A messenger service.
Picks up and delivers specific action, thought, or sensation. Effects taste, oral sensation, touch sensation
The Peripheral Nervous System
TBI is often called the
silent epidemic
Define: You don't see the deficits of TBI until some time has passed
Cognitive Stall
Types of TBI
Blast concusions, CVA, blunt force trauma, falls, sports injuries
Define: the cell structures that connect one part of the brain to another.
Axons
What contains the spinal cord and the brain. Considered the "master control" and "chief of all the nerves".
Central Nervous System (CNS)
Depending on the severity of the TBI, some skills can be spared and some skills are very impaired. It depends on
where the brain injury occurred.
Define: the first stop:
A go-between that connects the peripheral nervous system with the brain.
Messages go up and down your spine delivering stimuli to the brain.
Spinal cord
Define: The next stop from the spinal cord.
The Brain Stem
3 areas of the brain stem
Medulla, Pons, Midbrain
Part of the brain stem that contains: life-sustaining controls for blood pressure, heart rate, and breathing.
Medulla
Part of the brain stem that contains: a bridge linking medulla to the higher, more evolved areas of the brain.
Pons
Most people with TBI regain the ability to produce
Speech sounds
Side effects of TBI
Swallowing problems, drooling, slurred speech
The brain is a complex network of billions of nerve cells called
neurons
When a person is in a coma, the SLP performs coma stimulation. Part of this may be
oral stimulation, sound (speaking, music, sounds associated with things the person enjoyed)
During a TBI the ________ area is broken. Called a ___________
axon, Diffuse Axonal Injury (DAI)* (K said info on DAI is important)
Whenever there is diffuse axonal injury (DAI), the individual will have problems
learning or acting properly in situations that involve integration skills
The Pons
- Houses the _________
- Conglomeration of nerve fibers.
- Helps to control __________, reflexes, wakefulness, and mechanisms to keep one alert and ready to react to change.
reticular formation, muscle tone
provides eye muscle control and more reticular formation action.
Helps you stay more alert.
Helps you keep your reflexes honed.
Is a bridge between the brainstem and the cerebellum.
Is attached to the spinal cord by thick nerve fibers.
Midbrain
Behind the brainstem
Regulates all your movements, balancing, and adjusting every step and stance.
A "traffic manager", smoothing and coordinating your movement and speech muscles.
The Cerebellum
Patient with damage to cerebellum may have what speech problems?
Apraxia, dysarthria
The cerebellum contains the __________ which is located higher in the cerebrum and helps the cerebellum to _________&__________ all of your movements.
basal ganglia, modulate and modify
Located right above the brainstem and right below the cerebrum.
The gateway to higher thought and emotional depth.
The home of the hypothalamus and the thalamus.
The Diencephalon
The diencephalon is made up of four main components
the thalamus, the subthalamus, the hypothalamus, and the epithalamus.
All sensory information must pass through the _________.
Works like a switching station in a railroad yard.
A beehive of activity, sorting out messages and deciding which areas of the brain get what.
thalamus
A patient who has damage to the diencephalon may be
emotionally labile
#NAME?
Hypothalamus
Interlocking structures of nerve cells that run between the diencephalon and the intellectual cerebrum.
Controls emotions.
The Limbic System
Areas of the brain involved in emotion
limbic system (controls), hypothalamus (regulating), diencephalon (gateway to higher thought and emotional depth), Hippocampus and Amygdala (responsible for emotion, memory, thought)
#NAME?
THE CEREBRUM
Contained in the cerebrum
Hippocampus and Amygdala
damage to cerebrum
do not understand puns, jokes, sarcasm
#NAME?
Hippocampus and Amygdala
The hippocampus sits directly in the
temporal lobe
Hippocampus connected to all of your ______ and to the _____________
senses, limbic system.
Sister of the hippocampus, nestled within the limbic system itself.
Amygdala
If a child sustains a TBI the effects may not be seen until
the child starts school - problems with memory due to cognitive stall
Nontraumatic brain injuries can be caused by
#NAME?
National Head Injury Foundation (1995) defined TBI as:
"an________to the brain, not of the degenerative or congenital nature, but caused by an______________, that may produce a ___________or _____________state of consciousness".
insult, external force, diminished or altered
4 Elements of a blast injury
1 - Atmospheric pressure created by blast wave is followed by a vacuum. The wave pushes and the vacuum pulls. This can cause tiny bubbles in vascular system and problems with spinal column.
