Traumatic Brain Injury Flashcards
How often does someone die from a head injury or is permanently disabled?
Every 5 motha fuckin minutes
What is the most common mechanism of injury for a TBI?
MVA–50% of all injuries; followed by falls, and violence
What are the risk factors for TBI above the age of 65? (5)
- female
- poor vision
- hx of previous falls
- dementia
- polypharmacy (over medication or increase in meds)
What is the definition of a closed head injury (CHI)?
non-penetrating of the meninges in head injuries
What is an example of a closed head injury?
Concussion
What may we see in some closed head injuries? (6)
- brainstem damage
- contusions
- diffuse white matter lesions
- injury to blood vessels
- damage to cranial nerves
- CSF rhinorrea
What is the definition of a open head injury (OHI)?
A penetrating head injury where the meninges have been breached
True/False:
Open head injuries may be caused by accelerating or decelerating forces
True
True/False:
The amount of damage in open head injuries is due to the areas affected
True
What type of head injury would a gun shot wound be?
A fucking open head injury
What is associated with skull fractures? (5)
- increased risk of infection
- TBI
- meningitis
- encephalitis
- abscess
True/False:
Not all skull fx result in head injury, but ALL increase risk of infection
True
When does primary injury occur?
At the time of impact
When does secondary injury occur?
After the time of impact secondary to the body’s response to injury
What is local brain damage?
Damage that is localized to the area of the brain under the site of impact on the skull
What is the likely MOI for local brain damage?
Direct contact
What is polar brain damage?
Brain moves forward inside the skull, suddenly stops due to impact with the skull; damage occurs only on one side of the brain.
What is a diffuse brain injury?
Diffuse axonal injury
What is the likely MOI of a diffuse brain injury?
non-contact, acceleration/deceleration or rotational forces
What is a coup-contrecoup injury?
It is a brain injury that occurs on both poles of the brain.
What does coup mean?
It is the pole of the brain where the 1st injury takes place. Under the site if contact with the head
What does contrecoup mean?
Is the damaged cause by the brain ricocheting off the back of the skull, the opposite pole of the brain. The 2nd injury site.
When do we commonly see coup-contrecoup injuries?
Whiplash injuries
Can secondary injury be more life threatening then the primary injury?
- yes sir
What is hypoxic-ischemic injury?
due to insult to specific vascular territory due to brain shift, or diffuse injury caused by arterial hypoxemia.
What can be commonly seen with secondary injury? (4)
- intracranial hematoma
- mass effect
- increased intracranial pressure
- hydrocephalus
What is the mass effect?
shift of brain caused by edema
What can increased cranial pressure cause?
it can compress and compromise blood vessels
What are some causes of secondary injury? (6)
- neurochemical and cellular changes
- hypotension
- hypoxia
- increased ICP which leads to decreased CPP (cerebral perfusion pressure)
- electrolyte imbalances
- ischemia
What does a hematoma or clot create in the brain?
bleed creating the mass effect
Where is a intracranial hemorrhage?
inside the brain
What is vasoparalysis?
An arrest in circulation with instantaneous rise in ICP
What causes shearing forces?
A blow to the cranium causing rotation of the brain within the skull
What does does shearing forces lead to?
to diffuse axonal injury
What do contusions lead to?
hemorrhage and increase in ICP
What do lacerations cause?
Direct damage to neural tissue
When are shear injuries commonly seen?
In acute injuries due to the differences between gray and white matter. When you stop quickly, these layers will seperate
Where do the white and gray matter usually separate?
typically at cortico-medullary junctions
What is the prognosis for shear injuries?
Poor
What is an immediate complication of a head injury?
Edema
What is vasogenic edema?
it occurs in regions bordering those damaged during ischemia
What is cytotoxic edema?
it follows cerebral ischemia or hypoxia; caused by swelling of endothelial cells, neurons and glia
Does cytotoxic edema cause physical damage or damage because of lack of blood supply in cells?
lack of blood supply
What is the most common form of edema?
vasogenic edema
What is diffuse cerebral edema?
swelling/damage throughout the brain
What are other immediate problems in the brain? (2)
- herniation
- infection
What causes herniation?
increased pressure in the brain
What is the most appropriate diagnostic imaging of a head injury in the ER?
