TBI flashcards

Falls

What is the leading cause of TBI?

>75

What age is at greatest risk of TBI?

>65

Hospitalization and death as a result of TBI is most common in what age?

Motor vehicle accidents

Most common cause of moderate to severe TBI in younger adults?

Falls

Most common cause of TBI in older adults?

5 years

One in five individuals who receive inpatient rehabilitation services post-TBI die within __.

external forces that cause brain tissue to make direct contact with an object

rapid acceleration or deceleration forces

blast waves from explosion

Pathophysiological mechanisms of TBI

primary injury

due to direct trauma to the parenchyma

secondary injury

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 ICP.

contact injuries

often result in contusions, lacerations, and intracerebral hematomas.

primary injury

This damage is generally focal in nature as the brain comes into contact with bony protuberances on the inside surface of the skull or damage from the penetrating object.

anterior temporal poles, frontal poles, lateral and inferior temporal cortices, and orbital frontal cortices

Common areas of primary injury (focal injury)

diffuse axonal injury

the predominant mechanism of injury in most individuals with severe to moderate TBI

diffuse axonal injury

It is common in high-speed motor vehicle accidents and can be seen in some sports-related TBI.

parasagittal white matter of the cerebral cortex, corpus callosum, and pontine-mesencephalic junction

DAI most often occurs in discrete areas such as:

Wallerian-type axonal degeneration

The acceleration/deceleration forces disrupt neurofilaments within the axon, leading to __.

blast injury

__ is considered a signature injury of the U.S. military conflicts in the Middle East.

primary blast injury

results from the direct effect of blast overpressure on organs (in this case the brain)

secondary blast injury

results from shrapnel and other objects being hurled at the individual,

tertiary blast injury

occurs when the victim is flung backward and strikes an object

direct transcranial blast wave propagation

transfer of kinetic energy from the blast wave through the vasculature, which triggers oscillation in the blood vessels leading to the brain

elevations in cerebrospinal fluid

three mechanisms by which primary blast brain injury may occur:

secondary cell death

This occurs as a result of a chain of cellular events that follow tissue damage in addition to the secondary effects of hypoxemia, hypotension, ischemia, edema, and elevated ICP.

release of glutamate and other excitatory neurotransmitters exacerbates ion-channel leakage

This contributes to brain swelling and raised ICP.

hypoxic-ischemic injury

This 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.

elevated ICP

the rigid skull surrounds the brain, swelling, abnormal brain fluid dynamics, or hematoma can result in __.

5 to 20 mmHg

Normal ICP

uncal, central, and tonsillar

common types of herniation

UE and LE paresis, impaired coordination, impaired postural control, abnormal tone, and abnormal gait

Give examples of lifelong neuromuscular impairments

frontal lobes

many cognitive functions are controlled in the __. This makes people with TBI particularly susceptible to cognitive impairments.

unresponsive wakefulness

__ has been proposed for use in place of vegetative state; however, it has not yet gained wide acceptance.

coma

Many severe injuries begin with __, where the arousal system is not functioning.

False

T/F: A coma is usually permanent.

vegetative state

there is disassociation between wakefulness and awareness.

brain stem

this manages the basic cardiac, respiratory, and other vegetative functions, and the patient can be weaned off the ventilator.

coma

The patient’s eyes are closed, there are no sleep/wake cycles, and the patient is ventilator dependent. There is no auditory or visual function and no cognitive or communicative function.

vegetative state

Sleep/wake cycles are present. The eyes may be open, though awareness of surroundings is absent. Patients 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. A withdrawal response to noxious stimuli is present. Although patients in a vegetative state may appear to have purposeful movements, they are merely reflexive in response to external stimuli. Movement will also not be reproducible.

permanent vegetative state

no meaningful motor or cognitive function and a complete absence of awareness of self or the environment for a period greater than 1 year after TBI and greater than 3 months after anoxic brain injury.

minimally conscious state

there is some 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. Similar to a vegetative state, sleep/wake cycles are present. However, instead of withdrawing or posturing to stimuli, patients in a minimally conscious state will localize to stimuli and may inconsistently reach for objects. Patients may localize to sound location and demonstrate sustained visual fixation and visual pursuit.

stupor

is an unresponsive state from which the patient can be aroused only briefly with vigorous, repeated sensory stimulation.

obtunded

The patient in this state sleeps often and when aroused exhibits decreased alertness and interest in the environment and delayed reactions.

sympathetic storming

Elevated sympathetic nervous system activity occurs as a normal response to trauma; following TBI, this response may become overactive. Increased sympathetic activity results in increased heart rate, respiratory rate, and blood pressure; diaphoresis; and hyperthermia.

severe

Post-traumatic seizures occur between 12% to 50% of people with what type of TBI?

phenytoin

what antiepileptic/anticonvulsant medications are used for seizure prohalixis?

False

T/F: Individuals with TBI are more likely to experience motor-related activity limitations such as ADLs and basic mobility rather than long-lasting limitations in cognitive-related activities such as problem-solving, memory, and cognitive comprehension.

severe

Scores of 8 or less are classified as __ in Glasgow Coma Scale.

moderate

Scores of 9 and 12 are classified as __ in Glasgow Coma Scale.

mild

Scores of 13 and 15 are classified as __ in Glasgow Coma Scale.

