Term | Definition | | |
Open Injury | An injury of direct penetration through the skull to the brain. Location, depth of penetration, and pathway determine the extent of brain damage. Exasmples include GSW, knife or sharp object penetration, skull fragments, and direct trauma | | |
Closed Injury | An injury to the brain without penetration through the skull. Examples include concussion, contusion, hematoma, injury to extracranial blood vessels, hypoxia, drug overdose, near drowning, and acceleration and decelleration Injuries. | | |
Primary Injury | Initial injury to the brain sustained by impact. Examples include skull penetration, skull fractures, and contusions to gray and white matter | | |
Coup Lesion | A direct lesion of the brain under the point of impact. Local brain damage is sustained | | |
Countercoup Lesion | An injury that results on the opposite side of the brain. The lesion is due to the rebound effect of the brain after impact. | | |
Secondary Injury | Brain damage that occurs as a response to the initial injury. Examples include hematoma, hypoxia, ischemia, increased intracrainial pressure, and post traumatic epilepsy | | |
Epidural Hematoma | A hemmorhage that forms between the skull and dura mater | | |
Subdural Hematoma | A hemmorhage that forms due to venous rupture between the dura and arachnoid | | |
Coma | A state of unconsciousness and a level of unresponsiveness to all internal and external stimuli | | |
Stupor | A state of general unresponsiveness with arousal occuring from repeated stimuli | | |
Obtundity | A state of consciousness that is characterized by a state of sleep, reduced alertness to arousal, and delayed response to stimuli | | |
Delirium | A state of conciousness that is characterized by disorientation, confusion, agitation, and loudness | | |
Clouding of Conciousness | A state of conciousness that is characterized by quiet behavior, confusion, poor attention, and delayed responses | | |
Conciousness | A state of alertness, awareness, orientation, and memory | | |
Glasgow Coma Scale | A neurological Assesment tool used initially after injury to determine arousal and cerebellar cortex function. A total score of 8 or less correlates to coma in 90% o patients. Scores of 9-12 indicate moderate brain injuries and scores from 13-15 | indicate mild brain injury | |
Glassgow Coma Scale | Eye Opening
-spontaneous =4
-To speech =3
-To pain =2
-Nil =1
Best Motor Response
-Obeys Commands =6
-Localizes Pain =5
-Withdrawls =4
-Abnormal Flexion =3
-Extensor Response =2
-Nil =1
Verbal Response
-Oriented =5
-Confused converstion =4 | -Inappropriate Words =3
-Incomprehensible Sounds =2
-Nil =1 | |
I. No response | patient appears to be in a deep sleep and is compltely unresponsive to any stimuli | | |
II. Generalized Response | Patient reacts inconsistently and non-purposefully to stimuli in a nonspecific manner. Responses are limited and often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and or vocalization | | |
III. Localized Response | Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type os stimulus presented. May follow simple commands such as closing the eyes or squeezing the hand in an inconsistent, delayed manner | | |
V. Confused-Inappropriate | Patient is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, reponses are non-purposeful, random or fragmented. Demonstrates gross attention to the environment but | is highly distractable and lacks the ability to focus attention on a specific task. With structure, may be able to converse on a social automatic level for short periods of time. Verbalization is often innapropriate and confabulatory. Memory is | severely impaired, often shows inappropriate use of objects, may perform previously learned tasks with structure, but is unable to learn new information. |
VI. Confused-Appropriate | Patient shows goal-directed behavior, but is dependent on external input or direction. Follows simple directions consistently and shows carryover for relearned tasks such as self-care. Respones may be problems,due to memory problems but they are | appropriate to the situation. Past memories show more depth and detail than recent memory | |
VII. Automatic-Appropriate | Patient appears appropriate and oriented within the hospital and home settings; goes through daily routine automatically but frequent robot-like. Patient shows minimal to no confusion and has shallow recall of activities. Shows carryover for new | learning, but at a decreased rate. With structure is able to initiate social or recreational activities, judgement remains impaired. | |
