Normal Pressure Hydrocephalus and Closed Head Trauma
Increased Intracranial Pressure (ICP)
1- Intracranial Contents: a) 80% Brain Tissue b) 10% Blood c) 10% Cerebrospinal Fluid (CSF) 2- Increase in anyone of these causes increased intracranial pressure a) brain can swell b) excess blood can accumulate c) CSF can accumulate due to blockage of outflow
Nursing Assessment Closed Head Trauma [Neurological Assessment]
1- decreased neurologic function is best predictor of brain injury 2- most important variable to assess is Level of Consciousness 3- change or decrease in level of consciousness is the FIRST sign of neuro deterioration. 4- sleep disturbances
Nursing Assessment Closed Head Trauma [Airway/Breathing]
1- many traumatic brain injuries associated w/ cervical spine injuries especially in the elderly (C1 and C2) 2- Assess for indicators of spinal cord injuries 3- Assess need for "Intubation/Mechanical ventilation"
Nursing Assessment Closed Head Trauma [Circulation]
1- monitor blood pressure and pulse to detect possible changes "cerebral perfusion pressure" 2- patient may have hypotension or hypertension 3- assess for cardiac dysrhythmias 4- Cushing's Triad (LATE sign for Increased ICP) a- decrease heart rate b- irregular pulse pressure c- widened pulse pressure (increase btw systolic and diastolic)
Traumatic Brain Injury [Additional Guidelines]
1- monitor fluids and electrolytes "especially sodium" @160 for pt. w/TBI because sodium directly impacts both CPP and cerebral edema. a- Diabetes Insipidus (DI) b- Syndrome of inappropriate antidiuretic hormone (SIADH) 2- Infection prophylaxis 3- DVT prophylaxis 4- Analgesic/sedatives 5- Nutrition (enteral feeds within 72 hours) 6- Antiseizure prophylaxis
How to observe for cebrospinal leak?
1- note watery, clear fluid coming from nose or ears 2- sniffling or blowing nose may indicate CSF leak 3- Halo sign 4- Glucose test (may NOT be 100% accurate) blood has glucose in it as well.
Signs/Symptoms of a Epidural Hematoma
1-brief loss of consciousness followed by lucid intervals then show signs of rapid deterioration (talk to die phenomenon) 2-mark elevation in ICP 3-pt. becomes restless, agitated and confused leading to coma
Pediatric Concussions
A traumatic brain injury that is caused by a bump, blow, jolt, jarring or shaking and results in disruption or malfunction of the brain. they are the most common head injuries in children NOTE: there is a pediatric Glasgow comma scale the longer the symptoms last the more severe the concussion as the child losses consciousness from the injury.
Drug Therapy for Closed Head Trauma
Anti-seizure Meds Antipyretics Sedatives: Opioids such as Fentanyl, Propofol Analgesics Barbiturates: a) decrease metabolic demands of the body which decreases cerebral blood flow and edema b) Pentobarbital or Thiopentone are drugs of choice c) May need to induce a barbiturate coma for those w/ refractory increased ICP
Nursing Assessment for shunt care
Assess incision sites looking for infections well approximations drainage and how much CSF is being drained out
Nursing Assessment for Closed Head Injury
Assessment- Airway/Breathing 1- many TBI's associated w/ cervical spine injuries especially in the elderly (C1 and C2) 2- Assess for indicators of "spinal cord injuries" 3- Assess need for Intubation/Mechanical ventilation 4- Assess for changes in breathing pattern.
What does Brain Death look like?
Cardinal Signs: 1- coma 2- absence of brain stem reflex 3- apnea Diagnostic Tests 1- cerebral blood flow studies 2- EEG electroencephalogram measures electrical activity in the brain 3- Transcranial Doppler: measure the velocity of blood flow through the brain's blood vessels 4- Brainstem auditory-evoked potential
How is normal pressure hydrocephalus diagnosed?
