681-Traumatic Brain Injury Presentation

TRAUMATIC BRAIN
INJURY (TBI)
W A L L A C E F U L L E RT O N & H E AT H E R
WINTHROP
Wallace Davis Fullerton and Heather Dawn Winthrop
TRAUMATIC BRAIN INJURY (TBI)
HISTORY SECTION
Traumatic Brain Injuries (TBI) have a

long history
Ancient Mesopotamian cultures called
head injuries terdtu (Scurlock &
Andersen, 2005).
Ancient Mesopotamians gathered
information about TBI from wounded
warriors (Scurlock & Andersen, 2005).
o Damage of specific regions and resulting
deficits exhibited by wounded soldiers
were documented.
o The etiology was identified as resulting
from seizures, strokes, skull fractures,
cranial nerve injuries, spinal cord trauma.
In addition, gastrointestinal issues caused
http://www.theguardian.com/uk/2012/aug/06/soldier
s-archaeology-somerset-discovery-afghanistan
HISTORY SECTION
Ancient Egyptians also kept an

impressive record of head injuries and
their resulting deficits as evidenced by
the 3,500 year old Edwin Smith Papyrus
(Sanchez & Burridge, 2007).
o Ancient Egyptians knew that injuries to the
cranial region could result in a wide variety
of detrimental symptoms (Levin, 1982).
Detrimental effects of TBIs were

explained by Greek Hippocratic School
of medicine physician Valerius Maximus
(Levin, 1982).
o Mr. Maximus identified and described a case
of alexia brought on by a TBI.
o Also proposed the concept of contralateral
control of the body its manifestation in TBIs.
http://www.summagallicana.it/lessico/v/
HISTORY SECTION
During the Renaissance a number of

surgeons began researching TBIs
(Levin, 1982).
o Theses included Ambroise Par, Nicol
Massa, and Francisco Arceo.
In the 19th century the case of

Phineas Gauge further showed the
extent of damage which TBIs can
cause (Barker, 1995).
o Mr. Gauges frontal lobe damage resulted
in major personality changes.
o Mr. Gauges personality changes as well
as Dr. Brocas speech center were two
major contentions in the fight to recognize
the localization of brain functions.
http://fi.wikipedia.org/wiki/Phineas_Gage
HISTORY SECTION
In World War I the number of TBIs caused by

explosive shells confirmed localization of
function and began the process of mapping
(continued during World War II) (Jones, Fear,
& Wessely, 2007).
Alexander Luria, a Soviet brain surgeon,
looked into brain-injured veterans of World
War 2 and developed a number of
rehabilitation programs for soldiers (High,
Sander, Struchen, & Hart, 2005).
In the 1970s a greater emphasis was placed
on TBI treatment and research once again as
the number of car accidents increased.
http://pixgood.com/head-on-car-crash.html
In addition, the wars in Iraq and Afghanistan
since the year 2001 have resulted in
numerous veterans suffering from TBIs
(Jones, Fear, Wessely, 2007).
CURRENT THINKING
http://www.acnr.co.uk/2013/07/classification-of-traumatic-brain-injury/
Today, TBIs have been categorized as mild, moderate or severe based on severity
of damage (http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm#266623218).
These TBIs are caused by insults to the cranial region much as ancient medical
practitioners believed and resulting deficits are based on location and extent of
damage.
Generally, to prevent further brain damage the oxygen supply to the brain
becomes the main concern after damage.
CPR may also be utilized to revive someone and reestablish oxygen intake
(respiration).
CURRENT THINKING
Several different forms of the disorder

are known, these include:
o
o
o
o
o
Concussions
Skull Fractures
Contrecoup
Shaken baby syndrome
Damage to a major blood vessel can result
in a hematoma (heavy brain bleeding) and
comes in 3 varieties:
Epidural hematoma
Subdural hematoma
Intracerebral hematoma
o Anoxia
o Hypoxia
http://en.wikipedia.org/wiki/Traumatic_brain_inj
ury
PRIMARY SYMPTOMS/FEATURES/CHARACTERISTICS
OF TBIS
TBIs can come in a variety of forms
and are classified as mild, moderate,
or severe based on the severity of
the brain insult
(http://www.ninds.nih.gov/disorders/t
bi/detail_tbi.htm).
o Symptoms may not be evident or
manifest for many days after the insult
has taken place
(http://www.ninds.nih.gov/disorders/tbi/d
etail_tbi.htm).
TBIs are considered a form of