CT scan
What imaging detects cerebral blood flow mapping?
PET or SPECT scan
What are the 5 ways to image the head?
- x-ray
- CT scan
- MRI
- PET or SPECT
- EEG
What does the glasgow coma scale define?
level of consciousness after suspected brain injury
What is the neurosurgical definition of a coma?
no eye opening, no recognizable speech, no following of motor commands
What are the 3 things that the Glasgow coma scale assess?
1) eye opening - 4pts
2) motor responses - 6pts
3) verbal responses - 5pts
What is the min/max score you can get on the Glasgow coma scale?
3= min 15= max
True/False:
The higher the better on the glasgow coma scale
Ture, 15=best
True/False:
The lower the worse on the glasgow coma scale
True, 3= worse
What does scores between 13-15 represent on the GCS?
mild brain injury
What does scores between 9-12 represent on the GCS?
moderate brain injury
What does scores 8 or less represent on the GCS?
severe brain injury
What is common with Minor head injuries?
anterograde/retrograde amnesia
True/False:
Minor signs and symptoms may progress to more serious pathologies
True
What are the most common complaints with minor head injury? (4)
- seeing stars
- stunned
- nervous
- poor memory of events just prior to or just following the event
What is a concussion?
a violent jarring or shaking that results in a temporary disturbance of brain function
True/False:
A concussion is a mild form of diffuse axonal injury
True
True/False:
A concussion is a momentary interruption of the brain function with or without loss of consciousness
True
Do microscopic changes occur in neurons and glia within hours of a concussion?
Yes
True/False:
Return to play guidelines vary between sports/leagues
True
What are return to guidelines monitored by?
IMPACT testing
Does the patient need to be symptom free before he can return?
yesss
What are the 5 symptoms that are involved in post-concussion syndrome?
1) persistence of imld symptoms such as headaches, irritability, insomnia, poor concentration/memory
2) persist for weeks or months
3) organic basis
4) limit ability to complete ADLs or employment
5) may need cognitive retraining or psychological support
What are the 5 types of moderate head injury?
1) acute epidural hemorrhage
2) acute subdural hemorrhage
3) chronic subdural hematoma
4) cerebral hemorrhage
5) subarachnoid hemorrhage
How can you describe an acute epidural hemorrhage?
- no initial coma, but deterioration in neuro status if left unresolved
- resolved with surgical procedures
How can you describe an acute subdural hemorrhage?
- results QUICKLY in coma
- bleed arrested by increased ICP
- requires surgical intervention
- happens QUICKLY
How can you describe an chronic subdural hematoma?
- SLOW venous leak
- neuro deterioration over a period of weeks
- CT scan- encapsulated mass often mistaken as tumor
- surgical intervention
How can you describe an cerebral hemorrhage?
- disruption of intrinsic cerebral circulation
- managed similar to hypertensive stroke
How can you describe an subarachnoid hemorrhage?
- managed similar to epidural hemorrhage
- disruption of circulation into the brain
Severe head injury presents with immediate
loss of consciousness
Is there a complete paralysis of cerebral function with a severe head injury?
yes
What can we see immediately after a severe head injury? (5)
- cerebral lacerations
- SAH
- subdural hemorrhage
- coup-contrecoup sites
- damage along the line of force
True/False:
There will be multiple systems involved in a severe head injury
true
True/False:
Permanent deficits will persist after a severe head injury
true
How do you define, incompatible with life? (7)
- deep coma
- initially may be flaccid, become spastic or rigid with posturing
- unresponsive to pain and all stimuli
- ventilator required to maintain breathing
- deregulation of body temperature and BP
- poor EEG
- brain dead
What is brain dead?
The in capatable with life criteria must be present for 30 minutes at least 6 hours after onset of coma and apnea
What are the 4 criteria of brain death?
1) coma with cerebral unresponsivity
2) apnea- no spontaneous respiration
3) absent cephalic reflexes- like pupils etc
4) electrocerebral silence
What is the acronym PVS mean?
