Traumatic Brain Injury (TBI)

Concussion

Momentary loss of consciousness and reflexes.

Contusion

Bruising on the surface of the brain is sustained at the time of injury. Small blood vessels on the surface of the brain hemorrhage and lead to condition.

Definition of TBI

An insult to the brain caused by an external physical force; results in impairment of cognitive/physical function; produce diminished state of consciousness; result in disturbance of behavioral/emotional function

What are the two types of head injuries?

Open and closed head injury

Cause of open injury

Direct penetration through skull to the brain. (gun shot wounds, knife or sharp object penetration)

Outcomes of open injury

Location, depth of penetration and pathway determine the extent of brain damage.

Cause of closed head injury

Concussions, contusions, hematomas, injury to extra cranial blood vessels, hypoxia, drug over dose, near drowning & acceleration or deceleration injuries.

Closed or intracranial injury

Injury without penetration through skull.

Coup injury

Occurs in the same side of the brain as the impact. (Initial site of injury)

Contrecoup injury

Surface hemorrhages that occur on the opposite side of the trauma as a result of deceleration. (rebound area of impact)

Cerebral concussion

Alteration in mental status followed by brief period of post-traumatic amnesia; complaints of headache, dizziness, lack of coordination in hands, impaired concentration, or memory problems; no structural brain lesions

Cerebral contusion

Brain bruise; objective changes; seen in coup and contra coup; leads to cerebral edema and increase intracranial pressure

Cerebral laceration

Always associated with open head injury; may damage skull, scalp or meninges; pia arachnoid membranes are torn

Secondary brain damage

Occurs as result of primary lesion usually within a few hours; intracranial hematoma, cerebral ischemia and anoxia (caused by swelling), intracranial infection, hydrodcephalus, post traumatic epilepsy, nerve damage to cranial nerves (olfactory more often damaged), and herniation of brain stem

Intracranial hematoma

Arterial, venous or capillary bleed within brain

Emergency tx of TBI

Establish airway, stabilize BP, immobilize rigid backboard with neck, monitor vitals, take trauma center, general assessment of neuro status and other injuries, CT of head within 30 minutes of arrival at ER, and evacuate hematomas if present

When does brain swelling subside?

4-5 days

Cognitive Symptoms of TBI

Attention, concentration, memory, judgment, executive functioning; language (aphasia and anomia)

Behavioral/emotional Symptoms of TBI

Agitation, personality changes, depression, and decreased motivation, sexual disinhibition, lability…

Physical symptoms of TBI

Increased tone, weakness, incoordination, poor balance, and decreased endurance

Sensory symptoms of TBI

Absent or diminished touch, impaired taste or smell, decrease visual skills

Occupations affected by TBI

ADL, IADL, sleep, education, work, play, leisure, and social participation

Sxs of TBI

Extent and type of sxs experienced depends on if injury is diffuse or focal, severity, and part of brain affected; appear immediately or over days; sxs often persist for years

Obtundity

A state of sleep. When aroused they show disinterest in the environment and are slow to respond to sensory stimulation. (reduced alertness and arousal)

Stupor

A state of general unresponsiveness with arousal occurring from repeated stimuli.

Coma

State of unconsciousness and a level of unresponsiveness to all internal and external stimuli. (does not last longer 3 to 4 weeks)

Vegetative state of TBI

Presence of sleep wake cycle but minimally responsive; opens eyes spontaneously or after stimulation; cerebrum damaged; brain stem reflexes intact; can last 30 days

Minimally responsive state

Demonstrates meaningful behavioral response after a specific command or environment prompt; inconsistent responses

Lock-in syndrome

Full cognitive awareness with very limited motor and verbal response; occurs with damage to ventral pons

Definition of brain death

When the entire brain, including brain stem, has irreversibly lost all function; complete neurological exam required to confirm

Glasgow coma scale

Eye opening (1-4), motor response (1-6) and verbal response (1-5)

Galsgow coma score

3=totally comatose, <8=coma or severe TBI, 9-12=moderate TBI, and 13-15=mild TBI

Rancho los amigos levels of cognitive functioning

Tool used to measure and describe the patients level of cognitive function. Classify injury and assist with developing an appropriate POC l

Course of TBI

Variable; factors influence course (location, cause, severity of injury, age, length of PTA, increased intracranial pressure, alteration of consciousness); rapid improvements first 6 months; slow and gradual functional recovery

Heterotopic ossification (HO)

