Traumatic Brain Injury Prognosis Quiz
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Questions and Answers

What factor is associated with a faster recovery from loss of consciousness?

  • Presence of traumatic brain injury complications
  • Longer duration of loss of consciousness and severe initial deficits
  • Increased age at the time of injury
  • Shorter duration of loss of consciousness and mild initial deficits (correct)

    • Which state has a more favorable prognosis?

  • Coma
  • Minimally conscious state (correct)
  • Persistent vegetative state
  • Vegetative state

    • What is the prognosis for traumatic causes of disorders of consciousness compared to acquired TBI?

  • Prognosis is irrelevant in both cases
  • Traumatic causes have a better prognosis (correct)
  • Acquired TBI has a better prognosis
  • Both have the same prognosis

    • What percentage of patients in a vegetative state became functionally independent after a period of rehabilitation?

    <p>20%</p> Signup and view all the answers

    How does the prognosis differ between a vegetative state and a minimally conscious state?

    <p>Minimally conscious state has a more favorable prognosis</p> Signup and view all the answers

    What factor is significantly associated with poorer outcomes in older adults after experiencing a traumatic brain injury (TBI)?

    <p>Number of co-morbidities</p> Signup and view all the answers

    Which environmental factor can influence ADL independence in older adults with TBI?

    <p>Access to rehabilitation services</p> Signup and view all the answers

    What short-term outcome is associated with higher severity of TBI?

    <p>Worse functional outcomes</p> Signup and view all the answers

    Which medical complication is linked to worse outcomes after a traumatic brain injury?

    <p>Presence of secondary injuries</p> Signup and view all the answers

    After how many months post-injury can medical complications still influence outcomes in TBI patients?

    <p>12 months</p> Signup and view all the answers

    What is the assist level for a patient at Rancho Level IV?

    <p>Maximal Assist</p> Signup and view all the answers

    Which Rancho Level is characterized by a patient being purposeful and appropriate with modified independence?

    <p>Level X</p> Signup and view all the answers

    At which Rancho Level does a patient show no response?

    <p>Level I</p> Signup and view all the answers

    What type of response is characteristic of Rancho Level II?

    <p>Generalized Response</p> Signup and view all the answers

    Which level requires minimal assistance for daily activities?

    <p>Level VII</p> Signup and view all the answers

    What is the primary characteristic of a patient at Rancho Level V?

    <p>Confused and Inappropriate</p> Signup and view all the answers

    In the Rancho Los Amigos Scale, which level indicates a patient who is confused but appropriate?

    <p>Level VI</p> Signup and view all the answers

    Which Rancho Level is defined as confused and agitated?

    <p>Level IV</p> Signup and view all the answers

    What assist level is assigned to Rancho Level IX?

    <p>Stand-by Assist</p> Signup and view all the answers

    Which of the following levels indicates a total assist requirement?

    <p>Level I</p> Signup and view all the answers

    At which Rancho Level is a patient likely to show purposeful and appropriate behavior without assistance?

    <p>Level X</p> Signup and view all the answers

    Which level requires maximal assistance for a patient exhibiting confusion?

    <p>Level IV</p> Signup and view all the answers

    The classification of responses in Rancho Levels I-III primarily considers what aspect?

    <p>Responses to stimuli</p> Signup and view all the answers

    What is the primary function of the Rancho Los Amigos Scale?

    <p>To evaluate cognitive and behavioral recovery</p> Signup and view all the answers

    What is a significant finding when the Coma Recovery Scale-Revised (CRS-R) is used?

    <p>41% of patients previously thought to be in a vegetative state were found to be minimally conscious.</p> Signup and view all the answers

    What is considered an essential aspect of diagnosing a patient's condition?

    <p>Determining the level of consciousness.</p> Signup and view all the answers

    Which clinical level is defined as having no response?

    <p>Level I - No Response</p> Signup and view all the answers

    At which level does a patient require maximal assistance according to the clinical examination?

    <p>Level IV - Confused and Agitated</p> Signup and view all the answers

    What does post-traumatic agitation typically include?

    <p>Excessive behaviors in an altered state of consciousness.</p> Signup and view all the answers

    For patients classified at Level V, what type of assistance is required?