acquired brain damage which is
caused by a sudden injury to the
head
(http://www.ninds.nih.gov/disorders/t
bi/tbi.htm).
o The person may or may not lose
consciousness from the blow.
http://www.baumhedlundlaw.com/traumatic-braininjury/tbi-symptoms.php
OF TBIS
Common symptoms
include:
confusion
dizziness
headaches
ringing in the ears
bad taste in the mouth
lightheadedness
blurred vision
behavior changes
lethargy or fatigue
mood alteration
sleep pattern changes
difficulty with thinking,
concentrating, or attention
http://www.lasikcomplications.com/blurryvision.htm
OF TBIS
A person with a moderate or severe TBI will
experience similar symptoms, but will often
have:
headache which will worsen with time
repeated vomiting
nausea
seizures
convulsions
pupil dilation in one or both eyes
inability to awaken
weak or numb extremities
slurred speech
loss of coordination, agitation
increased confusion
restlessness
http://www.integrativehealthcare.org/mt/archives/2012/11/
Approximately half of individuals suffering from
seven_types_of.html
TBIs will require surgery to repair a broken blood
vessel (hematoma) or brain damage
(contusions).
OF TBIS
Disabilities which are acquired
after a TBI insult will differ based
on age, location of wound, severity
of wound, and the individuals
overall health.
Damage from TBIs can cause
difficulties and disorders of:
sensory system processing (sight,
smell, taste, touch, hearing)
cognition (memory, reasoning,
thinking)
behavioral or mental health
(depression, personality changes,
aggression, anxiety, socially
inappropriate behavior, or acting out)
communication difficulties (expressive
or receptive)
http://www.apextribune.com/falls-constitute-a-majorcause-of-head-injuries-in-children/22062/
OF TBIS
More serious head injuries may result in a stupor
where the individual is unconscious, but can be
awakened by sharp pains. Even worse the
individual may fall into a coma
If the coma persists for too long the individual
may also enter what is known as a vegetative
state.
If this continues for more than a month it will be
known as a persistent vegetative state (PVS).
o Adults have a 50% chance and children have a 60%
chance of awaking from a persistent vegetative state;
however, after 6 months it is increasingly less likely
that they will ever awaken
(http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm).
o Other possible outcomes can be locked-in syndrome,
where the individual is conscious, but the body is
unresponsive due to damage to the brainstem (unable
to respond to external stimuli except via blinks, or other
minor unaffected movements), and brain death
(http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm).
http://news.bbc.co.uk/2/hi/uk_news/northern_ireland/foyle_
and_west/7920694.stm
OF TBIS
http://deerated.com/who-am-i-why-anonymous/
TBI damage can result in a number of disorders and syndromes, these

can include:
o Post-concussion syndrome (PCS): 40% of individual will manifest these symptoms
after a TBI insult.
o Post-traumatic amnesia (PTA) both anterograde (inability to form new memories)
and retrograde (loss of prior memories).
o Many individuals with severe TBI will suffer from loss of cognitive functions,
specifically related to higher level mental skills (executive functions).
Loss of executive functions can also occur in mildand
moderate
cases and
as well.
Wallace
Davis Fullerton
Heather Dawn Winthrop
OF TBIS
o Communication disorders including fluent (Wernickes)
and non-fluent (Brocas) aphasia can result from
damage to temporal, frontal, or parietal lobes.
Wernickes Aphasia Is acquired via damage to the temporalparietal region and results in difficulty in interpreting
incoming speech and associating concepts in memory with
the correct linguistic labels.
Speak in complete sentences and even use correct grammar, but
speech will be filled with word salad
The individual will often be unaware of their difficulty
Brocas Aphsia is caused by damage to the frontal lobe. These

individuals will be capable of understanding language, but will
have great difficulty communicating it.
Speech will be telegraphic, slow, laborious and difficult to
OF TBIS
o Dysarthria may result which is
marked by the ability to think of the
correct word, but the inability to
detect the correct muscle groups to
activate to transmit that word.
o Individuals may also display prosodic
dysfunction, or the inability to
manifest intonation or inflection in
their speech.
o TBI may result in loss of motoric skills
and abilities in any musculature.
o Damage to sensory reception may
http://dublinneuropathy.com/
also result in irritating or painful
sensations which cannot be remedied
(itching, pain, and tingling).
OF TBIS
Wernickes Aphasia
OF TBIS
Brocas Aphsia
ASSOCIATED OR COMORBID
SYMPTOMS/DISORDERS
After TBI a victim can suffer from a
number of disorders causing longterm suffering
(http://www.ninds.nih.gov/disorders/
tbi/detail_tbi.htm#266623218).
Alzheimer's disease (AD) has been
linked to TBI injuries. TBI can
expedite or even trigger AD in
individuals who are predisposed.
o AD is a progressive neurodegenerative
disorder.
o Studies show a particular form of a
protein known as apolipoprotein E
(apoE4) can, if present, increase the
chance that an individual will develop
http://www.huffingtonpost.com/marie-marley/5things-to-never-say-to-a-person-withalzheimers_b_3662958.html
SYMPTOMS/DISORDERS
Parkinson's disease (PD) and other
motor problems have been related
to TBI injuries.
o The development of these disorders in
response to a TBI are rare.
o PD is characterized by the presence of
stiffness, tremors, stooped posture,
immobility (akinesia), laborious or slow
movement (bradykinesia), and a shuffling
gait.
o PD is a progressive disorder which is
incurable.
o Other movement disorders which may
develop after a TBI include:
Lack of coordination in motor movement
(ataxia).
Tremors
Shock-like muscle contractions (myoclonus).
http://splitsider.com/2012/08/nbc-wins-bidding-warover-new-michael-j-fox-sitcom-by-offering-22episodes-sight-unseen/
SYMPTOMS/DISORDERS
Other possible side effects, while rare,

increase in likelihood in tandem with the
level of trauma (National Institute of
Neurological Disorders and Stroke).
o Hydrocephalus may result, immediate
seizures, and post-traumatic ventricular
enlargement, vascular injuries,
infections, cerebrospinal fluid leaks, bed
sores, pain, cranial nerve injuries,
multiple organ failure, unconsciousness,
and polytrauama (damage to other
body regions).
o 25% of individuals with contusions, and
http://ispn.guide/book/ispn-guide-pediatric50% of individuals with penetrating
neurosurgery/hydrocephalus
head wounds will develop immediate
seizures within the first 24 hours. This
increases the risk of early seizures Wallace Davis Fullerton and Heather Dawn Winthrop
SYMPTOMS/DISORDERS
http://kidshealth.org/parent/medical/brain/hydrocephalus.html
o Post-ventricular enlargement or hydrocephalus occur when an

