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Traumatic Brain Injury - Coggle Diagram
Traumatic Brain Injury
Overview, Prevalence and Impact
Leading cause of death and disability in the US
47% of TBIs result form falls
Males> Females
TBI related Injuries and Mechanisms
:warning:
50-52% of TBIs in age 15-24 yo and 25-64 yo are related to
firearms
(respectively) 62-83% for
suicide
61% of TBI related death in >65o is results from
falls
77% of TBI related death in infants and age < 1yo result from
assault and maltreatment*
If you have 1 TBI you are 3x more likely to have a second
If you have 2 TBIs you are 8x more likely to have a third
Most common in older adults and infants
Sequelae of TBI (OB1 and 3)
Cognitive
: many functions controlled by the frontal lobe- attention deficits, planning, cognitive inflexibility, initiation and and self generation, response inhibition
Cognitive Impairments: GCS < 8=coma (no eye opening, no response to sensory stimulation and no motor response); altered consciousness occurs with DAI
Vegetative State
: 1) brainstem manages basic fxn and can wean from vent, 2)sleep/wake cycles present 3) awareness is absent and eyes open, 4) withdraw to noxious stim but not purposeful
Minimally Conscious State
: 1) min awareness of env, 2) sleep/wake cycles present 3) Inconsistent intentional behaviors occur 4) localize to noxious stim 5) visual fixation and visual pursuit
Coma
: 1) no arousal 2) eyes closed, no sleep/wake cycle, vent dependent 4) no auditory/visual fxn, >12mos or 3 mos after anoxic= vegetative state
Neuromuscular Impairments
: paresis, abnormal tone, motor function, gait, coordination and postural control deficits
Neurobehavioral
: linked to cognition but often more debilitating in long run
Primitive Postures
: Decorticate- above superior colliculus (UE flexed/LE ext) and Decerebrate - below superior colliculus (UE and LE ext)
Low frustration tolerance, agitation, sexual and aggressive inhibition, apathy, emotional lability, mental inflexibility, aggression, impulsivity, irritability
Communication
:
nonaphasic in nature
and are related to cognition, word retrieval difficulties, disinhibited and socially inappropriate language
Eating Dysphagia: NPO, TPN, feeding tube; MBS (Modified barium swallow study) FEES (Fiberoptic endoscopic evaluation of swallowing
Impaired Autonomic Control-
Paroxysmal Sympathetic Hyperactivity
; Increased HR, RR, BP and Temperature; Diaphoresis bc elevated sympathetic nervous system activity
Memory deficits
: Retrograde amnesia (nothing b4 accident), Anterograde amnesia (nothing after accident), PTA: time btwn injury and time when pt lays down new memories
Other information
Impaired attention: hyperactivity, impulsiveness, decreased attention span, easily distractible
Post-traumatic seizures: 12-50% (don't spin these pt)
Clinical Rating Scales (OB2)
Glasgow Coma Scale
: 13-15= Mild 9-12= Moderate <8=Severe
Rancho Los Amigos Level of Cognitive Function
I- No Response (Total Assist)
: pt appears to be in deep sleep, unresponsive to any stimuli
II- Generalized Response (Total Assist)
: Pt reacts inconsistently and nonpurposefully to stimuli. Limited response and may be physiological changes, gross body mvmts, and/or vocalizations
III- Localized Response (Total Assist)
: Pt reacts specifically but inconsistently and are directly related to type of stimuli. May follow commands such as closing eyes or squeezing hand in an inconsistent, delayed manner
IV- Confused Agitated (Max Assist)
: First level to qualify for IP Rehab (in some places), Pt is in heightened activity, bizarre and nonpurposeful behavior. Does not discriminate among persons or objects; unable to cooperate directly with Tx efforts. Verbalizations are incoherent and/or inappropriate to envir, confabulation may be present, gross attention to env is very brief, Pt lacks short-term and long-term recall
V- Confused Inappropriate (Max Assist)
: Pt is able to respond to simple commands fairly consistently. With increased complexity of commands or lack of any external structure, response is nonpurposeful, random or fragmented. Gross attention to env but highly distractible and lacks ability to focus attention on task. May converse on
social automatic level for short periods
, verbalizations often inappropriate confabulatory. Impaired memory, inappropriate use of objects,
VI- Confused-Appropriate (Mod Assist)
: Pt shows goal-directed behavior, dependent on external direction. Follows simple directions consistently and
shows carryover for relearned tasks
. Responses may be incorrect due to memory but are appropriate for situation. Past memories show more depth and detail than recent memories
VII- Automatic Appropriate (Min Assist)
: Pt appears appropriate and oriented within hospital and home, but goes through
routine automatically (robot-like)
. Shows minimal to no confusion and shallow recall. Carryover for new learning but at decreased rate. Able to initiate social or recreational activities, but judgment remains impaired
VII- Purposeful Appropriate (SBA)
