Chapter 8: TBI – Flashcards

A traumatic brain injury (TBI) is damage to the brain that results from an external and usually forceful event. Excludes damage to the brain resulting from disease, stroke, or surgery.

Severity can range from a concussion that cause transient amnesia and changes in consciousness to a more severe TBI that leads to coma or death

Falls Motor vehicle and traffic accidents Incidents of a person being struck by an object Sports accidents Violent assaults

Children younger than age 4 years Individuals older than 75 years Adolescent males

Closed head injuries Open head injuries

A subcategory of traumatic brain injury in which an individual's skill is not broken open; The skull remains intact

Acceleration-Deceleration Injuries Impact-based Injuries

Damage to the brain created by the external forces that act on the brain when it is moving through space very quickly or coming to an abrupt halt.

a pattern of brain damage that occurs when , due to external forces, the brain bounces back and forth inside the skull causing damage at the sites of impact.

The posterior of the brain impacts the interior rear of the skull. 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. The coup injury produces focalized damage to the most anterior-inferior portions of the frontal lobes and temporal lobes.

The coup injury produces focalized damage to the most anterior-inferior portions of the frontal lobes and temporal lobes.This damage usually results in personality changes, motor deficits, memory deficits, expressive-receptive language deficits, and deficits in attention and higher-level cognition. The contrecoup injury produces more generalized damage to the posterior part of the brain, the occipital lobes, and the vision areas. This damage in visual deficits such as visual agnosia.

A form of closed head injury in which a moving object impacts the head forcing the skull inward on the brain producing focal damage to the area of the brain compressed.

Violent Assault

In open head TBI an object penetrates the skull into the brain.

Common cause of open head TBI is ballistic trauma, such as when a projectile passes through the skull into the brain. Bullet or Piece of shrapnel

Increased Intracranial Pressure Cerebral Adema Traumatic Hydrocephalus Traumatic Hemorrhage Hematoma Seizures/Post-Traumatic Epilepsy

Intracranial pressure is the amount of pressure within the skull and therefore exerted on the brain. When the intracranial pressure in above normal is called increased intracranial pressure.

When damage to the brain occurs, multiple possible mechanisms create heightened and dangerous levels of intracranial pressure. Cerebral edema is the swelling of the brain tissue and can occur following trauma to the brain. This expansive swelling of brain tissue increases intracranial pressure.

a disruption of the brain's ability to reabsorb excess cerebrospinal fluid that is caused by a traumatic event and leads to a life threatening increase in intracranial pressure. Usually treated by the placement of a CSF shunt, a device placed into a lateral ventricle that drains off excess cerebrospinal fluid, thereby keeping intracranial pressure normal. A 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.

bleeding as a result of trauma. Usually are intracerebral, subdural, or epidural

the gathering of blood outside a blood vessel following a hemorrhage. Subdural hematoma- occurs when veins between the dura mater and the brain are broken and bleed out between the dura mater and brain Epidural hematoma- occurs when a blood vessel bursts between the dura mater and the skull and can cause increased intracranial pressure.

AKA Post-Traumatic Epilepsy These seizures cause additional damage to the brain and significantly and negatively affect prognosis for recovery of lost functions. Most common following gunshot wounds or military-type open head TBI. 50% of those with open head wounds experience some degree of PTE. The strongest risk factors for seizure activity following TBI include the severity of the damage to the brain, contusions, and subdural hematomas

Physically weakest among us:Infants Physically strongest among us :Athletes, Soldiers, and Military Personnel

A profile of traumatic brain injury seen in infants and small children most often caused by physical abuse, usually a shaking of the child, by the caregiver.

The usual trigger for abuse of an infant is the infant's crying.

One of the most common causes of death in children and physical abuse is the leading cause of these TBIs 80% of deaths of TBI in children younger than 2 years were non-accidental (intentional)

Vomiting 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 Bruises Broken Bones A history of or evidence of past injuries

These children also need physical, occupational, visual, and speech therapy as they recover, grow, and develop. Although the SLP probably plays no part in the emergency medical treatment of shaken infants, the SLP working in pediatrics and early pediatrics must be able to recognize the signs of this syndrome to make the quick and appropriate referrals for the well being of the child. The role of the SLP in shaken baby syndrome usually depends on the age of the injured child and the extent and nature of the injuries and deficits In the medical setting the SLP will probably focus on treating the acquired feeding or swallowing problems of shaken infants in the neonatal intensive care unit (NICU) Once the children reach school age, the school SLP can treat these children for articulation difficulties, language problems, and cognitive problems resulting from being shaken as an infant

TBIs are often of damage resulting from exposure to explosions. Makeshift bombs, AKA improvised explosive devices (IED) have been the primary weapon of choice by enemy combatants and insurgents in recent American wars in Iraq and Afghanistan.

the various types of trauma experience by soldiers expose to IED blasts.

