Week 11 TBI (Beta Test)

Question 1

An alteration in brain function, or other evidence of brain pathology, caused by an external force.

Answer 1

Traumatic Brain Injury (TBI)

Question 2

What are the causes of TBI from MC to LC?

Answer 2

Falls (32%)

Motor Vehicle/traffic accidents (19%)

Struck by/against events (18%)

Assaults (10%).

Question 3

In terms of age and TBI, answer the ff:
1. TBI is MC in young children aged ______

2. Hospitalization and Death as a result of TBI is MC in older adults aged ______

Answer 3

1. 0 - 4 y/o
2. > = 65 y/o

Question 4

Usually, TBI is categorized as two types of injuries. Enumerate them based on the ff definitions:
1. TBI d/t direct trauma to the parenchyma; it results from either brain tissue making contact with an object or rapid acceleration/deceleration of the brain.

2. TBI that results from a cascade of biochemical, cellular, and molecular events that evolve over time due to the initial injury and injury-related hypoxia, edema, and elevated intracranial pressure (ICP); Occurs because of a chain of cellular events that follow tissue damage in addition to the secondary effects of hypoxemia, hypotension, ischemia, edema, and elevated ICP.

Answer 4

1. Primary Injury
2. Secondary Injury

Question 5

Common areas of focal injury in Primary TBI injury are the:

Answer 5

Anterior temporal poles
Frontal poles
Lateral and inferior temporal cortices,
Orbital frontal cortices.

Question 6

This is d/t acceleration and deceleration causing shear, tensile, and compression forces within the brain; essentially the predominant MOI in most individuals with severe to moderate TBI.
 Common in high-speed MVAs; can also be seen in some sports-related TBI’s.

Answer 6

Diffuse Axonal Injury (DAI)

Question 7

DAI most often occurs in discrete areas:

Answer 7

The parasagittal white matter of the cerebral cortex
The corpus callosum
The pontine-mesencephalic junction adjacent to the superior cerebellar peduncles.

Question 8

 The acceleration/deceleration forces cause disruption of neurofilaments within the axon leading to:

Answer 8

Wallerian-type axonal degeneration.

Question 9

 Considered a signature injury of the U.S. military conflicts in the Middle East.
 Explosive device detonation -> transient shock wave produced -> causes brain damage.

Answer 9

Blast Injury

Question 10

Identify the 3 types of blast injury according to their definitions:
1. Results from the direct effect of blast overpressure on organs (in this case the brain).

2. Results from shrapnel and other objects being hurled at the individual.
3. Occurs when the victim is flung backward and strikes an object.

Answer 10

1. Primary Blast Injury
2. Secondary Blast Injury
3. Tertiary Blast Injury

Question 11

Blast related injury can result to:

Answer 11

o Edema
o Contusion
o DAI
o Hematomas
o Hemorrhage

Question 12

o ______ results from a lack of oxygenated blood flow to the brain tissue.
 It can be caused by systemic hypotension, anoxia, or damage to specific vascular territories of the brain.
 Because the rigid skull surrounds the brain, swelling, abnormal brain fluid dynamics, or hematoma can result in elevated ICP.

Answer 12

Hypoxic-ischemic injury

Question 13

Hematomas are usually classified according to their site:

Answer 13

Epidural, Subdural, or Intracerebral

Question 14

The normal value for ICP level is:

Answer 14

5 to 20 cm H2O

Question 15

Some impairments commonly associated with TBI include:

Answer 15

Neuromuscular
- Paresis
- Abnormal Tone
- Motor Function
- Postural Control

Cognitive
- Arousal level
- Attention
- Concentration
- Memory
- Learning
- Executive Functions

Neurobehavioral
- Agitation/Aggression
- Disinhibition
- Apathy
- Emotional lability
- Mental Inflexibility
- Impulsivity
- Irritability

Communication Impairment
Swallowing Impairment

Question 16

Under your neuromuscular impairments, these may present as life-long issues:

Answer 16

o UE and LE paresis
o Impaired coordination
o Impaired postural control
o Abnormal tone
o Abnormal gait

Question 17

In your neuromuscular impairments, these are the LC issues:

Answer 17

o Tremor
o Chorea
o Form and dystonic movt

Question 18

It is the mental process of knowing and applying information; controlled by the frontal lobe; Includes many complex neural processes, including arousal, attention, concentration, memory, learning, and executive functions.