excessive amount of CSF fluid builds up in the ventricular cavities
increasing inter-cranial pressure.
This may develop during the acute stage of TBI, or may occur at a
later point.
Generally, this issue develops within the first year after the injury is
incurred.
Neurological outcomes diminish along with a series of behavioral
changes, impaired consciousness, incontinence, ataxia (impaired
balance or coordination), or apparent increases in intracranial
pressure.
SYMPTOMS/DISORDERS
o Skull fractures often tear the protective
outer layer of the brain (meninges)
causing CSF leaking.
o Tears between the dura matter and the
arachnoid membrane can lead to
cerebrospinal fluid fistula.
This leak causes CSF to move from
the arachnoid space to the subdural
space, called a subdural hygroma.
CSF can also leak out of the ear and
nose allowing air, bacteria, and
harmful microorganisms to enter the
cranial region causing infections such
as meningitis.
Pneumocephalus occurs when air
pixgood.com
SYMPTOMS/DISORDERS
o Infections of the intracranial region are
highly dangerous and can affect any
layer of the meninges or the brain itself.
Most of these injuries will develop
within the first few weeks after the
injury and will typically are the result
of a penetrating injury or a skull
fracture.
These infections are treated with
antibiotics and may involve surgical
removal of affected tissue.
Meningitis is especially worrisome as
it may spread to other areas of the
brain and the nervous system.
http://www.surgicalneurologyint.com/article.asp?issn=21527806;year=2010;volume=1;issue=1;spage=52;epage=52;aula
st=Mathew
SYMPTOMS/DISORDERS
o Damage to the brain generally disrupts
and damages the vascular system which
provides blood flow (oxygen) to the
brain.
The immune system is capable of repairing
small blood vessels which are damaged, but it
cannot work on larger blood vessels often
leading to a stroke or other issues.
Damage to a major artery can cause a stroke
blood clots can develop elsewhere and lead to
other symptoms.
Thrombotic-ischemic strokes are treated with

anti-coagulates.
Surgery is the typical treatment for a
hemorrhagic stroke.
Vascular injuries may also lead to aneurisms
or vasospasm.
http://en.wikipedia.org/wiki/Thrombus
SYMPTOMS/DISORDERS
http://www.eyecalcs.com/DWAN/pages/v2/v2c008.html
o Skull fractures at the base of the skull can result in cranial

nerve damage.
9 of the cranial nerves project from the brainstem to the face and
are subject to damage.
The most commonly damaged nerve in TBI is the facial nerve (7 th)
which will result in facial paralysis. Wallace Davis Fullerton and Heather Dawn Winthrop
SYMPTOMS/DISORDERS
o Pain can be a serious
issue for TBI patients,
especially immediately
after the TBI has occurred.
Pain is often in the form
of headaches, but can
take many other forms.
Bed or pressure sores
may be an issue for
individuals in a coma or
vegetative state, in
addition, reoccurring
bladder infections, and
pneumonia, and other
deadly conditions may
arise including multiple
organ failure.
http://www.msktc.org/sci/factsheets/skincare/Recognizing-andTreating-Pressure-Sores
SYMPTOMS/DISORDERS
o General Trauma
Most TBI patients suffer from damage
known as polytrauma.
Polytramatic injuries require specialized
care and complicate the TBI recovery
process.
Other complications which may arise
include pulmonary (lung) dysfunction,
cardiovascular (heart) difficulties from
blunt force trauma, hormonal and fluid
imbalances, gastrointestinal
disturbances.
Isolated complications can include deep
vein thrombosis, fractures, excessive
blood clotting, infections, and nerve injury.
http://www.agmaske.de/fotogalerie/polytrauma.html
SYMPTOMS/DISORDERS
Trauma often results in an increased metabolic
rate (hyper-metabolism, the redirection of blood,
nutrients, and oxygen to the damaged tissue
results in muscle wasting and tissue death.
Neurogenic pulmonary edema (fluid buildup in the
lungs), aspirational pneumonia (foreign material
in the lungs), and blood or fat clots which may
block blood vessels and the lungs may also occur.
The hormonal and fluid imbalances often result in
complications for the treatment of high
intracranial pressure or hypermetabolism.
Pituitary, thyroid, and other glands can cause the
hormonal problems.
Hormonal complications often result from TBIs and take
the form of hypothyroidism and inappropriate secretion
of antidiuretic hormone (SIADH).
http://www.thrombosisjournal.com/content/1
0/1/4/figure/F1
SYMPTOMS/DISORDERS
Blunt force trauma to the chest
region may result in pulmonary
dysfunction.
This can take the form of damaged
blood vessels and internal bleeding.
Heart rate and blood flow problems.
Large or small intestines, the
pancreas, and the stomach are often
damaged in abdominal trauma.
Common symptom of TBI is erosive
gastritis, a condition where stomach
tissue is inflamed and degraded.
o Bacterial growth, aspiration
pneumonia chance increases.
TBI patients are typically treated
with prophylactic gastric inhibitory
medications to avoid bacterial and
stomach acid buildup.
http://doctorsgates.blogspot.com/2011/07/papillary-musclerupture.html
NEUROPSYCHOLOGICAL FACTORS
Neuropsychology is a multidisciplinary field