The most immediate impact of an IED explosion and is the direct result of the shock wave created by the explosion. A shock wave occurs when the rapidly combusting matter of the explosive device causes air pressure to rise dramatically above normal atmospheric pressure levels. Barotrauma- trauma induced by exposure to intense levels of pressure changes following an explosion.

In addition to the shock wave, explosions usually create flying debris and bomb fragments. When these bomb fragments or debris hit soldiers and bystanders this is known as the secondary level of blast trauma.

Results from the physical displacement of the body when impacted by the force of the wind associated with the shock wave. Often soldiers and bystanders are knocked off their feet or thrown into nearby structures by the shock wave. Closed or open head TBIs might occur

Any trauma created by the blast that is not attributable to primary, secondary, or tertiary mechanism. Examples of quaternary trauma are 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.

Chronic traumatic encephalopathy-A degenerative disease of the brain caused by repeated head trauma such as repeated concussions in sports or repeated exposure to IED blasts in soldiers that manifests within months or years of brain damage as dementia, confusion, memory loss, headache, depression, and excessive aggression. Recent attention has been directed to CTE as a result of a trend of suicide among retired NFL players

Female athletes are at higher risk for TBI than males because they have less muscle mass in the neck to stabilize the head and reduce sudden movements of the head during impact.

mild TBI or concussion.

Individuals with TBI are usually unconscious, minimally conscious, or at best, very confused and disoriented directly after their trauma. They will be in a hospital bed and hooked up to a ventilator that breathes for them. Many TBI patients requires immediate brain surgery to resolve secondary issues such as hemorrhage or increased intracranial pressure, so their heads are shaven. A nasogastric feeding tube might pass through the nose, the pharynx, and into the esophagus to deliver hydration and nutrition to the body while the person remain unconscious or unable to eat or drink. Because high intracranial pressure following trauma to the brain is often an issue, a cerebral spinal fluid (CSF) shunt may have been placed in the brain. A craniotomy is a surgery to remove part of the skull to allow the brain to swell without the brain incurring damage from increased pressure within the skull. As TBI patients recover from coma or a vegetative state, they can exhibit severe cognitive and language deficits leading to confusion, disorientation, and aggression. The speech of patients with TBI is usually characterized by any number of dysarthrias. Patients with TBI tend to show impulsivity and a lack of awareness of their deficits. SLPs can start to rehabilitate cognition and language by using strategies and therapies often used in other populations, such as those with aphasias, RH deficits, and dementia. Patient fatigue is an issue in patients with TBI. Patients at all recovery levels of TBI are highly susceptible to fatigue, and the therapist must monitor level of patient fatigue carefully.

The primary areas of the brain dedicated to motor function are within the frontal lobe Therefore, damage to the frontal lobes often results in problems moving the body. Diffuse bilateral damage to the upper motor neurons (UMNs) in the frontal lobes creates spastic bilateral paralysis or paresis in the body whereas unilateral traumatic damage to the UMNs in a single fontal lobe creates a contralateral hemiplegia similar to that seen in stroke patients. Often have severe gross and fine motor deficits. They might have abnormal muscle tone and possible damage to the cerebellum, which will create ataxia causing incoordination of movements and impaired balance. Particular motor deficits of concern to the SLP are deficits in the planning or execution of movements involved in production of speech (motor speech disorders) and swallowing (dysphagia). Motor speech disorders that can present are apraxia of speech and the dysarthria. Possible types of dysarthria are spastic, flaccid, ataxic, hypokinetic dysarthrias or a combination of the four.

It is common for those with TBI to spend time following the trauma in a coma or a decreased state of arousal when little or no cognition is possible. Those who do recover from coma and vegetative states often display an amnesia following the trauma referred to as post-trauma amnesia. A usual consequence of significant injury to the brain and typically presents as a combination of both retrograde and anterograde memory losses. This condition creates an inability to take on new memories (anterograde amnesia) to the extent that most individuals recovering from TBI usually cannot remember a large part of their hospital stay or rehabilitation following the trauma.

Result in damage to the frontal lobes. Individuals with TBI often display dramatic personality changes resulting from loss of social inhibition. These individuals might make inappropriate sexual advances toward others or say inappropriate things at inappropriate times. They are far less aware of or attentive to usual social and cultural conventions.

