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Year 2: Neuromuscular > Test 3: Severe TBI > Flashcards

Test 3: Severe TBI Flashcards

1
Q

what is severe TBI

A

most significant

Low GCS level

low level arousal

high need for medical management

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2
Q

GCS for severe TBI

A

<9

3-8

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3
Q

loss of consciousness for severe TBI

A

> 24 hours

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4
Q

O-log score for severe TBI

A

<25 for 7 days

Post Traumatic Amnesia (PTA) >7 days

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5
Q

what is post traumatic amnesia

A

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)

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6
Q

what is retro grade vs antero grade amnesia

A

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

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7
Q

scores on goat and O-log that indicate post traumatic amnesia

A

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

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8
Q

describe the Galveston Orientation and Amnesia Test

A

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

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9
Q

coma vs vegetative state vs minimally conscious

A

coma = complete absence of arousal and awareness

vegetative = arousal without awareness

minimally conscious = minimal, reproducible, but inconsistent awareness

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10
Q

describe Ranchos levels I-III

A

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

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11
Q

imaging for diagnosing severe TBI

A

head CT initially

MRI of brain 24-48 hours later for higher sensitivity or if CT initially negative

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12
Q

describe TBI MOI: axonal diffuse axonal injuries

A

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

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13
Q

what info do you want from history and interview of a pt with severe TBI

A

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

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14
Q

chart review contraindications

A

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

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15
Q

outcome measures for cognitive review of severe TBI pts

A

coma recovery scale- revised (CRS-R)

Moss Attention Rating Scale

Rancho Levels of Consciousness Scale

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16
Q

scores for CRS-R that indicate severe injury

A

score range from 0-23

higher score = increased consciousness

lower score = WORSE

17
Q

rating for MARS

A

attention related behaviors

frontal lobe damage affects attention

22 items

5 pt rating scale

higher scores = better attention

18
Q

3 body structure and function systems involved in TBI

A

neuromuscular

cognitive

neurobehavioral

19
Q

neuromuscular review for TBI

A

PROM testing - postureing/tone
motor exam
sensory exam
reflexes
- babinski
- hoffman
- DTRs
- clonus

20
Q

what would you look at/screen for cardiopulmonary system

A

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)

21
Q

MSK screen with TBI pt

A

screen for heterotopic ossification

contracture risk
- need slint?
- serial casting?

22
Q

what is heterotopic ossification

A

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

23
Q

early S&S of HO

A

swelling
joint pain
muscle pain
decreased ROM
redness
local warmth
possible low grade fever

24
Q

management of HO

A

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

25
Q

integumentary screen

A

wounds - primary from accident

pressure ulcers - secondary injuries due to prolonged bedrest and immobility

26
Q

GI/GU items you want to screen

A

foley catheters

fecal management systems

overactive or neurogenic bladder

27
Q

important considerations for TBI exam

A

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

28
Q

team members who may be involved with TBI

A

neurosurgery
neurology
internal medicine
nursing
pharmacy
social work
care management
social work
care management
OT
SLP
physical medicine and rehab (PMR)
RT
PT

29
Q

examples of interventions for severe TBI

A

arousal management
upright
postural stability
wheelchair seating
passive ROM
positioning
caregiver edu

30
Q

ways to increase stimulation with TBI pt

A

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

31
Q

ways to decrease stimulation with TBI pt

A

limit touch, sound, visual stimulus

create stimulation schedule

32
Q

how to introduce upright interventions for arousal

A

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

33
Q

describe a tilt in space wheelchair and its benefits/cons

A

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

34
Q

what is serial casting

A

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

35
Q

indications for serial casting

A

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

36
Q

contraindications for serial casting

A

risk of skin breakdown (pressure ulcer) or pt hurting themself with cast

monitor limb distal to cast for signs of swelling or circulatory problems

37
Q

important things to consider when providing caregiver education and training

A

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

38
Q
A

Year 2: Neuromuscular (20 decks)

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