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Neuro Final Sarah > Traumatic Brain Injury > Flashcards

Traumatic Brain Injury Flashcards

1
Q

How many people in the U.S receive treatment for TBI?

A

1.25 million

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2
Q

How many people are living in the U.S with disabilities related to TBI?

A

5.3 million

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3
Q

Most TBIs are closed-head injuries

A

True

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4
Q

How many TBI accidents are caused by motor vehicle accidents?

A

2/3 especially in the adolescent and young males. TBIs for younger children and older adults are most often due to falling

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5
Q

Are males or females more likely to have TBI?

A

Overall, males are two to three times as likely to have TBI as females

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6
Q

What are the risk factors for TBI?

A

Age
Gender
Substance Abuse
School adjustment and social history (poor academic performers or school dropouts more likely)
personality types- type A’s and competitive more likely
participation in high risk sports
military member/war veteran

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7
Q

Penetrating brain injuries

A
  • usually caused by missiles such as bullets, stones, artillery shell fragments
  • amount of damage depends on velocity of missile: pierce skull & brain-> bring foreign bodies in causing infections
  • low velocity- can fragment skull which can penetrate the brain. less damage tho as most of the impact was fracturing skull
  • penetrating brain injuries to brain stem usually fatal (respiration)
  • Adults with penetrating brain injury almost always have residual physical, cognitive or language impairment
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8
Q

High velocity missiles

A

cause more damage, they pierce the skull & brain and often bring foreign bodies, hair, etc into the brain, causing infection

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9
Q

Low velocity missiles

A

may fracture the skull rather than penetrate it, but the fracture can cause bone fragments to penetrate the brain.

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10
Q

Adults who live after penetrating head injury almost always have some…

A

residual physical, cognitive or language impairment

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11
Q

Nonpenetrating Brain Injuries- Closed Head Injuries (CHI)

A

The meninges are not penetrated - they remain intact and foreign matter does not enter

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12
Q

Two categories of CHI

A

nonacceleration and acceleration injuries

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13
Q

Nonacceleration Injuries

A

when the restrained head is struck by a moving object

less severe

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14
Q

Acceleration Injuries

A
  • Injury caused by sudden acceleration or deceleration of the head and results in injury to brain/brainstem due to their movement in the skull. cranial nerves are often damaged
  • blows to a moving head can be 20 times as severe as to stationary head
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15
Q

Blows to a moving head can be _ times as severe to a stationary head

A

20

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16
Q

Two types of acceleration injuries

A

linear acceleration and angular acceleration

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17
Q

Linear Acceleration

A

when the head is suddenly hit and pushed into acceleration by an outside force. Causes coup injury or contra coup injury

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18
Q

Coup Injury

A

the skull begins to move in the direction of the outside force, but the inner brain lags in its movement due to inertia. this causes the skull to slam into the brain

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19
Q

Contra Coup Injury

A

After a coup injury, the brain begins to move at the rate at which the skull is moving. the skull stops first (decelerates) and the brain takes a while longer to stop due to the inertia which causes the brain again to be compressed against the skull. this causes localized injury to the area opposite to the area of the first blow.

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20
Q

Coup and contra coup injuries typically happen on the sides of the skull

A

False, typically to the front or back of the head because there is more room

Coup and contra coup injuries produce focal damage to the brain tissue where the brain is compressed against the skull

shaken baby syndrome and whiplash can cause similar injuries to the brain

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21
Q

Is the brain tethered in the skull?

A

No
The head only moves so far because it is tethered by the neck muscles but the brain is not so firmly tethered inside the skull

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22
Q

Angular acceleration

A

caused by a blow that hits the head off center and cause the skull to rotate away from the blow. after a few milliseconds the brain begins to move in the same direction as the skull. this causes twisting and shearing motion of the midbrain, basal ganglia, brain stem and cerebellum. there is also a 2nd time of twisting and shearing that occurs when the skull stops but the brain is still moving.

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23
Q

Is angular or linear acceleration more severe?

A

damage caused by angular acceleration is usually more severe than the linear acceleration because of the twisting forces involved

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24
Q

Diffuse axonal injury

A

thought to be the cause of many of the impairments resulting from TBI and can be caused by angular or linear acceleration

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25
Q

Traumatic Hemorrhage and Hematoma

A
  • Another common occurrence in non penetrating brain injuries
  • Caused by cuts and bruises on the surface of the brain
  • There are prominences on the floor of the skull which contribute to damage on bottom of brain
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26
Q

Secondary Consequences of TBI

A

Cerebral Edema
Ischemic brain damage
Cerebral Vasospasm

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27
Q

Cerebral Edema

A

Fluid accumulates in cerebrum and causes increased intracranial pressure

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28
Q

Ischemic brain damage

A

reduced oxygen to brain

29
Q

Cerebral Vasospasm

A
  • Contractions of muscles surrounding blood vessels

- Can cause worsening of conditions such as alteration in the blood brain barrier

