Traumatic Brain Injury

What positional considerations are important for controlling ICP?

- stabilize head in a neutral position with towel rolls on either side - head elevated to 30° to facilitate venous drainage

Post-Traumatic amnesia time for moderate TBI

1-24 hours

Post-Traumatic amnesia time for severe TBI

1-7 days

Glasgow Coma Scale for mild TBI

13-15

What range of ICP in children is the threshold for concern? (aka needs intervention)

20-25 mmHg

Glasgow Coma Scale for severe TBI

3-8

If a patient gets to the minimally conscious state within ______ months of injury, this is associated with a more favorable outcome.

5 months

Loss of Consciousness for severe TBI

6-48 hrs

Glasgow Coma Scale for moderate TBI

9-12

Post-Traumatic amnesia time for mild TBI

<1 hour

Loss of Consciousness for mild TBI

<15 min

Loss of Consciousness for moderate TBI

<6 hrs

what cognitive/behavioral deficits might you expect from someone who has an injury to their medial prefrontal cortex?

Apathetic/Passive Presentation: - decreased affect - decreased motor and verbal production - less initiative - "pseudo-depression"

Why is it important to control intracranial pressure following TBI?

Cerebral swelling causes increase intracranial pressure, which can lead to decreased cerebral perfusion pressure, which causes a reduction in brain oxygenation --> secondary brain injury

A CT scan of a brain following a traumatic brain injury shows multiple small petechial hemorrhages at the gray-white matter junction. There is no midline shift, and ventricles are patent. What type of brain injury has occurred? a) Focal Lesion b) Diffuse Axonal Injury

Diffuse Axonal Injury

What is diffuse axonal injury (DAI)?

Diffuse axonal injury is the shearing (tearing) of the brain's long connecting nerve fibers (axons) that happens when the brain is injured as it shifts and rotates inside the bony skull. DAI usually causes coma and injury to many different parts of the brain. The changes in the brain are often microscopic and may not be evident on computed tomography (CT scan) or magnetic resonance imaging (MRI) scans.

what cognitive/behavioral deficits might you expect from someone who has an injury to their orbitofrontal cortex?

Disinhibition Emotional lability Decreased Judgement/ Impulsivity Distractibility Perseveration Social Inappropriateness ("immaturity") Denial of deficits Slow processing of information

what cognitive/behavioral deficits might you expect from someone who has an injury to their dorsolateral prefrontal cortex?

Dysexecutive Syndrome: - difficulty with new or complex situations - trouble developing a plan - concrete thinking (little imagination) - trouble evaluating performance (doesn't integrate feedback, difficulty recognizing errors)

Which of the following describes a coma? a) Eyes don't open spontaneously or to stimulation b) Eyes open, sleep-wake cycles resume, arousal sluggish and poorly sustained c) Eyes open, normal to abnormal sleep-wake cycles, arousal obtunded to normal

Eyes don't open spontaneously or to stimulation

Which of the following describes a minimally conscious state? a) Eyes don't open spontaneously or to stimulation b) Eyes open, sleep-wake cycles resume, arousal sluggish and poorly sustained c) Eyes open, normal to abnormal sleep-wake cycles, arousal obtunded to normal

Eyes open, normal to abnormal sleep-wake cycles, arousal obtunded to normal

Which of the following describes a vegetative state (unresponsive wakefulness)? a) Eyes don't open spontaneously or to stimulation b) Eyes open, sleep-wake cycles resume, arousal sluggish and poorly sustained c) Eyes open, normal to abnormal sleep-wake cycles, arousal obtunded to normal

Eyes open, sleep-wake cycles resume, arousal sluggish and poorly sustained

How is the FOUR score for level of consciousness different from the Glasgow Coma Scale?

FOUR score does not require verbal responses. Both FOUR score and GCS measure eye opening and motor response, but the FOUR score also measures brainstem-level responses and breathing, making it more sensitive to grading a minimally conscious state.

What is the leading cause of traumatic brain injury?

Falls (47%) - followed by being Struck By/Against an Object (15%), and MVA (14%)

True or false: the Disorders of Consciousness Scale (DOCS) is a very simple and quick test to determine an individual's level of consciousness following TBI.

False; it is a very involved assessment with multiple categories for an in-depth assessment involving social knowledge, taste/swallowing, olfactory, proprioceptive/ vestibular, auditory, visual, tactile, etc. Requires a 2-hour training to learn how to administer

A CT scan of a brain following a traumatic brain injury shows a midline shift and obliteration of the 3rd ventricle. What type of brain injury has occurred? a) Focal Lesion b) Diffuse Axonal Injury

Focal Lesion

You are working with a patient who suffered a TBI from a motor vehicle accident in which they sustained a left femoral neck fracture. While working with this patient, you notice a rapid loss in range of motion in the left hip over the course of a few weeks. You contact the physician to obtain a triple phase bone scan because you are concerned that the patient has developed _____________ _______________

Heterotopic Ossification (HO)

In order to make sure oxygen is reaching the brain, we want ICP to be relatively (low/high), and CPP to be relatively (low/high)

ICP = low CPP = high

What is a Coup-Contre Coup Injury?

Lesion to one side of the brain causes damage to opposite side as well; Force on one side causes brain to shift within the skull, creating impact on the opposite side of the brain against the skull

The following describes what Ranchos Level? Patient appears to be in a deep sleep and is completely unresponsive to any stimuli (sounds, sights, touch, or movement)

Level I: No response

The following describes what Ranchos Level? Patient reacts inconsistently and nonpurposefully to stimuli in a nonspecific manner. Patient responds in the same way to every stimulus

Level II: Generalized Response

The following describes what Ranchos Level? Patient may be awake for short periods of time. Patient reacts specifically but inconsistently to stimuli. Patient may begin to recognize family. May follow simple commands in an inconsistent, delayed manner, such as closing eyes or squeezing hand.