Answer 18

Cognition

Question 19

These can be categorized into the following main areas: planning, cognitive flexibility, initiation and self-generation, response inhibition, and serial ordering and sequencing.

Answer 19

Executive Functions

Question 20

These are disordered arousal states seen after severe brain injury.
1. Arousal system is not functioning. The pt’s eyes are closed, there are no sleep/wake cycles, and the pt is ventilator dependent. There is no auditory or visual function and no cognitive or communicative function. Abnormal motor and postural reflexes may be present. NOT permanent.

2. There is disassociation between wakefulness and awareness. The higher CNS centers are not integrated with the brainstem. The brainstem can manage basic cardiac, respiratory, and other vegetative functions and the pt can be weaned off the ventilator. Sleep/wake cycles are present. The eyes may be open though awareness of surroundings is absent, and sleep/wake cycle is present. Pt’s may startle to visual or auditory stimuli and briefly orient to sound or visual stimuli. Meaningful cognitive and communication function is absent. Reflexive smiling/crying may be present.
3. • There is minimal evidence of self or environmental awareness.
     
     • Cognitively mediated behaviors occur inconsistently and are reproducible or sustained such that they can be differentiated from reflexive behaviors.
     • Sleep/wake cycles are present. However, instead of withdrawing or posturing to noxious stimuli, pt’s will localize to noxious stimuli and may inconsistently reach for objects.
     • Pt’s may localize to sound location and demonstrate sustained visual fixation and visual pursuit.

Answer 20

1. Coma
2. Vegetative State
3. Minimally Conscious State

Question 21

• Pt’s in a permanent vegetative state may have no meaningful motor or cognitive function and a complete absence of awareness of self or the environment for a period greater than __ year after TBI and greater than __ months after anoxic brain injury.

Answer 21

1 year; 3 months

Question 22

 Commonly used terms to describe other altered LOCs.
1. It is an unresponsive state from which the patient can be aroused only briefly with vigorous, repeated sensory stimulation

2. Pt sleeps often and when aroused exhibits decreased alertness and interest in the environment and delayed reactions.

Answer 22

1. Stupor
2. Obtunded

Question 23

 Elevated sympathetic nervous system activity occurs as a normal response to trauma; following TBI this response may become overactive.
 Inc sympathetic activity results in inc HR, RR, and BP; diaphoresis; and hyperthermia.

 Other symptoms include decerebrate and decorticate posturing, hypertonia, and teeth grinding.
o The term paroxysmal sympathetic hyperactivity accurately describes this phenomenon.

Answer 23

Dysautonomia

Question 24

 For adults with severe injury, _____ (an anticonvulsant) is effective in decreasing the risk of early post-traumatic seizures.

Answer 24

Phenytoin

Question 25

 TBI is generally categorized as severe, moderate, or mild using the ____
o Developed by Teasdale and Jennett, it is the most widely used clinical scale that measures level of consciousness and helps define and classify the severity of injury.

Answer 25

Glasgow Coma Scale (GCS)

Question 26

What are the GCS scores based on the ff categories:
1. Severe Brain Injury:
2. Moderate Brain Injury
3. Mild Brain Injury:

Answer 26

1. Severe Brain Injury: 8 or less
2. Moderate Brain Injury: 9 - 12
3. Mild Brain Injury: 13 - 15

Question 27

 Unfavorable outcome is defined as dead, vegetative state, or severe disability as measured by the _____

Answer 27

Glasgow Outcome Scale (GOS)

Question 28

 Duration of ____ (PTA), the length of time between the injury and the time at which the patient is able to consistently remember ongoing events, is also an important factor in predicting recovery.

