Chapter 8-Traumatic Brain Injury

Adelaide Coma

(ACS); Adult coma scales are usually inappropriate for children because they take into account verbal and motor responses that are not present during various stages of childhood; A version of the GCS adapted for use in the pediatric population and takes into account a child's age and developmental level. The ACS is designed to be applied to infants too young to speak.

Glasgow Coma Scale

(GCS); a 15 point scale that rates patients on parameters of eye opening, motor response and verbal response; classifies patients with TBI as mild (13-15) moderate (11-12) or severe (8 and below)

List of strategies to address deficits in working memory.

-Be sure instructions and utterances are produced as succinctly (shortly) as possible. -Use functional tasks to target memory deficits in the context of activities of daily living -Avoid speaking fast -Emphasize important words or phrase to bring the individual's attention to the most important parts of the utterance -Increase automaticity of response -Break down complex tasks into individual components

Formal assessments of deficits associated with TBI:

-Burns Brief Inventory of Communication and Cognition (Burns, 1997) -Brief Test of Head Injury (Helm-Estabrooks & Hotz, 1991) -Cognitive-Linguistic Quick Test (CLQT; Helm-Estabrooks, 2001) -Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI; Adamovich & Henderson, 1992) -Ross Information Processing Assessment (2nd ed., RIPA-2; Ross-Swain, 1996)

For a diagnosis of a minimally conscious state to occur, individuals must be able to display one or more of which behaviors?

-follow simple commands -respond to yes/no questions verbally or through gestures (accuracy not a concern) -have intelligible utterances, though they may may be inconsistent or minimally present -show some level of purposeful behavior that is appropriate to environment

Selected sensory stimulation strategies include:

-visual stimulation -auditory stimulation -oral stimulation -olfactory stimulation -cutaneous stimulation -gustatory stimulation

Common symptoms of shaken baby syndrome?

-vomitting -difficulty feeding (poor suck/swallow) -lethargy -altered consciousness (comatose state) -irritability -retinal hemorrhages -impaired tracking of eyes -seizures -lack of smile and vocalizations -respiratory difficulties -Usually other signs of abuse are present such as bruises, broken bones, or a history of or evidence of past injuries

How many people experience TBI each year in the United States?

1.4 million

How many open (oenetrating) head wounds exoerience soem type of post-traumatic epilepsy?

50%

How many people live with three effects of TBI?

57 million

How many deaths from TBU in children younger than 2 years were nonaccidental?

80%

What is the range of the severity of a TBI?

A concussion that causes a transient anemia and changes in consciousness to a more severe TBI that leads to coma or death.

vegetative state

A condition in which a person is minimally responsive to stimuli but lacking consciousness and cognition. The likelihood of fully awaking from a vegetative state decreases the longer the patient remains in the vegetative state.

What is a long term fix and what is a short term fix?

A nasogastric feeding tube is usually a short-term fix, whereas a percutaneous endoscopic gastrostomy feeding tube might be placed for a longer term purposes, longer than a week.

Explain coup-contrecoup.

A typical profile of damage to the brain in acceleration-deceleration closed head TBIs. "Coup"n is the French word for a severe hit or impact. The first impact of the brain against the inside front of the skull is coup damage. The contrecoup injury occurs as a result of the secondary impact of the brain hitting the inside back of the skull.

What scales can be used to assess agitation and aggression?

Agitated Behavior Scale Overt Aggression Scale

which athletes are at the highest risk for concussion?

American football wrestling soccer hockey boxing High school athletes are at a higher risk than college athletes for concussion and require longer to recover Female athletes, especially adolescent female athletes are at 2 to 2.5 times more risk for concussion than males and have longer recoveries following concussion. This could possibly be because they have less muscle mass in the neck to stabilize the head and reduce sudden movements of the head during impact.

What can cause an increase intracranial pressure an compress brain tissue?

Blood pooling aroudn the dura mater and the brain

How can SLPs assess long-term memory durng the interview?

