TBI in 862 pt 2

classification of BRain injury

acquired brain injury

• TBI

• NTBI

acquired brain injury

• not hereditary, congenital, degenerative or induced by birth trauma

• result in changes in neuronal activity affecting the physical integrity, metabolic activity or functional ability of neurons

traumatic brain injury

injury caused by external forces

• impact to the head directly

• inertial forces that damage the brain

nontraumatic brain injury

caused by internal forces

• anoxia

• exposure to toxins

• infections

• pressure from tumor

• stroke

epimediology

• 2.8 million TBI-related ED visits, hospitilazations, and deaths

• TBI related ED visits increased by 54% (2006-2014)

• 812,00 children treated in EDs for sprots and recreation-related injuries (concussion or other TBI)

causes of TBI in 2014

1. falls (children and older adults

2. being struck by or against object

3. motor vehicle crashes

4. leading cause of TBI-related deaths: intentional self-harm

health inequities and TBI

• Native american: highest rates of TBI-related hospitalizations and deaths

• racial and ethnic minority groups are less likely to receive follow-up care and rehab

• prisoners, homeless, DV, service members/veterans, low income/health insurance, rural

risk factors

• young (0-4, 15-19) elderly (75+)

• male

• lower SES

• psychiatric diagnosis

• dementia

• contact sports, not using helmets

classification of injury severity

• mild

• moderate

• severe

criteria to calssify severity

• structural imaging

• loss of consciousness

• alteration of consciousness/mental state

• post-traumatic amnesia

• Glasgow coma scale

• slide 15

posttraumatic amnesia

a period of disorientation and difficulty consistently making new memories

• resolution: consistently oriented and able to make new memories

Glascow Coma Scale subscales

• eye opening

• motor response

• verbal response

• slide 17

posturing

abnormal flexion/extension

swelling in one hemisphere compressing diencephalon

asymmetrical motor response

• ipsilateral hand tries to remove

• babinski on contralateral foot

bilateral damage to diencephalon-upper midbrain

decorticate

• flexion of bilateral elbows, wrists, fingers

• toes pointed bilateral extending

bilateral damage to upper midbrain

deceretbrate

• uppers and lowers are extended

if there is a change in a day like decorticate to decerebrate

• means a deterioration of the condition,

• a change in their status,

• extension of damage into the brainstem

factors interfereing with GCS

• pre-exsiting factors

• effects of current treatment

• effects of other injuries or lesions

pre-existing factors

• language or cultural differences

• intellectual or neurological deficit

• hearing loss or motor speech impairments

effects of current treatment

• physical (intubation or trach

• pharmological (sedation or paralysis)

effects of other injuries or lesions

• orbital/cranial fracture

• dysphasia or hemiplegia

• spinal cord damage

raccoon’s eyes

• periorbital ecchymosis (brusisng)

• basilar slull fracture, more anterior

Battle’s sign

• retroauricular ecchymosis)

• basilar skull fracture, more posterior

mild TBI

traumatically induced physiological disprution brain function, as manifested by at least one of the following:

1. any period of loss of conscoiusness

2. any loss of memory for events immediately before or after the accident

3. any alteration in mental state at the time of the accident

4. focal neurological deficits that may or may not be transient, but where the severity of the injury doesn’t exceed the following

   1. loss of consciousness of 30 minutes or less

   2. after 30 min. an initial GCS of 13-15

   3. PTA not greater than 24 hours

primary injury

• axonal shearing (diffuse axonal injury)

• contusion

• epidurmal hematoma (EDH)

• subdurmal hematoma (SDH)

• subarachnoid hemorrhage

• hypoxic-ischemic

coup-contrecoup injury

a primary impact creates an acceleration of the brain that caues the front of the cranium to hit the front of the skull then ricochet to hit the back of the skull (secondary)

