Exam 3

what is TBI

injury to brain from mechanical force(damages tissue) that alters brain function

who is at risk for TBI

older aged adults

males

alcohol use

previous TBI

etiology of TBI

fall contact 35%

traffic accidents 17%

struck by/against 16.5%

unknown 12%

assault 10%

other 9%

types TBI

diffuse or focal

what is diffuse TBI

widespread (reach other areas)

concussion, diffuse axonal injury, blastwh

what is focal TBI

direct impact

contusion, penetrating, hematomas

what is an open TBI

penetrating

skull fx, breach meninges, brain tissue exposed

focal

what is a closed TBI

non penetrating

external force, skull intact, brain injured

usually diffuse but can be focal

impact coup to counter coup

primary injury of TBI

its a DIRECT injury:

contusion-bruising

cerebral laceration-tearing

intracerebral hemorrhage/hematoma

diffuse axonal injury

what hemorrhage is the worst

subdural as its closer to brain tissue

who is likely to get subdural hematomas

older population

severe initial CP

great midline shift

higher incidence of death

secondary injury of TBI

INDIRECT - exacerbate neuronal damage(hours-days after primary)

inflammatory

vascular changes

edema(incr ICP)

parenchymal changes

TBI imaging?

CT is best used and MRI after stabilize injury

indications for CT for TBI

vomiting, headaches, altered mental state, loss consciousness, intoxication, post trauma seizures/amnesia, basal skull fx, facial injury

poor prognostics for TBI

eye dilation not reactive

absent motor responses

recovery from TBI

continued recovery decreases assistance needed

know table of mild, mod, severe TBI

terms if consciousness: alert

awake, looks around, responds in meaningful manner to verbal instructions/gesturesterms if consciousness:

terms if consciousness: coma

unarousable and unresponsive, doesnt open eyes to deep pain

terms if consciousness: stupor

unresponsive except to vigorous stimuli, may attempt to verbalize to vigorous stimuli, open eyes to pain

terms if consciousness: confused

disoriented to time, place, person, memory difficulty, difficulty with commands, exhibits alteration in perception of stimuli, may be adjusted

terms if consciousness: delirium

confusion of circumstances, may hallucinate or act as if in dream like state, conversation may not make sense, often acute ICU setting, emergence from coma

terms if consciousness: lethargic

drowsy, oriented when awake but if left alone will sleep, loud voice needed to keep awake and engaged

CM of TBI physical

loss altered levels consciousness

seizures

hemiparesis(CL)

ataxia

impaired balance

cranial n deficits

abnorm posturing

CM TBI abnorm posturing/reflexes

decerebrate- extend (worse as below red nucleus)

decorticate - flex

TBI CM for cognitive/behavioral

memory deficits

difficulty with attention, reasoning and concentration

personality changes

impulsivity, irritability, and aggression

depression and anxiety

Rancho levels of cognitive functioning(levels of cognitive recovery)

level 1 vs 10

1=total assist

10=independent

CM TBI brain regions

frontal- CL hemiparesis, mood/behavior change

temporal- CL hemiparesis, visual/memory changes, seizures

parietal- CL sensory deficits, R-L discrim difficulty

early acute med manage of TBI

prevent hypotension (SBP >90)

prevent hypoxemia (o2 sat >90)

prevent elevated ICP (<20)

NOT USE - steroids, hypothermia/hyper-ventilation

monitor ICP indications

if GCS 3-8

unilat/B motor posturing

abnorm CT

>40yo

SBP>90

whats EVD- external ventricular catheter drain

allow accurate measurement/drainage of CSF

whats IPD- intraparenchymal devices

inserted into cortical-subcortical brain region

allows ICP monitoring with collapsed ventricles

what to do to avoid hematoma to prevent secondary injury and central herniation

decompress with craniotomy or craniectomy(for diffuse BI or delayed bone replace)