2 - Debris causes blunt trauma
3 - Force of blast can pick up a p
Symptoms of blast injury
Confused, seeing stars, headache, poor concentration, nausea, vision loss, dizziness, memory loss, fatigue, insomnia
A blockage of blood supply caused by air bubbles in a blood vessel or the heart.
Air embolism
The vascular system is also known as the
circulatory system
Consuming ________ should be avoided by people who sustain a TBI
alchohol
the repetition of a particular response (such as a word, phrase, or gesture) regardless of the absence or cessation of a stimulus.
Perseveration
Symptoms of TBI (additional to the blast symptoms)
poor balance, difficulty organizing (objects, schedule, thoughts), slow or slurred speech, increased rate of speech, impulsivity, managing saliva, poor self-monitoring, paralysis of vocal mechanism, hearing loss.
The majority of people with TBI are under the age of _____. Peak incidence age group are _______________.
30, young males 15-24
Children ages 5-9 sustain TBI mostly though
MVA
Preschool children can sustain a TBI through
child abuse, falls, home accidents
Children ages 10-14 sustain TBI's mostly through
sporting accidents, traffic accidents and falls
80% of ppl with TBI have _________with expectation of _________
mild injuries, excellent recovery
2 Types of head injuries
Penetrating (open)
Non-penetrating (closed)
____%-____% of penetrating head injuries cause seizures
30-40
____% of non-penetrating head injuries cause seizures
5
____________ is more severe as opposed to focal injury
DAI (diffuse axonal injury)
A coup injury is when the brain
accelerates to the front of the skull
A contracoup injury is when the brain
decelerates to the back of the skull
Different parts of the brain move at different speeds due to their relative weight. This results in direct and diffuse brain injury due to ___________, _______________, & _________________ (secondary effects).
axonal shearing, contusions, and brain swelling.
If severe brain swelling occurs, the brainstem nuclei controlling _________________________ will be compressed and the person will die.
breathing and heart functions
Define: Abnormal body posturing
due to unilateral or bilateral corticospinal tract damage (unit 8 ppt slide 7)
Abnormal body posturing which usually indicates swelling of the upper brainstem. Means greater impairment.
Decerebrate posturing
The severity and duration of abnormal postures contribute to the long-term outcome. The __________________, and __________________, the poorer the prognosis.
longer the duration and more severe the posturing
Glasgow Coma Scale
Severe =_______ points
Moderate = _______ points
Mild = ______ points
3-8, 9-12, 13-15
The _______ and ______ of a coma can be measured with the Glasgow coma scale
degree and depth
Define: The inability to create new memories after the event that caused the amnesia leading to a partial or complete inability to recall the recent past while long-term memories from before the event remain intact.
Anterograde amneasia
Define: The inability to recall memories created prior to the event are lost.
Retrograde amnesia
Which type of brain injury:
A loss of consciousness and/or confusion and disorientation will last less than 20-30 minutes after a ________.
No abnormalities found on scans
Pt may experience headaches, thought organization difficulties, memory problems , a
Mild Brain Injury
Severity of Injury and Time with Posttraumatic Amnesia:
_______ very mild injury, full recovery, though a few may experience post-concussion symptoms.
_______ moderate injury, likely recovery as above.
________ severe injury. Recovery period longer, may t
Up to 1 hour
1-24 hours
1-7 days
Which type of brain injury:
Glasgow Coma Scale score is from 9-12
There are abnormal imaging findings.
There is an operable intracranial lesion.
The length of hospital stay is at least 48 hours.
Moderate Brain Injury
Which type of brain injury:
The Glasgow Coma Scale score is < 9 within 48 hours.
Loss of consciousness is > than 30 minutes.
Memory loss after the injury lasts longer than 24 hours.
Deficits range from impairment of higher level cognitive functions to com
Severe Brain Injury
Prognostic Considerations in Recovery
Age at time of injury? If Pt. is < 40 years old, a better outcome is expected.
-Duration of coma
Patients who were in a coma less than 2 weeks have a better prognosis. Those with a Glasgow Coma Scale score less than 8 have a worse prognosis.
-Posttraumati
Define: the result of a mild injury with a brief loss of consciousness and/or post-traumatic amnesia
Disorientation is noted.
