Traumatic Brain Injury - NPTE Review

Open injury

direct penetration through the skull to the brain

Closed Injury

Without penetration through the skull. Concussion, contusion, hematoma, injury to extracranial blood vessels, drug overdose, near drowning, and acceleration or deceleration injuries

Primary injury - Coup lesion

A direct lesion of the brain under the point of impact. Local brain damage is sustained

Primary injury - Contrecoup lesion

An injury that results on the opposite side of the brain. The lesion is due to the rebound effect of the brain after impact

Secondary Injury

Brain damage that occurs as a response to the initial injury - epidural and subdural hematoma

Levels of consciousness

Coma, stupor, obtundity, delirium, clouding of consciousness, consciousness

Coma

A state of unconsciousness and a level of unresponsiveness to all internal and external stimuli

Stupor

A state of general unresponsiveness with arousal occurring from repeated stimlui

Obtundity

A state of consciousness that is characterized by a state of sleep, reduced alertness to arousal and delayed responses to stimuli

Delirium

A state of consciousness that is characterized by disorientation, confusion, agitation and loudness

Clouding of consciousness

A state of consciousness that is characterized by quiet behavior, confusion, poor attention, and delayed responses

Consciousness

A state of alertness, awareness, orientation and memory

Concussion Grade 1

No loss of consciousness, but typically some transient confusion by the pt, symptoms typically resolve within 15 mins of the event. May exhibit full memory of event. An athlete should be removed from competition and return only if symptom free after one week of rest

Concussion Grade 2

Transient confusion that will last longer than 15 mins. May exhibit poor concentration, retrograde and antegrade amnesia. An athlete should be removed immediately from the competition and receive a medical evaluation. CT scan is indicated if symptoms worsen and return to play should be deferred until the athlete is asymptomatic for two weeks at rest and with exertion

Concussion Grade 3

Any form of loss of consciousness, pt should require transport to emergency room for full neurological evaluation. An athlete should be withheld from competition once symptom free for a minimum of one month. Secondary to diffuse axonal injury and if severe can result in coma.

Rancho Los Amigos Levels of Cognitive Functioning

I. No response II. Generalized response III. Localized response IV. Confused-Agitated V. Confused-inappropriate VI. Confused-appropriate VII. Automatic-appropriate VIII. Purposeful-appropriate

Level I. No Response

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

Level II. Generalized response

Pt reacts inconsistently and non-purposefully 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.

Level III. Localized Response

Pt reacts specifically, but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as closing the eyes or squeezing the hand in an inconsistent, delayed manner.

Level IV. Confused-Agitated

Pt is in a heightened state of activity. Behavior is bizarre and non-purposeful relative to the 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. Pt lacks short and long-term recall

Level V. Confused - Inappropriate

Pt is able to respond to simple commands fairly consistently. However with increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or fragmented. Demonstrates gross attention to the environment, but is highly distractible and lacks the 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 info.

Level VI. Confused-appropriate

Pt 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.

Level VII. Automatic-appropriate

Pt appears appropriate and oriented within the hospital and home setting. Goes through daily routine automatically, but frequently robot-like. Pt 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

Level VIII. Purposeful - appropriate

Pt 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 dec ability relative to premorbid abilities, abstract reasoning, tolerance for stress, and judgement in emergencies or unusual circumstances.

Glasgow Coma Scale

Eye opening, Best motor response, Verbal response. Total score of eight or less correlates to severe brain injury and coma in 90% of pts. 9-12 indicate moderate brain injuries, 13-15 indicate mild brain injuries.

Anterograde Memory

Inability to create new memory. Usually the last to recover after a comatose state. Contributing factors include poor attention, distractibility, and impaired perception of stimuli

Post-traumatic Amnesia

The time between injury and when pt is able to recall recent events. Pt does not recall the injury or events up until this point of recovery. Post-traumatic amnesia is used as indicator of the extent of damage

Retrograde amnesia

An inability to remember events prior to the injury. May progressively dec with recovery.