• happen at 180 degrees form one another

• contusion

• difuse axonal injury

diffuse axonal injury

• Widespread shearing and retraction of damaged axons

• Sudden acceleration then deceleration of brain

• Shaken baby syndrome

contusion

brusie on the brain

EDH

• collection of blood between dura and cranium

• brief loss of consciousness followed by lucid interval, then headache, obtunded, hemiparesis

• if not treated can lead to death

SDH

• between dura mater and arachnoid mater

• headache, altered mental status, hemiparesis

• could lose consciousness

SAH

• bleeding into subarachnoid space

• often seen with aneurysms, but can be caused by TBI

hypoxic-ischemic injury

• NTBI

• systemic hypotension as a result of anoxia/hypoxia which can result in global damage

secondary injury

• cerebral herniation

• ischemic CVA from vascular compression

• excitotoxicity

• apoptosis

• inflammation due to trauma

• coagulopathy

major goal of medical management

prevent secondary injuries

intracranial pressure

• increased ICP is caused by abnormality of brain fluid dynamics adn hematoma

• normal is 4-15 mmHG

• herniation of brain

  • supratentorial

  • infratentorial

prinary goals of acute medical management

• prevent 2nd injury by surgiclal management

• ICP monitoring

• CVP/respiratory support

• management of concomitant injuries

• additional: reverse coagulopathy, DVT/PE prevention, early mobilization, nutrition

surgical management

• reduce depressed skull fracture

• remove penetrating bodies if accessible

• EDH/SDH

  • craniotomy/craniectomy

  • burr hole/catheter

craniotomy/craniectiomy

cryopreservation or subcutaneous storage followed by cranioplasty

red flags

• progressively declining level of consciousness

• progressively declining neurological exam

• pupillary asymmetry

• seizures

• repeated vomiting

• double vision

• worsening headaches

• can’t recognize people or disoriented to place

• behaves unusually or seems confused and irritable

• slurred speech

• unsteady on feet

• weakness or numbness in arms/legs

biomed complications

• seizures

• sympathetic storming

• hydrocephalus

• heterotropic ossification

• venous thromboembolism

seizures

• electrical disturbances in the brain

• multiple types (gneralized wit impaired awareness, focal awareness

• may be subclinical

risk factors for seizures

hydrocephalus, intracranial hemorrhage, depressed skull fracture, hematoma evacuations, low GCS, dural penetration, parietal lesions, focal neuro deficits

sympathetic storming

• paroxysmal sympathetic hyperactivity (PSH), dysautonomia

• uninhibited sympathetic outflow after CNS injury

• cycling of agitation/dystonia

clinical presentation of sypathetic stortming

• tachycardia, tachypnea, hypertension, hyperthermia, diaphoresis/hyperhidrosis, posturing

• diagnostic PSH-AM scale

hydrocephalus

• CSF accumulation in the ventricles

• may note

  • papilledema pressure that causes optic nerve swelling

  • decresed conscoiusness

  • memory deficits

  • headache

  • focal neuro deficits

impairments

• physical: abnormal tone, sensory deficits, decreased motor control/learning, paresis/paralysis, impaired balance, spasticity

• behavioral

• emotional

• cognitive

• slide 45

Ranchos Los Amigos levels of cognitive functioning (LOCF)

• most common

• 8-10 levels of cognitive and behavioral function

• describes progress after TBI, but patient can skip levels or plateau at any level

