Traumatic Brain Injury Flashcards
What is a TBI?
A TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain.
What group of individuals are at highest risk for a TBI? Age?
Young males (TBI is leading cause of death for individuals aged 1-34)
Old >65
What are 4 risk factors for TBI death or hospitalizations?
- Male gender
- Older age
- Previous TBI
- Drug/Alchohol Use
What scale is most commonly used to classify the severity of a TBI?
Glasgow Coma Scale
Has good prognostic value
What are 3 issues/drawbacks of the Glasgow coma scale?
- Score affected by intoxication
- Intubation can alter scoring between mild and moderate
- Not scorable if patient cannot understand examiner’s language
What is the best predictor of outcomes in patients with TBI?
Depth and duration of unconsciousness
Post traumatic amnesia is assessed via what 2 tools?
- Galveston Orientation Amnesia Test (GOAT)
Scores ≥75 twice within 48 hours - Orientation Log
Scores ≥ 25 on 2 consecutive days
What are the 4 characteristics associated with PRIMARY injury following a TBI?
- Occurs at moment of impact
- Focal – bleeding, bruising or penetrating injury isolated to a portion of the brain
- Diffuse – brain tissue suffers more widespread damage
- People can experience both at the same time
What are the 7 characteristics associated with SECONDARY injury following a TBI?
- Triggered by primary injury; causes even more damage to brain
- Usually diffuse, but can also be delayed focal events
- Inflammation
- Cell receptor-mediated dysfunction
- Free radical and oxidative damage
- Calcium or other ion-mediated cell damage
- Cerebral Edema
What 4 things occur as a result of a TBI?
- Contusions (bruising)
- Diffuse Axonal Injury (shearing and widespread injury)
- Open Head Injury (skull fracture)
- Bleeding
Where dose the coup and countercoup injury take place?
- Coup – at site of impact
2. Contrecoup – opposite impact site
What is an epidural/extradural hematoma/hemorrhage? What can it cause? Mortality?
- Bleeding between the skull and the dura
- Can cause increase in iCP and brain shifting
- Typically arterial, spreads quickly
- Mortality 15-20%
What is the most common area to experience a epidural/extradural hematoma/hemorrhage?
Most common in temporal region as bone is thin
What is the treatment and prognosis of a epidural/extradural hematoma/hemorrhage?
Treatment: evacuation via burr hole or craniotomy
Prognosis: more favorable if patient was conscious immediately following injury vs. comatose throughout
What is typically the first symptom of a epidural/extradural hematoma/hemorrhage?
Fixed and dilated pupil on side of injury due to oculomotor nerve compression
What is a subdural hematoma/hemorrhage? When do symptoms typically appear? Most common in what age groups?
- Bleeding between the dura and the brain
- Usually venous
- Symptoms may appear immediately or be delayed
- Most common in elderly and very young children
What is the most deadly of all head injuries? Mortality?
Acute subdural hematoma
Mortality: 60-80%
How is a subdural hematoma treated?
Craniotomy with dural incision to remove blood clot and control bleeding
What is a subarachnoid hemorrhage? Signs and symptoms? Mortality?
- Bleeding into subarachnoid space
- Can occur from a ruptured blood vessel (non-traumatic) or from a severe blow to the head
- Signs and Symptoms: severe headache, vomiting, confusion, altered consciousness, sometimes seizures
- Mortality Rate: 40-50%
What are the 3 most common complications following a subarachnoid hemorrhage?
Hydrocephalus
Seizures
Re-bleeding
What is an intraparenchymal hemorrhage?
Bleeding into the brain tissue
Sxs depend on location and size of hemorrhage
What are 2 consequences on an intraparenchymal hemorrhage?
Can elevate ICP
Can cause fatal herniations
What is an intraventricular hemorrhage? What percentage of TBIs does this occur in?
Bleeding into the ventricles
35% of moderate to severe TBI
What are three common CNS herniations? Symptoms of each?
- Subfalcine: common, headache and contralateral leg weakness
- Trasntentorial: CNIII paresis (ipsilateral pupil dilation), contralateral hemiparesion.
- Tonsillar: Obtundation (less than full awareness)
What is compressed by subfalcine, transtentorial and tonsillar herniations?
Subfalcine: compresses pericallosal arteries
Transtentorial: compresses PCA and oculomotor nerve
Tonsillar: compresses pons and medulla
What are 8 secondary mechanisms of injury in a TBI?
