NUR 211- TBI

Risk factors for subarachnoid hemorrhage?

+Same as for CVA Obesity diabetes htn smoking/nicotine use stimulant use- spike in bp+weak vessel long term alcohol use

What happens when a cerebral aneurysm ruptures and what needs to be done about it?What are the different types?

- a weak vessel ruptures. A ton of ppl have unruptured cerebral aneurysms! They usually go unnoticed until someone falls out. Person may notice crushing headaches, loss of vision. There are 3 types: a. congenital- a person has an unruptured aneurysm, as they mature their bp rises=more stress on the vessel wall. b. saccular (berrylike) occurs at the bifurcation of blood vessels. Grows on the outside of an artery which creates weakness in that part of the artery. If they have a rise in BP it ruptures. c. Fusiform... *Intervention- Monitor BP- nimodipine Surgery to remove blood, find the source and clip it.

Describe the different types of subdural hematoma?

1. Acute- Deterioration may be rapid, occurs after severe blow to the head. Clinical presentation depends on the severity of the injury, but you should look for deterioration in LOC, and lateralizing signs ( inequality of pupils or motor movements.) 2. Subacute- ex. Someone falls and hits their head, but they feel ok. They have a small leak, most of the time its small enough that the body clots it off. The exception to this would be alcoholics, or someone with clotting issues. If it doesn't clot off then it obviously becomes a problem. 3. Chronic- OLD PPL LEAK. Sometimes the body will reabsorb, but if its too much/too fast the body cant reabsorb, hematoma forms= increased ICP.

Describe the pathophysiology of a TBI if left untreated.

1. Brain suffers traumatic injury 2. brain starts to swell or bleed = increased cranial volume. 3. Rigid cranium allows no room for expansion = increased ICP 4. Pressure on blood vessels within the brain = decreased blood flow to the brain. 5. cerebral hypoxia and ischemia 6. ICP continues to rise = brain may herniate 7. Cerebral blood flow stops.

Clinical manifestations of epidural hematoma

1. Brief loss of consciousness- FOLLOWED BY PERIOD OF LUCIDITY. Lucid period is followed by rapid deterioration in LOC. 2. Dilated, fixed pupil on the SAME SIDE AS INJURY. *HALLMARK* 3. May complain of localized headache, sleepiness.

What are three ways we stop the bleeding for an aneurysm or AVM? Describe each.

1. Clipping- eliminates the risk of rebleed, allows more aggressive therapy post op, allows for slushing out excess blood and clots to reduce risk of vasospasm. usually will require more than one clip. +MRI is contraindicated- we don't try to figure out if the clip is magnetic or not. That isnt our job, we document it for radiology. 2. Coiling- Used for aneurysm deep in the brain that can't be clipped. Percutaneous transfemoral technique mostly used, use a cerebral angiogram to place, coil inserted in aneurysm sac, results in thrombus formation. Will go through carotid artery. 3. Surgical AVM excision- Depends on location and size of AVM if it is operable. *Post op maintain low BP to prevent rebleed, if lg tell the pt to expect multiple surgeries over 6-12 mos.

Describe the two types of TBIs and give examples/subtypes of each.

1. Open trauma- (penetrating) damage to soft tissue of the brain by penetrating object. 2. Closed trauma- (blunt) a. Acceleration- caused by head in motion. Sitting still and all of sudden the body is jolted quickly and the brain slams into the BACK OF THE SKULL. b. Deceleration- the head stops suddenly when moving really fast and the brain continues forward and slams into the FRONT OF THE SKULL. c. Rotational forces- affects the brain but also cuts off 02 to the brain- think neck injury.

Name the two most common causes of subarachnoid hemorrhage? (the answer is not a stroke.)

1. Rupture of a cerebral aneurysm 2. Arteriovenous Malformation (AVM)

How do you know if someone has increased ICP? List two things you would look for.