    <p>Maximal Assistance</p> Signup and view all the answers

    What does the Agitated Behavioral Scale primarily assess?

    <p>Observable agitated behaviors</p> Signup and view all the answers

    Which level indicates purposeful, appropriate behavior with modified independence?

    <p>Level X</p> Signup and view all the answers

    What is the definition of post-traumatic agitation?

    <p>Excessive behavior in an altered state of consciousness.</p> Signup and view all the answers

    What behavior characterizes Level VI in clinical examinations?

    <p>Confused and appropriate.</p> Signup and view all the answers

    At what level does a patient require stand-by assistance?

    <p>Level IX</p> Signup and view all the answers

    Which level of consciousness represents maximal assistance requirements with agitation?

    <p>Level IV</p> Signup and view all the answers

    What is indicated by a generalized response in clinical evaluations?

    <p>Minimal interaction with the environment.</p> Signup and view all the answers

    Which level corresponds to confused but non-agitated responses?

    <p>Level V</p> Signup and view all the answers

    What percentage of people hospitalized with TBI are at risk of having a seizure?

    <p>2.6-33%</p> Signup and view all the answers

    When is it recommended to use anti-seizure medication after a TBI?

    <p>Within the first 7 days of injury</p> Signup and view all the answers

    Which of the following is NOT a presentation of Paroxysmal Sympathetic Hyperactivity (PSH)?

    <p>Hypothermia</p> Signup and view all the answers

    What triggers Paroxysmal Sympathetic Hyperactivity in patients with severe TBI?

    <p>Trauma to autoregulatory centers</p> Signup and view all the answers

    What is the medical treatment recommended for Paroxysmal Sympathetic Hyperactivity?

    <p>Opioids, beta-blockers, and bromocriptine</p> Signup and view all the answers

    What is the definition of Heterotopic Ossification?

    <p>Formation of new bone within soft tissue</p> Signup and view all the answers

    Which of the following conditions can act as a trigger for Paroxysmal Sympathetic Hyperactivity?

    <p>Sepsis</p> Signup and view all the answers

    What percentage range of patients with severe TBI experience Paroxysmal Sympathetic Hyperactivity?

    <p>15-33%</p> Signup and view all the answers

    What is the purpose of using anti-seizure medication after TBI?

    <p>To prevent early post-traumatic seizures</p> Signup and view all the answers

    Which of the following is a common characteristic of Paroxysmal Sympathetic Hyperactivity?

    <p>Increased perspiration</p> Signup and view all the answers

    What is the relationship between invasive support and physical therapy frequency?

    <p>Patients who required invasive support received less frequent physical therapy.</p> Signup and view all the answers

    What is a common cause of Paroxysmal Sympathetic Hyperactivity (PSH)?

    <p>Unavoidable, non-noxious stimuli</p> Signup and view all the answers

    What is the typical duration of an episode of PSH?

    <p>A few minutes to 2 hours</p> Signup and view all the answers

    What percentage of PSH cases are related to unavoidable, non-noxious stimuli?

    <p>72%</p> Signup and view all the answers

    Which of the following best describes the frequency of physical therapy for patients needing invasive support?

    <p>Less frequent therapy is given compared to non-invasive patients.</p> Signup and view all the answers

    Which of the following factors is associated with the presentation of PHS episodes?

    <p>Triggered by non-noxious stimuli</p> Signup and view all the answers

    In which area is the practice of physical therapy being described?

    <p>Neurological Intensive Care Unit</p> Signup and view all the answers

    What aspect of patient management is highlighted regarding those who need invasive support?

    <p>Decreased frequency of physical therapy</p> Signup and view all the answers

    What is the defining characteristic of episodes of PSH?

    <p>Can last from minutes to hours</p> Signup and view all the answers

    Which of the following statements is true regarding invasive support and therapy?