indications for epidural hemorrhage TBI

on CT volume >30cc/>15mm

indications for subdural hemorrhage TBI

on CT thickness is >10mm and shift midline >5mm

GCS drops 2+

ICP >20

abnorm pupillary response

postop craniotomy/craniectomy

head bed =/>30

craniectomy=MUST wear helmet ALL time out of bed

lifting/exercise limit unitl DR says so

avoid things incr ICP

pharmacologic management of TBI

analgesics/anticonvulsants=decr pain/prevent seizures

neuroprotective drugs= reduce secondary injury(Ca channel blockers)

sedatives/anxiolytics= manage pain, agitation, anxiety

common side effects- sedate, confuse, dizzy, hypotension

TBI complications

post-traumatic epilepsy(seizures post injury, needs meds)

hydrocephalus- abnorm accumulation CSF > incr ICP (incr ICP> life emerg)

autonomic dysfunction- dysregulation HR, BP and temp control

what are red flags for PT TBI

>ICP/brain edema

acute/unstable fx(cervical spine)

severe/uncontrolled seizures

signs of ICP incr

headache, nausea, elevated BP, decline mental state, double vision, shallow breathing, non-reactive pupils, seizures, alter consciousness/coma

ELEVATE Head Bed -30

what to consider for TBI

dysautonomia(paraoxysmal symp hyperactivity)

executive function(need simple instruct)

judgement deficits

perceptual deficits

behavioral deficits

communication deficits

what us a stroke

the loss of neurological function bc impaired blood flow in the brain

-disrupt of cerebral flow that leads to ischemia/hemorrhage and lead to neuronal injury

nonmodify and modify risk stroke

modify: >55yo, gender, family history/genetics

nonmod: hypertension, afib, diabetes, dyslipidema, obesity, sedentary, birth control >35yo, smoking, cocaine use

types of stroke

TIA, hemorrhage, ischemic

what is TIA

transient ischemic atttack

focal neurologic symptoms resolves in 24hrs

what is ischemic stroke

can be thrombosis, embolism and majority of cases!!

what is hemorrhage

intracerebral/subarachnoid - less common

difference btw hemorrhage and thrombosis/embolism

hemorrhage is blood loss and psi where thromb/emb is block flow

imaging for stroke

CT very common- could have false negatives

MRA- see arteries and detect blood flow

MRI- soft tissue BEST OPTION (1st for stroke centers)

what does doppler US for strokes do

show carotid a. stenosis, post brain circulation and periph a.

NONINVASIVE

what does the arteriography and digital subtrction angiography do for strokes

xray carotid

DSA

INVASIVE

whats prognosis depend on for stroke

amt of neural damage

time onset symptoms

level cogn involvement

if someone has a stroke how likely are they to have another one

25% more likely

stroke sign BE FAST

Balance lost

eyesight changes

face drooping

arm weakness

speech difficulty

time call 911

CM of stroke

hemiparesis/plegia

impaired balance and coordination

cognitive and perceptual deficits

aphasia

dysarthria

visual disturbances

left brain damage cm of stroke

paralyzed right side

speech/language deficits

behavioral -slow/cautious

memory deficits(language)

right brain damage cm of stroke

left paralyzed

spatial/perceptional deficits

behavioral- quick/impulsive

memory deficits(performance)

whats a major branch of anterior circulation - stroke

middle cerebral artery (69%)

where does MCA supply

hands and mouth

with occlusion to MCA what can result

hemiplegia more in UE

hemisensory

hemianopsia

MCA occlusion if someone has L damage then what is affected

global aphasia

ideomotor apraxia

if R MCA occluded what could be an issue

L neglect(unilateral neglect)

what does the ACA supply afffect

LE

if ACA occluded what result in

CL hemiparesis/sensory loss more in LE

ideomotor apraxia

what PCA supply

vision and pain/sensory

PCA peripheral occlusion cause

visual deficits

memory deficits

if R PCA affected what side body

left!

