Week 2- TBI Flashcards
PART 1: TBI INTRODUCTION
PART 1: TBI INTRODUCTION
What is a TBI and what can cause it?
- A TBI is an injury that disrupts the normal function of the brain. It can be caused by a bump, blow, or jolt to the head or a penetrating head injury.
- Explosive blasts can also cause TBI, particularly among those who serve in the U.S. military.
- What is the mortality rate for severe TBI?
- What is the mortality rate for moderate TBI?
- 30-50%
- 10-15%
What populations are more at risk for TBI?
- Children
- Older Adults
- Men > Women 2:1
What are some additional groups that are at higher risk for a TBI?
- Racial and ethnic minorities
- Service members/veterans
- Homeless
- Incarcerated individuals
- Domestic abuse
- Rural areas
What are the (4) most common causes of TBI?
- MVA
- Falls
- Acts of violence
- Sports
What are the 2 categories in which our brain can be injured?
- Traumatic Brain Injury (TBI)
- Acquired Brain Injury (ABI)
What are the mechanisms of TBI? (4)
- Open head injury
- Closed head injury
- Deceleration injuries
- Hemorrhage/Hematoma
What are the mechanisms of ABI? (4)
- Chemical/toxic
- Hypoxia
- Tumor
- Infections
What is the difference between open injuries and closed injuries?
- Open injuries result from penetrating types of wounds where the skull is fractures or displaced or meninges are compromised.
- Closed injuries result from impact to the head but the skill is not fractured. Only cortical neuronal tissue is damaged.
- In which type of injury are meninges compromised?
- In which type of injury are cortical neuronal tissues damaged?
- Open
- Closed
With open and closed injuries, ________ Brain Damage is a result of the mechanical issue at the time of trauma.
Primary
Within Primary Brain Damage, what are the 2 types of injuries?
- Focal
- Diffuse
List the types of FOCAL injuries.
- Hematomas (Epidural and Subdural)
- Hemorrhages (Subarachnoid and Intracerebral)
- Coup Lesion
- Contrecoup Lesion
What is the difference between a hematoma and a hemorrhage?
A hematoma usually describes bleeding which has more or less clotted, whereas a hemorrhage signifies active, ongoing bleeding.
- ________ Hematomas occur between the dura mater and the skull.
- ________ Hematomas involve a rupture to the cortical bridging veins.
- Epidural Hematoma (EDH)
- Subdural Hematoma (SDH)
What is the classic presentation often seen post Epidural Hematoma?
- Unconscious, Alert, Deteriorate
- Patients lose consciousness, snap back and are with you, then rapidly start to deteriorate again.
What is the most common focal injury seen with geriatric population when they fall?
-Subdural Hematoma
What is the classic presentation often seen post Subdural Hematoma?
-Slow deterioration, little rattled after fall and may be ok after a couple of days. Family member usually notices that they are out of it.
- _______ Hemorrhages occur between the arachnoid and brain tissue.
- ________ Hemorrhages occur within the brain tissue itself.
- Subarachnoid Hemorrhage (SAH)
- Intracerebral Hemorrhage (ICH)
How are hemorrhages from strokes and TBIs different?
-They are almost entirely the same and can occur intracerebrally or in the subarachnoid space.
What type of focal injury is most life threatening?
- Subarachnoid Hemorrhage (SAH)
- 1/3 survive with good recovery, 1/3 survive with a disability, 1/3 will die
Does a bleed from a trauma or a rupture bleed faster?
-Trauma
What is a common sequela of SAH?
-vasospasm
What is a contusion?
-Bruising on the surface of the brain sustained at the time of impact. (small vessels on the surface of the brain hemorrhage)
What is the difference between a coup lesion and contrecoup lesion?
- Coup Lesion is a contusion on the same side of the brain as the impact.
- Contrecoup Lesion is surface hemorrhages on the opposite side of the brain trauma as a result of deceleration.
- More often than not we have both Coup and Contrecoup Lesions at the same time. What is this called?
- What are the most common structures involved?
- Coup-Contrecoup Injuries
- Anterior poles, underside of temporal and frontal lobes
With Coup-Contrecoup injuries, the __________ injury is most often worse.
-Contrecoup
- What is the main diffuse injury often seen with TBIs?
- What is the most common cause?
- Diffuse Axonal Injury
- Acceleration/Deceleration such as MVA
- Diffuse Axonal Injuries result in traumatic “______ ______” and have SIGNIFICANT __________ involvement.
- What are the most affected areas?
- “micro bleeds”, neurological
- corpus callosum, basal ganglia, brainstem, cerebellum
PART 2: SECONDARY INJURY AND ACUTE COMPLICATIONS
PART 2: SECONDARY INJURY AND ACUTE COMPLICATIONS
With open and closed injuries, ________ Brain Damage is caused by physiological responses to initial injury.