- Ischemia
- Hypoxia
- Hypotension
- Cerebral Edema
- Increased Intracranial
- Pressure
- Hypercapnia
- Acidosis
- Excitotoxicity
What are the 4 levels of consciousness?
Coma: No eye opening, no sleep/wake cycle (Level 1)
Vegetative State: return of sleep/wake cycle; no purposeful responses (Level 2)
Minimally Conscious State: inconsistent purposeful responses (Level 3)
Emerged into Consciousness
What is a coma?
State of unarousable unresponsiveness
No response to verbal, tactile, or noxious stimulation
What is occurs in a vegetative state?
- Brainstem function intact; cortical function severely impaired
- Sleep/Wake cycle returns
- Generalized response to stimuli (Withdrawal from noxious stimulation/Facial grimacing)
- Complex reflexes may be present (Eye movements. Yawning, Startling)
If vegetative state lasts > 1 year, referred to as _____.
Persistent Vegetative State
What characteristics are associated with a minimally conscious state?
Inconsistent, but clearly discernible behavioral evidence of consciousness
Localized responses to stimuli
Can use opposite limb to localize a noxious stimulus
Inconsistently follows 1 or 2 step motor commands
Emergence from minimally conscious state is characterized by what 2 criteria?
- functional object use (2 different objects on 2 consecutive days)
- Functional Communication (ability to accurately answer 6/6 visual or auditory situational questions)
What are favorable prognostic indicators for a TBI? (10)
Higher level of education Initial GCS > 5 Higher intelligence Pupillary response Social support Younger age Limited trauma Short duration of PTA Low Injury Severity Short or absent coma
What are unfavorable prognostic indicators for a TBI? (11)
Midline Shift Repeat injury Anoxia Mass lesion Elevated ICP Hypotension History of violence, Drug/ETOH use Poor work history Psychiatric history Diffuse Axonal Injury Premorbid disability
What does PT management of TBIs in an acute care setting entail?
- Early mobilization in ICU
- PROM/contracture management
- Maintain skin integrity (positioning)
4, Behavior management
(Motoric restlessness/Self-harm) - Ongoing monitoring for secondary complications
(DVT, HO, Elevated ICP, Seizures, Spasticity)
___% of patients with moderate to sever TBI will experience some manifestation of agitation.
30%
What are the 9 clinical characteristics of agitation?
- Physical aggression
- Explosive anger
- Increased psychomotor activity
- Impulsivity
- Verbal aggression
- Disorganized thinking (rambling, irrelevant, incoherent)
- Perceptual disturbances (misinterpretation, illusions, hallucinations)
- Reduced ability to maintain attention
9 Reduced ability to appropriately shift attention to new external stimuli
Agitation is characterized by damage to what area? Symptoms associated with damage to this area?
Damage to fronto-temporal areas (subcortical/brainstem regions as well)
Arousal – hyper or hypo
Attention – impulsivity, inattention
Memory – planning, problem solving
Limbic behavioral functions: depression, withdrawal, personality change, aggression, perseveration, disinhibition, amotivation, apathy
Additionally, damage to this area may cause subclinical seizures which trigger aggressive behaviors
Shifts in what neurotransmitters play a role in causing agitation?
1, Disruption of dopaminergic and noradrenergic (arousal and attention), and cholinergic (memory) systems
- Behavioral symptoms may result from serotonergic systems (aggression), dopaminergic systems (akathisia), or combinations (disinhibition and lability)
Other causes to consider: hypothalamic dysfunction, pain
How can agitation be managed environmentally and behaviorally?
- Reduce Stimuli:
Low light quiet area, Speak softly, Limit number of “bystanders” - Attempt to be restraint-free
3. Reduce/manage confusion: Same schedule every day Attempt to keep staff consistent Don’t switch patient room Re-orient often
List 5 medications that help treat agitation.
- Anti-Epileptics
- Dopamine Agonists (Amantadine)
- Antidepressants (Tricyclics)
- Antipsychotics
- Beta Blockers
What is spasticity?
UMN disorder
Characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks
What 2 descending motor tracts become overly active in patients with spasticity?
Vestibulospinal
Reticulospinal
How is spasticity assessed clinically?
Clinical Observation: observe resting position in bed and in wheelchair and note side to side differences in resting postures of extremities, head, and neck
Clinical assessment: Examine the following in supine: Slow PROM, AROM, fast PROM
What 2 tools are used to grade spasticity?
Modified Ashworth
Tradieu Scale
What are 7 ways spasticity is managed?
