TBI pt1

TBI

alteration in brain func or evidence of brain pathology caused by an external F

1.7 million

.___ sustain a TBI each yr in US

fall (32), MVA (19), struck by or against object (18), assault (10)

4 leading causes of TBI w/ %

MVA

most common cause btwn 5-65 is

falls

most common cause of those under 5 and over 65 are

children 0-4 and adolescents 15-19

age range at highest risk for TBI

1.5

men are ___x more likely for TBI

open head injury

frequently associated w/ intracranial hemorrhages

compound skull fx

scalp is cut; associated w/ dural tears which increase risk of intracranial infections

primary brain injury

damage occurs at the moment of impact

focal brain injury, blast injury, diffuse axonal injury (DAI)

3 types of primary brain injury

focal brain injury

occurs at site of impact; damage may take form of a contusion, laceration, or both

laceration, coup-contrecoup injury, polar brain injury

types of focal brain injuries

laceration

most often occur when skull irregularities cut brain surface; almost always associated w/ hematomas

polar brain injury

due to acceleration, deceleration, or rot Fs; common w/ head on collisions; body stops but brain doesn’t

temporal and frontal

w/ polar brain injuries, tips/poles on undersurface of brain (specifically ___ lobes) are most susceptible to injury as they come in contact w/ bony alignment of inner skull surface

tertiary blast injury

from being pushed or flung backwards and hitting an object

diffuse axonal injury

due to acceleration, deceleration, or rot Fs and occur in conjunction w/ focal and polar brain injuries

diffuse axonal injury

rapid brain movement causes widespread stretch/tear of neuronal axons w/in myelin sheath (subcortical white matter shearing)

diffuse axonal injury

damage not usually evident on CT or MRI so usually found during neurologic exam and based on pt's clinical presentation

secondary brain damage

occurs w/in mins to hrs after injury

intracranial hematoma, herniation, hypoxic-ischemic injury, post trauma epilepsy/seizures, intracranial infection

5 types of secondary brain damage

intracranial hematoma

rise in ICP occurs as blood accumulates leading to brain shifting/compression leading to 2^ndary brain damage

epidural hematoma

medial meningeal A damage

subdural hematoma

venous blood accumulates beneath dura; common in elderly related to brain shrinkage + excessive movement

intercerebral hematoma

intrinsic cerebral arterial blood that accumulates w/in brain; most deadly

uncal, CN3 paresis, hemiparesis, coma, homonymous hemianopia

.___ herniation: midbrain; hippocampal gyrus, oculomotor n (___), cerebral peduncle (___), RAS (___), PCA (___)

central, rigidity, coma

.___ herniation: midbrain and pons (___), RAS (___)

tonsillar, neck pain/stiff, coma, alternation of HR/RR/bp

.___ herniation: medulla; cerebellar tonsils (___), RAS (___), vasomotor centers (___)

hypoxic-ischemic injury

brain injury due to damage to other body parts depriving brain of O2

arterial hypoxemia, arterial hypotension, increased ICP, cerebral vasospasm

4 types of hypoxic-ischemic injury

arterial hypoxemia

systemic injury (exs: airway obstruction, pneumothorax, pulmonary embolism) leading to reduction of O2 circulating in blood

arterial hypotension

systemic blood loss due to body injury leading to low bp, less blood flow to brain result in widespread 2^ndary brain damage

increased ICP

causes brain to shift and cuts off circulation

cerebral vasospasm

constriction of cerebral blood vessels due to trauma

restore vital funcs, prevent secondary brain damage

top priority for medical management for TBI pts

glasgow coma scale (GCS)

outcome measure used to determine severity of injury

eye open, best motor response, verbal response

3 parts assessed/scored using GCS

4 spontaneous, 3 to speech, 2 to pain, 1 no response

GCS scores for eye opening

6 follows motor command, 5 localizes, 4 w/drawls, 3 abnorm flex, 2 extensor response, 1 no response

GCS scores for best motor response

5 oriented, 4 confused convo, 3 inappropriate words, 2 incomprehensible sounds, 1 no response

GCS scores for verbal response

3-8

GCS score for severe brain injury

9-12

GCS score for moderate brain injury

13-15

GCS score for minor brain injury

4-15mmHg

norm ICP level

15-20mmHg

after a TBI, an ICP level of ___ is expected

>20mmHg, 25mmHg

ICP of ___ is abnormly high; if remains elevated over a mean value of ___, measures will be taken to reduce the pressure

40mmHg

ICP of ___ will impair blood flow to brain causing 2^ndary injury

20mmHg

if ICP goes above ___, notify nurse/dr and modify intervention to prevent spikes

30mmHg

if ICP goes above ___, immediately stop all PT interventions and notify nurse/dr

rancho los amigos lvls of cog funcing

descriptive scale used to exam cog/behavioral recovery of pts w/ TBI as they emerge from coma

rancho los amigos lvls of cog funcing

doesn’t address specific cog deficits but is widely used to com the cog/behavioral status for planning and intervention

coma recovery scale-revised

used to assess pts w/ disordered consciousness

coma recovery scale-revised

23-item scale w/ 6 sub-skills used to measure auditory, visual, motor, motor com, arousal