1. They will have a change in LOC!- this is the first thing we assess with TBI. 2. Pupil response- blown pupil.

What type of meds do you anticipate giving to a pt. with TBI? why? give specific examples and anything specific you need to look out for with each med. (there are 5 types)

1. antibiotics- prophylactic, especially for someone with a ventriciostomy or burr holes. These patients will only benefit from antibiotics that cross the blood-brain barrier. Ex: metronidazole(flagyl), chloramephenicol. 2. Corticosteroids- decrease inflammation. Solu-Medrol (methylprednisolone) Monitor I&O, daily wt., observe for peripheral edema, and other signs of fluid volume overload= may decrease wbc, serum potassium and calcium and may increase serum sodium. *monitor for hyperglycemia. admin insulin prn. SE: peptic ulcers, thromboembolism, cushingoid appearance, immunosuppression, etc. 3. Diuretics- OSMOTIC- Mannitol, isosorbide. watch for electrolyte imbalance, renal failure, transient volume expansion. Monitor CVP, I&O, signs of fluid imbalance. 4. Hypertonic saline- 3% NS, decreases ICP, increases CPP, CO. It shifts fluid out of the cranial vault. 5. Anticonvulsant- Phenytoin (Dilantin) *this drug is ideal because it reaches therapeutic level (IV admin) quickly. These are given as prophylaxis against seizures in pt. with TBI until ICP is in normal limits. range= 10-20 mcg/ml , free 1.0-2.0 mcg/ml. MAJOR SE: hepatic failure watch for hypersensitivity syndrome- fever, rash, lymphadenopathy, *May lead to renal failure, rhabdomyolysis, hepatic necrosis- may be fatal! Signs of toxicity- nystagmus, ataxia, confusion, nausea, slurred speech, and dizziness. *TEACH: they can't consume alcohol with this drug!!

The best score on glascow coma scale

15

What is normal ICP range?

5-15 mmHg.

Jeff requests "something for his headache." Which medication is best for the nurse to administer to Jeff for his complaint of headache?

Acetaminophen (Tylenol). This is the best choice, because Tylenol is a non-opioid analgesic, and it will not cause CNS depression.

A pt. with suspected epidural hematoma comes into the ER with his family. what do you need to find out or assess ASAP.

Allergies and current meds baseline PTT, PT, INR History of rec. drug use, alcohol use, blood thinners how/when precipitation of event Changes in LOC after event Neuro checks.

What is Subdural Hematoma? what kind of injury is it most often related to, what is it associated with?

Bleeding between the arachnoid membrane of the brain and the dura. (below the dura) It's most often related to a rupture in the bridging veins between the dura and the brain. Blunt trauma TBI are major causes Often associated with cerebral contusions and intra cerebral hemorrhage. THERE ARE THREE TYPES.

If someone has a dura tear with a skull fracture what do you need to worry about leaking? How can you ID it?

CSF- clear fluid Halo test- put it on gauze makes a halo test for glucose

How does someone get subarachnoid hemorrhage, but not EDH or SDH? What do you need to assess for?

CVA Facial drooping Arm weakness Slurred speech Time- you need to know when the CVA occurred!

What is CPP? How is it calculated?

Cerebral Perfusion Pressure- represents the pressure gradient driving cerebral blood flow- which of course indicates 02 and metabolite delivery to the brain. Essentially CPP is BRAIN PERFUSION. CPP=MAP-ICP

True or false: Tachycardia is a manifestation that you may see with cushings after a head injury.

FALSE.

If someone has a TBI what do you need to consider when positioning them? what if they also have SCI?

HOB 35-45 degrees *guideline!* We look at the ICP to determine how far to raise the HOB. *Use the ventriciostomy as a guide, dont forget it needs to be level with the temple. *Keep the head midline to avoid blocking jugular veins. * With a SCI we can adjust the entire bed at an angle, but we can't move just the HOB.

What is Burr Hole Evacuation?

Holes are made in the skull with a perforator, which has an auto-stop mechanism to prevent damage to the dura. The procedure alleviates pressure by letting out fluid- decreasing the ICP.

What is a sign of brain herniation?

If patient's ICP is steadily increasing and then suddenly drops. This is a medical emergency and will be fatal if not treated. Remember to always assess the patient not just the monitor.

