Gen Med - TBI

TBI peaks at which 3 age levels

- 1 to 2 years

- 15 to 24 years

- Elderly

TBIs ages 1-2 are often related to

Child abuse

TBIs in 15-24 are often related to

Risk taking

TBIs in elderly are often related to

Falls

A closed head injury often occurs when

Soft tissue of the brain is forced in contact with the hard, bony skill

In a closed head injury, there is focal injury to the

Cerebral hemispheres or brainstem localized to the area under site of impact

What is a coup-countrecoup injury

Damage to the opposite end of the brain during impact as the brain bounces off the inside of the skull

Grey matter contains

Neuron cell bodies and dendrites

White matter contains

Myelinated axons

Open head injury occurs when

The skull and meninges have been disrupted leaving the brain exposed

What are the mechanisms of injury of an OHI

- Penetrating missile injuries

- Scalp lacerations

- Compound fractures

- Usually focal brain damage

Acute management of a brain injury consists of

- Rapid triage

- Resuscitation

- Stabilization to prevent secondary spinal injuries

- Efficient transport

Level of consciousness

Glasgow coma score

Which signs are valuable in localizing brain stem damage and depth of coma

Oculomotor and pupillary

Anything greater than _ difference in size or asymmetry should be considered abnormal with pupillary signs

1mm

X-rays reveal

Skull fractures

CT scans reveal

Presence of hemorrhage, swelling, or infarction

MRIs allow for

Sensitive detection of mild TBI

PET scan can identify

Structural and functional consequences of mild TBI

EEC is most valuable for

Indicating seizure activities

EECs can be useful for predicting

Coma outcomes

Common complications of a TBI includes

- Pressure changes

Pressure change in the head is primarily due to

A lack of oxygen in brain tissue

Increased ICP is a result of

Swelling or intracranial hematoma

PTA on the glasgow coma scale is

Post traumatic amnesia

Normal ICP pressure is

4-15 mmHg

ICP pressure greater than _ is associated with increased morbidity

20 mmHg

Pressure changes are generally monitored in patients with

GSC of 7 or less or abnormal CT scan

Distortion of the brain can occur because

Fluid is contained in a rigid skull leaving no room for expansion

Increased intracranial pressure can lead to

Herniation of the brain

The most common herniation of the brain is the

Lateral tentorial membrane separating from the cerebral hemisphere from the posterior fossa

Compression of the brain stem and other structures can lead to

Paralysis and death

Pharmacological acute management of a TBI includes drugs that

Decrease ICP and BP

Elevated ICP greater than 20 mmHg is a significant predictor of

Poor outcome

Cerebral fluid volume can be controlled with

Mannitol to control blood volume

Cerebral edema can be treated with

Glucorticoids

Patients that have a TBI should keep their systolic pressure at a minimum of

90 mmHg

What drug is effective at maintaining systolic stability in TBI patients

Phenylephrine

What is a craniotomy

A removal of a portion of the skull so that the brain has room to swell

Pressure on brain tissue is created from

Swelling or hematoma

Perfusion refers to the

Perfusion in the brain tissue itself

What is perfusion

The passage of fluid through an organ or tissue

Intracranial hypertension can interfere with perfusion by

Lowering the cerebral perfusion pressure

Under normal circumstances cerebral perfusion pressure is maintained at

50-150 mmHg

Brain swelling can occur from

An increase in intravascular blood within the brain as a result of vasodilation and increased cerebral volume

Brain edema is

An increase in extravascular brain fluid

Compressive damage may occur when

The brain shifts from its normal symmetrical position

Brain shifting may cause

Compression of the brain stem, pituitary gland, or other structures in the brain

What are things to look for in TBI patients

- Arousal level

- Confusion or disorientation

- Changes in neurological status, posture, and tone

- Changes in bodily functions

- Monitor for signs of infection (open wound)

