Introduction To Tbi

Front 1

Consequences of TBI:
What are some motor impairments?

Back 1

Orthopedic complications, decreases in strength, impaired functional mobility, poor coordination, balance impairments, problems with fine motor and hand function, impairments in speech, etc.

Front 2

Consequences of TBI:
What are the sensory impairments?

Back 2

taste, touch, hearing, vision, smell

Front 3

Consequences of TBI:
What are the autonomic impairments?

Back 3

arousal, awareness, sleep disturbances

Front 4

Consequences of TBI:
What are the cognitive impairments?

Back 4

memory, attention, difficulty learning, problem solving, planning, judgment and safety awareness

Front 5

Consequences of TBI:
What are some personality and behavioral changes?

Back 5

Social and coping skills, frustration, anger, denial, reduced insight, DISINHIBITION, IMPULSIVITY, apathy, anxiety, depression

Front 6

Consequences of TBI:
What are the lifestyle consequences?

Back 6

Loss of independence
Unemployment and financial hardship
Lack of transportation
Lack of leisure and recreation opportunities
Difficulty with interpersonal relationships
Loss of roles

Front 7

Fluids of the brain are non-compressible. What does this mean?

Back 7

Once pressure begins to build, ICP increases rapidly. This is a life threatening problem!

Higher ICP leads to less cerebral perfusion or a lower CPP. This, in turn can cause more damage to brain tissue.

Front 8

If the Systemic BP rises, then the cerebral vessels will ________ to maintain an even perfusion pressure.

Back 8

constrict; these mechanisms fail after brain injury

Some compensation occurs by blood & CSF moving into the spinal column; but too much pressure can lead to brain tissue herniation into the spinal column or midline shifting of the brain. These, of course, cause more brain damage!!

Front 9

If the Systemic BP falls, then the cerebral vessels will ________ to maintain an even perfusion pressure.

Back 9

dilate; these mechanisms fail after brain injury

Some compensation occurs by blood & CSF moving into the spinal column; but too much pressure can lead to brain tissue herniation into the spinal column or midline shifting of the brain. These, of course, cause more brain damage!!

Front 10

What are the 6 types of brain herniation? Which one is most common?

Back 10

1) Uncal
2) Central
3) Cingulate
4) Transcalvarial
5) Upward
6) Tonsillar - most common (tracts are very close together in the pons, so damage causes huge problems)

Front 11

What is normal ICP?

Back 11

0-15mmHg

Front 12

At what level of ICP is usually fatal if prolonged? What is the exception?

Back 12

25-30mmHG
Exception in children, who can tolerate higher pressures for longer times

Front 13

Patients with high ICPs will have exaggerated increases in ICP levels with what?

Back 13

coughing or fighting the ventilator/therapist

Front 14

What are symptoms of ICP?

Back 14

Cranial nerve palsies
headache with nausea/vomiting
mental status changes
confusion, agitation, lethargy

Front 15

What are the 2 different ways you can measure ICP?

Back 15

during a spinal tap & directly by a calibrated device drilled intracranially

Front 16

What are the 3 intracranial ways to monitor pressure?

Back 16

Intraventricular catheter, subarachnoid screw/bolt, & epidural sensor

Front 17

How does the intraventricular catheter work?

Back 17

It is a catheter that is threaded into 1 of the lateral ventricles of the brain. It is the MOST ACCURATE measurement with the advantage of allowing for drainage.

The NIH recommends patient's head of the bed to be elevated *30-45 degrees* both for measurement accuracy and safe device use.

The height of the bag is important! If it's too high, fluid won't flow out. If it is too low, TOO MUCH flows out. If the bag is just right, the fluid will only drain if the pressure in the head is above the prescribed limit.

Front 18

How does the subarachnoid screw/bolt work?

Back 18

This system consists of a screw or bolt placed just through the skull in the space between the arachnoid and cerebral cortex)

Front 19

How does the epidural sensor work?

Back 19

it is a sensor placed into the epidural space beneath the skull: this is less invasive but no fluid can be drawn from it.

Front 20

What are some DO's and DON'Ts w/ patients who have high ICP?

Back 20

Check with the client’s nurse before beginning therapy
Don’t raise the person’s legs, , turn the person on his or her side, or move the neck unnecessarily.
Minimize prolonged procedures and monitor ICP while performing functional tasks.
Only address necessary therapy needs - wound care, splinting, occasional chest PT.
May need to move slowly, stay quiet, take breaks to not overload client.