-Secondary
What are the 2 ways we can find ourselves in the Secondary Brain Damage?
- Ongoing increases in ICP causing swelling and mass effect with more damage to brain and higher rates of herniation and death.
- Acquired Brain Injuries
List some of the most common Acquired (non-traumatic) Brain Injuries.
- Stroke
- Infectious Disease
- Seizure
- Electric Shock
- Tumors
- Toxic Exposure
- Metabolic Disorders
- Neurotic Poisoning
- Lack of Oxygen
- Drug Overdose
- What is THE most common causes of ABIs?
- What is the most common cause of Anoxic/Hypoxic Injuries?
- Anoxic/Hypoxic Injury
- Cardiac Arrest
- Anoxic/Hypoxic injuries typically result in _______ damage and is associated with poor prognosis for _________ function.
- What are the more vulnerable areas with hypoxic/anoxic injuries?
- global damage, poor prognosis for cognitive function
- hippocampus, cerebellum, basal ganglia
What are the (3) classifications of blast injuries?
- Primary- Direct effect of blast overpressure on organs.
- Secondary- Shrapnel injury.
- Tertiary- Direct blow to head.
Acute Management of Brain Injury. (5)
- Diagnostic Imaging (MRI, CT, PET, EEG)
- Medication Management
- Surgical Management
- Secondary Complications
- Trauma Management
When will an EEG scan be used with these patients?
-If seizures exist.
What are the ways medication is used to manage these patients?
- ↓ BP and ICP
- ↓ Intracranial bleeding
- Anti-seizure
- ↓ body temperature
- ↓ infection rate
Why are hypothermic medications used?
-Due to hypothermia known neuroprotective effect.
What are some common secondary complications with these patients? (4)
- Increased ICP
- Post-Traumatic Seizures
- Dysautonomia
- Heterotropic Ossification
Increased ICP:
- __% of patients with serious injuries have ↑ICP.
- Increased pressure can compress brain tissue, decrease perfusion to brain tissues or possible herniation.
- Normal ICP = __-__ mm Hg
- Abnormal ICP + > __ mm Hg
- 70%
- 5-10mmHg
- > 20 mmHg
What are some activities that increase ICP?
- Full supine or Trendelenburg
- Cervical flexion
- Percussion and vibration
- Valsalva (coughing, sneezing, holding breath)
- Exertional activities
What are the S/Sx of increased ICP? (7)
- Decreased responsiveness
- impaired consciousness
- severe HA
- vomiting
- irritability
- papiledema
- ↑ BP and ↓ HR
If a patient has any ICP >___ mmHg do not touch them due to the risk.
-20mmHg
What are some events that trigger seizures?
- Stress
- Poor nutrition
- Electrolyte imbalance
- Missed medication or drug use
- Flickering lights
- Infection
- Fever
- Anxiety
What is the golden rule for treating patients with seizures?
-Patients need to be seizure free for 24 hours before mobilization is allowed.
What is dysautonomia?
-Umbrella term for anything that goes wrong with autonomic system.
-TBI survivors in the acute stages are at risk for PAID, what is this?
- Paroxysmal Autonomic Instability and Dystonia (“Sympathetic Storming”)
- Typically seen in severe TBI (GCS 3-8)
PAID (“Sympathetic Storming”) involves alterations in level of __________, __________, dystonia, HTN, hyperthermia, tachyardia, tachypnea, diaphoresis, and agitation.
-consciousness, posturing
- How is PAID diagnosed?
- How is it managed?
- Diagnosed via clinical observation.
- Managed via symptom management w/ medication “ride out the storm”.
- What is heterotopic ossification?
- Involved in __-__% of TBIs.
- Formation of abnormal bone growth around joint tissue.
- 10-20%
Heterotopic ossification onsets around __-__ weeks after brain injury and the cause is _______.
- 4-12 weeks
- unknown
What is the clinical presentation of patients with heterotopic ossification?
- Initial signs are loss of ROM and pain in joint area.
- Local erythema, pain with movement, swelling, warm to touch.
- Severe HO may result in vascular and/or nerve compression.
What PT interventions are utilized to help manage Heterotopic Ossification (HO)?
-PROM and stretching to maintain ROM and prevent further complications.
HO is mainly treated with medication, however, after ~___ years after injury surgical excisions are performed.
-1.5 years (recurrence possible)
Additional complications with TBI:
- 50% _________ difficulties
- 45% genitourinary deficits
- 34% ________ problems
- 32% ________ problems
- 21% dermatological impairments
- urinary and bowel incontinence
- hydrocephalus
- 50% GI difficulties
- 34% respiratory problems
- 32% CV problems
PART 3: CLINICAL MANIFESTATIONS OF TBI
PART 3: CLINICAL MANIFESTATIONS OF TBI
The extreme variability when treating patients with TBI has to do with what things?