Diagnosis is done via clinical exam Imaging of the brain and measurements of CSF pressure
Signs of increased ICP
EARLY Signs: a) Behavior Changes b) Restlessness c) Irritability d) Disorientation f) Changes may be subtle at first LATER Signs: a) Severe Headache b) Nausea c) Vomiting (OFTEN PROJECTILE) d) Seizure f) Papilledema (edema of the optic disk) g) Pupillary Changes h) Impaired eye movements Posturing Changes a) Decerebrate b) Decorticate
Nursing Assessment Closed Head Trauma [Temperature]
Fever in traumatic brain injury can be due to: 1- inflammatory Response 2-Infection 3- Central Fever: a- caused by hypothalamic damage b- very high fever lasting several days to weeks c- absence of sweating d- use hypothermia blanket or sponge baths
ICP Management IMPORTANT!!
ICP monitor in pt. w/ GCS<8 Use of "ventriculostomy catheter" is preferred for ICP monitoring it allows drainage of CSF to decrease ICP Sterile technique is CRITICAL!!!! Keep ICP less than 20mmHg Maintain CCP 50-70 mmHg, generally above 60mmHg Mechanical hyperventilation for acute neurological deterioration 1- Carbon Dioxide is a very potent vasodilator 2- Keep PC02 30-45 mmHg 3- Hypoxemia also can cause vasodilation 4- Keep P02 80-100 mmHg Suction only when needed, why? it increase ICP Avoid excessive coughing Hyper-oxygenate pt. w/ 100% oxygen prior to suctioning 1- may use Lidocaine or Sedation to decrease cough reflex Promote normothermia to mild hypothermia (33-34 degrees Celsius) Elevate head of bed to 45-90 degrees Head in neutral position Avoid excessive Neck and Hip flexion (this increases ICP) Do NOT cluster care, space out care/activities allow pt. to rest Put the pt. in quite, dim environment
What is brain herniation?
Increased ICP, swollen brain tissue may shift and herniate upward, downward or laterally. Uncal and central herniations are particularly associated with BAD outcomes
What imaging used to diagnosis Diffuse Axonal Injury?
Magnetic Imaging Spectroscopy. PET scan
What are the ICP values?
Normal Intracranial Pressure is 5-15 mmHg MAP should be btw 65-150mmHg Normal CCP is 70-100 mmHg
Pupillary Assessment Closed Head Trauma
Signs of Herniation 1- Asymmetric pupils 2- Unresponsive pupils 3- Unilateral or bilateral dilated pupils 4- Pinpoint, Fixed pupils 5- Ovoid pupil (early sign) Fixed, Dilated pupils are poor prognostic signs they're known as "BLOWN PUPILS".
Home Monitoring of child w/ closed head injury
Stay: with child for the first 24 hours Wake: the child every 2-4 hours ensuring that they move normally. Observe: closely observe child for a few days Call medical provider/emergency services if child presents w/ 1- constant headaches that gest worse 2- slurred speech 3- dizziness that doesn't go away 4- extreme irritability or other abnormal behavior 5- vomiting more than twice 6- clumsiness or difficulty walking 7-oozing blood or watery fluid from ears or nose 8-difficulty waking up 9-unequal pupils 10-unusual paleness lasting more than 1 hour 11- seizures Signs/Symptoms of increase ICP develops
What is a traumatic brain injury?
Traumatic force to the skull and brain most common causes are falls and motor vehicular accidents other causes are: fire arms, assaults', violent sports causing head injuries and war.
Traumatic Brain Injury
Types of head injuries 1) Classified by "Glasgow Coma Scale" a-GSC range from 13 to 15 mild head injury b-GSC range from 9-12 moderate head injury c-GSC range from 8 or less pt. is comatose
linear skull fracture/non displaced skull fracture
a break in the continuity of the bone
Basilar skull fractures
a fracture which occurred at the base of the skull and along the bony structures of the mid-face. Signs/Symptoms are: Raccoon's eyes and Battle sign Assess for any clear fluid which comes from the ears or nose which is CSF test, using a dextrose strip collect checking for glucose its NOT always 100% accurate since blood has sugar too. Collecting CSF fluid on gauze and assess for "Halo Sign" a drop of blood in CSF DO NOT insert any NG-tube into the pt. nose at all, use only an oral Gastric tube.