By posing biographical questions to parents regarding personal history, such as asking them where they grew up, who is in their family, what their profession is, and to describe significant family events.

How is traumatic hyrdocephalus treated?

By the placement of a CSF shunt, a device inserted into a lateral ventricle that drains excess cerebrospinal fluid, thereby keeping intracranial pressure normal. The CSF shunt is surgically placed under the skin of the patient and has a tube traveling under the skin from the brain out of the skull to drain excess fluid to a more appropriate place in the body, like the urinary system.

Therapy for TBI begins...?

By treating low-level cognitive deficits and slowly working up to re-mediate higher-level deficits.

What must an SLP do whe testing an individual with TBI fir any length of time?

Carefully monitor the patient's level of fatigue

What are closed head injuries?

Forms of trauma causing damage tot he brain that do not break in an individual's skull open and penetrate the cerebral meninges surrounding the brain. The skull remains intact.

What are the most commonly used scales for adults?

Glasgow Coma Scale and Ranchos Los Amigos Levels of Cognitive Functioning Scale

persistent vegetative state

If a vegetative state continues longer than 4 weeks.

epidural hemorrhage

If the bleed occurs between the dura mater and the skull.

subdural hemorrhage

If the traumatic hemorrhage occurs between the dura mater and the arachnoid mater.

when are TBIs resulting from a fall most common?

In very young children, but are also common among older adults.

What is the role of the speech language pathologist in shaken baby syndrome?

It sually depeends ont he age of the injured child and the extent and nature of the injury and deficits. However, in the medical setting the SLP probably focuses on treating the acquired feeding or swallowing problems of shaken infants in the neonatal intensive care unit (NICU).

How often does TBI occur?

More common that AIDS, breast cancer, multiple sclerosis, and spinal cord injury combined.

What is diffuse axonal shearing?

Often seen in traffic accidents; The breaking of neuronal connections that occurs across large areas of the brain and that is seen commonly in closed head traumatic brain injury.

What must occur in speech language therapy for a language deficit?

One patients recover language abilities, rehabilitation must then focus on training the appropriate use of those language abilities as these individuals struggle to regain their former lives.

Assessment of Oientation

Orientation is evaluated as a component of most standard cognitive assessments such as the Mini-Mental State Examination.

How is immediate recall of auditory information tested?

Presenting an unrelated string of words and asking the patient to repeat them.

post traumatic epilepsy

Seizures occuring consequent to TBI (ex: postonset, or after the onset, of TBI)

How do victims of shaken baby syndrome survive?

Surival of these children depnds on timely recognition of the abuse and immediate medical attention.

What is the most common cause of death in children ?

TBI

Which scale is used in pediatrics?

The Adelaide Coma Scale

What hapoens if intracranial pressure rises above the arterial blood pressure?

The heart cannot force more blood into the brain and the subsequent lack of oxygen can lead to coma or death.

What is the usual trigger for abuse of an infant?

The infant's crying

How is the assessment to use determined?

The type of assessment used with individuals with TBI varies according to the patient's age, educational level, and severity of deficits.

Why do TBI patients get their heads shaved?

They require immediate brain surgery to resolve secondary issues such as hemorrhage or increased intracranial pressure.

What should happen in the case of an athlete suffering a concussion?

They should immediately evaluated and, if a concussion is present, pulled from the game and placed on at least 3-day period of physical and cognitive rest to allow the brain to heal.

What is common for individuals with TBIs to experience cognitively?

To spend time following the trauma in a coma or a decreased state of arousal when little or no cognition is possible.

What is impact-based TBI?

Traumatic injury to the brain that occurs as a result of an individual's head being struck by a moving object.

What questions are used to assess orientation to person, place, or time?

What is your name? What is your age? Were are you? What city are we in? What happened to you? (Why are you here?) What time is it? What day is it? What month is it? What year is it? Who is the President of the United States?

What is a open head TBI?

