Exam 1 TBI

What are the 2 injuries of organs and tissues that respond to pressure fluctuations?

- accelerate body organs that vary in density - cause displacement, stretching, and shearing of adjacent structures

How long are absence seizures?

1 to 20 seconds

What is the the range of an eye-opening response post-injury?

10 to 14 days (after that spontaneous eye-opening returns even in pt's who make no other significant gains)

How long are atonic seizures?

15 seconds

What does a score 1 on the RLOS? a 10?

1= coma (most severe); 10= most independent

3 meters from central point, person experiences ____ times greater than ____ meters away

9; 6

What is CTE also considered?

A tauopathy (neurofibrillary tangles) seen in AD

What is the most important part of neurologic evaluation of comatose patient?

Best motor response (GCS)

What is CTE?

Chronic traumatic encephalopathy

RLOS: Level VI

Confused appropriate: moderate assistance

RLOS: Level V

Confused inappropriate; non-agitated: Maximal assistance

RLOS: Level IV

Confused/agitated: Maximal assistance

T/F: second impact syndrome involves sustaining two different lesion sites

FALSE- when a person sustains a second head injury before recovering from the previous one

What GCS range would you expect for a severe TBI?

GCS 3-8

What type of the body part is affected in a primary mechanism of injury?

Gas-filled/air-filled structures (lungs, GI tract, middl ear)

RLOS: Level II

Generalized response; total assistance

RLOS: Level III

Localized response; total assistance

LOC is b/t 0 to 30 mins (GCS 13 to 15)

Mild TBI

LOC is greater than 30 mins to 24 hours (GCS 9 to 12)

Mod TBI

RLOS: Level I

No response; Total assistance

Direct exposure to effects of blast _______ on brain

Overpressure (primary blast injury)

What is common following exposure to explosive blasts?

PTSD

What's the difference b/t mild TBI and PTSD?

PTSD: flashbacks; mild-TBI: headaches, dizziness, nausea, vomiting

What can be a primary injury?

Penetrating forces (open head injury_; non-penetrating forces (closed head), blast injuries

RLOS: Level VIII

Purposeful appropriate: stand by assistance

RLOS: Level X

Purposeful, appropriate, modified independence

RLOS: Level IX

Purposeful, appropriate: standby assistance on request

Most random and unpredictable of injuries are _____

Quaternary blast injuries

LOC is greater than 24 hours (GCS less than 9)

Severe TBI

T/F: Damage will not show on CT scans or MRI scans in mild TBIs?

TRUE

T/F: Diffuse axonal injury is a primary blast injury?

TRUE

T/F: survivors neglect medical attention w mild TBI

TRUE

Does molecular damage occur from cavitation effects?

YES

What is epilepsy?

a condition in which a person experiences 2 or more seizures

CTE

a progressive neurodegernative disease caused by multiple TBI's

What is a seizure?

a temporary alteration in brain function due to abnormal electrical activity of a group of brain cells (causing sudden, transitory, and abnormal alterations in consciousness, motor, sensory, autonomic, or psychic processes)

What is level X: purposeful, appropriate, modified independence?

able to think about consequences of decisions or actions w assistance when requested

What is Level IX: purposeful appropriate: stand by assistance on request?

able to think of consequences of decisions or actions w assistance when requested. Initiates and carries out steps to familiar personal, household, community, work, and leisure routines. Independently and unfamiliar personal household work, and leisure tasks w assistance when requested

What is level IV- confused/agitated: maximal assistance? (RLOS)

agitated. alert. very active. aggressive or bizarre behaviors. performs motor activities but behavior is non-purposeful. extremely short attention span

What are the characteristics of a quaternary injury?

all explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms

What does the best motor response test?

all four limbs and supraorbital ridge for response to pain

What is translational acceleration?

also referred to as linear; vector of force is applied through the object's center of gravity. ACROSS A LINEAR AND STRAIGHT LINE OF OBJECT

What does extension mean in GCS?

an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arches backward

What does flexion mean in GCS?

an abnormal posture that can include rigidity, clenches fists, legs held straight out, and arms bent inward towards the body with the wrists and fingers bent and held on to the chest

What is PTSD?