What is Shaken Baby Syndrome (SBS)?
a severe form of injury found in infants which is caused by parents who become frustrated from a baby who's crying and their tired. Important diagnostic symptom is retinal detachment/and or hemorrhage. intracranial or intraocular hemorrhages classic s/s of shaken baby syndrome an ophthalmoscope is used to r/o retinal hemorrhages.
What is a concussion?
a temporary loss of neurologic function with structural damage to the brain usually caused by blunt force to the head and damages are at the cellular level damage to brain tissues (gray and white matter)
What is the Glasgow Coma Scale?
a type of scale which assess for level of level of consciousness and its used to determine severity of brain injuries. It also measures mental status, eye, verbal and motor responses the score ranges from 3 to 15 Eye opening response (1-4) Verbal Response (1-5) Motor Response (1-6) A score of 8 or less pt. is in a coma
Direct vs. Indirect (TBI's)
a- direct contact to the head and brain b- indirect contact r/t intracranial hemorrhage, cerebral edema and seizures, decrease blood flow results in decrease auto regulation c- this may involve the scalp, skull, meningeal layers cerebral blood vessels, brain tissue and neurons
Open vs Closed Head Injuries (TBI's)
a- open injury shows both brain and skull b- closed shows an intact skull
Primary vs Secondary brain injuries (TBI's)
a- primary injury r/t to the initial assault b- secondary injury evolves over the ensuing days after initial injury and results in inadequate delivery of nutrients and oxygen to cells.
What is Cluster/Biot's breathing?
breathing in short burst Pontine lesion
closed skull fracture
broken bone with intact skin
Subdural Hematoma
collection of blood btw the dura mater and brain they tend to be venous in origin they bleed slowly and they can be acute or chronic older adults are most at risk because brain tissue begins to atrophy (shrink) and often are on anticoagulation tx or alcohol. Acute subdural hematoma s/s: changes in level of consciousness (LOC) pupillary signs Hemiparesis (paralysis on one side of body) Chronic subdural hematoma: are the time from injury to the time from when symptoms appear this can be (3 wks. to mths) often mistaken for a stroke. Signs/Symptoms for chronic subdural hematoma: 1- headaches which comes and goes 2- alternating focal symptoms 3- personality changes 4- mental deterioration and focal seizures
What is hyperventilation?
deep rapid breathing Midbrain lesion Hypoxia, metabolic acidosis, pain and anxiety
What is Chronic Traumatic Encephalopathy?
degenerative brain disease found in individuals with repetitive brain trauma from football and boxing sports. unable to diagnosis after pt. death during an autopsy. some pts. commit suicide major risk factor. protein called "Tau" forms clumps that spread throughout the brain, killing brain cells. Signs/Symptoms: Early symptoms are: Mood and Behavior changes Late symptoms are: Cognitive changes and Dementia
What is Normal Pressure Hydrocephalus?
enlarged ventricles with sometimes little or no increase intracranial pressure. pts. presents with a "triad of symptoms" 1) Gait disturbances: wide base gait with short steps that is slow and shuffling 2) Cognitive Impairments: pts loss the loss in interest in daily activities, difficulty performing routine task and they experience short term memory loss. 3) Impaired bladder control: urinary frequency and urinary urgency
Complications from a Basil Skull Fracture
hemorrhage from the carotid artery meningitis due to CSF leak cranial neve damages particularly cranial nerves four through 6 Assess for "extraocular eye movements".
What is ataxic breathing?
irregular breathing leads to agonal respirations and death lesions of the medulla
How is normal pressure hydrocephalus treated?
main treatment is shunts, which starts in the brain ventricles and drain into other parts of the body such as: peritoneal cavity ventricular atrial or ventricular pleural Endoscopic Third Ventriculostomy: a small hole is made in the bottom of the third ventricle which allows the CSF to drain. Complications can develop such as: Fever and Infections
Epidural Hematoma (EDH)
most life threatening this involves arterial blood, losing oxygenated blood which it collects btw the skull and dura mater. compression displaces the brain tissue inward showing a concave appearance. this is a neuro-surgical emergency!!
depressed skull fracture
occurs when the bones of the skull are forcefully displaced downward and can vary from a slight depression to bones of the skull being splintered and embedded within brain tissue
Mannitol (Osmitrol)
osmotic diuretic which pulls water out of the extracellular spaces of the edematous brain tissue and puts it back into the systemic circulation this decreasing ICP Administer IV using "filter needle" Keep pt. serum osmolality btw 310-320 May need to also used "Furosemide" to prevent systemic fluid overload
displaced skull fracture
part of the skull is sunken from the trauma and may require surgical intervention
What are post concussion syndrome?
post concussion symptoms can last for over a year. they're complications of having a severe concussion Signs/ Symptoms pts. develop are: headaches sleep problems appetite changes fatigue trouble concentrating memory problems depression or anxiety sensitivity to light and noise dizziness seizures.
