862: TBI

Rancho level I - no response

Patient appears to be in a deep sleep and is completely unresponsive to stimuli

Rancho level II - generalized response

pt reacts to stimuli inconsistently, without purpose and 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 vocalizations

Rancho level III - localized response

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, squeezing hand in an inconsistent, delayed manner

Rancho level IV - confused and agitated

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

Gross attention to environment is very brief; selective attention is often nonexistent. Pt lacks short term and long term recall

Rancho level V - confused and inappropriate

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 distractingly and lacks ability to focus attention on a specific task

With structure, may be able to converse on a social automatic level for short periods of time. Verbalization is often inappropriate and confabulatory

Memory is severely impaired; often shows inappropriate use of objects; may perform previously learned tasks with structure but is unable to learn new information

Rancho level VI - confused and appropriate

Patient 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

Memories from long in the past show more depth and detail than do more recent memories

Rancho level VII - automatic and appropriate

Pt appears appropriate and oriented within the hospital and home settings; goes through daily routine automatically, but frequently robot like

Pt 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; judgement remains impaired

Rancho level VIII - purposeful and appropriate

Patient 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 judgement in emergencies or unusual circumstances

Diffuse axonal injury

The shearing (tearing) of the brain’s long connecting nerve fibers (axons) that happens when the brain is injured as it shifts and rotates inside the bony skull

Disorders of consciousness

State where consciousness is affected due to a brain injury

Post traumatic amnesia

A state of confusion that occurs immediately following a TBI in which the injured person is disoriented and unable to remember events that occur after the injury

Primary injury

Results from brain tissue coming into contact with an object or a rapid acceleration/deceleration or rotation of the brain creating a cortical disruption

Contact injuries

Usually become contusions, lacerations, or intracerebral hematomas

This damage is focal to the area that is in contact with the skull or external object

Acceleration/deceleration or rotation injuries

Create shear, tensile, and compression forces within the brain causing a diffuse axonal injury

Normal upright posture ICP

5.9-8.3 mmHg

Normal supine ICP

0.0-16.3 mmHg

Anoxic brain damage

Occurs when the brain is deprived of oxygen either due to decreased circulation or impaired respiratory function

DOC arousal level - coma

• both arousal and awareness are present

• Patients eyes will be closed, no sleep wake cycles, no auditory or visual function, no cognitive or communication present

• Ventilator dependent

• Abnormal motor and postural reflexes may be present

DOC arousal level - unresponsive wakefulness (vegetative state)

• disassociation between arousal and awareness due to higher CNS centers not integrating with the brain stem

• Pts not aware of self or environment

• May be aroused to external stimuli

• Meaningful cognitive and communication function is absent

DOC arousal level - minimally conscious state

• evidence of self or environmental awareness

• Inconsistent but reproducible cognitively mediated behaviors that can be differentiated from reflexive behaviors

• Will localize to stimuli and may inconsistently reach for objects

• May localize to sound location and show sustained visual fixation and visual pursuit

• May inconsistently communicate thought yes/no responses

Stupor

An unresponsive state where the pt can only be aroused briefly with vigorous and repeated stimuli

Obtunded

• in this state the pt sleeps often but when aroused demonstrates decreased alertness and/or interest in the environment

• Has delayed reactions

Criteria for brain death

• cessation of circulation and respiration

• No response to stimuli

• Pupils are nonreactive

• Absent ocular reflexes

• Absent gag and cough reflexes

Paroxysmal sympathetic hyperactivity

Elevated sympathetic nervous system activity that occurs as a normal response to trauma, but in TBI this can become overactive

Symptoms: increased HR, increased RR, increased BP, diaphoresis, hyperthermia

Classification of brain injury by the GCS

• Minor brain injury: 13-15 points

• Moderate brain injury: 9-12 points

• Severe brain injury: 3-8 points

ICF: health condition (neuronal)

• recovery: restoring function in neural tissue that was initially lost after injury

• Compensation: neural tissue acquires a function that it did not have prior to injury

ICF: body functions/structure (performance)

• recovery: restoring the ability to perform a movement in the same manner as it was performed before the injury

• Compensation: performing an old movement in a new manner

ICF: activity (functional)

• recovery: successful task accomplishment using limbs or end effectors typically used by nondisabled individuals

• Compensation: successful task accomplishment using alternate limbs or end effectors