When an object penetrates the skull into the brain. A common cause is ballistic trauma, such as when a projectile (a bullet or piece of shrapnel) passes through the skull and into the brain. Open head TBI can also occur as a result of a fall in which the individual's head impacts an object sharp enough to penetrate the skull.

What is the secondary level of damage delivered by a bomb?

When bomb fragments or debris hit soldiers and bystanders this is known as the secondary level of blast trauma.

What is increased intracranial pressure?

When intracranial pressure rises above normal. If intra cranial pressure becomes higher than blood pressure, the heart will have difficulty pushing blood into the brain. Then, hypoxia or anoxia occurs, causing brain damage or death if not treated quickly.

What is traumatic hydrocephalus?

When the brain becomes unable to reabsorb old cerebrospinal fluid while it still produces fresh cerebrospinal fluid in the lateral ventricles; This can raise intracranial pressure to a life threatening level.

Explain internal memory strategies vs. external strategies.

Whereas internal memory strategies are cognitive acts an individual uses to compensate for memory deficits, external strategies or memory aids are material devices

chronic trauma encephalopathy

a degenerative disease of the brain caused by repeated head trauma, such as repeating concussions in sports or repeated exposure to IED blasts in soldiers. It manifests as dementia, confusion, memory loss, headache, depression, and excessive aggression within months or years of brain damage.

the fifth edition of Benton Visual Retention Test

a formal test of visual memory that is appropriate to use in populations of brain damage and dementia. It accounts for possible concomitant perceptual deficits that can co-occur in these populations.

tracheotomy

a hole was cut into into the trachea below below the larynx through which a mechanical ventilator delivers air to the lungs for respiration.

coma

a period of unconsciousness lasting more than 6 hours during which the unconscious individual cannot be awakened and is unresponsive to sensory stimuli. The duration of the coma is a known prognostic variable. Prognoses of individuals who experience shorter comas are more positive for recovery than those of patients who experience deeper and longer altered states of consciousness.

craniotomy

a surgery to remove part of the skull to allow the brain to swell without incurring damage from from being crushed by pressure within the skull. Commonly performed if the threat of increased intracranial pressure is considered life threatening.

What kind of motor problems might occur in an individual with TBI?

abnormal muscle tone and possible damage to the cerebellum, which will create ataxia, causing incoordination of movements and impaired balance.

What are the primary mechanisms of damage to the brain in traumatic brain injury?

acceleration-deceleration forces that produce coup-contrecoup injuries, rotational forces that produce diffuse axonal shearing,the compression forces present in impact based TBI, and the violent penetration of a foreign object into brain tissue.

What two primary categorizations of closed head TBI?

acceleration-deceleration injuries and impact-based injuries (can occur singly or in combination)

Who are most likely to acquire a TBI as a result of motor vehicle accidents or assault?

adolescent males from 15 to 19 years of age.

risk factors for TBI

alcohol and recreational drugs, previous TBIs, lower SES

Traumatic brain injury, which is a common source of speech, language, and cognitive problems occur in which age group?

all age groups, form infants to older adults

post-traumatic amnesia

amnesia that is displayed from those who do recover from comas and vegetative states. It typically presents as a combination of both retrograde and anterograde memory losses.

Describe the reticular formation:

an important structure housed within the brain stem that regulates the sleep-wake cycle and level of arousal.

What kind of language deficits can follow closed head injuries that are often present but can be dwarfed by deficits in arousal and cognition?

anomia and aphasia

What is the quaterary level of damage delivered by a bomb?

any trauma created by the blast that is not attributive to primary, secondary, or tertiary mechanisms. Some examples include: difficulties breathing following inhalation of the toxic gases, smoke, or dust of an explosion and burns to the body sustained as a result of the blast.

How many of those with sever head injuries display a persistent vegetative state 1 year post trauma?

approximately 3%

Which motor speech disorders can present with TBI?

apraxia of speech and dysarthria; Possible types of dysarthria present in TBI are spastic, flaccid, ataxic, hypokinetic, or some combination of these four.