30
Q

Blood Brain barrier

A

regulates the movement of substances from blood into the brain

The severity and nature of the neuropathology determines the severity and nature of the symptoms and is strongly related to the patient’s recovery

31
Q

Prognostic Indicators in TBI

A
  • Duration of coma: longer=poorer prognosis
  • Level of consciousness
  • Duration of Post traumatic amnesia
32
Q

How to measure level of consciousness (duration of coma)

A

Glasgow Coma Scale (GLS)

The Comprehensive Level of Consciousness Scale (CLOCS)

33
Q

Glasgow Coma Scales

A

based on eye opening, motor behavior and verbal responses.
it is a good predictor of recovery but after non-neurologic contributors are gone (alcohol)
-given 6 hours after accident

34
Q

GCS scores

A

8 or less: coma
3-8: severe head injury
9-12: moderate head injury
13-15: mild head injury

35
Q

CLOCS

A

It has a broader range of responses and is more sensitive to subtle changes than GLS
developed to meet the problems of the GCS

36
Q

Post traumatic amnesia that lasts less than 2 weeks is associated with good recovery but when it lasts more than 12 weeks, patients don’t make a good recovery

A

True

pt. can’t store new info - memories following injury

37
Q

Galveston Orientation and Amnesia Test

A

assesses orientation and memory and is designed for patients emerging from coma

38
Q

Rancho Los Amigos Scales of Cognitive Levels

Glasgow Outcome Scale

A
  • rates levels of arousal, responsiveness, restlessness, attention, memory and executive ability
  • rating scale for patient’s outcome
39
Q

Patient Related Variables

A
  • age: most important predictor: older pts. poorer prognosis
  • substance abuse: affects outcome negatively
  • intelligence and SES: higher have better outcomes
  • premorbid personality: pts. with emotional problems prior to TBI have poorer outcome
40
Q

Behavioral and Cognitive Recovery:

  • Pts. recover in steps with periods of rapid improvement alternating with periods of little recovery
  • Steps of recovery: usually predictable->
A
  • period of unconsciousness from few seconds to months
  • return to consciousness when patient is awake but with little response
  • patient becomes more responsive and focused
  • *Similar to Rancho Los Amigos
41
Q

Assessing Adults with TBI

A
  • Assess level of consciousness & responsiveness
  • Assess orientation
  • Assess cognitive and communication abilities
  • Agitation
  • Assess Language and Communication
  • Assess Abstract Thinking
  • Assess Reasoning
  • Assess Planning and Problem solving
42
Q

Assess level of consciousness & responsiveness

A
  • Use Glasgow Coma Scale or Glasgow Assessment Schedule and observation
  • assess if pt. is easily aroused from sleep through sounds or verbalizations, touching, shaking
  • assess pts. stimulation when awake (response to TV, noise, people)
  • assess pts. response to speech - does he turn toward speaker
  • assess pt’s response to visual stimulation- look at lights, colored objects
  • assess response to tactile stimulation: light touching, pinching
  • olfactory stimulation: performs, bad odors (alcohol)
43
Q

Assess Orientation

A

-how pt. relates to self and environment
-As pt. turns to consciousness (RLS level 4 and 5) they experience disorientation, confusion and agitation
-Assess orientation for:
Person: what’s your name? mother’s name?
Place: where are you
Time: what year, day is this?

44
Q

Assess Cognitive and Communication Abilities

A

When pts are at RLS levels 5 they may be able to tolerate testing for this.

  • Alertness and attention
  • visual processing: usually resolves after early stages
  • memory - very problematic for TBI pt
45
Q

Assess Agitation

A
  • Common problem with TBI- may pull out tubes, get out of bed, be abusive
  • Agitated Behavior Scale rates extent of agitation
46
Q

TBI language and communication problems

A
  • Pts at RLAS level 5 and above usually have speech that is WNL unless there is brain stem, cerebellar or PNS damage. To assess speech use dysarthria battery
  • Pts main problems with language involve: irrelevance, confabulation, circumlocution, tangential speech, fragmentation or noncohesion. Their language is usually OK semantically, syntactically and morphologically
  • Similar to Wernicke’s
  • Can use PPVT to assess auditory comprehension, word finding tests, naming tests (Boston Naming), reading tests
  • Pragmatic problems are prominent: turn taking, initiating conversation
  • Samples of conversation are useful
  • may have problems with reading and writing
47
Q

Use PPVT to assess

A

auditory comprehension using word finding tests, naming tests and reading tests

48
Q

One main difference between aphasia and TBI

A

patients with TBI have more pragmatic problems

49
Q

How to assess abstract thinking

A
  • proverb interpretation
  • similarities and differences
  • categorizing and sorting tasks
50
Q

To assess reasoning (typically impaired)

A

use verbal reasoning tests such as the Stanford-binet or Wechsler IQ scale

51
Q

To assess planning and problem solving

A

tinker toy test- pt is given the toy and asked to make whatever they want in 5 minutes. the construction is scored looking at complexity, # of parts, etc.