- Brain injury can occur anywhere in the head.
- There are a bunch of types of brain injuries.
- Additional level of high medical complications.
- Next level of cognitive/behavioral considerations.
There are a bunch of similarities between clinical presentation of _______ and TBI.
-stroke
Clinical presentation of Frontal Lobe TBIs.
- Initiation
- Problem solving
- Judgement
- Inhibition of behavior
- Planning/anticipation
- Self-monitoring
- Motor planning
- Personality/emotions
- Awareness of abilities/limitations
- Organization
- Attention/concentration
- Mental flexibility
- Speaking (expressive language)
Clinical presentation of Temporal Lobe TBIs.
- Memory
- Hearing
- Understanding language
- Organization and sequencing
Clinical presentation of Parietal Lobe TBIs.
- Sense of touch
- Differentiation (size/shape/color)
- Spatial perception
- Visual perception
Clinical presentation of Brain Stem TBIs.
- Breathing
- Heart rate
- Arousal/consciousness
- Sleep/wake functions
- Attention/concentration
Clinical presentation of Occipital Lobe TBIs.
-Vision
Clinical presentations of Cerebellum TBIs.
- Balance
- Coordination
- Skilled motor activity
_________ deficits often take the front seat with regards to disability with TBIs. Unlike strokes, TBI patients often do well recovering from neuromuscular deficits.
-Cognitive
- What is meant when talking about “Walkie-Talkie Patients”?
- These patients may fill in info with fabricated stories, what is this?
- May be able to ambulate independently without an AD negotiating barriers but might not know their name or family members.
- Confabulation
What are the 5 categories of attention?
- Focused
- Sustained
- Selective
- Alternating
- Divided
S/Sx of impaired attention.
- Unable to engage on relevant or functional information.
- Unable to sustain attention to task.
- Unable to switch to ____ task.
- Unable to resist __________.
- Unable to _________.
- Unable to manipulate mental information while maintaining overarching goal in mind.
- new
- distraction
- multitask
What are 3 additional cognitive impairments seen with TBIs?
- Memory
- Executive Function
- Language
Memory Deficits:
- _________ and/or ________ amnesia.
- _____ term > ______ term memory deficits.
- _________ and ________ memory often both difficult.
- retrograde and/or anterograde amnesia
- short-term > long-term
- Declarative and procedural
- Language deficits are generally ___-______ in nature and related to _________ impairment.
- What are some common language deficits seen with TBI patients?
- non-aphasic, cognitive
- Disorganized and tangential oral and written communication, imprecise language, word-retrieval difficulties, disinhibited language.
- What is the most enduring and socially disabling of impairments after TBI?
- These issues are very prominent in patients classified as having Rancho ___ and ____ brain injuries.
- Behavioral Issues
- Rancho IV and V
Frontal Lobe Syndromes are also known as “__________ Syndrome”.
-Dysexecutive Syndrome
What are the 2 commonly presenting dysexecutive syndromes?
- Orbitofrontal Lobe Syndrome
- Frontal Convexity Syndrome
These symptoms describe which Dysexecutive Syndrome?
- Impulsive
- Inappropriate jocular affect, euphoria
- Emotional lability
- Poor judgement and insight
- Distractibility
-Orbitofrontal Lobe Syndrome
These symptoms describe which Dysexecutive Syndrome?
- Apathy
- Indifference
- Psychomotor retardation
- Motor perseveration and impersistence
- Stimulus-bound behavior
- Motor programming deficits
- Poor word list generation
-Frontal Convexity Syndrome
What are some motor and sensory impairments we can see with TBIs?
- Strength deficits
- Tone Abnormalities
- Sensory deficits
In regards to strength deficits, more _____ lesions result in hemiparesis/hemiplegia while ______ lesions are more characterized by motor control and coordination deficits over true strength deficits.
- focal
- diffuse
- In regards to tone abnormalities, posturing results from injury to the ________.
- __________ Rigidity = LE ext/UE flex
- __________ Rigidity = LE and UE ext
- brain stem
- Decorticate
- Decerebrate
With sensory deficits, ________ and __________ deficits are most common.
-Proprioceptive and Kinesthetic
What structures are also in the brainstem and are important to test if we have a TBI?
-Cranial Nerves
- CN__ is damaged in 7% of all TBIs.
- Intact pupillary response indicates injury is above level of ________.
- CN1
- brainstem
- Conjugate gaze palsy = CNS or PNS?
- Unilateral gaze palsy = CNS or PNS?
- Tonic downward gaze = injury to ______, ______, or ____.
- Tonic upward gaze = injury to both ________.
- Rapid horizontal eye movement = _______ activity.