Calcium deposits that occur in soft tissue; tissue with hematoma and atrophy muscles

Predictors of outcome

Severity of injury (8 or below on GCS) for 6 hours predicts 50% survival; quality of care; extent of physical and mental deficits; premorbid lifestyle and adjustment; post traumatic amnesia

Mild TBI

GCS=13-15, PTA=<1 hr, loss of consciousness=<30 min, and CT shows no abnormalities

Moderate TBI

GSC=9-12, PTA=30 min to 1 hr, loss of consciousness=1-24 hr, and abnormal CT scan findings

Severe TBI

GSC=3-8, PTA=>1 day, loss of consciousness=>24 hr, and abnormal CT scan findings

2 types of brain damage

Primary (occurs at impact) and secondary (occurs in days to weeks after injury and is result of subsequent pathologic processes

Decerebrate posturing

Injury to upper brainstem; UE/LE are held in extension/abd/external rotation and trunk is extended

Decordicate posturing

Damage to one or both corticospinal tracks and causes damage to hemispheres and deep into brain capsule; arms are flexed/adducted with the wrists and fingers are flexed and legs are extended with feet plantar flexed

Why is monitoring and measuring level of consciousness important?

Info about severity; predicts prognosis and outcome; changes in level can indicate changes in brain recovery and development of secondary complications

What is the most reliable response on the glasgow come scale?

Motor

Hypoxia

A lack of oxygen.

Symptoms of Concussions

Dizziness, disorientation, blurred vision, difficulty concentrating, nausea, alterations in sleep, headache, and loss of balance, retrograde amnesia and Post traumatic amnesia.

Subtypes of closed injury

Concussions, Contusions (coup & counter coup lesion), Hematomas, Locked in syndrome, acquired brain injuries.

Retrograde amnesia

Loss of memory prior to the injury.

Post traumatic amnesia

Unable to remember or learn new information.

The duration of post traumatic amnesia

Is considered a clinical indicator of the severity of the injury.

Concussion classification Grade 1

-No loss of consciousness (LOC)

-Some transient confusion by the patient.

-Symptoms typically resolve within 15 min

-May exhibit full memory of the even

-Athletes should be removed from the competition and return only if symptom free after one week of rest.

Concussion classification Grade 2

-Moderate head injury with transient confusion that will last longer than 15 min.

-may exhibit poor concentration, retrograde amnesia, and ante grade amnesia.

-Athlete should be removed immediately from competition and receive a medical eval.

-CT scan is indicated if symptoms worsen and return to play should be deferred until athlete is as symptomatic for two weeks at rest and with exertion.

Concussion classification Grade 3

-Head injury with any form of LOC

-Pt should require transport to the emergency room for full neurologic evaluation.

-Hospilization is warranted if altered consciousness or mental status persist.

-Athlete should should be withheld from competition after a grade __ concussion once symptom free for a minimum of one month.

Hematomas

Vasucular hemorrhage with hematoma formation.

Epidural hematomas

Between the dura mater and the skull.

Subdural Hematomas

Acute venous hemorrhage that results because of repture to the cortical bridging veins.

Antegrade amnesia

Cannot remember things after injury

Locked in syndrome

• A rare neurological disorder that can result after TBI.

characterized by complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement.

• individuals remains conscious and possesses cognitive function but is unable to move.

-poor prognosis.

Acquired brain injuries

-Occur at the cellular level and affect the cells throughout the entire brain.

-Causes may include: airway obstruction, near drowning, MI, CVA, exposure to toxins, electric shock and lightning strike.

Delirium

Disorientation, confusion, agitation and loudness

Clouding of consciousness

Quiet Behavior, Confusion, Poor Attention, and delayed responses

Consciousness

A state of alertness, awareness, orientation and memory.

Vegetative State

Demonstrates a return of brainstem reflexes and sleep-wake cycle yet remains unconscious.

Persistent vegetative state

Person has been in a vegetative state for a year or longer. No improvement in his neurologic status and no further improvement is expected.

TBI characteristics

-altered consciousness

-cognitive and behavior deficits

-changes in personality

-motor impairments

-alterations in tone, speech and swallowing issues.

Post traumatic epilepsy

Secondary complication. MORE COMMON IN OPEN HEAD INJURIES, SUBDURAL HEMATOMA, & OLDER ADULTS. Discrete clinical events defecting temporary brain dysfunction, characterized by hypersynchronous cortical neuron discharge.