Overt Aggression Scale

assesses the presence of aggression in the absence of agitation; measures verbal aggression and physical aggression against others, oneself, and objects

What is becoming standard for athletesof all kinds prior to the playin season?

baseline cognitive tests; as researchers and clinicians attempt to track and attemptto track and prevent the imediate nd long-term effects of sports-related concussina nd address these deficits appropriately.

Describe traumatic hemorrhage.

bleeding as a result of trauma; usually intracerebral, subdural, or epidural. If a traumatic hemorrhage occurs within the brain, it is an intracerebral hemorrhage.

Which parts of the body are most susceptible to barotrauma?

brain, eyes, and air filled and fluid filled organs of the abdomen.

How is reorientation to self, person and place following TBI accomplished?

by repetitively exposing them to relevant facts.

Assessment of Communication/Language/Cognition

can use the same types of assessment methods as used for aphasia, right hemisphere disorders, and dementia

Ranchos Los Amigos Levels of Cognitive Functioning Scale

categorizes patients on an eight level scale. Patients are scored on responsiveness, orientation, purposeful activity, self regulation, memory, spontaneity, and independence. Levels of severity range from no response to purposeful and appropriate.

What is an additional threat secondary to any other form of brain damage?

cerebral edema, ro swellign of the brain. Cerebral hematoma also raises intracranial pressure.

What are the most at risk populations?

children younger than 4 years of age, individuals older than 75 years, and adolescent males. Male children 4 years and younger experience the highest rates of TBI.

What are the two primary forms that make up traumatic brain injuries?

closed head injuries and open head injuries.

internal memory strategies

cognitive acts that can increase the likelihood of retaining information over the short and long terms.

What are the two issues of decreased arousal?

coma and vegetative state

What can happen when there is damage to the reticular formation?

coma or vegetative states

Immediate and acute symptoms of concussion

confusion loss of self awareness possible loss of consciousness

What do focal lesions do?

create deficits constrained to certain abilities while leaving the holistic function of the brain intact.

What happens when unilateral traumatic damage occurs to the upper motor neurons in a single frontal lobe?

creates a contralateral hemiplegia similar to that seen in stroke patients.

How often do sensory stimulations often occur?

daily and might involve stimulation of only one sensory modality or all five.

traumatic brain injury

damage to the brain that results from an external and usually forceful event. Excludes damage to the brain resulting from disease, stroke, or surgery.

What kind of cognitive deficits do individuals with TBI have?

deficits in the areas of orientation to self, orientation to place and time, sustained attention, selective attention, alternating attention, divided attention, working memory, short-term memory, long-term memory, problem solving, and inferencing, and they can also experience personality changes.

Agitated Behavior Scale

designed specifically to assess level of agitation and track changes in agitation over time in patients with TBI

restorative memory approaches

do not allow the patient to compensate for deficits using external devices (external memory strategies) or cognitive methods and devices (internal memory strategies); They work to rehabilitate memory abilities.

PEG tube

enters the abdomen and delivers nutrition and hydration straight into the stomach.

What are the most common causes of TBIs?

falls, motor vehicle and traffic accidents, incidents of a person being struck by an object, sports accidents, and violent assaults.

When is posttraumatic epilepsy most common?

following open head TBI such as gun shot wounds or military-type open head TBI.

What is an additional task to test sshort-term recall of auditory information? (purer version)

free recall tasks in which the SLP recites multiple swords or numbers and asks the patient to recall as many words or numbers as possible.

Which area of the brain is dedicated to motor function?

frontal

coma scales

generally assess deficits in arousal; These are simple categorical scales that assign a person a number that indicates his or her level of arousal based on the presence of certain behaviors and response to stimuli.