52
Q

Test Batteries for TBI

A

RIPA
Brief Test of Head Injury
SCATBI

53
Q

Tests for general population that can be use to assess TBI

A

Woodcock-Johnson Psychoeducational Battery
Woodcock-Johnson Tests of Cognitive Abilities
Woodcock-Johnson Tests of Achievement
Peabody Individual Achievement Test

54
Q

Treatment of TBI

A
  • Sensory Stimulation
  • Environmental Control: use consistent & predictable routines to reduce confusion and agitation
  • Behavior Management
  • Pharmacologic Management: meds can be effective in reducing agitation and improving attention
  • Orientation Training: environmental prompts like calendars, notes, clocks, schedules. Prominently displayed. Signs indicating dining room, bathroom. Drills are good: where do you live, how old are you, year?
  • Component Training (Cognitive Rehabilitation or Cognitive Therapy)
  • Compensatory Training
55
Q

Sensory Stimulation

A

For Comatose or semi-comatose
pt is presented with different stimuli (tactile, auditory, visual, olfactory) in short intervals (10 mins) throughout the day. Supposed to bring person out of coma but there is not a lot of evidence to support this

56
Q

Behavior Management

A
  • target specific behaviors to decrease maladaptive behaviors and increase good behaviors
  • reinforcement and punishment are used to elicit good behaviors and decrease bad behaviors
  • they often don’t respond to verbal praise so tangible reinforcement is needed.
  • Tx is often unwanted by pt. so you may use termination of an activity as a reward- if the respond to 2 more questions ex.
  • pts. often lack inhibition as their cortical control centers are not working well
  • agitation and aggression are part of brain injury
57
Q

Component Training (Cognitive Therapy or Cognitive Rehabilitation Therapy)

A

-typically focuses on cognitive process of attention, memory and language communication.
-Structured hierarchical drills are typical (ex: memory exercises using environmental cues such as calendars, etc.)
-Attention
Visual attention training: visual cancellation, auditory tasks, alternating attention, divided attention
-Visual processing
visual scanning tasks (find all the as) , figure ground, copying geometric shapes
-Memory Impairments
repetitive drills to restore memory: pt memorizes list of words, numbers. Computer based memory programs: not much success
-Reasoning and problem solving:
problem solving, role play, structure daily activity, balance check book

58
Q

What does the SLP work on in regards to language and communication

A

-Related to underlying impairments of attention, memory, reasoning, abstract thinking and problem solving
-SLP works on the underlying impairments
work to improve the appropriateness, relevance and efficiency of the patients communication
-Pragmatics is the main target of communication tx
-similar to RHS because they are both impulsive, difficulty with abstract thinking, verbose, circumlocutory and inappropriate in their communication

59
Q

4 categories of compensatory strategies because impairments do not improve sufficiently and pt. must recognize that impairments exist

A
  • External compensations: changes in environment (pt. bothered by light, change it)
  • Situational compensations: for particular situation like missing a bus. make a list of steps for this procedure.
  • Recognition compensations: taught to recognize when they are being confused. Ex. write down key points about book not to become confused
  • Anticipatory compensations- hardest for TBI- use strategies as soon as they are aware of a possible problem
60
Q

2 categories for compensatory strategies used for memory problems

A

Internal Strategies

External Strategies

61
Q

Internal Strategies

A

-Mnemonic Devices:
Verbal chasing: put list of words to be remembered in a sentence: dog, book, rain, bus-> the dog ate the book and ran under the bus to get out of the rain
first letter mnemonic device: first letter and phrase like cranial nerves
-Imagery- mental picture to help them remember (dog eating a book and lying under bus in rain)

62
Q

External Strategies

A
  • Provide cues and reminders to compensate for memory problems (notes, checklists, audio recordings)
  • Memory reminder can be posted in appropriate places (mirror, kitchen, car)
  • Items can be placed strategically to help pt (closet, kitchen) blouse with pants
  • Environmental Compensation
63
Q

Group Treatment

A

important for TBI pts
allows to practice pragmatics
aids in orientation, support, communication and generalization

64
Q

Community Re-entry

A

final stage of TBI and preparation can take several months and typically occurs in a rehab setting

65
Q

Working with Family 1st Stage where pt is comatose

A

families need objective information as to what is the problem and what the probable outcome will be. needs to be repeated because families cannot take it all in at once

66
Q

Working with Family 2nd Stage where pt returns to consciousness

A

families need to be educated as to usual course of recovery in TBI and the stages involved

67
Q

Working with Family in 3rd Stage where pt is in rehabilitation

A

families may have a hard time adjusting to fact of slow recovery, family needs help in learning how to cope with a future with the impaired TBI pt

68
Q

Which causes more damage? Low velocity or high velocity missiles?

A

high velocity missiles cause more damage because it often leads to infection

69
Q

Which causes more damage? Non-acceleration or acceleration injuries?

A

acceleration injuries

Neuro Final Sarah (5 decks)

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