No loss of consciousness or if so lasting less than 20 minutes.
If hospitalized, less than 72 hours.
GCS score greater than 12.
Post-Concussive Syndrome (PCS)
About 15% of patients with PCS will continue to experience problems one year after the injury.
Patients could be left with life-long disability that may include
Headache and dizziness
Changes in sense of smell and/or taste
Fatigue, reduced energy level
Irritability
Impaired memory and concentration
Tinnitus
Insomnia
Lower tolerance for noise and light
Anxiety and depression
Changes in appetite and libido
Duration of coma
Patients who were in a coma less than_________________have a better prognosis. Those with a Glasgow Coma Scale score less than ___________have a worse prognosis.
2 weeks, 8
Most commonly used scale
Measures the depth and degree of a coma
The Glasgow coma scale
PTA (post-traumatic amnesia) Classification system
Mild
Moderate
Severe
Very severe
Mild TBI = coma time + PTA < 1 hour
Moderate TBI = coma time + PTA of 1-24 hrs
Severe coma tme + PTA of 1-7 days
Very severe TBI = coma time + PTA extending greater than 7 days
Devised by Russell (1932).
Represents the period from the time the pt. regains consciousness but remains in a disoriented and confused state and until the time the pt.'s memory for ongoing events becomes reliable and accurate.
Duration of posttraumatic amnesia (PTA)
-Known as PTA Classification System
Time :________ = recovery may take many months long lasting cognitive problems are likely. Should be able to work and enjoy social/family life.
(Prognosis if TBI recovery based on time with posttraumatic amnesia)
1- 2 weeks
Very prolonged recovery, one year or longer.
Permanent deficits are likely.
Very unlikely to be able to do same job as before.
(Prognosis if TBI recovery based on time with posttraumatic amnesia)
2-12 weeks
Significant disabilities requiring
long term retraining and management.
Unlikely to ever work again, though may be able to manage a sheltered workshop.
(Prognosis if TBI recovery based on time with posttraumatic amnesia)
12+ weeks
These are common and may occur immediately within
24 hours of injury or 7 days post injury
Late seizures (after 7 days) occur in 5-19% of cases.
About 33-50% of patients develop _____________.
Posttraumatic seizures
Define the condition: Cerebral spinal fluid (CSF) cannot exit the ventricles of the brain to be reabsorbed back into the bloodstream which causes swelling and pressure on adjacent cortical areas of the brain.
Hydrocephalus
Neurological / Physical Deficits with TBI
Epilepsy
Coordination, muscle weakness / paresis
Sensory deficits
Cognitive / Intellectual Deficits with TBI
Memory
Decreased IQ
Slower processing speed
Attention
Executive functioning
Pragmatics
Emotional / Behavioral Deficits
withe TBI
Personality changes
Awareness of deficits
Self-monitoring
Motivation or drive
Impulsivity
Aggressiveness
Disinhibition
Interpersonal skills
Anxiety and/or depression
Biomechanics of TBI include:
#NAME?
What happens in TBI? (biomechanics)
Brain tissue is compressed.
Brain tissue is torn apart by the effects of tension.
Brain tissue is sheared by rotational forces.
Occurs from application of force to the head.
Mechanical loading
Results from slow or rapid forces applied to stationary head so that it is crushed (compression of the head).
Static loading
Results from very brief insult, which has either been applied directly to the moveable head (impact) or by impact elsewhere on the body causing a sudden movement of the head (e.g., whiplash).
Dynamic loading
Contrecoup is also called
secondary impact
The axon is an extension of a __________, similar in shape to a thread, that transmits impulses _________from the cell body.
nerve cell, outward
A DAI is
Widely distributed.
Most lesions occur deep within the white matter areas of the cerebral hemispheres and in the brainstem.
(DAI continued) During ___________________ of the head, the brain does not compress but changes shape or distorts.
-Brain attempts to follow the motion of the skull as it rotates around the brain.
-_______________ takes place in all parts of the brain as
rotational acceleration, Shearing distortion
DAI:
Is a________________.
Is the principal type of injury in ____________ head injury.
Is the most important single factor in determining recovery and ultimate outcome in TBI.