Front 21

What is a closed head injury?

Back 21

When a person receives an impact to the head from an outside force, but the skull does not fracture or displace

Front 22

What happens when a brain swells after a closed head injury?

Back 22

There is no room for expansion, so compression causes further injury. As it swells, it may expand through any available opening in the skill, including the eye sockets.

Front 23

Which cranial nerve is especially susceptible to compression after a closed head injury?

Back 23

CN III; the CNs controlling the eye muscles & function can become impaired.
If CN III is compressed, a person's pupil will appear dilated. This is one reason why you can assess intracranial pressure through pupil size in initial trauma; a "blown pupil" can be a sign of herniation or cranial compression

Front 24

What is an open head injury?

Back 24

If the force that hits a person's head is great enough, the skull can fracture or become displaced, termed an “open head injury”

Front 25

What are the pros and cons to having an open head injury?

Back 25

The good: When the skull is open the brain has room to swell. This can assist in reducing compression of brain tissues.
The bad: Because the skull is damaged or open, it cannot protect the brain as it did before. The once protected brain is now exposed, which leaves it vulnerable to infections and further injury.
The ugly: If the skull is fractured or displaced, bone fragments from the skull can enter the brain and cause further injury.

Front 26

If a piece of the skull is displaced or removed due to extreme swelling, where may it be stored?

Back 26

between the layer of fat and muscles in the abdomen to keep it healthy & surgically replaced at a later date.

Front 27

If an individual has an obvious skull deficit, where might you see a pulse?

Back 27

on the side of the head

Front 28

What may be prescribed to protect the brain when the person begins to get out of bed?

Back 28

a helmet

Front 29

What is a depressed skull fracture?

Back 29

The broken piece of skull bone moves in towards the brain(open or closed head injury)

Front 30

What is a compound skull fracture?

Back 30

The scalp is cut and the skull is fractured

Front 31

What is a basilar skull fracture?

Back 31

The skull fracture is located at the base of the skull (neck area) and may include the opening at the base of the skull
Raccoon eyes: bruising around eye orbits;
Battle's sign (caused when blood collects behind the ears and causes bruising); CSF can also leak through the eyes and nose.

Front 32

TBI is an insult to the brain caused by what?

Back 32

an external physical force; it is NOT degenerative or congenital in nature

Front 33

What are the 8 types of traumatic brain injury?

Back 33

Concussion
Contusion
Diffuse Axonal Injury
Coup-Contrecoup Injury
Second Impact Syndrome
Penetration
Locked-in Syndrome
Shaken baby Syndrome

Front 34

What causes Diffuse Axonal Injury? How is it diagnosed?

Back 34

Caused by shaking or strong rotation of the head, or by rotational forces, such as with a car accident; diagnosed by MRI, not CT.

Front 35

Diffuse Axonal Injury: How does injury occur?

Back 35

Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.

There is extensive tearing of nerve tissue throughout the brain. This can cause a chemical reaction in the brain with a release of WBCs used for “damage control” which can actually cause damage as they target healthy & unhealthy tissue.

Front 36

Brain tissue damage can produce....

Back 36

temporary, permanent, localized, or widespread brain damage, coma, or death.

Front 37

What kind of impairments would a person with diffuse axonal injury have?

Back 37

A person with a diffuse axonal injury could have a variety of functional impairments depending on how much and where the shearing occurred.

Front 38

A concussion occurs when....

Back 38

the brain receives trauma from an impact or sudden momentum or movement change

Front 39

Concussion: What happens to the blood vessels in the brain?

Back 39

they may become stretched or torn (hemorrhage). CN damage can also occur

Front 40

What some causes of a concussion?

Back 40

a few include a direct blow to the head, a gunshot wound, violent shaking of the head, or whiplash.

Closed & open head injuries can produce concussions

Front 41

What is the most common type of traumatic brain injury?

Back 41

concussions

Front 42

Does everyone with a concussion experience a brief loss of consciousness?

Back 42

They may or may not experience a brief loss (not exceeding 20 minutes). A person may remain conscious, but feel "dazed" or "punch drunk"

Front 43

Does arterial or venous insult cause more damage?