Head trauma in children
prognosis depends on extent and severity of injuries and any complications Nursing Assessment of: 1- health hx 2- mental status 3- level of consciousness (LOC)/Peds Glasgow coma scale 4- lethargy 5- irritability and abnormal behavior 6- vomiting 7-seizures activity 8-headaches, visual changes, and neck pain 9-focal neuro-changes such as eye twtiching Pediatric Physical Exams: objective assessment ABC's airway breathing and circulation Level of Consciousness, Seizure activity pupillary response (fixed, dilated, sluggish or constricted)
What is apneustic breathing?
prolonged pause at the end of inspiration lesion proximal to cranial nerve 5 in the Pons area of brain
How to determine shunt malfunction?
pt. will have their symptoms returned such as: 1-severe headaches and redness along the shunt 2-difficulty walking and gait disturbance 3-cognitive challenges 4-urinary urgency or incontinence 5-swelling along shunt tract 6-fever and redness along shunt tract. Tx: shunt will be removed and an external shunt will be replaced and for infection antibiotics
Craniotomy Post-Op Nursing Care
pt. with Supratentorial craniotomy elevate the HOB to 30 degrees to decrease cerebral edema pt. with Infratentorial craniotomy must keep the HOB FLAT to prevent higher brain structures from pressing down on the excision site Turn all patients every 2 hours IV corticosteroid (dexamethasone) given to decrease post-op cerebral edema
What is Cheyne-Stokes breathing?
regularly increasing depth of breathing alternating w/ decreasing depth followed by a short period of apnea Results from: diffused cerebral injury Absence of forebrain breathing control in metabolic disease
What is diffuse axonal injury?
results from widespread shearing and rotational forces that produce damages throughout the brain to axons: located in the 1) axons in the cerebral hemispheres 2) corpus callosum and brainstem Signs/ Symptoms: pt. develops sympathetic storming episodic tachycardia tachypnea hypothermia spontaneous motor posturing
Open skull fracture
shows scalp laceration or tear in the dura matter.
comminuted skull fractures
splintered or multiple fracture lines.
What is a vascular injury?
subarachnoid hemorrhages are associated with poor outcomes in pt. w/ Traumatic Brain Injuries. they are r/t brain aneurysms or arterial dissection's from the carotid or vertebral arteries of the neck. Signs/ Symptoms of subarachnoid hemorrhages are: pt. complains sudden headaches (worst they ever had) blood in CSF stiff neck local vasospasms (tx w/ CCB Amlodipine) Horner's Sign Ipsilateral (same side of the injury) Miosis (eye constriction) Ptosis (eye dropping) Anhidrosis (no to little sweating) Ipsilateral miosis, ptosis, and anhidrosis
What is a Brain Contusion?
superficial bleeding on the surface of the brain often at the point of impact deficits based on lobe involvement Coup/ Countercoup injury or severe acceleration- deceleration force or blunt trauma. Signs/Symptoms are: injuries which expand and form hematomas develops due to bleeding and cerebral edema.
What is the Monroe-Kellie Doctrine?
the cranial vault is a ridged structure and therefore the total volume of the contents determines ICP. Cerebral Perfusion Pressure (CPP)= MAP-ICP
Concussion Signs and Symptoms
the nurse must monitor: symptoms show up in 72 hrs. 1-decrease or loss of LOC 2- worsening headache 3-dizziness 4- seizures 5- abnormal pupillary response 6-vomiting 7-irritability 8-slurred speech 9- numbness or weakness in the arms and legs Main treatment for concussions is allowing the brain to rest this allows healing too.