LOCF levels

1. no response: total assistance

2. generalized response: total assistance

3. localized response: maximal assistance

4. confused-agitated: maximal assistance

5. confused-inappropriate: maximal assistance

6. confused appropriate: moderate assistance

7. automatic-appropriate: minimal assistance

8. purposeful-appropriate: standby assistance

9. purposeful-appropriate: standby assistance on request

10. purposeful-appropriate: modified independent

DRS

• slide 50

• mod-severe TBI

• within 72 hours of admission and discharge

GOS: extended

51

consciousness

• arousal

• awareness of self/environment + motivation to respond

arousal

global state of wakefulness

• stage 3 non-REM sleep to high vigilance

awareness

ability to perceive one or more specifc stimuli

• Visual

• Tactile

• Auditory

• Gustatory

• Olfactory

• Vestibular

• Proprioceptive

• Interoceptive

motivation

the drive to act on stimuli, both internal and external, that have entered conscious awareness

reticular formation

• Wakefulness

• Eye movements

• Swallowing/vomiting

• Posture/locomotion

• Respiration

• Blood pressure

• Sensory awareness

ascending arousal system

networkk of neurons that project to multiple brainstem source nuclei from within and next to RF to the cortex through thalamic and extrathalamic pathways

• network is complex and diffuse

thalamic pathway

starts in RF, projects to thalamus then spreads out to cortical regions

extrathalamic pathway

RF to thalamus but mainly bypassing the thalamus. then hypothalamus, basal forebrain to cerebral cortices

thalamic specific fibers

• both are cholinergic

• pedunclulopontine tegmental nuclei (PPT)

• lateraldorsal tegmental nuclei (LDT)

how does one become aware of stimuli

• Conscious awareness and arousal states interact

• No arousal: no awareness

• High arousal? Awareness can focus on one modality at expense of others

• Interactions between the cortex and specific and nonspecific thalamic nuclei (e.g., reticular, intralaminar)

ascending reticular activating system

originates in teh reticular formation, projections activate the cerebral cortex via glutamtergic relays in the thalamus

thalamus

• Relay station and filters and modulates information

  • Coordinates activity in widespread areas

• Cortico-striatopallidal-thalamocortical loops

• Cortico-thalamocortical loops

frontal/parietal systems

function is movement planning/execution

Frontal eye fields (FEF)

Supplementary motor area (SMA)

Anterior cingulate cortex (ACC)

Posterior parietal cortex (PPC)

arousal systems

Basal forebrain (BF) and brainstem cholinergic (LDT/PPT)

Locus ceruleus (LC)

Mesencephalic reticularformation (MRF)

brainstem attention capture mechanism

redirects attention to peripheral sensory inputs

Pretectum (PT)-OKN

Cerebellar/vestibular orientation (VOR)

Acoustic startle (ASR)

Tendon somatosensory feedback afferents

Nociceptive afferents

Postural reflexes

thalamus interactions with striatum

strong and largest efference to striatum

• provides connection to large cerebral networks: potential mechanism for translating sensory/motor activity to awareness

resting state networks

• connnectomes

• default mode

connectomes

spontaneous resting brain activity, functionally connected brain regions

default mode

what happens in your brain when you stop thinking about everything

pathophysiology of disorders of consciousness

slide 24

five basic wave forms

1. gamma

2. beta

3. alpha

4. theta

5. delta

6. frequency is the key characteristic

alert wakefulness

• Alpha waves (8–13 Hz, more posterior, prominent with EC and/or relaxation)

• Beta waves (13–30 Hz, more anterior, prominent with mentation)

• Gamma waves (more than 30 Hz, information processing during a cognitive task)

decrease in cortical arousal

• Theta waves (4–7 Hz, drowsy)

• Delta waves (less than 4 Hz, highest amplitude; deep, dreamless sleep: stages 3–4)

sleep wake cycle and EEG activity

• alpha = awake

• beta = REM sleep

• theta = stage 1

• delta = 2-4

sleep is 1/3 of life

• Suprachiasmatic nucleus of hypothalamus

• Reduced motor activity

• Decreased response to stimulation

• Relatively easy reversibility

Suprachiasmatic nucleus of hypothalamus

• Regulates circadian rhythm

• Melatonin released from pineal gland

• Light inhibits release of melatonin

• GABA inhibits neurons involved in wakefulness

Monoaminergic

• Maximum activity during wakefulness

• Decrease during non-REM sleep

• Almost zero activity during REM sleep

• Similar to motor neurons

• Dopaminergic activity patterns

Cholinergic

Difference from monoaminergic: activity increases during REM sleep

Sleep-Wake Cycle Neural Activity

Monoaminergic (NE, 5HT, Hist)