drawing on the work of psychologists,
neurologists, and physiatrists (Podell,
Gifford, Bougakov, & Goldberg, 2010).
Looks at nervous system functioning and the
behavioral, emotional, and neurocognitive
strengths and weaknesses of an individual.
o Aim is to link cognition, emotion, and behavior.
The fields goal is to establish greater

understanding of strengths and weaknesses
of disorders and to help in the creation of
interventions directly aimed to bolster these
strengths and remediate weaknesses.
http://www.molecularimaging.net/topics/molecular-imaging/neuroimaging/not-so-fast-signslewy-body-dementia-not-seen-dopamine-spect
This field is particularly helpful

in the case of TBIs as it
provides a window into the
cognitive functioning of a
victim.
o This field is an integral part of the
diagnosis, treatment, and monitoring
for TBI patients.
TBIs can cause a number of

heterogeneous disorders along
a wide continuum of severity.
Neuropsychologists look at
factors including social
support, emotional state, and
cognitive abilities.
http://www.princeton.edu/~hanliu/
About 14% to 61% of individuals who

receive a TBI, experience depression
within the first year after the injury.
o The reason the numbers are so varied is
because depression and TBIs both result
in similar symptoms making It is difficult
to disentangle the two disorders.
Post-Traumatic Stress Disorder (PTSD)

and TBI share many features as well.
These include working memory and
attentional deficits. Both disorders
cause disruption in attention, again
they are hard to disentangle.
http://www.huffingtonpost.com/2014/01/19/ptsdguide-dog-commercial-service-animalvideo_n_4627945.html
Psychiatric History and prior mental

illnesses seems to have little impact
on outcome for TBI patients.
Substance Abuse generally results
in similar scores in cognitive ability
and memory capabilities to mild TBI.
o Alcohol use results in disruption of
executive functioning, perceptual-motor
tasks, and learning.
o Chronic opiate use generally connected
with executive functioning and working
memory deficiencies.
http://www.youreanovercomer.com/?p=2027
Several domains can suffer neuropsychological

changes after a TBI:
o Language and Speech
o Visuospatial/Construction
o Attention/Concentration
o Memory
o Executive Control
o Sensory and Motor
o Affect and Personality
Severity of TBI in relation to Neuropsychological Functioning

o Mild TBI
Generally an acute case of cognitive, emotional, behavioral, sensory, and
physiological symptoms can result.
Concussion related symptoms are common such as fatigue, dizziness,
headache, increased sensitivity to light or sound, imbalance, emotional
liability, disturbed sleep patterns, and blurred or double vision.
These symptoms generally clear up within a few hours to a couple weeks.
Acute changes in memory, thinking, fatigue, feeling tired, concentration,

forgetfulness, trouble focusing, poor attention, irritability, and poor
multitasking.
Most of these deficits clear up over time.
On the other hand, persistent loss of speed of processing seems to be
common.
Depression, fatigue, and anxiety are common.

Depression can range in severity and length.
Other factors of the individuals life play into these aspects as well.
Severity of TBI in relation to Neuropsychological

Functioning
o Moderate TBI
Distinction between moderate and severe is poorly defined.
These individuals can often return to a fairly normal life, but they will
suffer from long-term losses.
Damage to the frontal lobe results in loss of executive functioning
(Behavioral control, working memory, executive functions).
Damage to the temporal lobes results in learning and memory deficits.
In addition, emotional behavior is poorly controlled; depression and
anxiety are also common.
These changes have a drastic impact on day-to-day life.
Recovery from these deficits is common for the first year.

Return to work varies with 46% of individuals having not returned after
1 year.
About 45% return to work within 6 months, while 65% will return within
two years (often with diminished capacity).
Severity of TBI in relation to Neuropsychological Functioning
o Severe TBI
Only about 10% of individuals fall into this category after receiving a TBI.
Very costly to rehabilitate and care for.
Losses are global in the areas of behavior, functioning, and cognition.
These losses last years if not permanently.
Cognitive losses are often related to learning, working memory, attention and executive
functioning deficits.
Executive/frontal lobe damage is the most debilitating resulting in impulsivity, flattening
of affect, apathy, motivation, poor planning, weak initiation, little insight, and disrupted
organization.
Self-regulation, awareness, and guidance are a major issue with server TBI suffers.
Often have trouble regulating behavior and this can result in outbursts and depression.
Individuals with severe TBIs cannot regulate their behavior and cannot correct behavior
mistakes via social feedback loops.
These individuals are poorly focused, easily distracted, and have great difficulty with
multitasking.
Retraining, work, and independence are often not an option for these individuals.
These individuals have poor acquisition and retrieval skills, as well as weak source memory.
Generally, recognition will be better than other memory skills.
SYMPTOMS/DISORDERS
Realted to TBIs is dementia pugilistica
(chronic traumatic encephalopathy).
o This disorder often is related to boxers due to
the repeated cranial trauma which they endure.
o Symptoms include dementia and Parkinsons
disease caused by the consistent head trauma
over a long period of time.
o Symptom onset begins somewhere between 6
and 40 years after begining career.
Average of about 16 years to onset of symptoms.
Post-traumatic dementia is a disorder

similar to dementia pugilistica;
however, this develops from a single
devastating blow which causes a
coma.
Floyd Mayweather Jr. vs Arturo Gatti