Persistent Vegetative State
What does it mean to be in PVS?
wakeful, reduced responsiveness with no evident cerebral cortical function
How long is the life expectancy with patients with PVS?
weeks, months, years
What is the prognosis for a patient in PVS longer then 3 months?
Poor
What can you usually see in a patient in PVS? (5)
- posturing
- some movement
- no communication
- tube feeding
- uses reflexes for movement
What is shaken baby syndrome?
Trauma to the brain of a small child or infant due to repetitive shaking
Is shaken baby syndrome considered child abuse?
unfortunately yes
What type of brain damage is seen in shaken baby syndrome?
polar brain damage
True/False:
Occipital damage will have visual deficits
True
What is the definition of near drowning?
Surviving 24 hrs or longer after the physiologic effects of hypoxemia and acidosis from submersion in fluid
What is dry drowning?
inhalation of little to no fluid with minimal lung injury–laryngeal spasm
What is wet drowning?
Aspiration of fluid into the lungs–asphyxia
Does respiratory distress occur after a near drowning incident?
you’re damn right it does
What is the second leading cause of death in people under 15 years of age?
Near drowning
What are the risk factors of near drowning? (6)
- alcohol consumption
- seizure disorder
- MR
- MI
- head or spinal cord injury at time of accident
- failure to use floatation device
What determines near drowning pathological events?
duration of submersion and temperature of water
What does hypoxia lead to?
global cell damage
How long until neurons and cardiopulmonary cells suffer irreversible damage?
4-6 minutes in neurons
up to 30 minutes for cardiopulmonary cells
What does the clinical picture and prognosis of near drowning depend on?
extent and duration of hypoxic event
What is the least reversible complication of near drowning?
neurological injury
True/False:
Cerebral edema secondary to injury may cause increased ICP which leads to reduction of cerebral blood flow
True
What are the cognitive problems associated with TBI? (6)
- memory
- Attention
- Concentration
- Communication
- Reasoning
- Impaired Judgement
What was the Rancho scale first known as?
Levels of cognitive functioning
What was the Rancho scale developed for?
as a way to describe the stages of cognitive improvement as a person with brain injury becomes more responsive.
Is the Rancho scale a test?
nope, it’s a method of organizing and describing observations in a generalized way to help communicate with families.
True/False:
Rancho Los Amigos Levels of cognitive functioning has an element of predictability
truth
Improvement through the the Rancho scale depends on what?
upon the extent and severity of the brain injury
How many levels are part of the Ranchos Los Amigos Levels of Cognitive Function?
10 levels
What describes level I on the scale?
no response to pain, touch, sound or sight
What describes level II on the scale?
generalized reflex response to pain
What describes level III on the scale?
localized response; blinks to strong light, turns toward/away from sound, responds to physical discomfort, inconsistent response to commands
What describes level IV on the scale?
Confused/agitated; alert, very active, aggressive or bizarre behaviors, performs activities but behavior is non-purposeful, extremely short attention span.
What describes level V on the scale?
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.
What describes level VI on the scale?
Confused/appropriate; inconsistent orientation to time and place, retention span/recent memory impaired, begins to recall past, consistently follows simple directions, goal orientated behaviors with assistance
What describes level VII on the scale?
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.
What describes level VIII on the scale?
purposeful/appropriate
What describes level IX on the scale?
purposeful, appropriate: stand-by assistance-on
What describes level X on the scale?
purposeful, appropriate: modified independent.
The clinical picture of TBI in the physical/movement stand point? (9)
- speech problems
- vision problems
- hearing problems
- headaches
- sensory problems.losses
- loss of coordination
- muscle tone changes (25% of patients)
- seizures
- sleeping problems
The clinical picture of TBI in the social stand point? (4)
- fatigue
- anxiety
- depression
- emotional instability
What are the 4 immediate medical management techniques of TBI?
1) preservation of life - ABCs
2) ICP, infection, nutrition
3) Determination of severity of injury
4) Prevention of further damage
What are the 5 medical complications associated with TBI?
1) post-traumatic seizures
2) hydrocephalus
3) DVT
4) Heterotopic ossification
5) GI/GU issues