anxiety after experiencing a traumatic event; avoidance behaviors, hyperarousal; re-experiences events; can occur alone or combo w mild TBI

What are some common symptoms shared by PTSD and mild TBI?

anxiety, depression, attention, difficulty concentrating, memory deficits, irritability, sleep disturbances

What part of the body is affected in a quaternary injury?

any body part

What parts of the body can be affected in a tertiary injury?

any body part

What body part is affected in a secondary injury?

any body part can be affected

What classifies a mild TBI?

any period of self-reported confusion, disorientation, impaired consciousness; self-reported memory (amnesia) around injury; neurological dysfunction; any LOC 30 mins or less

Primary injury occurs _____

at the time of injury

RLOS: Level VII

automatic appropriate: minimal assistance

Proprioception

awareness of where body part is in space

Why do blast waves occurring in water cause more damage?

because water has a higher density than air

What are focal/partial seizures?

begins w an electrical discharge in one limited area of the brain; cause is usually unknown

Where is the subdural hematoma located?

between the dura and arachnoid space

Where is the epidural/extradural hematoma located?

between the dura mater and skull

What are the types of primary injuries?

blast lung, tympanic membrane and ME damage, abdominal hemorrhage and perforation, eye rupture, concussion

What are the types of injuries in a quarternary injury?

burns, crushing injuries, closed and open head brain injuries, asthma, COPD, breathing problems from smoke, dust or toxic fumes, angina, hyperglyercima, hypertension

what are the 2 types of fatigue?

central fatigue: impacts primary mental processes (feeling really tired in your head); peripheral fatigue: impacts physical, metabolic, and muscular processes (physical exhaustion)

What is level VIII- purposeful appropriate: stand by assistance? (RLOS)

consistently oriented to person, place, and time. initiates and carries out steps to complete familiar household, community, work, and leisure routines w stand-by assistance and can modify the plan when needed w min assistance

What is the cortical damage from the subdural hemorrhages in primary blasts?

contusions from rubbing interior surface of cranium and shearing strain

What happens w translation acceleration?

coup and countrecoup

What is level III-localized response; total assistance?

demonstrates withdrawal or vocalization to painful stimuli. responds inconsistently to comands

What are the characteristics of a concussion?

direct blow ("impulsive force") to part of the head; rapid onset or short-lived impairment of neurological function; neuropathological changes (more functional disturbance); may or may not result in a LOC

What are the 3 different types of hematomas?

epidural, subdural, and intracranial

Post-traumatic confusional state?

extended periods of wakefulness; confused and disorientated; consistent one step commands and sentence level speech (y/n)

What is fatigue?

extreme tiredness from mental or physical exhaustion

What 3 components does the Glasgow Coma Scale assess?

eye opening, motor response, verbal response

What are the persistent symptoms of mild TBI?

fine motor coordination problems, loss of emotional control, memory loss, diplopia, headaches, dizziness, tinnitus, loss of balance and stability, reduced speed of information processing, fatigue, sleep disturbance, "fogginess"

what are the symptoms of post-concussion syndrome?

fine motor coordination, vestibular dysfunction, loss of emotional control, memory loss, diplopia, headaches, dizziness, tinnitus, loss of balance, stability, reduced information processing

What are the classifications for seizures?

focal, generalized, unknown, or bilateral onset; dependent on awareness; motor versus nonmotor dysfunction

What are the types of injuries in a tertiary injury?

fracture and traumatic amputation, closed and open brain injury

What are the common locations for seizures?

frontal and temporal lobes

Where does CTE usually develop?

frontal and temporal lobes; enlarged ventricles

What is level II- generalized response: total assistance? (RLOS)

generalized reflex response to pain

What areas of brain damage are there in a primary blast?

gray matter of frontal and temporal lobes, diffuse axonal injury, air emboli in vessels supplying blood to brain

What is level V: confused inappropriate nonagitated: maximal assistance? (RLOS)

gross attention to environment, highly distractible, requires continual redirection, difficulty learning new tasks, agitated by too much stimulation. may engage in social conversation but w inappropriate verbalization

What are the neurophyschological dysfunctions of a mild TBI in adults?