http://cdn2.cagepotato.com/wpcontent/uploads/2012/02/gattimayweather.jpg
ETIOLOGY OF TBIS
TBIs are caused by a forceful
collision affecting the body or
specifically the cranial region
(http://www.mayoclinic.org/diseases
-conditions/traumatic-braininjury/basics/causes/con20029302).
TBI damage can be classified as
either open or closed skull injuries.
(http://www.northeastern.edu/nutra
umaticbraininjury/what-is-tbi/typesof-tbi/)
http://la.indymedia.org/news/2003/03
/40641_comment.php
ETIOLOGY OF TBIS
o Open TBI
An open TBI (or penetrating TBI) is caused by a
broken skull and open scalp area.
This often occurs when a foreign object passes
through the skull and enters the brain causing
specific and direct damage.
This localized brain damage is found along a path

following the trajectory of the object.
Area of the brain damaged determines what (if
any) deficits will occur.
o Closed TBI
Caused by an external force striking the head with
great force.
The skull is not broken, nor is any kind of fracture
http://la.indymedia.org/news/2003/03
/40641_comment.php
of penetration incurred.
Damage is often more global than open TBIs
(wide-spread and diffused across multiple
regions).
Symptoms depend on level of damage which
hasDavis Fullerton and Heather Dawn Winthrop
Wallace
http://korean.people.com.cn/65098/15410467.html
ETIOLOGY OF TBIS
'Well, you're in the
hospital.' And he
said, 'Well, why am
I here?' And I said,
'because you
suffered a
concussion today.'
Troy Aikman Concussion

http://blogs.dallasobserver.com/unfairpark/2013/10/troy_aik
man_concussion.php
Five minutes
passed. Aikman
again turned to
Steinberg,
confused, and
asked, "What am I
doing here?"
The type of event along with the force of the blow often determines the
severity of the damage incurred (http://www.mayoclinic.org/diseasesconditions/traumatic-brain-injury/basics/causes/con-20029302).
Common events which lead to a TBI include:
o
o
o
o
o
Sports Injuries
Falls
Vehicle related collisions
Violence: About 20% of TBIs are caused by violence
Combat Injuries or Explosive Blasts
ETIOLOGY OF TBIS
Statistics of TBI Causes
(http://www.northeastern.edu/nutrauma
ticbraininjury/what-is-tbi/incidence-oftbi/).
o Two leading entities have done a number of
studies, the Centers for Disease Control and
Prevention (CDC) and Brain Injury
Association of America (BIA-USA).
They found that individuals age 0-4 and 15-19
are at the greatest risk to incur a TBI.
o The CDC also found that between the years

2006 and 2010 approximately 40.5% of all
TBI cases were due to a fall of some kind.
o The CDC stated that approximately 15.5%
were caused by unintentional blunt trauma.
o The CDC also stated that approximately 14%
of TBIs were caused by a motor incident.
o The CDC stated that approximately 10% of
TBIs were caused by assault.
https://www.cprcertified.com/blog/first-aid-tips-forcaregivers
ETIOLOGY OF TBIS
o Common causes affecting
children include:
Males and females 10-19
years of age who played
sports were at a higher risk
for a TBI.
Motor vehicle accidents were
the leading cause of TBI for
individuals age 15-20 years
of age.
Children and the elderly are
more likely to suffer from a
fall.
http://aboutmormons.org/3660/byu-graduate-studentcreates-smart-foam
ETIOLOGY OF TBIS
o In 2010, over 50,000
individuals perished
from TBI related
injuries.
o Between the years
2006 and 2010, men
were more likely to
visit the emergency
room for nonfatal TBIs
than women.
o Individuals age 65
and older were the
most likely age group
to be hospitalized for
a TBI.
http://www.dailymail.co.uk/health/article-1307250/Frail-elderlypatients-left-hungry-hospitals-admit-thirds-NHS-nurses.html
ETIOLOGY OF TBIS
o Children up to age 4 were the most
likely to be seen in the emergency
room for a TBI.
o Falls were the most common cause
for emergency room, TBI related,
visits.
On the other hand, assaults were
the most common cause for TBI
emergency room visits for
individuals age 15-24.
o In regard to TBI Hospitalization,

falls were the most common for
ages 0 to 14, and 45 plus.
o Motor vehicle accidents were the
most common cause of TBI
hospitalization for individuals ages
15 to 44.
http://bizblog.blackberry.com/2014/09/how-mobile-security-islike-a-street-fight/
PREVALENCE AND INCIDENCE RATES

FOR TBI
http://www.nbcnews.com/health/health-news/cdc-cracks-down-labs-after-anthrax-bird-flu-scares-n153636
Despite the rates of TBI decreasing to 50.7 per 100,000

children in the age range of 0 to 4, and 23.1 per 100,000
for children ages 5 to 14 during the years of 2009 and
2010 in the United States (the previous rates were 70.3
and 54.5 for those age ranges respectively for the years
2001 and 2002), there remains some discussion about how
Wallace
Davis Fullerton(CDC).
and Heather Dawn Winthrop
accurate the reported TBI rates are
for children

FOR TBI
According to the authors of an
article published by the
Psychology department at the
University of Canterbury in New
Zealand, the true rates for TBI
among children are difficult to
ascertain due to (McKinlay#1):
level of severity of the TBI
age of the child
when the injury takes place, and
whether or not the
If childs injury is considered severe
enough for them to be taken to the
hospital or have it reported
http://www.lifemartini.com/important-factsabout-head-injuries-in-children/