PCA central occlusion causes

thalamic pain

pain and sensory impairs

CL hemiplegia

involuntary movements

webers syndrome

which artery supply CM is webers syndrome

PCA central!!

what kind of a stroke is webers syndrome

PCA or midbrain stroke

what does webers syndrome affect

ipsilat cn3(occul palsy)

CL hemiparesis

sometimes ataxia(red nuc) or rigidity(sn)

goals for acute medial management - stroke

improve cerebral perfusion

maintain oxygenation

maintain BP/CO

medical manage ischemic stroke-acute

tPA/TNK- admin within 3 hrs

surgical manage ischemic stroke-acute

mechanical thrombectomy- clot remove within 6hrs

surgical bypass for revascularization

carotid endarterectomy- plaque removed, for stenosis 60-90%, reduce risk CVA 55%

angioplasty/stents- open up blocked artery

medical and surgical manage of hemorrhagic stroke-acute

endovascular - prevent rupture by block contrib flow

surgical clipping stop bleed

bypass for revascularization

stroke- pharmacologic manage

anticoagulants/anitplatelets-aspririn/warfarin

thrombolytics-TNK/tPA

antihypertensives and statins- beta blockers, Ca channel blockers

cautions with stroke pts

decr in sight to deficits of R brain stroke

fall risk

psi injuries

contraindications to pts with stroke

TNK/tPA-not start PT 12-24hrs from administration

BP monitoring!!!

PT measures for pt post stroke

10 m and 6MWT

functional gait assessments

5 times sit - stand and ABC scale

Berg balance scale

etiology of meningitis

inflammation of meninges of brain/spinal cord

pathogenesis of meningitis

infection carried by blood products/other fluids causing damage to cerebral capillary organisms

blood brain barrier fails prevent entry infectious organisms

what is most common cause meningitis type of inflammation

viral/aseptic meningitis

what is aseptic meningitis

contamination of CSF by virus/fungus(enteroviruses, herpes simplex virus 2, epstein barr virus, systemic lupus erthematosus, intracranial tumors)

occurs days-weeks after exposed

where is bacterial meningitis

organisms in mucosal surfaces in upper respiratory tract- sinusitis, otitis, mastoiditis

whats neonatal meningitis

birth canal transferred to infant from mother- ecoli, listeria, group b streptococcus

CM of meningitis

fever, headaches - stiff/painful neck(nuchal rigidity)- kernigs/brudzinskis signs

pain lumbar area and post thigh

cranial n palsies and deafness

changes in mental status/behavior

fever

late disease process CM of meningitis

focal neurological signs- weakness, visual disturbance, aphasia

meningitis medical management

blood test/lumbar puncture determine bacterial/viral

CT brain inflammation

treatments- antibiotics, IV fluids, steroid meds

hospital stay- few days-weeks

etiology of encephalitis

inflammation of grey matter

-mosquito/tick(west nile)

-herpes simplex virus(skin contact, resp droplets)

pathogenesis of encephalitis

cerebral edema destroys n cells causing intracerebral hemorrhage and brain damage

CM of encephalitis

headache, nausea, vomiting- altered consciousness(coma)

fever

agitation

focal neurologic signs- hemiparesis, apraxia, ataxia, disorder limb movement, visual disturbances, aphasia

seizures common

diagnosis encephalitis

CT or MRI - brain inflammation

lumbar puncture- infection/autoimmune antibodies

blood/urine - viruses

EEG- brain electrical activity

treat encephalitis

mobility restrict

incr fluid intake

autoinflamm(steroids)

antivirals/IVIG/plasma exchange

follow up therapy

PT for CNS infections - primary vs secondary

recognize when refer to MD/PCP = primary

secondary= treat complications of weakness, impaired balance, AS, motor coordination

types CNS inflammation

meningitis and encephalitis

classify neoplasms

names by cell origin

primary v secondary

benign v malignant

histologic grade

anatomic location

childhood v adult

grade

grade

grade

grade