Language losses occur often and are determined by the location and extent of damage to the brain. Language deficits such as anomia and aphasia following closed head injuries are often present but can be dwarfed by deficits in arousal and cognition.

The type of assessment used with individuals with TBI varies according to the patient's age, educational level, and severity of deficits. Because most TBI patients begin therapy with deep cognitive deficits, a formal interview or opportunity to observe connected speech might not be possible. In this scenario, the patient's background and medical history must be taken from medical records, charts, and interviews with the family and any rehabilitation or medical professionals who have been interacting with the patient.

Individuals can display deficits in working memory, short-term memory, long-term memory or any subcategory of these. The SLP can assess long-term memory during the interview by posing biographical questions to patients 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. Many tests of visual memory require the patient to draw from memory the visual stimuli presented earlier. Benton Visual Retention Test is a formal test of visual memory that is appropriate to use in population with brain damage and dementia.

Coma Scales Deficits in arousal are generally associated with com scales. These are simple categorical scales that assign as person a number that indicates his or her level of arousal based on the presence of certain behaviors and response to stimuli. The most commonly used scales are the Glasgow Coma Scale and the Ranchos Los Amigos Levels of Cognitive Functioning Coma Scale The Adelaide Coma Scale is used in pediatrics.

Orientation is evaluated as a component of most standard cognitive assessments such as the Mini Mental State Examination Orientation to person, place, and time is usually assess simply by asking patient simples questions When assessing for orientation it is important to remove clocks, calendars, and any other external indicator that the patient can use as a cue.

As patients recover from coma and vegetative state, their motor skills might return faster than their cognitive skills, creating the problematic situation of a motorically intact patient who is severely disoriented, confused, and possibly agitated. Generally have a disregard for safety and often require some level of physical restraint to keep them unharmed in their bed and to keep them from hurting anybody else. The Agitated Behavior Scale is designed specifically to assess level of agitation and track over time changes in agitation in patients.

• Evaluation of communication, language, and cognitive deficits in TBI can use the same types of assessment methods as used for aphasia, right hemisphere disorders, and dementia.

SLP might prefer to apply a formal assessment for deficits associated with TBI. Must carefully monitor the patient's level of fatigue. Formal assessments: Burns Brief Inventory of Communication and Cognition. Brief Test of Head Injury Cognitive-Linguistic Quick Test Scales of Cognitive Ability for Traumatic Brain Injury Ross Information Processing Assessment

Goals for the treatment of the patient with TBI reflect the patient's deficits as identified in assessment. Depend on the severity and location of damage.

Sensory Stimulation Therapy:AKA Coma Stimulation Therapy, is used in the hope of increasing level of arousal in a patient in a coma or vegetative state. Selected sensory stimulation strategies: Visual Stimulation Auditory Stimulation Oral Stimulation Olfactory Stimulation Cutaneous Stimulation Gustatory Stimulation

Present in right and left hemisphere deficits.

The particular tasks used to address problem-solving deficits in TBI are dictated by the capabilities and deficits of the patient. Paper-and-pencil tasks available in worksheet-style therapy books are used. Functional problem-solving tasks can be used to target the patient's deficits in activities of daily living.

Recommendations for Targeting Working Memory Restorative Memory Approaches Internal Memory Strategies External Memory Strategies

1. Be sure instructions and utterances are produced as succinctly (shortly) as possible. 2. Use functional tasks to target memory deficits in the context of activities of daily living. 3. Avoid speaking fast. 4. Emphasize important words or phrases to bring the individual's attention to the most important parts of the utterance. 5. Increase automaticity of response. 6. Break down complex tasks into individual components.

Restorative memory approaches do not allow the patient to compensate for deficits using external device or cognitive methods and devices. Restorative memory approaches word rehabilitate memory abilities. Spaced retrieval training is a strategy that involves presenting information to the patient to recall the information over increasingly longer intervals of time, effectively stretching his or her memory ability

Are cognitive acts that can increase the likelihood of retaining information over the short and long terms. Rehearsal Training Mnemonics Imaging and visual association Verbal Chaining

Training patients to repeat information to themselves that hey need to remember increases the likelihood of the patients retaining the information

A method of consciously converting information into a format that the brain can more easily remember and retain.

Training the patient to create a visual image of the information to be recalled increases the likelihood of retaining that information.

Information can be strung together in a narrative to increase the likelihood of effective recall.

Are material devices are used to allow for compensation of memory deficits. These strategies can be low tech or high tech devices Low tech: Checklists, calendars, schedule, memory books, dairies, memo pads, watch alarms High tech: smart phones or computers.

Reorientation to self, person and place following TBI is accomplished by repetitively exposing the patient to relevant facts.