: Recall and integrate past and recent events, is aware of and responsive to env. Carryover for new learning and needs no S once activity is learned. May continue to show decreased ability to premorbid abilities, abstract reasoning, tolerance for stress and judgment in emergencies or unusual circumstances
Mechanism of Injury
:!!:
Blast Injury
Primary blast injury - direct effect of blast overpressure (DAI)
Secondary Injury: Shrapnel and other objects hurled at individual
Tertiary Injury: Victim flying backwards striking an object
Quaternary: Burns, toxic inhalation
Secondary Injury
(goes with Primary or blast injury)
Secondary cell death - chain fo cellular evens following tissue damage and secondary effects of hypoxemia, hypotension, ischemia, edema, elevated ICP --> cell death
Hypoxic-ischemia injury: lack of O2 blood to brain
HII
: Lack of O2ed blood to brain, systemic hypotension, anoxia (
drug overdose
, drowning, cardiac arrest); global damage and associated with poorer cognitive function and lower expected outcomes
Primary Injury
A: Brain tissue is in contact with an object, focal in nature
B: Rapid acceleration/deceleration of brain creating cortical disruption (Coup-Countercoup injury or Diffuse Axonal Injury)
Focal Injury
: Hematoma, edema contusion and/or laceration; Coup-Contrecoup injury: site of impact (coup) occurs opposite side that was hit -brain bounce (contrecoup)
DAI
: acceleration/deceleration and rotational forces are the cause
-widespread shearing and retraction of damaged axons
-Correlates with less clinical recovery
Diagnosis
CT is insensitive to many of lesions immediately after trauma but does not rule out something like DAI which is often undetectable until brain atrophy shows later
Prognosis and Goal Setting
Main Factors Affecting Outcome of TBI
Loss of Consciousness: longer is worse
Length of PTA: less days better, longer worse
Alternation of Consciousness: longer is worse
Radiological Exam: most of the time imaging is going to be normal or maybe slightly abnormal in moderate/severe cases but does NOT rule out severe damage to the brain
GSC
Determination of PTA
: 1) Westmead Post Traumatic Amnesia Scale 2) GOAT and 3) O-Log
GOAT and O-Log look at the pt
orientation
:check: Positive Predictors: Years of education and family support
:red_flag: Negative Predictors: Low GCS, pupillary reactivity, Age, Race, Lower educational level, alcohol or drugs @ time of trauma, petechial hemorrhages, subarachnoid bleed, obliteration of 3rd ventricle, midline shift, subdural hematoma
PT Exam, POC and Tx interventions (OB 4 and 5)
PT Focus: Prevent secondary impairments, begin earl mobilization and initiate pt and family education
PT Exam Components:
Arousal, Attention and Cognition
,
Behavior
, Integumentary (immobilization), Sensory integrity, ROM, Tone, Motor function/coordination, respiratory ventilation/gas exchange,
Goal for Mod/Severe TBI Acute:
Reduce secondary impairments, motor control improvement, postural control and tolerance of activities
, tone management, joint and skin integrity, mobility, coordinated care, and education (pt and family
Treatments
Sensory Stimulation:
NO evidence that is does anything but no evidence that it doesn't. If you have nothing else to wake these pts up it can be beneficial to get them to participate
Keep 15-30 min sessions, eliminate distractions, include family, use stimuli that is meaningful
Ranch I, II and III Tx
:
-Prevent secondary impairments
-improve arousal, pt/fam education
-manage tone
-Early transition to sitting postures (head supported, midline orientation)
-Tilt table (upright tolerance)
-Motor relearning is physically and mentally fatiguing!
-Transfers, bed mobility, gait, CIMT, aerobic and endurance conditioning
Faster movements facilitate arousal, monitor pt BP,
AVOID spinning - may trigger seizures
, watch fro physical protective reactions or delayed balance reactions during these activities
Rancho IV Tx:
-Expect no carryover
-Model Calm Behavior
-Expect egocentricity
-Flexibility and options are NEEDED
-Safety (you and pt)
Rancho V-VIII Tx:
-Be intentional with Dosage, Intensity and Contextualized activities
-Pt safety, functional mobility, strength, endurance, ROM - almost an othro type pt at this point
Serial Casting
Increase PROM of
DF by at least 5-10 deg
and
Knee ext at least 10 Deg
If not achieving appropriate goals then discontinue as it is not complementing therapy well
:red_cross:
Indications for Emergent Removal:
:red_cross:
Weak Pulse
Delayed Capillary Refill
Cold to touch
Swelling
Cast is saturated with water or fluids
Skin Reaction
Unusual odor
First time: leave on for 2-5 days and take off and reapply- Timpson's Tip is to NOT do it on a Friday for the first time - want to monitor pt closely
Frequency of Cast Change
: Every 7-10 days for 1-4 weeks
Often PF and Biceps contractures
:star:
Early Medical Management
Large intracranial hematomas are evacuated and ICP monitored closely
(>20 mmHg is NOT ok for therapy)
SBP may be >90mmHg, O2 >90%, HOB >30 deg