Rancho Los Amigos Scale-Revised

Rancho Los Amigos Scale-Revised

• The scale assesses the level of assistance required for patients
• Levels range from no response (total assistance) to modified independence (level X).

Clinical Examination Levels

• Level I: No Response: Patient shows no response to any form of external stimulus.
• Level II: Generalized Response: Response to external stimuli is inconsistent and not purposeful; responses may be the same regardless of the stimulus.
• Level III: Localized Response: Response to external stimuli is inconsistent but specific to the stimulus.
• Level IV: Confused and Agitated: Hyperactive behavior with bizarre and inappropriate actions; behavior stems more from internal confusion than external stimuli.
• Level V: Confused, Inappropriate, Non-Agitated: Patient may follow simple commands but verbalization and behavior are often inappropriate and confused.
• Level VI: Confused, Appropriate: Patient can follow simple commands consistently. They retain familiarity tasks but struggle with new learning.
• Level VII: Automatic and Appropriate: Patient is oriented in familiar settings and performs daily tasks automatically.
• Level VIII: Purposeful and Appropriate: Patient is independently oriented to person, place, and time, and performs familiar tasks in a distracting environment; needs assistance with complex tasks.
• Level IX: Purposeful, Appropriate: (Stand-by Assistance on Request): Patient independently shifts tasks, recognizes impairments, and uses compensatory strategies.
• Level X: Purposeful, Appropriate (Modified Independence): Patient can independently complete multitasking in different environments using extra time or assistive devices.

Rancho Los Amigos Level-Revised Review

• Level I (No Response): Total Assistance: No response to external stimuli.
• Level II (Generalized Response): Total Assistance: Inconsistent, non-purposeful responses to external stimuli.
• Level III (Localized Response): Total Assistance: Inconsistent but specific responses to external stimuli, often related to the stimulus.

Disorders of Consciousness Rancho I-III

• Coma: No response, absent motor function, reflexes, and postural responses.
• Vegetative State: Present sleep-wake cycling, postural responses to noxious stimuli, and possible startle response.
• Minimally Conscious State: Occasional, inconsistent but intelligible verbalization or gestures.

Importance of determining level of consciousness

• Ensure precise distinctions between vegetative and minimally conscious states.

Post-traumatic Agitation

• Defined by excessive behavior during altered consciousness and cognitive impairment.
• Incidence post TBI is reported in range of 10-96%.
• Symptoms include verbal abuse, impulsivity, rage, sudden mood swings, lack of cooperation, and distractibility.

Additional Medical and Rehab Considerations

• Sleep dysregulation is common.
• Patients with brain injuries may have urinary dysfunction, CN injuries, and fatigue.

Acute care/ICU management

• Neurosurgery consultation is needed in case of intracranial damage.
• Intracranial pressure monitoring is important to ensure appropriate management.

Cerebral Perfusion Pressure [CPP]

• CPP = Mean Arterial Pressure [MAP] - Intracranial Pressure [ICP]
• The normal CPP target range is 60-70 mmHg.
• The typical normal MAP range is 70-100 mmHg.

Monitoring Intracranial Pressure [ICP]

• ICP monitoring uses various techniques such as intraventricular or intraparenchymal catheters, or subdural catheters.

Post-Traumatic Hydrocephalus

• Incidence is higher in moderate or severe TBI. (70% develop ventriculomegaly which can be due to atrophy).
• Three common symptoms are change in gait, change in cognition, and urinary incontinence.

Post-Traumatic Seizures

• Incidence varies based on injury type and timing of seizure.
• Anti-seizure medications (ASMs) are recommended in the early stages (within the first 7 days post injury).

Paroxysmal Sympathetic Hyperactivity [PSH]

• PSH is predominantly in response to non-noxious stimuli, and may last from minutes to 2 hours.
• PSH is usually seen in patients with a GCS<8.
• PSH is predominantly seen in younger males.

Heterotopic Ossification

• Heterotopic ossification is the formation of bone in non-osseous tissues.

Craniotomy/Craniectomies

• Decompressive bone flap removal and placement after decompression is performed.
• Surgical excision of the bone flap is performed until swelling is resolved; repositioning is called cranioplasty.

Precautions

• Patients with craniotomies/craniectomies may require custom helmets when out of bed.
• The head of the bed should be elevated and patient's should consult with the team for possible activity restrictions.

Further Facility Training

• Crisis Prevention Training and De-escalation Training are crucial for facility staff.

Multi-disciplinary Team

• A multidisciplinary team approach is critical in patient care encompassing social workers, speech therapists, doctors, physical therapists, recreational therapists, caregivers, nurses, and other professionals as required.

Prevention of TBI

• Educate all regarding the risk factors and management of seizures
• Take proper precautions, and Manage triggers.

Imaging

• CT scans are common in TBI assessment.
• CT scans evaluate for intracranial pathology like depressed skull fractures, subdural hematoma, epidural hematoma, etc.

Specialized Long-Term Care Facilities

• Depending on the patient's individual medical needs, long-term care facilities may be needed.

Glasgow Coma Scale (GCS)

• GCS scores in the initial 24 hours correlated to outcomes.
• Lower GCS scores are associated with poorer patient outcomes
• Motor scores of the GCS are highly accurate in predicting patient outcomes.

Other Factors Affecting Prognosis

• Duration of coma
• Age at injury

Neuroimaging

• Bilateral brainstem lesions on MRI are not associated with positive outcomes.
• CT findings of epidural, subdural, or subarachnoid hemorrhage may correlate with poorer outcomes.

Motor Recovery and TBI

• Most motor recovery happens within the first 6 months of the injury.
• A shorter duration of loss of consciousness and mild initial deficits associates with faster recovery.

Prognosis in Disorders of Consciousness

• Minimally Conscious State has more favorable prognosis than Vegetative state.

Factors Affecting ADL Independence in Older Adults with TBI

• Age is significantly correlated with worse outcomes.
• Co-morbidities are associated with poor outcomes.
• Medical complications (including those related to injury) can negatively impact outcomes, sometimes for 12 months or more.