TBI

TBI

Nondegenerative, noncongenital alteration in brain functon caused by an external force

external forces

‒ Falls

‒ Assaults

‒ Motor vehicle accidents

‒ Sports

‒ Combat

focal injury

limited to one area of the brain

• Common in moderate to severe TBI

• Can be open or closed

• Damage to a specific location in the brain

• Contusion: visible bruising on the brain issue

• Hemorrhage or hematoma bleeding wiithin

the skull on the brain

• Deficits related to area of brain damaged

diffuse axonal injury

damage at muliple areas of the brain

• Occurs throughout the brain

• Shearing & tearing of neurons when the brain moves in the skull

• Damage to pathways connecting different parts of the brain

‒ Messages in the brain are slowed or lost

primary brain damage

occurs at the time of injury

‒ Coup contracoup injuries

‒ Cellular level (DAI: difuse axonal injury)

secondary brain damage

occurs within hours/days of initial injury

‒ Typically a consequence of the physiological response to the injury (e.g., inflammation, increased intracranial pressure [ICP], ischemia)

chronic traumatic encephalopathy

progressive, degenerative

secondary impact syndrome

“recurrent traumaic brain injury”

• 2nd injury occurs before 1st one heals

‒ More likely to cause swielling and more global damage

• Death can occur rapidly

locked in syndrome

• Patient is awiare & awiake

• Unable to move or communicate

• Can move eyes

• Result of brain stem lesion

‒ Anterior part of pons

brainstem herniations

• Can be primary or secondary

• Can be caused by swelling

• A downward displacement of the brainstem through the foramen magnum

• Also increased pressure of the tentorial contents

• Cingulate, uncal, & transtentorial herniaion

etiology TBI

- History of TBI

• 3 times more likely to have a 2nd TBI

• 8 times more likely to have a 3rd TBI

- Falls

• Children < 5 years of age

• Elderly

- Motor vehicle accidents

• Adolescents & adults

• Males > females

- Violence

• Males > females (except for domestic violence = women & children)

- Homicide: children aged 0-4 years

- Sports related injuries

- Work related injuries

• Variance related to causes: age, gender, occupation

• Alcohol & drug use

• Alcohol use signifcantly associated with increased risk

• No neuroprotective infuence/efect (mortality)

• At least 45% of individuals wiith a TBI requiring rehabilitaion wiere intoxicated at the time of their injury

• Mental health issues + alcohol abuse

• Young males

shaken baby syndrome

• Violent criminal act

• Whiplash motion

• Blood vessels betwieen brain and skull rupture & bleed

• Causes

• Seizures

• Disability

• Coma

• Death

epidemiology TBI

Worldwide, leading cause of death & disability for children & young adults

• Cause for 10% of all cases of long term disability

• Contributing factor to a third (30%) of all injury related deaths In the United States

• Men are 3x more likely to die from TBI

• 2nd most prevalent disability

• Low & middle income countries: greater prevalence

• Rural areas: greater incidence (compared to urban areas)

• Young males aged 15i25 years: highest demographic

• Twice as likely than women to sustain a TBI

• Children < age 5 years

• Adults aged > 75 years

more diffuse symptoms

increased number of symptoms

more severe symptoms

higher the intensity & diversity of symptoms

severity of residual motor symptoms

varies

• All levels of severity associated with residual cognitive & psychosocial symptoms

TBI signs and symptoms

• Spinal fluid coming out of ears or nose

• Consciousness

• Dilated pupils

• Dizziness

• Respiratory failure

• Coma

• Paralysis

• Slow pulse

• Slow breathing rate

• Vomiting

• Lethargy

• Headache

• Confusion

• Ringing in ears

• Emotional responses

• Difficulty speaking

• Loss of bowel/bladder

TBI secondary diagnoses

• Fractures

• Concomitant spinal cord injury

increased intracranial pressure (diagnosis)

Swelling of the brain

cerebral hypoxia and ischema (diagnosis)

Blood vessels are ruptured or compressed

intracranial hemorrhage (diagnosis)

Hypoxia to issues that were fed by the hemorrhaging blood vessels

electrolyte imbalance and acid-base imbalance (diagnosis)

cell death by swelling or necrosis

TBI signs and symptoms

• Medical complications

• Sensorimotor deficits

• Visual deficits

• Visual perceptual deficits

• Cogniive deficits

• Psychosocial impairments

• Cranial nerve dysfunction

DSM-5 Criterion A

Met for major or mild neurocognitive disorder

DSM-5 Criterion B

1 or more of the followiing

• Loss of consciousness (LOC)

• Posttraumaic amnesia

• Disorientation & confusion

• Neurological signs (e.g., neuroimaging demonstraing injury; a new onset of seizures; a marked worsening of a preexising seizure disorder; visual field cuts; anosmia [loss of smell]; hemiparesis).