What if your patient with epidural hematoma has been taking coumadin, lovenox, or plavix?

If taking coumadin- Vit. K If taking lovenox- protamine sulfate if taking plavix- there's no reversal agent we can give them clotting factor (factor VII), platelets, or cryoprecipitate.

What is a primary injury? give examples.

Initial injury resulting from the traumatic event. Occurs at the moment of impact. Can be mild to severe. Ex. contusion, laceration, shearing injuries, hemorrhage.

What do you expect a patient's BP to look like initially after TBI and what do we need to do about it and why? What do you need to consider if their BP is not what you expected, and why is it significant?

Initially- Hypertension is common with severe TBI because the brain is trying to compensate due to swelling. WE MUST CONTROL HTN TO PREVENT SECONDARY INJURTY CAUSED BY ICP. If they have hypotension- we need to rule out other injuries such as internal bleeding. This is significant because we need to know if they have other injuries, but also because hypotension causes inadequate perfusion to neural tissue. **IT IS NOT TYPICAL TO HAVE HYPOTENSION WITH TBI B/C BODY IS TRYING TO SHUNT BLOOD TO THE BRAIN.

What is a secondary injury? Give an example.

Insult to the brain subsequent to the original primary event. This is the swelling that if not prevented or is left untreated leads to ISCHEMIA. Ex. Cerebral Edema

What is an epidural hematoma?What kind of injuries is it associated with?

It is an arterial bleed between the dura and the skull (outside or above the dura.) Associated with skull fractures and middle meningeal artery laceration.

What is MAP how is it calculated?

Mean ARterial Pressure is the average BP during a single cardiac cycle. ART LINE. MAP=2xDBP+SBP -------------- 3

How is rebleed prevented?When do we need to intervene? Is it a severe complication?

Monitor clotting times find out if pt. takes blood thinners 50% wont make it after rebleed- its severe We prevent it by managing the BP- SBP needs to be no more than 150 mmHg!!!! We can give IV nitro, metoprolol, hydralazine to decrease BP also- prophylactic anticonvulsants- Dilantin, Keppra, Depakote.

What fluids can be administered with Phenytoin? Can it be administered with other meds?

NS 0.9 ONLY, not compatible to be mixed with other meds

The day after a pt was transferred to the Surgical Unit, he becomes very irritable and requests that his drapes and door be closed, and that the lights be turned off. He tells the unlicensed assistive personnel (UAP) that he has a severe headache and wants to be left alone.

Notify the health care provider of these symptoms. these are symptoms of meningitis.

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Why would the statement that "I can apply powder under the liner to help with sweating," require further instruction?

Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

What should our neuro checks consist of and how often are we going to do them with these pts?

Q 1 hr. Instruct pt to blink eyes, squeeze your hands, smile, stick out tongue, wiggle toes. you also need to perform babinski, and get baseline vitals and PTT, PT, INR.

What is a craniectomy, what is the goal of this treatment?

Removing of a piece of skull (a bone flap) and storing it in the SQ tissue of the abdominal cavity. *Removing the bone flap allows the brain to swell, which DECREASES the ICP= the goal. After swelling goes down the bone flap will be put back.

What is the treatment for epidural and subdural hematoma?

STOP THE BLEEDING and GET RID OF CLOTS. The meds discussed for TBI can be given (especially the osmotic diuretics) except 3% saline- which would increase the bp. Surgical intervention- craniectomy or burr holes to remove blood and allow access to cauterize vessels, prevent ICP from increasing.

What is an AVM? What do we need to do about it?

Tangle of abnormal blood vessels connecting arteries and veins in the brain forming a bulge. *This is a problem because veins arent meant to have that much pressure, if they are getting eh same pressure as arteries they can rupture=sudden brain bleed=death. *Blood that is supposed to be going into the arteries to "feed" the brain is instead being shunted back through the venous system= brain loses 02/nutrients and may atrophy over time. Interventions- monitor BP, nimodipine, teach stress reduction, limit activity *no exercise) Diagnosis based on clinical presentation, non contrast ct, lumbar puncture if CT is negative- looking for blood in csf. Cerebral angiography can be used to id cause and location and to find the feeder artery and draining veins Symptoms of unruptured AVM - headaches with dizziness or syncope, fleeting neuro defecits. Goal of med. management is to preserve neuro function, support vital functions, control ICP if LOC is decreased. Prevent rebleeding.

