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211 exam 1
Closed head injury/TBI
| Question | Answer |
|---|---|
| types of head injury | Concussion Contusion Hemorrhagic injury Open head injury- penetrating trauma Closed head injury Can be focal or diffuse |
| TBI | outside force that impacts the head hard enough to cause the brain to move within the skull which creates damage to the brain |
| examples of causes of TBI | motor vehicle collisions, falls, gunshot wounds, sports, physical violence, etc. Closed Head Injury vs. Open Head Injury |
| leading cause of TBI | falls Rates highest in 0-4 years, 65+ Huge increase since last analysis (MVA was most common) |
| common causes of TBI | struck by/against (unintentional blunt trauma) motor vehicle accident |
| leading cause of BI death | motor vehicle traffic injury Rates highest for 15-24y Includes all vehicles – cars, trucks, motorcycles vs. other vehicles, bicycles, pedestrians, etc |
| acquired brain injury | Not hereditary, congenital, degenerative, or induced by birth trauma – occurs after birth |
| how is acquired BI different than TBI | not caused by external force |
| mechanisms of BI | Acceleration Deceleration Rotation Shearing Penetrating Coup and Contrecoup |
| coup | Laceration or contusion at sight of impact |
| contrecoup | Injury occurs at the opposite side due to movement of the brain |
| TBI can be ____ or ____ | open, closed |
| penetrating brain trauma | trauma caused by any missile that penetrates skull and brain |
| exampled of penetrating brain trauma | GSW Knives, ice picks Nail guns High risk for infection Very high seizure risk |
| diffuse axonal injury (DAI) is a ____ head injury | closed |
| what causes DAI | Unequal acceleration/deceleration, rotation mechanism (e.g. cracked helmet, rollover vehicle, fast rotation) |
| what occurs in DAI | shearing of the axons |
| prognosis for DAI | Poor clinical status with relatively normal CT scan |
| characteristics of mild TBI | LOC < 30 minutes = Concussion GCS 13-15 No CT results 75% of TBIs are classified as mild residual symptoms |
| residual symptoms of mild TBI | Memory loss Headache Vestibular symptoms Sleep disorders |
| how long can post concussion syndrome last? | Can last 1 week to 1 year after initial injury, but typically improves/resolved by 3 months |
| most common symptoms of post concussion syndrome | Headache – myofascial vs vascular/nerve injury Dizziness – vestibular changes, N/V Confusion/disorientation Hearing loss, tinnitus, photophobia and other visual changes Speech and cognitive deficits Irritability and poor attention Sleep disorders |
| characteristics of moderate TBI | GCS 9-12 LOC > 30 minutes Abnormal CT scans Physical, cognitive, behavioral impairments last for several months or are permanent extensive post concussive symptoms may be extensive |
| recovery for moderate TBI | may have good recovery or long term deficits |
| characteristics of severe TBI | combination of focal and diffuse spread throughout the cortex and brainstem LOC hoursdays; coma GCS < 8 Deficits are widespread and severe |
| recovery for severe TBI | Most will have permanent residual deficits involving cognition, swallow, speech, mobility and/or bladder |
| cognitive characteristics associated with frontal lobe pathology | loss of verbal fluency loss of nonverbal or visual design fluency decreased attention increased distractibility loss of ability to monitor and self correct loss concrete thinking mental inflexibility poor abstract decreased processing |
| behavioral disturbances associated with frontal lobe pathology | disordered planning lack of inhibition euphoria, inappropriate joking confabulation irritability, lability, depression flat affect denial of deficit motor, sensory, verbal preservation agitation decreased initiation |
| motor deficits from BI | Monoplegia or hemiplegia Weakness or reduced force production, impaired motor control Abnormal reflexes Flaccidity at onset Progression to increased tone, spasticity and rigidity primitive postures from abnormal tone |
| flaccidity | no DTR's, commonly seen at onset of BI |
| how does tone change with TBI? | flaccid to increased tone and spasticity, progress to increased tone more quickly than CVA |
| decorticate posturing | Flexion posturing UE flexed posture; LE and trunk extended posture |
| what lesions are seen with decorticate posturing? | at or above brainstem (red nucleus) |
| decerebrate posturing | Extension posturing UE, LE and trunk in extension |
| what lesions are seen with decerebrate posturing | Lesion lower in brainstem; typically worse prognosis |
| what determines post BI prognosis | variable cumulative effects of repeated concussions injury severity |
| what symptoms correlate with poor prognosis with TBI | diffuse swelling, hematoma, diffuse axonal injury coma |
| what is associated with limited success for recovery with TBI | hx of substance abuse, low educational level, psychiatric disorders |
| ranchos los amigos levels of cognitive functioning | |
| 4 states of recovery | Coma Vegetative State/Unresponsive Wakeful State Minimally Conscious Post Traumatic Amnesia |
| coma stage of recovery | No evidence of sleep wake cycles No spontaneous or stimulus induced eye opening No command following No purposeful movement No intelligible speech or awareness |
