Acute Care - Tbi

Front 1

Leading cause of TBI in elderly

Back 1

Falls

Front 2

Leading cause of TBI in general

Back 2

MVA

Front 3

64% of infant death due to:

Back 3

Brain injury as a result of child abuse

Front 4

Gender differences in TBI rates

Back 4

Greater in men! 78%

Front 5

Age population most at risk:

Back 5

0-4, 15-19, 65+

Front 6

Percent intoxicated at time of injury

Back 6

50%

Front 7

TBI Definition

Back 7

disruption in function of brain caused by blow or jolt to head, a penetrating head injury, or a global anoxic (without O2) event

Front 8

TBI Classification

Back 8

Glasgow Coma Scale (mild, moderate, severe)

Front 9

Mild TBI

Back 9

one or more of following:
1. any alteration in metal state (dazed and confused)
2. brief loss of consciousness <30min
3. loss of memory
4. focal neurological deficit; includes concussions and contusions

Front 10

Moderate TBI

Back 10

1. loss of consciousness lasts from a few min to few hours; 2. confusion lasts from days to weeks;3. physical, conginitve, and or behavioral impairments last for months or are permanent

Front 11

Glasgow Coma Scale Components:

Back 11

1. Eye Opening (1-4)
2. Best Motor Response (1-6)
3. Verbal Response (1-5)

Front 12

Glasgow Coma Scale Scores

Back 12

Mild: (13-15)
Moderate: (9-12)
Severe: (<9)
<7 typical in a coma

Front 13

Open Head Injury

Back 13

- skull is fx or displaced;
- allows brain room to swell;
- bone fragments from skull can enter brain and cause further injury;
- brain is exposed;
- pt may be issued a helmet; skull may be surgically replaced later or an artificial skull flap may be used

Front 14

Closed Head Injury

Back 14

- brain swells with no place to go;
- increased ICP;
- compression of brain tissues;
- brain may expand through any available opening in skull (eye sockets -> compression of CN III -> dilated pupil);
- surgery for evacuation of hematoma or decompressive craniectomy (skull flaps surgically replaced later)

Front 15

Diffuse Axonal Injury

Back 15

- caused by stretching/shearing or strong rotation of the head;
- nonmoving brain lags behind the movement of the skull causing brain structures to tear; - extensive tearing of nerve tissue causes brain chemical to be released -> additional injury;
- can produce temporary or permanent widespread brain damage, coma or death

Front 16

Acquired Brain Injury

Back 16

- Anoxic brain injury (anoxic, anemic, or toxic anoxia)
- Hypoxic brain injury
- Poorer prognosis compared with TBI

Front 17

Coup-countrecoup Injury

Back 17

Contusions at the sit of impact AND on the complete opposite side of the brain

Front 18

Pathogenesis of TBI - Contusions

Back 18

- Primary injury
- Present in >90% of fatal TBI
- Vascular damage leads to infarction
- Characteristic distribution in frontal and temporal lobes

Front 19

Pathogenesis of TBI - Secondary Damage

Back 19

- Brain swelling
- Impaired cerebral perfusion
- Obstructive hydrocephalus
- Post traumatic epilepsy

Front 20

Pathogenesis of TBI - Skull fx

Back 20

- Exerts pressure on brain
- Most common over frontal and temporal lobes
- Increased ICP
- Skull fx and depressed consciousness are strong predictors of intracranial hemorrhage (ICH) development

Front 21

Pathogenesis of TBI - Hematomas

Back 21

- Collection of blood within the cranium that results from leakage from a blood vessel
- Life threatening --> "talk and die"
- Epidural
- Subdural (can be acite or chronic
- Intracerebral

Front 22

Pathogenesis of TBI - Lacerations

Back 22

Cuts or tears of brain tissue or blood vessels

Front 23

Pathogenesis of TBI - Diffuse Axonal Injury

Back 23

High velocity shearing injury

Front 24

TBI Impairment and Memory

Back 24

- Loss of anterograde memory (inability to form new memories)
- Post-traumatic amnesia (unable to remember new info. during a pose-injury period & don't recall injury itself
- Retrograde amnesia (partial or total loss of ability to recall events that occurred immediately preceding the head injury)
- Short term memory deficits