    <p>Patients requiring invasive support often have reduced therapy frequency.</p> Signup and view all the answers

    Study Notes

    Rancho Los Amigos Scale-Revised

    • Levels of clinical examination and assist level
    • Level I (No Response): Total Assistance. No response to external stimuli.
    • Level II (Generalized Response): Total Assistance. Responds inconsistently and non-purposefully to external stimuli. Responses are often the same regardless of the stimulus.
    • Level III (Localized Response): Total Assistance. Responds inconsistently and specifically to external stimuli. Responses are directly related to the stimulus. (e.g., patient withdraws or vocalizes to painful stimuli; responds more to familiar people/family vs strangers).
    • Level IV (Confused and Agitated): Maximal Assistance. The individual is hyperactive with bizarre, non-purposeful behavior. Demonstrates agitated behavior from internal confusion. Absent short-term memory.
    • Level V (Confused, Inappropriate, Non-Agitated): Maximal Assistance. Behavior and verbalization is often inappropriate and confused. Memory is severely impaired, and learning new information is difficult.
    • Level VI (Confused, Appropriate): Moderate Assistance. Able to follow simple commands consistently. Able to retain learning for familiar tasks. Demonstrates increased awareness of self, situation, and environment but lacks awareness of specific impairments and safety concerns.
    • Level VII (Automatic, Appropriate): Minimal Assistance for Daily Living Skills. Oriented in familiar settings, able to perform daily routine automatically. Demonstrates carry-over for new tasks.
    • Level VIII (Purposeful, Appropriate): Stand-by Assistance. Consistently oriented to person, place, and time. Independently completes familiar tasks in a non-distracting environment. Shows awareness of impairments. Requires stand-by assistance to compensate.
    • Level IX (Purposeful, Appropriate): Stand-by Assistance on Request. Shifts between tasks independently, acknowledging impairments. Requires assistance for anticipating obstacles.
    • Level X (Purposeful, Appropriate): Modified Independence. Able to multitask in varied environments. Independently anticipates obstacles and takes corrective actions. Able to independently make decisions and act appropriately.

    Disorders of Consciousness Rancho I-III

    • Describes the clinical picture of various levels of consciousness
    • Uses different scales like the Glasgow Coma Scale for assessment
    • Classifies levels of consciousness using categories such as coma, vegetative state, and minimally conscious state

    Post-traumatic Agitation

    • Excessive behavior within the context of an altered state of consciousness and diminished cognitive function.
    • Incidence rate post-TBI reported as 10-96%
    • Behaviors observed may include verbal abuse, impulsivity, rage, sudden mood changes, distractibility, and lack of cooperation.
    • Behavioral observations measured by a scale which monitors 14 different behaviors with an observational scale from 0-4
    • Severity of agitation graded from severely agitated to not agitated

    Post-Traumatic Interventions

    • Change the environment: Decrease stimulation, lights, noise, and interactions in the environment.
    • Provide orientation: Gently reorient the patient to place and situation.
    • Encourage mobility: Allow for walking or wheeling around the unit; staff support as needed.
    • Limit the number of visitors/providers: Allow 2-3 people present, and one person speaking at a time.
    • Behavioral modifications: Develop plans to maximize participation, keep rooms quiet and calm, refrain from excessive talking, and follow the patient's lead.

    Imaging

    • CT-scans assess for intracranial pathology
    • Common findings such as depressed skull fractures, subdural/epidural hematoma/subarachnoid hemorrhage, intraventricular hemorrhage

    Glasgow Coma Scale (GCS)

    • Scores collected in the first 24 hours correlate with outcomes.
    • Lower scores predict worse outcomes.
    • Motor scores are most accurate predictors.

    Other factors affecting prognosis

    • Duration of coma. Coma longer than 4 weeks is unlikely to have good recovery; coma shorter than 2 weeks often means fewer severe disabilities.
    • Age at injury. Older age is associated with poorer prognoses and less likelihood of recovery.

    Neuroimaging

    • Bilateral brainstem lesions on MRI are not associated with positive recovery.
    • CT findings (epidural hematoma, subdural/subarachnoid hemorrhage, significant midline shift) are associated with worse outcomes.

    Motor Recovery and TBI

    • Most motor recovery occurs within the first 6 months
    • Shorter duration of loss of consciousness and mild initial deficits are associated with quicker recovery

    Prognosis in Disorders of Consciousness

    • Minimally conscious state tends to have a better prognosis than a vegetative state
    • Traumatic injuries usually have a better prognosis than acquired injuries
    • 20% of patients in a vegetative state receive inpatient rehabilitation and achieve functional independence, returning to work after 1, 2, and 5 years.