- Conjugate gaze palsy = CNS
- Unilateral gaze palsy = PNS
- thalamus, midbrain, or pons
- both hemispheres
- seizure activity
- Damage to what cranial nerve results in loss of sensation to the nose, eyebrow, and forehead.
- Damage what cranial nerve causes muscle weakness, loss of tear production, decreased saliva secretion, and taste.
- CN5 (trigeminal)
- CN7 (facial)
As many as 50% of people who have a TBI report signs of what?
-Vestibular Dysfunction (dizziness and imbalance)
Vestibular rehabilitation may take up to ___ as long as those without a TBI.
-3x
- What is a “Labyrinthine Concussion”?
- It is often related to the development of _______.
- Damage to the inner ear due to head trauma with no well-defined injury or skull fracture, resulting in sensorineural hearing loss with or without vestibular symptoms.
- BPPV
Autonomic dysfunction is common post TBI. What are some common ANS symptoms seen with TBI?
- HR variability
- RR variability
- Elevated body temp
- BP changes
- Excessive sweating, salivation, tearing
- Dilated pupils
- Vomiting
- Anxiety, panic disorder, and PTSD all tied to autonomic system imbalance
___% of individuals with TBI will have other injuries which increase the complexity of the rehabilitation program.
-40%
PART 4: OUTCOME MEASURES AND PROGNOSIS
PART 4: OUTCOME MEASURES AND PROGNOSIS
What are the 2 things our TBI outcome measures revolve around?
-Arousal and Cognition
What are the main outcome measures used for arousal and cognition? (7)
- Glasgow Coma Scale (GCS)
- Ranchos Los Amigos Levels of Cognitive Function (LOCF)
- Rappaport’s Disability Rating Scale (DRS)
- Glasgow Outcome Scale (GOS)
- Galveston Orientation and Amnesia Test (GOAT) and Orientation Log (O-Log)
- Coma Recovery Scale (CRS-R)
- Disorders of Consciousness Scale (DOCS)
What are the (3) things that GCS measures?
- Pupillary Response
- Motor Activity
- Ability to Verbalize
How is the GCS scored?
- 3-8 = severe
- 9-12 = moderate
- 13-15 = mild
GCS Scoring- Mild
- GCS = __-__
- LOC = _____
- _______ alteration of consciousness
- Post traumatic amnesia
- GCS = 13-15
- LOC = 0-30 minutes
- Brief (<24hrs) alteration of consciousness
- Post traumatic amnesia <1 day
- Imaging = normal
GCS Scoring- Moderate
- GCS = __-__
- LOC = _____
- Alteration of consciousness >_____
- Post traumatic amnesia _______
- Imaging = _______
- GCS = 9-12
- LOC = >30 minutes but < than 24hrs
- Alteration of consciousness > 24hrs
- Post traumatic amnesia >1 day but <7 days
- Imaging = normal or abnormal
GCS Scoring- Severe
- GCS = __-__
- LOC = _____
- Alteration of consciousness >_____
- Post traumatic amnesia >_______
- Imaging = _______
- GCS = 3-8
- LOC = >24hrs
- Alteration of consciousness > 24hrs
- Post traumatic amnesia >7 days
- Imaging = normal or abnormal
- The DRS is a ___ point scale that tracks progress for patients in a coma through community integration phase and can predict return to work.
- What is the scoring?
- 30 point scale
- Higher scores = higher level of disability
The DRS evaluates 8 areas of function in what 4 categories?
- Consciousness (eye opening, verbal, motor)
- Cognitive ability (feeding, toileting and grooming)
- Independence/ dependence level of function
- Employability
The GOS is a 8 level global scale for functional outcome that rates patient status into what 5 categories?
- Dead
- Vegetative State
- Severe Disability
- Moderate Disability
- Good Recovery
List some prognostic indicators for TBI.
- Age/gender
- GCS score
- Length of PTA (post-traumatic amnesia)
- Traumatic over acquired (vascular/anoxic)
- Higher education level/pre-injury IQ
- Early use of neurostimulants
- Presence of pre-injury psychological issues or substance abuse
- GOS: Level 1-3
What are the (4) aspects of community integration?
- Assimilation
- Social Support
- Occupation
- Independent Living
TBI Residual Impairments:
- Decreased ________ inhibitions (lack of filter)
- Impaired ______ control
- Impaired ________, ______, sequencing and high level problem solving
- Perseveration or word finding issues
- Impaired ______
- Impaired _______ or calculating ability
- ________ impairments (return to driving issues)
- _______/routing issues
- _______ issues/incoordination
- Decreased social inhibitions (ie. Lack of filter)
- Impaired motor control
- Impaired attention, memory, sequencing & high level problem solving
- Perseveration or word finding issues
- Impaired speech
- Impaired writing or calculating ability
- Vision impairments (return to driving issues, etc)
- Topographic/ routing issues
- Balance issues, incoordination