What is g-force?

gravitational; refers to the amount of force exerted on an object by acceleration forces.

cognitive effects of concussion

impulsiveness depression irritability chronic headache dizziness word finding deficits vertigo attention and working memory deficits

What kind of behaviors are exhibited in cognitive deficits in individuals with TBI injuries?

impulsivity of behaviors, emotional lability (inappropriate emotional responses), periods of aggression or agitation, or a lack of motivation. They are typically unaware of their deficits , which can lead them to be non-compliant during therapy or passive and unengaged in rehabilitation. Because of depressed cognitive skills they tend to apply their impaired judgement to themselves and severely underestimate their deficit levels .

Where are closed head injuries most likely found?

in motor vehicle and traffic accidents where vehicles collide and suddenly change from great speeds to less speeds, as when a fast-moving car hits a stationary object. It can also occur when a still car is hit by a moving vehicle.

What knowledge is imperative to the SLP?

knowledge of traumatic brain injury, how it occurs, how to recognize, and how to address it in therapy.

What professions are at great risk for TBI?

law enforcement and military personnel

improvised explosive devices

makeshift bombs that can be manufactured in any number of ways with various materials and have been the primary weapon of choice by enemy combatants and insurgents in recent American wars in Iraq and Afghanistan. They were planted on roadways to explode when run over by military vehicles or on footpaths to explode when tread upon.

What did soldiers often suffer from lack of medical knowledge when treating injuries?

meningitis and chronic cerebral abscesses

nasogastric feeding tube

might pass through the nose, pharynx, and into the esophagus to deliver hydration and nutrition to the body while the person remains unconscious or unable to eat or drink

Therapy for attention deficits

mirror the therapy for attention deficits present in the right and left hemisphere disorders

Where is the damage from a coup-contrecoup?

not constrained to an anterior-posterior profile in the brain and can occur, depending on forces involved, in any one area and its opposite area of the brain.

epidural hematoma

occurs when a blood vessel bursts between the dura mater and the skull and can cause increased intracrania pressure.

acceleration-deceleration closed head injuries

occurs when a person's body, and therefore brain, is moving very fast through space and then comes to a very abrupt halt that is sudden enough to cause the brain a s a result of inertia to slam into and bounce around the inside of the skull with damaging levels of force.

subdural hematoma

occurs when veins between the dura mater and the brain are broken and then bleed out between the dura mater and brain.

locked in syndrome

often mistaken fro a coma or vegetative state. Occurs when an individual lacks all volitional motor ability of the body except for some movement of the eyes. These individuals are cognitively intact but are unable to respond to their environment with their body in nay other way than the movement of the eyes.

shaken baby syndrome

one of the most common and devastating forms of traumatic brain injury

What was the most common traumatic brain injury during World War I and II?

penetrating or open head wound as a result of a gunshot to the head.

What is the leading cause of TBIs in children?

physical abuse

What damage can be caused as a result of damage to the brainstem?

possible deficits in arousal and other autonomic functions.

compensatory strategies to increase orientation using external devices:

posting a calendar or clock in the patient's room to assist in keeping the patient oriented to date and time; Posting family photos in the room.

How can you test short-term memory for auditory informaion?

presenting an unrelated string of words followed by a distracter task (such as asking one or two simple unrelated questions), and then returning to the primary task, asking the patient to remember the words presented.

What does diffuse damage to the brain do?

produce generalized deficits in most skill areas

What kind of damage does an open head TBI cause?

produces focal lesions at the point of penetration into the brain, unlike acceleration-deceleration closed head TBI, which causes damage over larger areas of the brain.

Where is the damage from a coup injury?

produces focalized damage to the most anterior-inferior portions of the frontal lobes and temporal lobes. The damage usually results in personality changes, motor deficits, memory deficits, expressive-receptive language deficits, and deficits in attention and higher-level cognition.

What does the diffuse damage to the brain prduce?

produces generalized deficits in most skill areas.

What is an additional task to test sshort-term recall of auditory information?

reciting a detail heavy paragraph or story to the patient, and then asking the patient to recall as many details as possible.

Selected internal memory strategies include the following:

rehearsal training, mneumonics, imaging and visual association, verbal chaining.