| how long does coma stage of recovery last? | rare to last more than 2-4 weeks |
| vegetative state/unresponsive wakeful state | Return of sleep wake cycles Intermittent eye opening No evidence of sustained, voluntary, or behavioral responses Reflexive responses present |
| when is permanent vegetative state defined? | after 12 months in the trauma population and after 3 months in the non-trauma population |
| minimally conscious state | Inconsistent awareness of self and environment Emergence of simple command following Localization to noxious stimuli Intelligible verbalizations Nonfunctional communication Appropriate laughter or crying in response to environment |
| post traumatic amnesia | Patient must demonstrate one of the following: Functional interactive communication Functional use of at least two different objects on two separate occasions |
| rancho level 1 | no response, total assistance |
| rancho level 2 | generalized response, total assistance |
| characteristics of rancho levels 1 and 2 | no response in Level 1 Level 2 begins to demonstrate generalized response inconsistent non-purposeful |
| medical management of a rancho level 1 and 2 pt | Maintain vital functions Prevent secondary complications airway and pulmonary care maintain ICP's |
| secondary complications that may be seen at rancho level 1 and 2 | Hypoxemia Hypotension Fever PneumoniaResp failureARDS DVT/PE Hypermetabolic and hypercatabolic state Seizure Sepsis -->CIP/CIM Storming |
| critical illness neuropathy | see slide 28 iatrogenic- caused by medications |
| normal ICP | 4-15 mmHg |
| what exercise can pts with ICP bolt do? | bed rest, some dr's will allow to get up |
| positioning for ICP pts | HOB 30 degrees |
| positions that increase ICP | Trendelenburg lateral neck flexion extreme hip flexion |
| conditions that increase ICP | Valsalva noxious stim pain coughing |
| what can raised ICP cause | compression of brain structures fatal brain herniation |
| precautions for an EVD drain pt | drain must stay at a certain level, determined by nursing, if you need to get the pt up must have nursing adjust the drain first |
| storming | uncontrolled activation of the sympathetic nervous system. |
| when is storming more common? | after DAI |
| when does storming occur? | 24 hours up to 2 weeks after injury |
| what does SNS control? | body arousal HR, resp, perspiration, adrenaline release, hormone release |
| what does PNS control | de-arousal |
| clinical presentation of storming | Temp 38.5C (100.3F) Posturing HTN Tachycardia (HR>130) Tachypnea (RR >40) Diaphoresis Agitation Disorientation Arrhythmia Dystonia 3 days with 1 cycle per day |
| what is elevated in the blood during storming? | epinephrine and catecholamines |
| treatment for storming | treat symptoms, but no treatment for underlying cause Treat fever, HTN, arrhythmias Sedatives, paralytics, narcotics |
| consequences of unmanaged storming | Secondary brain injury Prolonged HTN Arrhythmia -MI Hyperglycemia Hyperthermia (can prolong storming episode) Hypernatremia (from severe diaphoresis) Muscle wasting, weight loss Neurogenic pulmonary edema |
| what can cause secondary brain injury with storming? | decrease in cerebral tissue oxygenation |
| risks associated with storming | Death Cardiac arrest Hemorrhage Increased cerebral temperature Rhabdomyolysis |
| PT intervention for rancho levels 1 and 2 | JFK scale ROM/positioning splinting skin inspection caregiver education sensory stimulation |
| sensory stimulation for rancho levels 1 and 2 | Orientation stimulate reticular activating system prevent secondary complications mobility facilitates drainage of tubes Assess w/c positioning EOB if spine and ICP’s stable |
| benefits of early mobilization | Decreased LOS in ICU and in hospital Decreased days on vent Decrease in complications Increased mobility |
| rancho level 3 | localized response - total assistance |
| characteristics of rancho level 3 | localized response may follow simple commands but inconsistent |
| PT intervention for rancho level 3 | JFK scale Orientation Motor priming activities Postural assessment (Unsupported, Bed, Wheelchair) Begin mat activities (Weight bearing, Head/trunk control) |
| rancho level 3 PT interventions continued | standing frame do familiar and automatic tasks use pictures of family and friends identify what is meaningful and motivating to the client ongoing caregiver education pulmonary hygiene Motomed Aquatics |
| rancho level 4 | confused/agitated- max A |
| characteristics of rancho level 4 pts | Confused Agitated/restless Insecure /emotional Paranoid Inappropriate Poor attention Poor short term memory Unpredictable |
| treatment focus with rancho level 4 | decrease confusion and agitation |
| treatment goal for rancho level 4 | sense of safety |
| team goal for rancho level 4 | nurture |
| rancho level 4 medical management | Rule out drug interactions/reactions Rule out pain/irritation Rule out liquid/food intake problems Assess for infection Assess for neurologic complications Assess for metabolic alterations Assess sleep-wake cycles Minimize sedation |
| patient support for rancho level 4 | Family and friends are educated regarding visitation and stimulation levels Gather information about the patient Determine what motivates the patient Have family/friends set up the patient’s room so it is a familiar environment |