DSM-5 Criterion C

The neurocognitive disorder presents immediately after the occurrence of the traumatic brain injury or immediately after recovery of consciousness & persists past the acute post injury period

postconcussion syndrome

includes physical, cognitive, sleep, & behavioral symptoms that began or have worsened since concussion onset & have persisted 3 months or more

second impact syndrome

a second concussion occurs before the first concussive symptoms resolve, resuling in an altered mental status & sometimes LOC within seconds to minutes of the second hit

Glasgow Coma Scale

TBI classified by levels of severity based on _

80-90%

_ of TBIs are considered mild

• even mild injuries can be life altering and cause long-term disability

• remaining 10-20% are considered moderate to severe

closed TBI injury

does not penetrate the skull

• Rapid oscillating movement of brain in the skull

• Results in bruised & torn brain issue & blood vessels

• More common

penetrating TBI injury

• Caused by bullets or other objects piercing the brain

• Skull fracture & tearing of dura mater exposing brain issue

concentration/confusion

physical: headache/nausea

emotional: feeling nervous

maintenance: mental fatigue

memory

physical: dizziness/balance problems

emotional: mood, behavior & personality changes

maintenance: feeling drowsy, sluggish, groggy

mentally foggy/not “feeling right”

physical: noise/light sensitivity, visual problems

emotional: easily angered/agitated

maintenance: sleeping too much/too little

slowed processing

physical: neck pain

emotional: saddness/depression

maintanenace: difficulty initiating maintaining sleep

TBI course and prognosis

• Onset: sudden

• Response to treatment & recovery are variable

  • Individual factors: preinjury history, level of educaion, absence of substance abuse, less anxiety

  • Varied neuropathological efects

• Hypoxia or hypotension in ER: relate to worse outcomes

• Severity of memory loss, age, intoxication at time of injury

  • Younger age at injury improves chance of survival & overall outcome in adults

  • Intoxication & substance use are negatively correlated wiith outcomes

• People wiith TBI: reduced life expectancy by 9 years

• Residual damage to brain structure & function: more vulnerable to developing other deficits (e.g., opic neuropathy, premature ageirelated cogniive decline)

factors for recovery

• Pre injury intelligence

• Personality

• Age

• Cause & type of injury

• Immediacy of care on injury

• Length of retrograde & post traumaic amnesia

• Depth & Duration of coma

• Post traumaic cogniion changes

• Post traumaic behavioral changes

• Family support

• Pattern & quality of sensory recovery

factors determinng prognosis

• Trauma score

• GCS

• Presence of certain biomarkers

• Presence/absence of hypoxia

• Length of coma

• Duration of post traumaic amnesia

Levels of Cognitive Functioning Scale (LCFS) or Rancho Los Amigos Scale

• Inpatient rehab

• Classifies 8 levels of cognitive functioning

• From coma to purposeful, appropriate functioning

• Difficulty measuring small changes in recovery

moderate to severe TBI: functional prognosis

• Reduced independence in home & community activities

  • Employment

  • Parenting

  • Driving

  • Leisure activities

• Need for greater reliance on others

• Reduced social roles & profound social isolaion

• Emotional distress

• Difficulty accessing postacute services

• Difficulty reestablishing meaningful roles & a productive daily routine

medical intervention for TBI

• Focus: preservation of life, management of secondary complications, prevention of secondary damage

• Rehabilitation

• Motor related complications: contractures, heterotopic ossifcaion, DVT

  • Range of motion

  • Splinting

• Sensory related: hypo/hypersimulaion

initiation

• Generate ideas or plans

• Begin activities wiithout procrasination

inhibition

• Control impulses, actions, or automatic tendencies

• Think before acting

• Ignore distractions

working memory

• Hold, update, & manipulate mental information

• Keep track of information within an activity

cognitive flexibility

• Transition or move easily between tasks

• View situations from different perspectives

• Revise plans

• Adapt to new or changing circumstances

paroxysmal sympathetic hyperactivity

• Previously known as “Storming”

• Loss of cortical suppression of sympathetic nervous activity

• Occurs in 33% of individuals with severe brain injury

• Tachycardia, tachypenia, hyperthermia, hypertension, hyperhidrosis, & posturing

• Observed when sedatives & paralytics are being tapered

• Can be triggered by external stimulation

disinhibition

• Unable to monitor and regulate socially inappropriate impulses & behaviors

• Dress & speak in a socially inappropriate way

• Sexually inappropriate

neuro behavioral difficulties

• Inappropriate behavior is often experienced Level III-V

• Although it is expected it should not be allowed without comment

• Appropriate feedback may need to be repeated

• At the lower levels of Rancho lengthy explanations not needed, just a statement to stop behavior