FOR TBI
One aspect that calls into
question the reported rates of TBI
is that many TBIs are considered
mild and therefore, the individual
is often not admitted to the
hospital (McKinlay#1).
The World Health Organization
states that between 70 and 90
percent of TBIs are in the mild
category
Although unreported due to their
level of severity being considered
mild, there are still lasting
effects due to these TBIs.
http://detroit.cbslocal.com/2014/08/11/headsup-on-concussions-millions-go-unreportedevery-year/
ASSOCIATED SCHOOL-RELATED PROBLEMS

(COGNITIVE/ACADEMIC/SOCIAL) OF TBI
Ability to identify the precise
outcomes of TBIs proves to be
more elusive than one might
imagine.
Although many studies have
been conducted to look at the
after-effects of TBI on childrens
cognitive, social, and academic
functioning, differences in the
age severity and how long after
the injury the childs progress
and abilities were examined led
researchers to come to differing
conclusions about effects of TBI
on children (McKinlay, Grace #2).
http://www.psychiatrictimes.com/specialreports/traumatic-brain-injury-children-andadolescents

Depending on the age at which the child
sustains the injury, this may have differing
levels of effect in terms of the impediment to
the childs development.
In the 2002 Christchurch Health and
Development study in New Zealand, which
looked at a children who had experienced a
mild traumatic brain injury (MTBI) before the
age of 10, which resulted in a hospital stay
of 2 days or less, the children were more
likely to be referred by a parent or teacher
as having attention deficit hyperactivity
disorder or conduct disorder by the time
they reached the ages of 10 to 13 years old.
In comparison, the children who had undergone an
MTBI which had only resulted in the need for
outpatient care or had not required them to be
hospitalized were comparable to children who had
not sustained an injury in terms of referrals for
these disorders.
http://www.ramadachristchurch.co.nz/

TBIs sustained during childhood impact
children in a variety of ways.(Glang)
Some of the functional areas that are
impacted when a child sustains a TBI
include the childs personality, behavior,
cognition, social interactions, and
learning (Glang).
Examples of the impact that TBI can
have on children include deficits or
impairment in the following areas:
memory
intellectual ability
academic skills and ability
http://allaboutautismbni.com/2013/06/27/areall-children-really-included/
social skills and behavior

challenges regarding peer interactions and
relationships

Because the damage incurred
by a TBI during childhood
takes place during the course
of development, it is probable
that this will impact the
childs skills obtained prior to
the TBI as well as their ability
to acquire new skills.
The true extent of the damage
and the subsequent impact on
functioning is not known until
the child is expected to perform
complicated tasks.
http://www.todaysparent.com/wp-content/uploads/2011/09/Troublewith-school-Nov2011-iStock.JPG

Studies that have been
conducted to ascertain the
long-term effects of TBIs
sustained during childhood
indicate that the lasting
impacts on the childs
academic, social, and
behavioral functioning have a
tendency to be persistent and
sometimes become
progressively worse.
Children who have sustained a TBI
are at an increased risk of falling
behind their classmates.
http://www.slate.com/content/dam/slate/articles/double_x/doublex/20
13/12/131203_DX_PISAResults.jpg.CROP.promo-mediumlarge.jpg
ASSESSMENT/DIAGNOSTIC INDICATORS OF
TBI
One diagnostic scale used to
assess individuals who have had
some type of accident that would
indicate the possibility of a TBI is
the Glasgow Coma Scale.
Fifty percent of TBIs are due to
automobile or traffic accidents.
Individual may be evaluated at

the scene of an accident by
emergency medical personnel or
at the hospital.
The first two goals are to stabilize the
patient and to help ameliorate
additional damage.
http://www.dailyexaminer.com.au/news/dead-man-identified-dadhurt/303259/
TBI
Some of the primary concerns
include assuring that there is
adequate oxygen flow to the brain
and stabilizing blood pressure and
blood flow. Once oxygen supply,
blood flow, and blood pressure
have been stabilized the
emergency medical personnel
attend to any additional injuries
that may be present.
In order to stabilize and prevent
additional injuries to the spinal
cord and the head, the injured
person is typically put on a backboard
https://meded.ucsd.edu/clinicalmed/vital.htm
TBI
Once the patient has been
stabilized, emergency medical
personnel conduct an
examination.
In the process of testing these
three areas a number of
different physiological tests
are conducted, including
checking the individuals
pulse, their blood pressure,
rate of breathing, and
pupillary reflexes in response
to light.
http://origin-dictionary.reference.com/browse/examination
TBI
One of the important tests that is
conducted is the Glasgow Coma Scale
which is used to determine the injured
individuals neurological functioning and
their level of consciousness.
The GCS consists of a fifteen-point test
which is standardized and includes three
areas:
verbal response
eye-opening
motor response
Based on the answers or responses to

these test items, a patient is given a
score which can indicate anything from:
http://www.revistaenred.com/cuentos-y-relatos.html
mild head injury with a score of 13 to 15

a moderate head injury from 9 to 12
a severe head injury from 3 to 8
TBI
The Glasgow Coma Scale is used to evaluate patients level of trauma
after a TBI incident.
o The eye opening scale has four levels:
4
3
2
1
=
=
=
=
The individual can spontaneously open their eyes.

The individual can open eyes to verbal command.
Patient only opens eyes in response to painful stimuli.
If patient cannot open eyes in response to any stimulus.
o The verbal response scale has five levels:
5
4
3
2
1
=
=
=
=
=
Patient can orient and speak coherently.