| environmental management for rancho level 4 | Assessed for safety Implement low-stimulation environment Implement structured schedule Structured activity alternating with rest periods Limit visitors Provide privacy for the patient wander guard GPS system restraints wc alarm sitter |
| beds for Rancho level 4 | enclosure bed craig bed posey bed bed alarm |
| therapeutic pt interaction for rancho level 4 | Calm and soothing environment Model calm and appropriate behaviors Re-orient periodically Slowed movements by staff Move patient slowly and gently Minimize talking, increase gestural communication by staff Break down into simple steps |
| how to ask questions with a rancho level 4 pt | Use yes/no questions Minimize questioning |
| Much of the agitation seen with TBI is ____ in nature ,occurs in response to something | reactive |
| ____ undesirable behavior, do not try to reason with them | redirect |
| alternate ____ and ____ | rest, activity |
| behavioral modification program for rancho level 4 | 1. team approach 2. use measurement tool (ABS, JFK-CRS) 3. set up consistent daily schedule 4. determine what motivates the client and set up activities accordingly 5. Promote patient centered activities 6. Promote carryover |
| behavior modification techniques | -Written Behavioral plan -May need contract -Set up a reward system -Time out if needed -Role playing/modeling -Distraction/redirection -Relaxation training -Document all interventions and reactions -Use of Agitated Behavior Scale |
| techniques for calming the agitated pt | Swaddling Rhythmic rocking Surround in pillows Soma bed Light touch or approximation Soft voice Music/Humming Gentle ROM/positioning White noise Turn off lights Turn off tv/stereo |
| what to do if aggression is escalating | Call for help Maintain eye contact Do not leave the person alone Keep person in sight Provide a safe environment for the patient and you |
| where should you position yourself in the room if a pt is agitated | between the pt and the door |
| rancho level 5 | Confused Inappropriate Non-Agitated – Maximal Assistance |
| Rancho level 6 | Confused Appropriate – Moderate Assistance |
| characteristics of rancho levels 5 and 6 | confused non-agitated decreased attention to task decreased STM inappropriate but moving towards appropriate beginning to have some carryover |
| treatment focus for rancho levels 5 and 6 | orientation |
| treatment goal for rancho levels 5 and 6 | awareness of self |
| team goal for rancho levels 5 and 6 | supportive |
| medical management for rancho levels 5 and 6 | 1. rule out drug interactions/reactions 2. rule out nutritional deficits |
| environmental management for rancho levels 5 and 6 | mild to moderate demand treatment redirect to tasks to maintain participation provide rest breaks consistent staff, schedule and routine keep tasks functional and goal oriented |
| how to keep tasks functional and goal oriented | must be meaningful and motivating client centered goals |
| treatment ideas for rancho levels 5 and 6 | use of day planner and/or journal adjust interventions as needed keep client engaged in activities during non-treatment and non-rest periods continued use of behavior modification techniques if needed Simulate job, home activities |
| Rancho level 7 | Automatic Appropriate – Minimal Assistance |
| Rancho level 8 | Purposeful Appropriate – Stand by Assistance |
| Rancho level 9 | Purposeful Appropriate – Stand by Assistance on Request |
| Rancho level 10 | Purposeful Appropriate – Modified Independence |
| greatest deterrents to progress | tx or environment that requires cognitive function higher than the client’s level of function tx or environment that appeals to all senses simultaneously tx or environment at a rate, amount, duration, and complexity too high or too low |
| principles for recovery | Use it or Lose it Use it to Improve it Specificity Repetition matters Intensity matters Time matters Salience matters Transference Interference Age matters |
| use it or lose it principle of recovery | Areas of brain not used atrophy Learned non-use |
| Use it to improve it principle of recovery | Practice, practice, practice Training enhances function CIMT, BWSGT |
| specificity principle for recovery | You get better at what you practice Training needs to be specific to the function being improved Task specific |
| why does repetition matter for recovery | Repetition enhances behaviors CNS changes occur after repetition |
| components of intensity | Effort Load |
| how does time affect recovery | Neural plastic changes occur in a continuum rather than all at once Neural changes occur over time Neural changes occur days after injury |
| salience matters principle of recovery | Relevant and meaningful to the patient Active involvement |
| transference | One experience can enhance the acquisition of a behavior |
| interference | One experience can interfere with the acquisition of a behavior Once specific neural circuitry is used by one behavior, it cannot be used again for another |
| why does age matter for recovery | Young people demonstrate greater neuroplasticity As we age the process becomes slower |
| variables for recovery | type of stimulation, timing, intensity, duration |
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