Heterotopic ossification

Secondary complication. bone develops in abnormal anatomical locations

Anoxic injuries

Brain demand 20% of body's oxygen intake to maintain proper oxygen saturation and metabolic functions. (Occurs most in cardiac arrest pts & drowning) more vulnerable areas hippocampus (involved in memory storage) cerebellum and basal ganglia. which explains why the prevalence of amnesia and movement patterns in this patin population.

Intracranial pressure

Common in TBI

-Adult skull is rigid and does not expand to accommodate increasing volumes of fluid.

-Increased pressure can lead to compression in brain tissue.

ICP Pressure

Pressure greater than 20 mm Hg are considered abnormal and can result in neurologic and cardiovascular changes.

ICP Monitoring

-Device placed in head- senses pressure inside the skull and sends its measurement to recording device.

Activities that may increase ICP

-Cervical Flexion

-Performance of percussion and vibration techniques and coughing.

ICP Signs and Symptoms

-decreased responsiveness

-impaired consciousness

-Severe headaches

-vomiting

-irritability

-Papilledema- swelling of optic deck whew optic nerve enters the eye ball usually associated with increase in intraocular pressure

-changes in vital signs including BP and decreased heart rate.

ICP Treatment

-Careful monitoring

-pharmacological agents

-VP shunts ventricular peritoneal shunting if permanent correction is needed.

Events that may trigger Post traumatic epilepsy

-stress

-poor nutrition

-electrolyte imbalance

-missed medications or drug use

-flickering lights

-infection

-fever

-anger worry and fear

Post traumatic epilepsy contraindications

-Certain PT interventions. Vestibular stimulation techniques (fast spinning and irregular movements with sudden acceleration and deceleration.

-Grand mal seizers should be transfers to the floor to avoid possible injury.

Post traumatic epilepsy Medication

-Prescribed according to seizure type:

• Dialantin (phenytoin)

• Phenobarbital (Luminal)

• Tegretol (cabamazepine)

Common side effects:

Sedative effects that decrease pt's arousal, memory, cognition, ataxia, dyarthria, double vision, and hepatoxticity.

Ataxia

Loss of coordination

Dysarthria

Difficulty forming words.

Dialantin Considerations

-monitor potential side effects from anticonvulsant meds.

-periods of confusion

-nervosness

-gait ataxia
PTA SHOULD IMMEDIATELY REPORT ANY OF THESE OBSERVED FINDINGS TO THE SUPERVISING PT

Glasgow Coma Scale (GCS) purpose

-Used to asses the individuals level of arousal and function of the cerebral cortex.

-specifically evaluates pupillary response, motor activity and pt's ability to to verbalize

-scores can range from 3-15

HIGHER scored indicating less severe brain damage and better chance of survival.

GCS score of 8 or less

The patient is in a coma and has sustained severe brain injury.

GCS of 3 or 4

Often do not survive.

Decerebrate rigidity

Patients LE are in ext
hips are adducted & internally rotated
knees are extended
ankles are plantar flexed
feet are supinated.
UE's are internally rotated and extended at the shoulders
extended at the elbows
pronated at the forearm
and flexed at the wrist and hand.Thumbs may be entrapped within the palm of the hand.
Damage to one or both corticospinal tracts.
Results from severing of neuroaxis in the mid brain region

Decorticate rigidity

UE in flexion with adduction and internal rotation of the shoulders, flexion of the elbows, pronation of the forearms, flexion of the wrist and ext of the LE's.
Damage to upper brainstem

Severity of TBI Mild

GCS of 13 or higher.
A loss of consciousness lasting less than 20 min,
normal CT scan

Severity of TBI Moderate

GCS score 9-12
confused on admission and unable to answer questions appropriately.
Many have permanent functional and cognitive impairments.

Severity of TBI Severe

-Disorientation
-poor attention span
-loss of memory
-poor organization and reasoning skills
-inability to control emotional responses,

• the severity of individuals cognitive deficits greatly affects the ability to learn new skills an ability that is an integral part of the rehabilitation process.

Ranchos level I (1)

No response

Ranchos level II (2)

Generalized response: Total assistance

Ranchos level III (3)

Localized response; total asst.

Ranchos level IV (4)

Confused agitated; Max assist.

Ranchos V (5)

Confused; inappropriate max assist

Ranchos levee VI (6)

Confused appropriate mod assist

Ranchos levels VII (7)

Automatic, appropriate, min assist

Ranchos level VIII (8)

Purposeful appropriate stand by assit