    Factors affecting ADL independence in older adults with TBI

    • Personal: Age (older age associates with worse outcomes), number of comorbidities.
    • Injury-related: Severity (worse functional outcomes), Medical complications (severe complications associate with worse outcomes up to 12 months post-injury).
    • Environmental: Social support (social support is important), access to rehabilitation services.

    Craniotomy/Craniectomies

    • The removal of a portion of cranium to reduce pressure on brain tissue.
    • Bone flap is removed and replaced following decompression procedure.
    • Decompression bone flap is removed and left out until swelling subsides. Then replaced, process is called cranioplasty

    Precautions

    • Individuals post-craniectomy need custom helmets when out of bed.
    • Medical and provider input should be sought regarding HOB elevation, lifting restrictions, and activity limitations

    Intubation/tracheostomy

    • This procedure is used for patients who cannot breathe independently, and may need mechanical ventilation.

    Acute care/ICU management

    • Neurosurgery consultation is necessary if there is intracranial damage.
    • Monitoring and maintaining intracranial pressure (ICP).
    • Various imaging techniques or combinations to monitor ICP.
    • ICP therapy (which lowers pressure) is instituted when ICP readings exceed 20mm Hg

    Cerebral Perfusion Pressure (CPP)

    • CPP = mean Arterial Pressure (MAP) - intracranial pressure (ICP).
    • CPP target range 60-70 mmHg.
    • Normal MAP range 70-100 mmHg

    Monitoring Intracranial Pressure (ICP)

    • Different techniques for monitoring ICP

    Post-Traumatic Hydrocephalus

    • More prevalent in patients with moderate to severe TBI.
    • 70% of patients experience ventriculomegaly post TBI
    • 3.7-45% develop post-traumatic hydrocephalus
    • common symptoms: (1) Gait changes, (2) Changes in cognition and (3) Urinary incontinence

    Post-Traumatic Seizures

    • Incidence varies depending on injury type, age, when seizure occurs.
    • 1 out of 10 people hospitalized with TBI will have a seizure.
    • Recommended to use anti seizure medication for the early post-TBI to prevent seizures.

    Paroxysmal Sympathetic Hyperactivity (PSH)

    • Caused by unavoidable non-noxious stimuli, lasts few minutes-2 hours
    • Typically resolves in 2 weeks
    • Characterized by increased sympathetic activity (e.g., increased BP, increased respiratory rate, increased heart rate, diaphoresis, hyperthermia, dystonia).
    • Occurs in 15-33% of those with severe TBI.

    Heterotopic Ossification

    • Formation of new bone tissue in unusual locations, common in individuals with TBI, around shoulders/elbows, hips, rarely knees.
    • Can be a major issue in functional mobility/rehabilitation.

    Additional Medical and Rehab Considerations

    • Sleep dysregulation: Common post-TBI
    • Pain management, contracture management: Crucial to prevent complications.
    • Swallowing deficits
    • Spasticity management: Important for improving functional mobility.
    • DVT prophylaxis: Prevent blood clots.
    • Urinary dysfunction: Post-TBI consequence
    • CN injuries: Post-TBI complication
    • Fatigue: Common post-TBI symptom
    • Development of psychiatric disorders: Significant post-TBI complication
    • Alcohol and drug abuse

    Rehabilitation Considerations

    • Crisis Intervention/ De-escalation: Important Training for management of acute behaviors post-injury.
    • Multi-disciplinary Team: Involvement of several professionals is crucial (Social Worker, Speech Therapist, Doctor, Physical Therapist, Recreational Therapist, Occupational Therapist, caregivers, nurses, neuropsychologists).

    Advocacy and Connecting Individuals with Resources

    • Vocational rehabilitation assistance, such as grants and waivers.
    • Conferences for people, families, and providers focused on brain injury.

    Specialized Long-Term Care Facilities

    • Depending on individual medical needs

    Prevention of TBI

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    Description

    Test your knowledge on the factors influencing recovery and outcomes in traumatic brain injury (TBI) cases. This quiz covers various aspects, including prognostic factors, independence post-rehabilitation, and complications associated with TBI. Perfect for students and professionals interested in brain injury rehabilitation.

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