Level III: Localized response

The following describes what Ranchos Level? Patient is very confused, frightened, and overreacts to stimuli through agitation and aggression. Patient may need to be restrained. Often has no selective attention and has difficulty following directions, making them unable to cooperate directly with treatment efforts

Level IV: Confused-Agitated

The following describes what Ranchos Level? Patient is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, responses are nonpurposeful, random, or fragmented. Demonstrates gross attention tot he environment, nut is highly distractible and lacks ability to focus attention on a specific task (short attention span). Patient needs step-by-step instructions for basic tasks. Verbalization is often inappropriate 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.

Level V: Confused-Inappropriate

The following describes what Ranchos Level? Patient is oriented and follows simple directions consistently, but needs external input for direction. Responses may be incorrect because of memory problems, but appropriate to the situation. Patient will remember main topics, but not details. Can pay attention in a non-distracting environment, and is more aware of physical problems than mental/safety issues.

Level VI: Confused-Appropriate

The following describes what Ranchos Level? Patient appears appropriate and oriented within hospital and home setting; goes through daily routine automatically, but frequently robot-like with minimal-to-absent. Patient is able to take care of themselves and follows a set schedule. Still has trouble paying attention in distracting environment. Often able to talk through a process, but can't execute it.

Level VII: Automatic-Appropriate

The following describes what Ranchos Level? Patient realizes they have a cognitive deficit, develops compensation strategies, and is able to learn new tasks.

Level VIII: Purposeful-Appropriate

What is a normal intracranial pressure for adults? At what point should it be treated medically?

Normal: <15 mmHg Treatment if >22 mmHg

What happens if CPP is too low?

Oxygen is not being driven into the brain tissue

To what degree is a person able to communicate when they are in unresponsive wakefulness (vegetative state)?

Person cannot communicate; No evidence of yes/no responses, no verbalization or gestures

What is the current theory that explains the cause of paroxysmal sympathetic hyperactivity?

There is a disconnection of descending sensory inhibitory input. This loss of inhibition causes benign (non-noxious) sensory input to cause increased excitatory interneuron activity, which triggers the fight-or-flight response because the sensory input is being perceived as noxious stimuli.

What is the pharmacological treatment for lowering ICP when it is too high?

administration of drugs that increase blood pressure to maintain CPP at a high enough level to drive oxygen into the brain tissue. CPP = MAP - ICP

What happens if ICP is too high?

blood can't make it to the brain tissue to provide oxygen :(

What age group(s) are most likely to sustain a TBI?

children, older adolescents, and adults 65 and older

If a patient is showing difficulties with planning and problem-solving, such as trouble developing a plan, concrete thinking (has a hard time imagining things), and trouble evaluating performance (doesn't integrate feedback, difficulty recognizing errors), this person likely experienced an injury to what area of the brain? bonus question: what is this "syndrome" called?

dorsolateral prefrontal cortex dysexecutive syndrome

true or false: a person can still be considered "in a coma" even if they briefly open their eyes

false; if person is in a coma, their eyes don't open AT ALL to any stimulation. If eyes are opening, they are not in a coma anymore they have moved beyond that to unresponsive wakefulness or minimally conscious state

A 29 year old patient suffered a TBI and had an initial GCS of 13 and had PTA for about 36 hours. CT scan showed no mass lesions, and CPP is 53 mmHg. There is no evidence of hypoxia or anoxia. What is this patients expected prognosis? (good/poor)

good :)

What is the main benefit of using the Coma Recover Scale - Revised (CRSR)?

it reliably distinguishes between a vegetative and minimally conscious state

Why is it important for patients experiencing PSH to have proper nutrition to maintain body weight?

large energy expenditure from the reaction that occurs (increased metabolic rate) can lead to weight loss

Recommended CPP values for children are (lower/higher) than for adults

lower

TBI is more common in: a) females b) males

males

If a patient is showing decreased affect, inactivity, not speaking, and is generally apathetic, they likely experienced an injury to what area of the brain?

medial prefrontal cortex

If a patient is exhibiting emotional lability, distractibility, perseveration, and social inappropriateness, they likely experienced an injury to what area of the brain?

orbitofrontal cortex

A patient who is 3 weeks post-TBI begins having episodes of increased heart rate, blood pressure, sweating, and fever after being taken off of sedative medications. The patient's posture was previously relaxed, but is now showing decorticate and decerebrate posturing. There is no clear explanation for these symptoms. This patient is likely experiencing what complication associated with TBI?

paroxysmal sympathetic hyperactivity

Autonomic storming and dysautonomia are two common alternative names for what condition?

paroxysmal sympathetic hyperactivity

A 78 year old patient suffered a TBI and had an initial GCS of 4, and had PTA for about 4 months. CT scan showed mass lesions in the brain, and ICP was 50 mmHg. What is this patient's expected prognosis? (good/poor)

poor :(

What is the effect of DAI on prognosis following brain injury?

poor prognosis as this type of injury is very severe. Patient will likely remain in a persistent vegetative state.

Why is it important to use repeat attempts when determining responsiveness in a patient who has suffered a TBI?

see if responses are consistent

What is Cerebral Perfusion Pressure? What is the recommended range for adults?

the net pressure gradient that drives oxygen delivery to cerebral tissue. CPP = MAP - ICP recommended range: 60-70 mmHg

What is perseveration?

the pathological, persistent repetition of a word, gesture, or act. Person may be fixated on one particular thing and unable to "let it go"; this can present in different ways

Other than pharmalogical intervention, what is the procedure that is performed to decrease ICP in patients who have suffered a TBI?

ventriculostomy - catheter inserted through brain tissue to drain CSF and relieve pressure on the brain