Has been believed that DAI is an immediate effect of closed head injury, but i
primary diffuse lesion,
nonpenetrating,
progressive, degenerative process
mTBI stands for
mild TBI
There is clinical evidence of DAI microscopically for a period of_____________hours and possibly beyond (The axon stump swells and forms a retraction ball or bulb)
12-Jun
DAI is neither __________ or ____________. It occurs particularly in many areas. It is ______________ & _____________.
symmetrical nor uniform
wide spread & diffuse
When small________________ are present, DAI is assumed to be present
hemorrhagic lesions
Coma of more than ________ hours is also clinical evidence of DAI
6
____________________predict a poor prognosis in terms of outcome of rehabilitation in that they are indicative of severe DAI.
Tissue tear hemorrhages
Gennarelli et al. (1982) designated 3 classes of DAI:
-Mild - evidenced by coma of 6-24 hours.
-Moderate - evidenced by prolonged coma of more that 24 hours with prominent signs of _________________.
-Severe - evidenced by coma of more that _________ with
brain stem dysfunction
24 hours
cortex
Disability Rating Scale (DRS) 4 levels
1. Arousability, awareness and responsivity
2. Cognitive ability for self care activities
3. Dependence on others
Level of functioning
4. Psychosocial adaptability
Employability
Linguistic and Non-Linguistic Deficits in
TBI and PCS
- Language deficits not evident in mild TBI
- Decreased processing of language occurs in 90% survivors with more severe TBI
- Word-finding (major deficit) and tangential speech
- Noted difficulty sequencing information
- Poor synthesis of written and verb
Aphasia occurs in _______ of patients with TBI
03-Jan
Although pragmatic issues occur after a TBI, __________ and ____________ language tends to be unaffected.
Automatized and over-learned
Readiness for learning when...
Can attend to task for 15-20 minutes
Can tolerate 20-30 minutes of stimulation
Can function in a group of 2 or more
Can engage in meaningful communication
Can follow basic directions
Displays an interest in learning
The Ranchos Los Amigos has _____ Levels of Cognitive functioning. Better functioning is rated ______ on the scale.
10, higher
Why don't regular language tests apply to TBI patients?
Find in textbook
Treating Executive Functions
Self-Regulation
Work with the patient to judge own behavior
Develop the patient's ability to control impulses (remember: these folks are disinhibited!)
Reduce perseveration and obsessive behavior.
Optimize the patient's ability to act independently with t
Three types of long term memory
- Semantic - knowledge (basic facts such as math
7 x 3=21, Washington DC is capitol of U.S., etc.)
- Episodic - event related to time (personal where/ when something took place and recall for the personal and meaningful event)
- Procedural - performance (
_________ approach may cause more harm than good in an ICU patient.
Hands-off
Early intervention can minimize and possibly reverse the impact of __________ and __________ in the ICU patient, which can impact oromotor and laryngeal functions
myopathy (muscle disease) and neuromotor degradation
SLP should provide intervention within _______ hours and should establish a _____________ for the pt with TBI.
24, functional communication system
Before you enter ICU, you should
Case Hx review, discuss condition of pt with the nurses
condition, stability, present neurologic status, precautions with nurse, relevant respiratory statusm amount/consistency of secretions
Current neurologic status : https://www.americannursetoday.com/e
Baumgarden, Brewer, Bruener (2008)
Speaking valve reduces the risk of ____________
aspiration
EKG stands for
electrocardiogram
When you enter the room look for
Equipment, oral or nasal intubation, ventilator?, tracheotomy?, vital signs - heart rate (ask nurses if its fast, slow, etc), blood pressure (Hr and BP can give you a baseline rate for before and during Tx). See more on SLP in ICU Ppt.
MAP stands for________, and ranges from 60-120.
mean arterial pressure
Bedside observations
Movements, posturing, agitation, eye opening, eye gaze (in sync?), motor, symmetry of musculature, spontaneous swallows?, voluntary or reflex cough?, .
Posturing which indicates lower brainstem lesion. Hands typically have thumbs tucked into fist.
Decorticate or flexor
Observation of spontaneous movements may be the only means of assessing pts. who are ___________
orally intubated
Assessment componants (4)
Cognitive-linguistic ability
Swallowing status
Laryngeal status
Oropharyngeal status
15% of TBI have symptoms lasting ____ or more
1 year
Decorticate typically has GCS score of ____
Decerebrate has GCS score of _____
3, 2