Indicates patient is disoriented; however, they can speak coherently.
Use of incoherent or inappropriate words.
Incomprehensible sounds.
Patient gives no verbal response at all.
o Motor response has six scores:

6 = Patient can move arms and legs (extremities) in response to verbal command.
5-2 = Patient responds to stimuli (including pain) with motor movements.
1 = Patient does not respond with motor movements to stimuli.
o Scores are added to derive and overall trauma score:

3-8 = Severe head injury has been incurred.
9-12 = Moderate head injury.
13-15 = Mild head injury.
TBI
Glasgow Coma Scale
http://pguploads.com/2013/12/28/glasgow-coma-scale-made-easy/
TBI
Additional diagnostic tools used in determining the severity
of a TBI are imaging tests such as computed tomography
(CT) scan and magnetic resonance imaging (MRI).
CT scans are used with individuals who have suffered from
a moderate or severe TBI because they can reveal existing
contusions, swelling of brain tissue, hematomas, brain
tumors, and hemorrhages.
MRIs are useful once the TBI has been assessed, and are
able to identify minimal alterations to brain tissue by
utilizing magnetic fields.
MRIs are more capable of showing minute features of the
brain tissue in comparison to CT scans or x-rays.
INTERVENTIONS/TREATMENT FOR TBI

In order to qualify under IDEIA law as a student
having a TBI many states require some type of
documentation from the parents that describes the
medical history of the student and the event that
most likely caused the TBI (Glang, Todis, Thomas,
Hood, Bedell, & Cockrell, 2008).
The two techniques or methods that are most
useful in determining the types of support that will
be necessary for a student who has sustained a TBI
are the functional assessment of behavior and the
frequent progress monitoring provided in the RTI
model (Dykeman, 2009).

The recovery
process for
children who
have had a TBI
generally
undergoes
three stages in
terms of
developmental
progress.
http://www.brainline.org/content/2010/03/understanding-tbi-part-3the-recovery-process_pageall.html

o Stage 1 TBI recovery
for children often
includes challenges
with information
processing, increased
irritability, impulsive
behaviors, and
confusion.
o Stage 2 TBI recovery
for children often
includes challenges
such as lack of
tolerance for being
overstimulated and
denial regarding having
http://childdevelopmentinfo.com/child-psychology/depression_in_children_and_teens/

o Stage 3 TBI recovery for children
often includes increased
recognition of their social and
cognitive challenges related to
their brain injury, as well as an
understanding of the
permanence of these difficulties.
During the third stage of
recovery children are likely to
experience emotional reactions
including anger, increased
anxiety, and depression, as a
result of the knowledge that
their deficits are permanent.
http://anxietyinchildren1.com/anxiety-in-children-can-destroy-their-future/

Due to the variation in the
length of recovery time for
each child who has
sustained a TBI, based on
the level of severity of the
injury and the degree of
support provided, a
beneficial way to gauge the
childs progress throughout
the three stages of recovery
is to conduct a functional
behavior assessment
(Dykeman, 2009).
http://afterdeployment.dcoe.mil/topics-traumatic-brain-injury

The 2004 reauthorization of the
IDEA law requires schools to
perform functional assessments
when children display difficult
behaviors such as avoidance of
challenging or lengthy tasks.
Since children who have
sustained a TBI often exhibit
such behaviors, along with
avoidance of social activities,
conducting a functional behavior
assessment and developing a
positive behavioral intervention
plan for these students is
recommended.
http://myweb.usf.edu/~aheindel/PBSsection3c.html

The functional assessment is a
method of tracking the behaviors of
children with TBI by monitoring their
duration, severity, frequency, and
intensity across the three stages of
recovery.
The functional assessment also provides
a means of determining the function or
goal of the behavior.
Applying and RTI strategy to children

with TBIs is a good way to observe
whether treatment or intervention
strategies are working by using
frequent progress monitoring.
This is especially useful for children with
TBI because of the changes they undergo
during the stages of recovery
http://opi.mt.gov/Programs/SchoolPrograms/RTI/

Although the typical sequence of
RTI begins with tier 1
interventions, students who are
going back to school after
sustaining TBIs typically require
tier 2 or tier 3 services.
Children who have sustained a
TBI often display the some of the
same learning problems that are
described as the qualifications
for being labeled with a specific
learning disability in the 2004
version of IDEA (Dykeman,
2009).
http://marketing.sm/

Most students who have sustained a
TBI will have some memory deficits,
whether the TBI ranges from mild to
severe.
Due to the teachers knowledge of their

particular students areas of strength,
memory strategies can be selected to suit
that particular childs needs paired with
their unique abilities (Pershelli, 2007).
One of the reasons that memory

deficits are such a pronounced
challenge for children with TBI is that
there is not one singular area of
memory problems; there are a range of
memory problems due to the variety of
different areas of the brain that can be
damaged when a child suffers a TBI.
http://londonmumsmagazine.com/wp-content/uploads/2013/03/kidsconcentration-memory-deficit-photo-pin.jpg

Different memory strategies will work
for different students, and the
strategy should be designed for the
individual student by the teacher that
works most directly with him or her
on a regular basis.
Many children with a TBI do not realize
that they have memory deficits until
they have returned to school and are
working on an assignment or trying to
complete an exam.
Depending on which areas of memory

that are impaired, whether it is shortterm, working memory, or long-term
memory, different strategies will
have to be taught to students.
http://www.brainline.org/content/2008/08/memory-matters-now-what-did-icome-here-strategies-remembering-what-yoursquore-looking.html

