length
contraindications for serial casting
risk of skin breakdown (pressure ulcer) or pt hurting themself with cast
monitor limb distal to cast for signs of swelling or circulatory problems
important things to consider when providing caregiver education and training
stimulation schedule
splinting schedule
PROM
pressure injury prevention
bowel/bladder management
body mechanics
DC planning/prognosis
equipment usage
- lifts
- hospital bed
- WC
- feeding equipment
- assistive technology
- cushion management