\
moderate

LOC: >30 min and

severe

LOC: >24 hr

mild

LOC: 0-30 min

mild

AOC: brief >24 hr

moderate, severe

AOC: >24 hr

mild

PTA: 0-1 day

severe

PTA: >7 days

moderate

PTA: >1 and

mild

GCS: 13-15

severe

GCS:

moderate

GCS: 9-12

motor score and pupillary reactivity

low initial scores on the __ and _ have been identified as predictors of poor recovery in patients with moderate to severe TBI.

interdisciplinary team

The foundation for successful rehabilitation following TBI is __.

family

this is the center of the interdisciplinary team

conduct a complete medical record review

The first step in beginning an examination at this early stage of recovery is

abnormal tone and posturing

Patients with severe TBI who are in a low arousal state may present with __ and _.

decorticate rigidity

In __, the upper extremities are in a flexed posture and the lower extremities are extended.

decerebrate rigidity

With __, both the upper and lower extremities are positioned in extension.

Disorders of Consciousness Scale

The __ can be used to differentiate states of consciousness (i.e., vegetative state and minimally conscious state) and assist in determining prognosis for recovery.

THHE

Ranchos Los Amigos Levels of Cognitive Functioning

The is a descriptive scale used to examine cognitive and behavioral recovery in individuals with TBI as they emerge from coma. This scale does not address specific cognitive deficits but is useful for communicating general cognitive and/or behavioral status and for treatment planning.

Coma Recovery scale revised

The __ is recommended to assess patients with disordered consciousness.

hard cervical collar

A __ may be useful to assist with head control.

Passive seated bikes

Functional electrical stimualtion bikes

Assisted sitting

Give examples of interventions that can promote early mobilization

II Generalized Response

Patient 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

V Confused-Inappropriate

Patient 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. 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.

IV Confused-Agitated

Patient 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. Patient lacks short- and long-term recall.

I No Response

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

VII Automatic-Appropriate

Patient 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.

III Localized Response

Patient 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

VI Confused-Appropriate

atient 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

VIII Purposeful-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 judgment in emergencies or unusual circumstances

contractures, decubiti, pneumonia, and DVT

Give examples of secondary impairments

neutral; slightly flexed

When the patient is in bed, the head should be kept in __. The hips and knees should be _, but range of motion (ROM) should be monitored to ensure that contractures do not develop.

turning

__ will help prevent skin breakdown and pneumonia.

2 hours

Patients should be repositioned every __ when in bed

Multi-podus boot

__ used for ankle and foot positioning and to prevent skin breakdown on the heel. This type of positioning device may not be beneficial for the patient with moderate to severe tone at the ankle; it is not strong enough to prevent the ankle from plantarflexing.

Serial casting

__ may be used to maintain or improve ROM. It is often used for plantarflexor or biceps contractures.

short leg cast

With a plantarflexion contracture, the ankle is stretched into as much dorsiflexion as possible and then a __ is applied.

pelvic and head

Proper __ positioning and _ positioning are key elements in promoting good posture in a wheelchair.

open injuries

What type of injury result from penetrating types of wounds. such as those received from a gunshot, knife, or other sharp objects. The skull can be either fractured or displaced.

closed injury

An individual is said to have sustained a __ when there is an impact to the head, but the skull does not fracture or displace.

concussion

most common type of TBI

concussion

A trauma that induces an alteration in mental status (physical and cognitive abilities) that may or may not involve a loss of consciousness.

dizziness, disorientation, blurred vision, difficulty in concentrating, alterations in sleep patterns, nausea, headache, and a loss of balance

Symptoms of concussion

retrograde amnesia

It is characterized by a loss of memory of the events before the injury

Coma Recovery Scale–Revised (CRS-R)

The __ is recommended to assess patients with disordered consciousness. It has six subscales: auditory, visual, motor, oromotor, communication, and arousal.

Disorders of Consciousness Scale (DOCS)

The __ is a valid and reliable scale also designed to measure arousal and neurobehavioral recovery in patients with disorders of consciousness. This assesses social knowledge, taste/swallowing, olfactory function, proprioception, tactile sensation, auditory function, and visual function.

Rancho Los Amigos Levels of Cognitive Functioning (LOCF) Scale

The __ is a descriptive scale used to examine cognitive and behavioral recovery in individuals with TBI as they emerge from coma.

Impact of impairment is reduced

Ability to improve physical actions, tasks, or activities is improved

Patient satisfaction is enhanced

Care is coordinated among all team members

Goals and outcomes anticipated for patients with **severe** to moderate TBI in acute stage

increase irritability

decreased attention and concentration

deterioration in performance of physical skills

delayed initiation

Signs of mental fatigue

mild TBI

A __ is a type of TBI induced by biomechanical forces that disrupt physiological brain function.

Mild TBI

__ is primarily a functional injury of the CNS, which is thought to be due to metabolic dysfunction, neurotransmitter disturbances, and microstructural changes.