headache, dizziness, irritability, fatigue, poor concentration

Physical symptoms of TBI

headaches, fatigue, seizures, sleep disturbances,

What can ICP be caused by?

hemmorhages (any sort of bleeding into brain) and selling (edema), hematomas

What are persistent symptoms of post-concussive syndrome?

hx of learning difficulties, older ages at time of injury, lowest level of education

Where is an intracranial hematoma located?

in the brain

Mutism

inability to vocalize or speak

What is level VI: confused appropriate: moderate assistance? (RLOS)

inconsistent to time and place, retention span/recent memory impaired, begins to recall past, consistently follows simple directions, goal directed behavior w assistance

Explosion generates _________ and _________ rise in surrounding air pressure

instantaneous; substantial (primary blast injury)

Minimally conscious state

intermittent periods of wakefulness; cognition is inconsistent but clear-cut behavioral signs of self-awareness or environmental awareness; inconsistent lang (inconsistent one step commands spontaneous single words/phrases); visual pursuit

vegetative state

intermittent periods of wakefulness; no cog; no lang; inconsistent visual stare; involuntary movement only

What are the areas affected by a diffuse axonal injury?

internal capsule, places where grey and white matter interface, upper brainstem structures, corpus callosum

What is post-traumatic seizures?

irregular neuronal firing which causes changes in consciousness, movement, feelings, and thinking following brain injury

What are atonic/ akinetic/drop seizures?

lasts 15 seconds; muscles suddenly lose strength (eyelids droop, person drops things, collapsing and falling to the ground), person remains conscious

How long are tonic seizures?

less than 20 seconds

At what RLOS score is NPO?

less than 3

In cavitation effects, it changes from a ____ to a ____ state

liquid; gas

Anosmia

loss of smell

What are the 3 areas of injury for a primary blast?

lungs, middle ear (TM), and cortical damage from subdural hemorrhages

What is post-traumatic seizures caused by?

mechanism of injury, hydrocephalus, sepsis, hypoxia, metabolic issues

What is the most common injury in primary blast?

middle ear (rupture of TM)

Consciousness state: 5 min to 60 mins

mild

GCS total score of 13 to 15 is indicative of a ____

mild TBI

Consciousness state: 1 hour to 24 hrs

moderate

GCS total score of 9 to 12 is indicative of a ____

moderate TBI

What are tonic seizures?

muscle tone is greatly increased (sudden stiffening); lasts 20 seconds; person is conscious; involves mostly all of brain and both sides of body,

Cavitation effects

negative pressure drops below vapor pressure of intracellular fluid; causes multiple small explosions that destroy brain cells

How long are myoclonic seizures?

no more than 1 to 2 seconds

What is level I-no response: total assistance? (RLOS)

no response to pain, touch, sound, or sight

Coma

no sleep-wake cycle; no cog; no lang; no visuoperception; primative reflexes only

GCS: verbal response

normal conversation: 5; disoriented conversation: 4; words, but not coherent: 3; no words, only sounds: 2; none: 1

Locked-in syndrome

normal sleep wake cycle, normal to near-normal; normal; aphonic; normal

GCS: Motor Response

normal: 6; withdraws to pain: 4; flexion: 3; extension: 2; none: 1

What type of TBI are seizures more common with?

open-head injuries

What are the types of secondary injuries?

penetrating blast injuries or blunt injuries, eye penetration

Primary blasts can cause ____

people to be thrown through space into other objects (secondary blast)

What is level VII- purposeful appropriate: minimal assistance

performs daily routine in highly familiar environment in non-confused but automatic robot-like manner. Skills noticeably deteriorate in unfamiliar environment. Lacks realistic planning for own future.