Back 43

Arterial damage causes very severe damage as compared to venous which is usually absorbed

Front 44

How can a concussion be tested?

Back 44

it may or may not show up on a diagnostic test, such as a CT scan, because the damage may only be microscopic, non-localized but widespread

Because skull fractures, bleeding, or swelling may or may not be present, concussions are sometimes a diagnosis of exclusion and are considered a complex neurobehavioral syndrome.

Front 45

A concussion can cause what?

Back 45

diffuse axonal type injury resulting in permanent or temporary damage

Front 46

How long does it take for concussions to heal?

Back 46

may take a few months to a few years for a concussion to heal

Front 47

What is pot-concussion syndrome?

Back 47

Patients may report problems with concentration, recent memory abstract thinking.
Dizziness, irritability, fatigue, double vision and personality changes.
Elderly patients are particularly affected by disequilibrium and chronic dizziness even after minor trauma.

Front 48

What is second impact syndrome?

Back 48

also termed "recurrent TBI, “ & can occur when a person sustains a 2nd TBI before the damage from the 1st TBI has healed.

Front 49

When can the second impact syndrome injury occur?

Back 49

from days to weeks following the first. Loss of consciousness is not required. The 2nd impact is more likely to cause brain swelling & widespread damage.

Front 50

Why is emergency medical treatment needed ASAP for people with second impact syndrome?

Back 50

because death can occur rapidly

Front 51

What are the long-term effects of recurrent brain injury?

Back 51

can be muscle spasms, increased muscle tone, rapidly changing emotions, hallucinations, & difficulty thinking and learning.

Front 52

What should you do if you're working with a sports team and someone has a concussion?

Back 52

DO NOT let players re-enter a game unless you are certain they do not have a concussion!!!
YOU need to advocate that TBI/concussion/contusion becomes part of your patient’s medical record!!

Front 53

What is a contusion?

Back 53

a localized bruise (bleeding) on the brain (macroscopic)

Large contusions may need to be surgically removed

Front 54

What is a contusion a result of?

Back 54

can be the result of a direct impact to the head.

Front 55

Where are the most common locations for contusions?

Back 55

Orbitofrontal cortex, anterior temporal lobe, and posterior portion of the superior temporal gyrus area, with the adjacent parietal area

Front 56

What is a coup-contrecoup injury?

Back 56

These are contusions that occur from the impact, with damage at the site of the blow as well as damage from “rebound” when the brain impacts the opposite side of the brain.

Front 57

How do coup-contrecoup injuries occur?

Back 57

These injuries occur when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, causing additional damage.

Front 58

What is a penetration injury?

Back 58

These injuries occur from the impact of a bullet, knife or other sharp object that forces hair, skin, bone and fragments from the object into the brain

They can also be caused by objects traveling at a low rate of speed through the skull and brain. These can ricochet within the skull, widening the area of damage.

Front 59

What is a "through-and-through" injury?

Back 59

A "through-and-through" injury occurs if an object enters the skull, goes through the brain, and exits the skull. Through-and-through traumatic brain injuries include the effects of penetration injuries, plus additional shearing, stretching and rupture of brain tissue.

Front 60

What is locked-in syndrome?

Back 60

a rare neurological condition in which a person cannot physically move any part of the body except the eyes.

The person is conscious and able to think.
Vertical eye movements and eye blinking can be used to communicate with others and operate environmental controls.

Front 61

What is acquired brain injury?

Back 61

This “basket” term describes any trauma that occurs to the brain after birth.
Although traumatic injury is one form of acquired brain injury, acquired brain injury also encompasses damage from disease processes like brain tumors, stroke, infection, or substance disease.
Acquired brain damage can also occur from anoxia – or lack of blood supply to the brain.
(near drowning, heart attacks)

Front 62

What are some symptoms of acquired brain injury?

Back 62

Cognitive impairment- Problem solving skills, especially memory
Behavior problems- Psychosis, depression, restlessness, combativeness, hostility
Muscle movement disorders

Front 63

What does anoxic mean?

Back 63

occurs when the brain does not receive any oxygen. Cells in the brain need oxygen to survive and function.

Front 64

What does hypoxic mean?

Back 64

Results when the brain receives some, but not enough oxygen

Front 65

What are some causes of acquired brain injury?

