TBI Final

TBI
DEFINITIONS
 Traumatic Brain Injury is an insult to the brain caused
by an external physical force
 Diffuse Axonal Injury the tearing and shearing of
microscopic brain cells
 Acquired Brain Injury is an insult to the brain that has
occurred after birth, for example; TBI, stroke, near
suffocation, infections in the brain, anoxia
ACQUIRED BRAIN INJURY
TRAUMATIC NON-TRAUMATIC
 Open
 Closed  Anoxia
 Aneurysms
 Brain Tumors
 Encephalitis
 Meningitis
 Metabolic Encephalopathy
 Stroke with
Cognitive Disabilities
COUP-CONTRA COUP INJURY
A French phrase that

describes bruises that occur
at two sites in the brain.
When the head is struck,
the impact causes the brain
to bump the opposite side
of the skull. Damage
occurs at the area of impact
and on the opposite side of
the brain.
DIFFUSE AXONAL INJURY
Brain injury does not require a direct head
impact. During rapid acceleration of the head,
some parts of the brain can move separately
from other parts. This type of motion creates
shear forces that can destroy axons necessary
for brain functioning.
These shear forces can stretch the nerve
bundles of the brain.
DIFFUSE AXON INJURY
IS A VERY SERIOUS INJURY, AS IT DIRECTLY IMPACTS THE MAJOR
PATHWAYS OF THE BRAIN.
HEAD INJURY
TYPES OF HEAD INJURIES
• Scalp lacerations
– Can bleed profusely
• Skull fractures
– Linear or depressed
• Linear is from a low velocity injury
– Simple, comminuted, or compound
– Closed or open
HEAD INJURIES
• Frontal fracture
– May see air in the forehead tissue, CSF coming out of their nose
• Orbital fracture
– Raccoon eyes, may have optic nerve injury
• Parietal fracture
– Battle signs, facial paralysis
• Basilar fracture
– CSF out ears, nose, battle signs, trouble hearing or tinnitus, facial
paralysis, conjugate gaze, vertigo.
HEAD INJURY
• Epidural hematoma
– Results from bleeding between the dura and the inner surface of the
skull
– Neurologic emergency!!!
– Venous or arterial origin
 Epidural hematoma
 Classic signs include
Initial period of unconsciousness
Headache
Nausea, vomiting
Focal findings
HEAD INJURY
 Subdural hematoma
 Occurs from bleeding between the dura mater and arachnoid layer of
the meningeal covering of the brain
 Subdural hematoma
 Acute subdural hematoma
Signs within 48 hours of the injury
Similar signs and symptoms to brain tissue
compression in increased ICP

Patient appears drowsy and confused
Ipsilateral pupil dilates and becomes fixed

HEAD INJURY
 Intracerebral Hematoma
 Occurs from bleeding within the parenchyma
 Usually occurs within the frontal and temporal lobes
 Size and location of hematoma determine patient
outcome
 Most of the time from a bullet (missile injury), stabbing,
HEAD INJURY
• Subarachnoid Hematoma
– Bleeding into the subarachnoid space
• Most common causes are subarachnoid aneurysm, head
trauma, or hypertension
EFFECTS: PHYSICAL AND
COGNITIVE
Physical Changes Cognitive Changes
 Headaches  Difficulty concentrating
 Difficulty speaking  Trouble with attention
 Blurry eyesight  Forgetfulness
 Trouble hearing  Difficulty making decisions
 Loss of energy  Repeating things
 Change in sense of taste or

smell
 Dizziness or trouble with
balance
13
HEAD INJURY
DIAGNOSTIC STUDIES AND
COLLABORATIVE CARE
 CT scan
 Best diagnostic test to determine craniocerebral trauma
 MRI
 PET
 Transcranial Doppler studies

 Looking for vasospasm
 Cervical spine x-ray
 You must see from 1 – 7 to see that they have no injury
 Glasgow Coma Scale (GCS)
SEQUELAE OF TBI
SEQUELAE OF TBI
CLINICAL RATING SCALES
 Glasgow coma scale
 Galveston and amnesia test
 Rancho Los Amigos Level of Cognitive Functioning
 Glasgow Outcome Scale
 Disability rating Scale
 Functional independence measure and functional

assessment measure
RX
 Treatment principles
 Prevent secondary injury in the brain
 Timely diagnosis
 Surgery if necessary
 Assessment
 Airway
 Semi-Fowler’s positioning, really good oral care
 Glasgow Coma Scale score
 Neurologic status
 Presence of CSF leak
 Collaborative problem: Increased ICP

ICP MONITORING
 Indications
 severe head injury (GCS < 9)
 abnormal head CT
or
 Coma >6 hrs
 Intracranial
hematoma requiring evacuation
 Delayed neurologic deterioration from mild to moderate
(GCS>9) to severe (GCS < 8)
 Requirement for prolonged ventilation
 Pulmonary injury, surgery etc.
CLINICAL RATING SCALES
 Glasgow Coma Scale (GCS)
 Measures level of
consciousness
 Coma is commonly defined as
scores ≤ 8
 Scores ≤ 5 are classified as
severe brain injury


Scores between 9 and 12 are
defined as moderate and 13 to
15 are classified as mild brain
injury
REHABILITATION PERSPECTIVE
 Interdisciplinary team
 Patient and family
 Physician
 Speech language pathologist
 Occupational therapist
 Rehabilitation Nurse
 Case manager/Team coordinator
 Medical social worker
 Neuropsychologist
REHABILITATION
 Rancho I, II, III
 Sensory Stimulation.
 Structured program of stimulation
 Stimulating each sense
 Educate family and significant others
 PROM
 Auditory stimulation
 Visual stimulation
 Olfactory stimulation
 Vestibular stimulation
REHABILITATION
 Gustatory stimulation
 Tactile stimulation
 Positioning
REHABILITATION
 Rancho IV, V,VI
 Sensory regulation.
 To decrease over stimulation
 Sitter and/or Bed Enclosure as needed.
 Behavioral Medicine.
 Set-up Behavioral Modification Program
 Mobility skills.
 Self-care skills.
 Cognition/communication
REHABILITATION
 Rancho VII,VIII,XI and X
 Mobility
 Balance
 Task oriented
 Gait
PHYSICAL THERAPY EXAMINATION
& TREATMENT

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TBI

A French phrase that

compression in increased ICP

Ipsilateral pupil dilates and becomes fixed

 Difficulty speaking  Trouble with attention

 Blurry eyesight  Forgetfulness

 Trouble hearing  Difficulty making decisions

 Loss of energy  Repeating things

 Change in sense of taste or

 Transcranial Doppler studies

 Rancho Los Amigos Level of Cognitive Functioning

 Glasgow Outcome Scale

 Disability rating Scale

 Functional independence measure and functional

 Collaborative problem: Increased ICP

severe brain injury

 Speech language pathologist

 Case manager/Team coordinator

 Medical social worker

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