What are the clinical manifestations of a TBI

- Area specific

- Sensory impairments

- Abnormal tone

- Cognitive/behavioral impairment

- Balance/vestibular/coordination impairment

- Communication/speech impairment

- Visual-perceptual impairments

- Swallowing impairments

What functions does the frontal lobe control

- Voluntary movement

- Motor integration

- Expressive language

- Social functioning

- Inhibition of impulse

- Emotions

- Lack of initiative

- Short term memory

What functions does the temporal lobe control

- Hearing

- Smell

- Long term memory

- Receptive language

- Musical awareness

What functions does the parietal lobe control

- Sensation

- Comprehension of speech and reading

- Production of writing and calculation

- Awareness of spatial relationships

The occipital lobe is in charge of

Visual perception

The cerebellum is in charge of

Balance and coordination

The brainstem is responsible for

- Appetite

- Chewing and swallowing

- Hearing and balance

- Wakefulness

- Motor speech

- Upper intestine peristalsis

- Regulation of pulse, respiration, and BP

- Vision

- Eye and eyelid movement

- Smell

- Facial and neck muscle movement

- Facial sensation

- Taste

Decorticate positioning

Decerebrate positioning

The glasgow coma scale is scored from

3-15

A GSC score of 8 or less indicates

Coma/severe head injury

A GCS score of 9-12 indicates

Moderate head injury, PTA>24 hours, LOC>30 min

A GCS of 12-15 indicates

Mild head injury, PTA<24 hours, LOC <30 min

Cognitive impairments include

- Problems with attention, memory, concentration, executive function

- Learning disorder, complex information processing, loss of abstract thinking and complex problem solving

- Confusion and disorientation

- Mood disturbances, depression, and anxiety

- Difficulty adjusting to environmental changes, erratic wandering, motor and verbal preservation

- Imitation of gestures, restlessness, refusal to cooperate

- Impulsiveness and hyperactivity

- Behavioral changes including irritability, agitation, acting out

- Sexual inappropriateness

- Lack of inhibition of social behaviors

- Emotional liability

- Confabulation

What is retrograde amnesia

The partial or total loss of the ability to recall events that occurred during the period immediately preceding the head injury

What is posttraumatic amnesia

The time lapse between the injury and the point where memory returns

What is anterograde memory

The ability to form new memory

Loss of _ is common in TBI

Anterograde memeory

Rancho levels of cognitive function ranges from

Level 1 to 10

Level _ of cognitive function is common in TBI patients

4

Level 1 of cognitive function indicates

No response; complete absence of observable change in behavior when presented with stimuli

Level 2 of cognitive function indicates

Generalized response; Generalized reflex response to stimuli, but may be the same regardless of type or location of stimuli

Level 3 of cognitive function indicates

Localized response; Demonstrates withdrawal or vocalization to painful stimuli and may respond differently to different stimuli

Level 4 of cognitive response indicates

Confused and agitated; alert and heightened state of activity, absent short term memory, non-purposeful movements, may cry and scream out of proportion to stimulus; aggressive behavior, and unable to cooperate with treatment efforts

Level 5 of cognitive response indicates

Confused-inappropriate; alert but not agitated, may become agitated to external stimulus, not oriented, impaired recent memory

Level 6 of cognitive function indicates

Confused-appropriate; inconsistently oriented, able to attend to highly familiar tasks in non distracting environment, vague recognition of staff, emerging awareness

Level 7 of cognitive function indicates

Automatic-appropriate; Consistently oriented, minimal supervision for new learning, able to attend to highly familiar tasks, carry over to new learning, initiates and carries out routines.

Level 8 of cognitive function indicates

Purposeful-appropriate; Consistently oriented, independently attends to familiar tasks, able to recall and integrate past and recent events, uses assistive memory devices to recall daily schedule

Level 9 of cognitive function indicates

Purposeful-appropriate; SBA on request; independently shifts back and forth between tasks and completes them, uses assistive memory devices, initiates and carries out familiar personal work, aware of and acknowledges impairments

Level 10 of cognitive function indicates

Purposeful-appropriate, Mod I; Able to handle multiple tasks simultaneously, independently procure and maintain assistive memory devices, independently initiates and carries out familiar work, anticipates impact of impairments

If sensory impairments are present in TBI patients, the pt and family should be educated on

Protecting the skin

TBi patients should be encouraged to attend to the

Involved side

Family and visitors should approach TBI patients on the

Involved side

TBI patients should get up on the

Involved side

When performing ROM exercises with TBI patients, give

Extra tactile input on the involved extremity

Which movements should have emphasis placed upon them in ROM exercises

- DF

- Knee extension

- Hip extension

TBI patients should be in _ as much as possible

Sitting or standing

Patients who have a TBI need _ on a regular basis

Orientation reminders

TBI injury severity is one of the main factors that determines

Outcome

What are factors that indicate a more favorable prognosis in TBI

- Absence of substance abuse

- Absence of previous TBI

- Higher education

- Stable work history

What condition might indicate brainstem damage and is associated with poor outcome

Loss of pupillary light reflex

What kind of deficits reflect cerebral damage consistent with severe cognitive deficits

Oculomotor

Within 7 days, the occurrence of _ is often related to poor outcome

Epilepsy

After the age of _, TBI patients have worse functional outcomes

40

Better TBI outcomes are possible is rehab is started

ASAP

PTA is better related to outcome than

Lesion size

What is a vegetative state

A persistent state characterized by reduced responsiveness associated with wakefulness

What is a severe disability

When the patient is conscious but requires 24 hour dependence

When assigning a level of cognitive function, it is necessary to

Observe an individual at different times of the day and in different settings