VIII. Purposeful Apropriate | Patient is able to recall and past and recent events and is aware of and responsive to environment. Shows carryover for learning and needs no supervision once activities are learned. May continue to show a decreased ability relative to | premorbid abilities, abstract resoning, tolerance for stress, and judgement in emergencies or unusual circumstances. | |
Anterograde Memory | The inability to create new memory. Anterograde memory is usually the last to recover after a comatose state. Contributing factors include poor attention, distractability, and impaired perception of stimuli. | | |
Post-traumatic amnesia | The time between the injury and when the patient is able to recall recent events. The patient does not recall the injury or the events leading up until this point of recovery. Post-traumatic amnesia is used as an indicator of the extent of damage. | | |
Retrograde Amnesia | An inability to remember events prior to the injury. Retrograde amnesia may progressively decrease with recovery. | | |
TBI Treatment | -Emphasis on motivation
-Promote Independence
-THerapy should be goal=directed, functional, and recreational
- Focus on orientston
=Focus on behavior midification activities
-THe use of repetiition may be helpful
-Educate the patient in | compensatory strategies for sucess
-Strucon the level of the patient
structure is essential depending on the level if the patient
-Avoid overstimulation during therapy
-Use of calm voice and simple commands
-Perform activities that are both | familiar and enjoyable to the patient
-Family education and support can enhance and assist in the rehab process
-Allow the patient to choose activities on occassion
-Flexibility in treatment is needed based on patient's immediate needs and state ofmind |
Diuretic Agents | Decreases the volume of fluid in the brain and the intracranial pressure | Ex: Mannitol, and Glycerol | |
Antidepressant Agents | Reduce disruptive or agressive behavior | Ex: Elavil, Prozac | |
Anticonvulsant Agents | Preventipn of early seizures in head injury | Ex: Dilantin, Tegretol, Klonopin | |
Electrolytes | Adequate stores are needed during the acute phase of head injury | Ex: Magnesium Sulfate | |
Calcium Channel Blocker Agents | May improve trauma for subarachnoid hemorrhage | Ex: Nimotop | |
Selective Serotonin Reputake Inhibitor Agents | May benefit patients with head injury and emotional inhibition/impairment | Ex: Zoloft, Paxil | |
TBI Examination | -past medical history
-history of current condition
-Social history (caregiver support)
-Medications
-living environment
-Systems Review
-Cognitive and language Assesment
-Behaviral Assessment
Safety Assessment
-Skin Assesssment
-Postural tone | Assessment
-Sensation, Proprioception, and kinesthesia
-ROM
-Motor Assessment
-Endurance Assessmnet
-Mobility Skills | |
TBI Intervention | -Cognitive and orientation training
-Therapeutic Exercise
-Positioning
-Sensory Integrity
-Balance and vestibular training
-ROM
-Motor function training
- WC and AD prescription
-Splinting and serial casting
-Mobility training | | |
TBI Goals | -Maximize functional mobility
-Maximize community independence
-Maximize strength
-Maximize ROM and prevent hetertrophic ossification
-Maximize static and dynamic balance
-Maximize endurance
-Maximize patient/caqregiver competence with: | -positioning
-Use of AD and orthotic/splinting devices
-HEP | |
Acute Diagnostic Management | Glasgow Coma Scale: level of arousal and cerebral cortex function
Cat Scan: observe intracranial structures
X-Ray: Fractures
MRI: Observe intracranial structures
Cerebral Angiography: Observe blood vessels and internal anatomy of the brain | Evoked Potential/Electroencephalogram: localizing structural damage
PET: cerebral metabolic abnormalities
Ventriculography: radiography used to observe cerebral ventricles following CSF removal.
Radioisotope Imaging: allows for a 2D view of brain | |
IV. Confused-Agitated | Patient is in a heightened state of activity. Behavior is bizzare and non-purposeful relative to the immediate environment. Does not discriminate among persons or objects, is unable to cooperate directly with treatment efforts. Verbalizations | frequently are incoherent and/or inappropriate to the environment, confabulation may be present. Gross attention to environment is very breif; selective attention is often nonexistent. Patient lacks short and long term recall | |