What is an absence seizure (petit mal seizure)?

person blanks out for 1 to 20 seconds; awareness and responsiveness are impaired; begin and end suddenly; person not usually aware of seizure happening

Nausea, dizziness, hypersensitivity to light is an example of

physical impairments w mild TBI

What are secondary mechanisms of injury?

physiological changes to the brain after primary injury (both intra and extra cranial)

What are the two different types of headaches?

post traumatic headache: develops with a week (7 days) after trauma; chronic post traumatic headache: more than 2 months most injury

How does an epidural/extradural hematoma form?

pressure of pooling blood causes the dura mater to pull away from the inner surface of the skull; elastic rebound of skull pulls dura mater away from skull and blood spills into created space

Consciousness state: more than 4 weeks

profound

What factors may contribute to dysphagia?

prolonged ventilation, medications, level of alertness, neuromuscular and/or sensory issues, cog-com issues, behavior

What are the 4 factors that affect severity in primary blasts?

proximity to the center of explosion, if explosion is in a confined space (greater damage), blast waves in water, no body armor

What is second impact syndrome?

rapid brain swelling after second mild concussion; particularly dangerous in young athletes, dangerously fatal

What are the physiological changes occurring with concussion?

rapid elevated BP, irregular respiration, decreased EEG, increased ICP, temporary impairment w blood-brain barrier, diffusely scattered swelling of axons in cerebral white matter

What are the causes of second impact syndome?

reactive swelling of axons (temporary anatomical changes that occur with concussion); metabolic changes (cerebral blood flow decreases at the same time that brain has increased need for energy;

What is a post-traumatic epilepsy (PTE)?

recurring seizures w/o an immediate cause post-injury; may result in early or late seizures

What are the characteristics of a secondary injury?

results from flying debris and bomb fragments

What are the characteristics of a tertiary injury?

results from individuals being thrown by the blast wind

What are clonic seizures?

rhythmic jerking movements of arms, legs, body; quite rare

What are the neurophyschological dysfunctions of a mild TBI in infants/kids?

seizures, irritability, lethargy, vomiting

Photophobia

sensitivity to light

Consciousness state: 1 day to 7 days

severe

GCS total score of 3 to 8 is indicative of a ____

severe TBI

What 2 blast waves cause a sudden change in pressurization?

shock wave and blast wind (primary blast injury)

What are the 2 types of absence seizures?

simple (just staring); complex (changes in muscle activity, eye blinks, movement o tongue, repeated contraction and relaxation of specific muscles)

What are the most frequent tertiary injuries?

skull fractures, brain contusions of concussion, open and closed brain injuries

GCS: Eye opening points

spontaneous: 4; to voice: 3; to pain: 3; none: 1

What is an atypical absence seizure?

staring behavior but person is often somewhat responsive, lasts 5 to 30 seconds, staring may be accompanied by eye blinking or lip twitching

What are the common symptoms of a seizure?

strange movement of body (head, arms, legs, eyes) such as stiffening or shaking, unresponsiveness and staring, chewing, lip smacking, fumbling movements, strange smell, sound, feeling taste or visual images, sudden tiredness or dizziness, not being able to speak or understand others

What are the 3 primary sources of a quaternary blast injury?

structural collapse of building leading to crush injuries; TBI's associated with falling from height or being struct by heave objects; exposure to noxious materials (fire, gas, toxic dust, radiation)

What should you know about an intracranial hematoma?

the swelling in the brain controls the bleeding; reduction of swelling bleeding may reoccur and result in hematoma formation

What are tonic-clonic seizures?

tonic phase is first (all muscles stiffen); followed by clonic phase (jerking rapidly and rhythmically); lasts between 1 to 3 minutes

A subdural hematoma is ___ as common as an epidural hematoma?

twice; more serious too bc of proximity to brain tissue

What are the characteristics of a primary mechanism of injury?

unique to high order explosives, resulting in an impact of an over pressurization wave on the brain and body

What are the immediate symptoms of a mild TBI?

vacant stare, delayed motor verbal responses, confusion, slurred speech, inability to focus, attention, disorientation, incoordination, emotions out of proportion, memory deficits, retrograde/anterograde amnesia, headache, nausea/vomiting

If pt is aphasic, ____ is not valid for determining LOC?

verbal scale

What are myoclonic seizures?

very brief jerks that lasts no longer than 1 to 2 seconds, may have single jerks or multiple within a short time period, involves the neck, shoulders and upper arms

Consciousness state: less than 5 mins

very mild

Consciousness state: 1 week to 4 weeks

very severe

Traits of vegetative state

vocalizing but not verbalizing; no meaningful response to external environment; awake w no signs of awareness

What are tertiary blast injuries?

when a person strikes head because of being thrown to the ground or against a stationary object