Answer 28

Post-traumatic amnesia

Question 29

Your post-traumatic amnesia (PTA) can be measured with:

Answer 29

The Galveston Orientation and Amnesia Test (GOAT), or Orientation Log (O-Log).

Question 30

___ TBI often results in a functional injury of the CNS rather than a structural one, which is thought to be due to metabolic dysfunction.
o Fortunately, most individuals fully recover in approximately 3 months.

Answer 30

Mild TBI

Question 31

Identify your Rancho Los Amigos Level’s of Cognitive Function on the ff definitions:
1. Pt appears to be in a deep sleep and is completely unresponsive to any stimuli.

2. Pt reacts inconsistently and nonpurposefully to stimuli in a nonspecific manner. Responses are limited and often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and/or vocalization
3. Pt reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as closing eyes or squeezing hand in an inconsistent, delayed manner.
4. Pt is in a heightened state of activity. Behavior is bizarre and nonpurposeful relative to immediate environment. Does not discriminate among persons or objects; is unable to cooperate directly with treatment efforts. Verbalizations frequently are incoherent and/or inappropriate to the environment; confabulation may be present.

Answer 31

1. I No Response
2. II Generalized Response
3. III Localized Response
4. IV Confused-Agitated

Question 32

Identify your Rancho Los Amigos Level’s of Cognitive Function on the ff definitions:
1. Pt is able to respond to simple commands fairly consistently. However, with increased complexity of commands or
lack of any external structure, responses are nonpurposeful, random, or fragmented. Demonstrates gross attention to the environment but is highly distractible and lacks ability to focus attention on a specific task.

2. Pt shows goal-directed behavior but is dependent on external input or direction. Follows simple directions consistently and shows carryover for relearned tasks such as self-care. Responses may be incorrect due to memory problems, but they are appropriate to the situation. Past memories show more depth and detail than recent memory.
3. Pt appears appropriate and oriented within the hospital and home settings; goes through daily routine automatically,
   but frequently robot-like. Patient shows minimal to no confusion and has shallow recall of activities. Shows carryover for new
   learning but at a decreased rate. With structure is able to initiate social or recreational activities; judgment remains impaired.
4. Pt is able to recall and integrate past and recent events and is aware of and responsive to environment. Shows carryover for new learning and needs no supervision once activities are learned. May continue to show a decreased ability relative to premorbid abilities, abstract reasoning, tolerance for stress, and judgment in emergencies or unusual circumstances.

Answer 32

1. Confused-Inappropriate
2. Confused-Appropriate
3. Automatic-Appropriate
4. Purposeful-Appropriate

Question 33

Identify the Principles of Experience-Dependent on Neuroplasticity
1. Failure to drive specific brain
functions can lead to functional degradation.

2. Training that drives a specific
   brain function can lead to an
   enhancement of that function.
3. The nature of the training
   experience dictates the
   nature of the plasticity.
4. Induction of plasticity requires
   sufficient repetition.
5. Induction of plasticity requires
   sufficient training intensity

Answer 33

1. Use It or Lose It
2. Use It and Improve It
3. Specificity
4. Repetition
5. Intensity

Question 34

Identify the Principles of Experience-Dependent on Neuroplasticity
1. Different forms of plasticity
occur at different times during
training.

2. The training experience must
   be sufficiently salient to induce
   plasticity.
3. Training-induced plasticity
   occurs more readily in younger
   brains.
4. Plasticity in response to one
   training experience can
   enhance the acquisition of
   similar behaviors
5. Plasticity in response to one
   experience can interfere with
   the acquisition of other
   behaviors.

Answer 34

1. Time Matters
2. Salience Matters
3. Age Matters
4. Transference
5. Interference