Cholinergic (Ach)

are brain injuries similar

no, no two are alike due to

• remote injuries

• hidden injuries

• personal factors

cognition should not

limit functional goals

• thus change how you approach intervention based on cognition

hiearchy of cognitive recovery

1. wakefulness

2. awareness

3. perception and recognition of info

4. speed o info processing

5. memory

6. reasoning and problem-solving

7. executive functioning

Patient exam

• observation

• history

• systems review

• funcitonal asessment

• outcome measures

observation

• really variable depending on setting and patient

• could include: the room, lines and tue, people, vitals, surgical incision, trauma, patient repsponse when you walk into the room or talk

HPI

• MOI

• acuity of injury

• PMH

• clarify any precautions

• diagnostic imaging: orthopedic injuries, CT/MRI

social history

• social supports and home setup (helps to dictate discharge)

• life roles and interests to get a picture of daily life and help with salience

systems review

• cognition

• cardiovascular

  • vitals

  • prolonged stay and immobility can impair upright tolerance

  • could be the first one getting the patient up

• integumentary

  • effects of trauma

  • surgical site

  • bony prominences

  • implications of increased tone (pressure wounds)

• MSK

  • precautions or fractures

  • ROM restrictions

  • pain

• neuromuscular

  • gross coordination of movements/motor control

  • spontaneous vs. to command

  • muscle overactivity at rest and with mobility

outcome measures

• core set for adults w/ neurologic conditions

• TBI EDGE

• Rehabilitation Measures Database

• COMBI website

core set

• berg

• FGA

• ABC

• 10MWT

• 6MWT

• 5STS

TBI EDGE

• moderate to severe TBI

• slides 20-21

rehab measures database

will give details on the measures themselves

COMBI

center for outcome measurement in brain injury

disorders of consciousness

• coma, VS?UWS, MCS

• many emerge from coma within 2-4 weeks, but might not recover consciousness quickly → DoC

• deemed go have limited active participation in rehab and if documentation fails to detect progress beyonf VS and MCS → denied at inpatient rehabs

• can return home or to SNF where follow-up care to determine state of consciousness is minimal to none

misdiagnosis

• high rates are misdiagnosed as being in VS when they should be MCS

• greater prognisis for mergence from MCS than from VS

level l

complete absence of observable change in behavior whren presented stimuli

coma

complete failure of arousal system with no spontaneous eye opening and inability to be awakened by vigorous sensory stimuli

Level II

• generalized reflex response to painful stimuli

• responds to repeated auditory stimuli with increased or decreased activity

• responds to external stimuli with generalized physiollogical changes, movements or vocalizations

• responses are the same regardless of the stimuli

• could be delayed responses

VS/unresponsive wakefulness syndrome criteria

1. no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to stimuli

2. no evidence of language comprehension or expression

3. intermittent wakefulness manifested by the presence of sleep-wake cycles

4. sufficient preservation of autonomic function to permit survival with adequate medical care

5. bowel/bladder incontinence

6. variable preservation of cranial nerves and spinal reflexes

level III

• demonstrates withdrawl or vocalization to painful stimuli

• turns towards or away from auditory stimuli

• blinks when strong light crosses visual field

• follows moving object passed through visual field

• responds to discomfort by pulling tubes or restraints

• responds inconsistently to simple commands

• responds directly related to type of stimulus

• may respond to some persons

MCS

occasionally demonstrates clear cut signs of self or enviornmental awareness

diagnosis requires evidence of one or more of

1. simple command following

2. gestural or verbal “yes/no” responses

3. intelligible verbalizations

4. movements or affective behaviors that occur in contingent relation to relevant environmental stimuli