Back 65

Airway obstruction
Near-drowning, throat swelling, choking, strangulation, crush injuries to the chest
Electrical shock or lightening strike
Trauma to the head and/or neck
Traumatic brain injury with or without skull fracture, blood loss from open wounds, artery impingement from forceful impact, shock
Vascular Disruption
Heart attack, stroke, arteriovenous malformation (AVM), aneurysm, intracranial surgery
Infectious disease, intracranial tumors, metabolic disorders
Meningitis, certain venereal diseases (syphilis), AIDS, insect-carried diseases, brain tumors, hypo/hyperglycemia, hepatic encephalopathy, uremic encephalopathy, seizure disorders
Toxic exposure

Illegal drug use, alcohol abuse, lead, carbon monoxide poisoning, toxic chemicals, chemotherapy (not all the time).

Front 66

What is a intracranial/intracerebral hematoma? When can it occur?

Back 66

Trauma causes vessel to leak..can occur with a contusion or concussion. Can occur with or without open brain injury

Front 67

What are the 4 different types of intracranial/intracerebral hematomas?

Back 67

Subdural, epidural, subarachnoid, and intraparynchemal hematom

Front 68

What is a subdural hematoma (SDH)?

Back 68

a collection of blood below the inner layer of the dura but external to the brain and arachnoid membrane.

Front 69

What is the most common type of traumatic intracranial mass lesion?

Back 69

subdural hematoma

Front 70

What a epidural hematoma (EDH)?

Back 70

a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane.

Front 71

How do EDHs often occur? What does this trauma usually result in?

Back 71

often occur from a focused blow to the head, such as that produced by a hammer or baseball bat
In 85-95% of patients, this type of trauma results in an overlying fracture of the skull.

Front 72

In an EDH, what are the sources of the hemorrhage?

Back 72

blood vessels in close proximity to the fracture

Front 73

What is the prognosis for people with an EDH?

Back 73

Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to patient's preoperative neurologic condition.

Front 74

What is a subarachnoid hemorrhage?

Back 74

Underneath the arachnoid, between the arachnoid and the brain itself, is cerebrospinal fluid bathing and circulating around the brain. Blood leaking into the cerebrospinal fluid is known as a sub-arachnoid hemorrhage.
“The worst headache of their lives."

Front 75

What is an intraparynchemal hemorrhage?

Back 75

Blood pools in white matter of brain.
Brain trauma can cause several severe IPHs, and can result in white matter shear injury—extensive loss of axons w/extensive brain injury.
This can cause diffuse axonal injury.

(best hemorrhage to have)

Front 76

How are brain injuries diagnosed? How is it managed medically? What are some medications?

Back 76

by head CT, MRI, (sub arachnoid by lumbar puncture as well-blood in CSF); cerebral angiography (exact location of bleed)

Craniotomy, blood evacuation, ICP monitoring

Meds: Anti-seizures, Diuretics to reduce swelling, "hyperosmotic agents" (like mannitol, glycerol, and hypertonic saline) may be used to reduce brain swelling; anti-hypertensives; Calcium channel blockers decrease the incidence and severity of cerebral vasospasm.

Head of bed normally elevated to relieve cerebral pressure, often reverse trendelenberg.
Hydrate, but avoid fluid overload.

Front 77

Who typically performs the GCS?

Back 77

emergency personnel typically determine the severity of neurological injury

Front 78

What terms are used to describe the level of initial injury in relation to the neurological severity caused to the brain

Back 78

The terms Mild Brain Injury, Moderate Brain Injury, and Severe Brain Injury

Front 79

What does a person with a GCS of 1 look like?

Back 79

no motor response
no verbal response
eyes remain closed

Front 80

What does a person with a GCS of 2 look like?

Back 80

extends arm
makes unintelligible sounds
eyes open to painful stimulus

Front 81

What does a person with a GCS of 3 look like?

Back 81

flexes arm
states recognizable words or phrases
eyes open to voice

Front 82

What does a person with a GCS of 4 look like?

Back 82

withdraws from stimulus
conversant, but confused
eyes open spontaneously

Front 83

What does a person with a GCS of 5 look like?

Back 83

localizes stimulus
oriented

Front 84

What does a person with a GCS of 6 look like?

Back 84

obeys commands

Front 85

What is a mild brain injury? What are the corresponding GCS levels?