Often students with TBIs will have
difficulty storing data in long-term
memory or trouble retrieving the
information when they need to recall
it.
In order to help students with these
difficulties it is less important to know
where the memory impairment is.
It is more important to teach them
compensatory strategies that they
can use to store and retrieve
information, as well as prompts for
the new strategies that can be used
to automatize the new memory
process strategies.
http://www.brainline.org/content/2010/03/research-update-the-use-of-grouptreatment-for-improving-memory-after-tbi.html

Damage and loss of working
memory abilities make
solving math problems with
multiple steps as well as
comprehension of short
reading passages very
difficult for students with a
deficit in this memory area.
Basically, the information

needed to solve the problem
is not held in working memory
long enough to utilize it to
complete the problem.
http://p3tr1ch0r.tumblr.com/

Students who had very high
achievement prior to their TBI and
now have working memory
deficits may engage in aggressive
behaviors or suffer depression
due to this experience.
The emotional reactions to a TBI
are not restricted to the student
who suffered the TBI; many times
the students teacher and parents
will experience feelings of
frustration and inadequacy over
not being able to help the student
complete simple tasks.
http://doctor.ndtv.com/photodetail/ndtv/id/8133/dealing-with-an-aggressivechild.html

Everyone utilizes memory
strategies, and these are unique
to the individual. The difficulty
for children with TBI is that the
memory strategies that were
previously effective for them,
prior to their TBI, may not work
due to the location of their
injury.
For example, a child who has

excellent auditory processing abilities,
and then sustains an injury to their
temporal lobes may not have the
same ability to hear things and then
store them in long-term memory.
http://avivahwerner.com/2014/06/18/auditory-processing-important-childssocial-skills/
http://relationshipnotes.info/2010/11/08/listening-mistake-rehearsing/
In order to help students with TBI in the area of memory

teachers can use the following three types of memory
strategies:
1.Lock in memory strategies-These are strategies to assist with
memory retention. The following are three types of lock-in
memory strategies:
Association strategy
Rehearsal strategies
Grouping strategy
1.Lock in memory strategies

2.Recall memory strategies
These assist in helping the student develop a
strategy for retrieving the information that
they have encoded.
Due to the childs TBI they may not be able to
recall information simply because it has been
encoded and stored in long-term memory.
These strategies help the child when their
attempts at retrieval are unsuccessful.

1.Lock in memory strategies
2.Recall memory strategies
3.Ease of Burden memory strategies
These are strategies that act as memory supports or act to supplement
memory ability.
The Ease of Burden memory strategies are for students who cannot
retrieve information even when they have a physical object to act as a
cue.
For students such as these there are By Pass Strategies which involve
the use of a computer and different programs to help the student
organize information for recall and read text.
Most of the programs in this category will read aloud the highlighted
information in the text to help the student know which words to attend to
and will also provide definitions.
The information from the computer programs can also be color-coded and
printed out.
The color-coding helps the student to chunk information.
THANK YOU
H AV E A W O N D E R F U L W E E K !

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TRAUMATIC BRAIN

Wallace Davis Fullerton and Heather Dawn Winthrop

TRAUMATIC BRAIN INJURY (TBI)

Wallace Davis Fullerton and Heather Dawn Winthrop

Traumatic Brain Injuries (TBI) have a

Wallace Davis Fullerton and Heather Dawn Winthrop

Ancient Egyptians also kept an

Detrimental effects of TBIs were

Wallace Davis Fullerton and Heather Dawn Winthrop

During the Renaissance a number of

In the 19th century the case of

Wallace Davis Fullerton and Heather Dawn Winthrop

In World War I the number of TBIs caused by

Several different forms of the disorder

Wallace Davis Fullerton and Heather Dawn Winthrop

TBIs are considered a form of

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

TBI damage can result in a number of disorders and syndromes, these

Brocas Aphsia is caused by damage to the frontal lobe. These

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Other possible side effects, while rare,

o Post-ventricular enlargement or hydrocephalus occur when an

Wallace Davis Fullerton and Heather Dawn Winthrop

Thrombotic-ischemic strokes are treated with

Wallace Davis Fullerton and Heather Dawn Winthrop

o Skull fractures at the base of the skull can result in cranial

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Wallace Davis Fullerton and Heather Dawn Winthrop

Neuropsychology is a multidisciplinary field

The fields goal is to establish greater

Wallace Davis Fullerton and Heather Dawn Winthrop

This field is particularly helpful

TBIs can cause a number of

Wallace Davis Fullerton and Heather Dawn Winthrop

About 14% to 61% of individuals who

Post-Traumatic Stress Disorder (PTSD)

Wallace Davis Fullerton and Heather Dawn Winthrop

Psychiatric History and prior mental

Wallace Davis Fullerton and Heather Dawn Winthrop

Several domains can suffer neuropsychological

Wallace Davis Fullerton and Heather Dawn Winthrop

Severity of TBI in relation to Neuropsychological Functioning

Acute changes in memory, thinking, fatigue, feeling tired, concentration,

Depression, fatigue, and anxiety are common.

Severity of TBI in relation to Neuropsychological

Recovery from these deficits is common for the first year.

Post-traumatic dementia is a disorder

Floyd Mayweather Jr. vs Arturo Gatti

Wallace Davis Fullerton and Heather Dawn Winthrop

This localized brain damage is found along a path

Troy Aikman Concussion

o The CDC also found that between the years

Wallace Davis Fullerton and Heather Dawn Winthrop