- Weight bearing
- Stretching
- Serial Casting
- Splinting
- Botox
- Oral Medications
- Intrathecal baclofen
__ out of __ people with TBI will have a seizure that requires hospitalization
1 out of 10
What causes a seizure?
Electrical disturbances in the brain, usually localized to the area of initial trauma
Early Post-Traumatic Seizure occurs in ___ of patients within the first week after injury
25%
Late Post-Traumatic Seizure occurs more than ___ days after injury
7
What 6 symptoms area associated with seizures?
- Uncontrolled movements of head, body, arms, legs, or eyes (tonic clonic)
- Unresponsiveness/staring
- Chewing movements
- Strange smell, sound, feeling, taste, or visual hallucination
- Sudden fatigue or dizziness
- Language changes
What 4 factors can exacerbate a seizure?
- High fever
- Loss of sleep/extreme fatigue
- Drug and alcohol use
- Chemical changes in the body (electrolytes)
What are 6 common side effects of epileptic drugs?
- Sleepiness
- Balance deficits
- Lightheadedness or dizziness
- Trembling
- Double Vision
- Confusion
What causes post traumatic hydrocephalus? Presentation?
Can be caused by either overproduction of CSF, blockage of CSF flow, or insufficient absorption of CSF (or combination)
Can present as either normal pressure hydrocephalus or may cause increased ICP
What are 2 classifications of hydrocephalus? Onset?
Classified as either Non-Communicating (obstructive) or Communicating (non-obstructive)
Onset of PTH may vary from 2 weeks to years after TBI
What are the clinical presentations of acute and chronic hydrocephalus?
Acute – coma, focal neurological deficits
Chronic – gradual decline in functional status or failure to improve (USUALLY PICKED UP BY THERAPISTS)
What are 3 cardinal symptoms of hydrocephalus?
- progressive gait disorder (similar to Parkinsonian gait),
- impaired cognition
- urinary incontinence
What are the 2 most common symptoms of non-communicating hydrocephalus?
- Papilledema
2. Cognitive changes
How is hydrocephalus managed?
- Shunt Placement
2. Return to rehab for PT, OT, and ST
What are 3 other common complications related to TBI?
- DVT
- Autonomic Dysregulation
- Heterotopic Ossification
What is a complication of DVTs in patients with TBI?
May be unable to utilize anti-coagulants due to brain bleeding from initial trauma
IVC filter placement
What is autonomic dysregulation?
- Central Fevers
2. Sympathetic Storming: highly elevated blood pressure and heart rate, posturing
What is heterotopic ossification? Where is it most common? Symptoms?
- abnormal bone growth around a joint
- Most common in hip > knee > elbow > shoulder
- Sudden decrease in ROM (hard end feel), warmth, redness, swelling
What 3 PT intervention help to reduce mortality, secondary complications and overall prognosis in TBI?
- Early mobilization
- ROM/stretching
- Spasticity management
True or False: Pediatric TBI has a favorable diagnosis as compared to TBIs in adulthood.
FALSE
Unfavorable prognosis due to:
- incomplete myelination
- Cerebral blood flow is less compared to adults up until age 6-7
A mild TBI is also known as a _____.
Concussion
What is a concussion? It is manifested by at least one of what 4 symptoms?
Traumatically induced physiological disruption of brain function, manifested by at least one of the following:
- Any loss of consciousness
- Any loss of memory for events immediately before/after accident
- Any altered mental state at time of incident
- Focal neurological deficits that may or may not be transient
In a concussion/mild TBI, injury severity does not exceed what 3 criteria?
- PTA < 24 hours
- After 30 minutes, GCS of 13-15
- LOC < 30 minutes
What are some common symptoms seen in patients with a concussion?
Cognitive: difficulty remember, concentrating, thinking clearly
Physical: headache, nausea, dizziness, and balance problems
Emotional: irritability, sadness, nervousness, anxiety
Sleep: sleeping more/less than usual, trouble falling/staying asleep
How are concussions treated?
- REST (both physical and cognitive)
- Rehabilitation (PT – cervical strengthening, headache management, balance, vestibular
Ocular/Vision therapy) - Symptom-based medication
- Neuropsychology
What are 5 possible short/long term consequences of concussions?
- Predisposition for re-injury
- Cognitive slowing
- Early-onset Alzheimer’s
- Second Impact Syndrome
- Chronic Traumatic
- Encephalopathy
What is the timeline for concussion recovery?
- Most concussions resolve within 1 week
- 10-15% take > 4 weeks
Post-Concussion Syndrome: no return to baseline function
Increased risk of second impact syndrome