Back 85

GCS 13-15

Loss of consciousness is very brief, usually a few seconds or minutes or does not occur at all-dazed and confused.
Testing or scans of the brain may appear normal
A mild TBI is diagnosed only when there is a change in the mental status at the time of injury—the person is dazed, confused, or loses consciousness. The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion.

Front 86

What are symptoms of mild brain injury?

Back 86

Headache, fatigue, sleep disturbance
Irritability, sensitivity to noise/light, balance problems
Decreased concentration and attention span
Decreased speed of thinking, decreased memory
Nausea, depression and anxiety
Emotional mood swings
Can be debilitating. Confusing to family as they are thinking, brain injury is mild.

Front 87

What is moderate brain injury? What are the corresponding GCS levels?

Back 87

GCS 9-12

Loss of consciousness lasts from a few minutes to a few hours
Confusion lasts from days to weeks.
Approximately 60% will make a good recovery, and another 25% or so will be left with a moderate degree of disability

Physical, cognitive, and/or behavioral impairments last for months or are permanent.

Front 88

What is severe brain injury? What are the corresponding GCS levels?

Back 88

GCS 8 or less

Severe brain injury occurs when a prolonged unconscious state or coma lasts days, weeks, or months.

Front 89

Severe brain injury is categorized into what subgroups

Back 89

ComaVegetative State
Persistent Vegetative State
Minimally Responsive State
Akinetic Mutism
Locked-in Syndrome

Front 90

What is the definition of a coma?

Back 90

Coma is defined as a state of unconsciousness from which the individual cannot be awakened, in which the individual responds minimally or not at all to stimuli, and initiates no voluntary activities.

Persons in a coma appear to be asleep, but cannot be awakened
There is no meaningful response to stimulation

Front 91

Define vegetative state.

Back 91

Arousal is present, but the ability to interact with the environment is not.
Eye opening can be spontaneous or in response to stimulation
General responses to pain exist, such as increased heart rate, increased respiration, posturing, or sweating
Sleep-wakes cycles, respiratory functions, and digestive functions return.
There is no test to specifically diagnose Vegetative State; the diagnosis is made only by repetitive neurobehavioral assessments.

Front 92

Define persistent vegetative state.

Back 92

Persistent Vegetative State (PVS) is a term used for a Vegetative State that has lasted for more than a month.
The criteria is the same as for Vegetative State
The use of this term is considered controversial because it implies a prognosis

Front 93

Define minimally responsive state.

Back 93

A person is no longer in a coma or a Vegetative State. Persons in a Minimally Responsive State demonstrate:
Primitive reflexes 
Inconsistent ability to follow simple commands
An awareness of environmental stimulation
Brief head turn to noise/voices
Notice lights, TV on and off

Front 94

Deinfe Akinetic Mutism.

Back 94

It's a neurobehavioral condition that results when the dopaminergic pathways in the brain are damaged. Damage to these pathways results in:
Minimal amount of body movement
Little or no spontaneous speech
Speech which can be elicited (For example, the person can answer a question if asked, but otherwise does not voluntarily start saying anything).
Eye opening and visual tracking
Infrequent and incomplete ability to follow commands.

Front 95

What is the difference between akinetic mutism and minimally responsive state?

Back 95

Akinetic Mutism is different from the Minimally Responsive State because the lack of movement and speech with Akinetic Mutism is not because of neuromuscular disturbance

Front 96

Define brain death.

Back 96

The brain shows no sign of functioning.
The physician performs a specific formal brain death examination.

Families must be asked for organ donation at this stage. High grief while making this decision. So important to talk to your family. Many legal issues…

Front 97

Prognosis depends on what?

Back 97

Pre-Injury Characteristics (past medical history, psychological conditions, social status, economic status)
Age (plasticity is improved in younger clients)
Severity of brain injury (site of lesion, mechanism of injury, secondary damage)
Severity of other injuries.
Medical complications
Length of time between injury and the initiation of rehabilitation
Duration of coma (>20 days predicts poor functional outcome)

Front 98

What are some models of care in TBI?

Back 98

Acute Medical Rehabilitation (Acute care, Acute rehab, Coma or slow to recover programs)
Community Integrated Rehabilitation (Comprehensive outpatient neuro programs, Day programs, Residential/transitional programs, LTC – nursing home or community group homes)
Adapted Lifestyle Sustaining Services (Case management, Residential programs, Respite programs for caregivers, Home-based services)