Front 25

Ranch los amigos Scale

Back 25

Levels of cognitive functioning
- Pt. may plateau at any level
- Levels 1-3 (low level response)
- Levels 4-6 (mid level response)
- Levels 7-8 (high level response)

Front 26

Rancho Level 1

Back 26

- No response
- Appears in a deep sleep
- Unresponsive to any stimuli

Front 27

Rancho Level 2

Back 27

- Generalized response
- Reacts inconsistently and non-purposefully to stimuli in a non-specific manner

Front 28

Rancho Level 3

Back 28

- Localized response
- Reacts specifically, but inconsistently

Front 29

Rancho Level 4

Back 29

- Confused & agitated
- In a heightened state of activity with severely decreased ability to process information
- Brief attention to environment (you are just an object in their environment)
- Disoriented x3
- Response out of proportion to stimulus
- Purposeful attempts to remove restraints
- Get OOB
- Pull out tubes
- Verbalization is incoherent and/or inappropriate

Front 30

Rancho Level 5

Back 30

- Confused and inappropriate
- Appears alert and is able to respond to commands fairly consistently
- Highly distracted
- May not make sense in conversation
- Stressful situations may upset them, but agitation is not a problem
- With cues and structure they may respond appropriately for brief periods of time
- Increased frustration as elements of memory return

Front 31

Rancho Level 6

Back 31

- Confused, but appropriate
- Shows goal directed behavior, but is dependent on external input for direction
- Follow simple directions consistently
- Shows carryover for relearned tasks (ADLs)
- Require max assist for learning and caryover is poor

Front 32

Rancho Level 7

Back 32

- Automatic and appropriate
- Appropriate and oriented in hospital and home settings
- Robot-like with daily routines

Front 33

Rancho Level 8

Back 33

- Purposeful and appropriate
- Alert and oriented
- Able to recall and integrate past and present events

Front 34

Summary of Rancho los amigos Levels 1-3

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NOT AWARE OF ENVIRONMENT
- Do not interact with environment appropriately
- May turn head toward or away from loud noise
- Response relates to stimulus
- Delay in response

Front 35

ICP level where surgery is considered:

Back 35

> 25 mmHg

Front 36

ICP level where monitoring can be discontinued

Back 36

<20 mmHg for 24 hours

Front 37

Anticonvulsants given to TBI patients because:

Back 37

Seizures are quite common

Front 38

Early prediction of outcomes from TBI

Back 38

1. Pupillary response
2. Age (5-60)
3. Monitor response

Front 39

Risk markers on outcomes from TBI

Back 39

- Mortality increases with age and severity of injury
- Severity of injury correlates with : duration of post-traumatic amnesia, duration of altered consciousness, and ICP

Front 40

TBI Prognosis Assessment

Back 40

Glasgow Outcome Scale (GOS)
- Assessment of general functioning of pt.
- Quantifies the level of recovery of TBI patients
- 5 level score (from dead to good recovery)
- Extended glasgow outcome scale (GOS-E) = 8 level score

Front 41

Cognitive Deficits Associated with TBI

Back 41

- Learning
- Memory
- Communication
- Complex information processing
Big 3 = attention, memory and executive function

Front 42

Behavioral Deficits Associated with TBI

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- Sexual dis-inhibition
- Apathy
- Aggression
- Depression

Front 43

Sensory/motor Deficits Associated with TBI

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- General deconditioning
- Hemiparesis/bilateral hemiparesis
- Imbalance
- Ataxia and dis coordination
- Associated injuries

Front 44

PT Considerations for SEVERE TBI

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- Focus on communication system
- Positioning to prevent skin breakdown and contractures
- Be on alert for heterotropic ossification

Front 45

PT Considerations for MODERATE TBI

Back 45

- Daily routine is ESSENTIAL
- Simple commands
- Offer options (gives pt. control)
- Emphasize safety
- Numerous activities through session due to decreased attention span (<5 min per task)