What is the tertiary level of damage delivered by a bomb?

results from the physical displacement of the body when impacted by the force of the wind associated with the shock wave. These individuals might suffer further trauma to the body or the brain a s result of the impact with the ground or an object . Closed or open head traumatic brain injuries might occur on the tertiary level.

What can result from shaken baby syndrome?

severe phsyical, visual, and cognitive disabilitiesare often present in those who survive. Multiple mechnaism s of damage toa child's brain occurs as a result of being shaken. Diffuse axinal shea ring is often a component of the injuries. Localized contusions to a child's brain are also likely to occur as a result of the shaken child's brain impacting irregular or jagged areas on the inside of the cranium.

What are the strongest risk factors for seizure activity following TBI?

severity of damage to the brain, contrusions, and subdural hematomas.

What is displayed in individuals with generalized damage across large portions of the brain?

some level of receptive and expressive language deficit

What is an often used restorative strategy that involves presenting information to the patient and cueing the patient to recall the information over increasingly longer intervals of time, effectively stretching his or her memory ability?

spaced retrieval training

What happens when diffuse bilateral damage occurs to the upper motor neurons?

spastic bilateral paralysis r paresis in the body.

what makes a hematoma a common threat?

stretching and trauma to to blood vessels in and around the brain during TBI

What are the sources of damage tot he child's brain in shaken baby sydrome?

strong rotational and acceleration-deceleration forces imposed on it by the intensity of the back and forth shaking. Capillaries of the pia mater surrouning the brains of infants are very fragile, and any significiant level of rotational or acceleration-deceleration forces is likely to break blood vessels open, resulting in subdural hematoma, which can cause intracranial pressure to rise, limiting blood flow intot h brain and posing significant risk of death tot he child.

What is intracranial pressure?

the amount of pressure present within the skull and therefore the amount of pressure exerted on the brain.

How is the type and severity of deficits that arise from TBI determined?

the areas of the brain that are damaged ad the severity of the damage.

hematoma

the gathering of blood outside a blood vessel following a hemorrhage

What happens with language deficit with open head TBI with focal damage?

the individual might have more specific language deficits.

What is the primary level of damage delivered by a bomb?

the most immediate impact of an IED explosion and is the direct result of the shock wave created by the explosion. This wave of intensive heat and compression emanates from the explosive device and is followed by a reactionary wave of decompressed air molecules that reduces air pressure far below normal levels.

Disorders stemming from stroke and degenerative diseases overwhelmingly occur in what demographic?

the older demographic

What is dictated by the capabilities and deficits of the patient?

the particular tasks used to address problem solving deficits.

What does sensory stimulation therapy target?

the stimulation of all senses in a structured fashion to increase awareness and decrease the long-term effects of coma and vegetative state.

What is cerebral edema?

the swelling of brain tissue and can occur following trauma to the brain. This expansive swelling of the brain tissue increases intracranial pressure.

concussion

the typical sports related TBI also known as mild TBI; traditionally defined as a period of confusion following impact to the head with no loss of consciousness.

polytrauma

the various types of trauma experienced by soldiers following exposure to an IED blast.

minimally conscious state

those who following brain damage and those coming out of a coma who display inconsistent but distinct behavioral signs of consciousness.

How much more likely are individuals who have previously experienced a TBI to experience additional TBI?

three times more likely.

What can functional problem solving tasks be used to do?

to target the patient's deficits in activities of daily living.

What is a more severe variant of traditional locked in syndrome?

total locked in syndrome: individuals do not have the ability to move or even blink their eyes

barotrauma

trauma induced by exposure to intense levels of pressure changes following an explosion. Although it can be devastating to the body, it can also produce less severe results such as concussion or mild TBI.

trauma

used to describe serious and potentially life threatening levels of physical injury.

What can cause hemorrahaging (bleeding) of blood vessels to occur?

warping or movement of the brain within the skull

When does a shock wave occur?

when the rapidly combusting matter of the explosive device causes air pressure to rise dramatically above normal atmospheric pressure levels.