What is the goal of treatment for TBI?

The goal is to decrease ICP to prevent secondary injury.

What is Vasospasm? Describe treatment, and important interventions

The narrowing of the arteries caused by a persistent contraction of the blood vessels, which is known as vasoconstriction. This narrowing can reduce blood flow.When the vasospasm occurs in the brain, it is often due to a subarachnoid hemorrhage after a cerebral aneurysm has ruptured. *This can collapse the whole circulatory system of the brain. Usually happens 3-5 days after inital bleed and can last 3-4 weeks. Treatment is Triple H therapy: Induced HTN, Hypervolemia, and Hemodilution therapy. Keeps vessels open to prevent collapse. MEDS: Nimotop-(nimodipine) neurospecific CCB decreases chances of vasospasm Papacon- (papaverine) increase diameter of the vasospastic blood vessel- decreases chances of vasospasm We do not use restraints on these ppl if we can help it! Alternative- Propofol (diprivan) has an instant on/off effect so we can still monitor LOC.

What is hypercapnia treatment? give an example of how it would be used.

This is an older treatment that is used less often now. The theory is that excess CO2 promotes vasodilation which would increase blood flow/02/glucose to the brain, which (in theory) helps prevent ischemia. *The reason it's not used as much now is because someone realized that vasodilation leads to more swelling in the brain. *This is used in a case by case basis, but it's not the standard. EX. Pt. on a vent with normal ABG's. Dr orders hypercapnia tx=we would HYPOVENTILATE THEM by decreasing the rate &/or volume.

What is a subarachnoid hemorrhage? What happens physiologically?

This is bleeding or clotting deep inside the brain. Caused by bleeding in the cerebrum, or ischemia due to the lack of 02/blood to that part of the brain.

Which nursing intervention should the nurse include when administering the Mannitol?

Use IV tubing with a filter. . It should be administered undiluted, but through a filter to prevent the administration of any particulates.

How is ICP measured? What are some important things to remember while using this measuring device?

Ventriciostomy- ventricular drain *Can be put in bedside in ICU *MUST BE LEVEL WITH THE TEMPLE *Has 3 way stop-cock to release CSF= decrease ICP. *Monitor these patients for infection - Temperature.

What are the three components measured by the GCS?

Verbal response, motor response, and eye opening. The GCS measures responses that are spontaneous and completely oriented to responses only from noxious stimuli to no response at all.

How do we monitor ICP for a patient that we know has a hematoma?

We monitor their LOC. We do not use a ventriciostomy because we know what the problem is. It is not the swelling of the brain, but the accumulation of blood.

a client with quadriplegia is in spinal shock, what findings would the nurse expect to find?

absence of reflexes along with flaccid extremities

Which assessment techniques are used to determine physiological manifestiations of a TBI?

behind the ears nasal drainage around eyes pupil equality

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as

coma

The most important nursing priority of treatment for a patient with an altered LOC

maintain a clear airway to ensure adequate ventilation

How is subarachnoid hemorrhage diagnosed?

non contrast ct

How is epidural or Subdural hematoma diagnosed?

observation of clinical signs and a CT. If severe enough midline shift will present on CT *poor prognosis at this point.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoons eyes and battle sign

Which type of hematoma results from venous bleeding with blood accumulating in the space below the dura?

subdural

What does a glascow coma scale of 3 say about a pt.

they are 100% unresponsive.

If someone has had a subarachnoid hemorrhage what do you need to be careful about administering? why?

thrombolytics. if they had a hemorrhagic stroke they dont need thrombolytics, if theyve had an ischemic stroke we need to give it within 4 hours of the CVA. If past 4 hours they'll have different treatment, because we dont want them to throw a clot.