9/16 TBI Traumatic Brain Injury

Location of Subdural, Intracerebral, and Epidural Hemorrhages

Epidural Hemorrhages (bone and brain) Subdural (brain and dura) Intracerebral

What GCS score indicates coma?

GCS <8 = coma

Target hematocrit required for TBI patients for adequate perfusion?

Goal is to maintain a hematocrit greater than 30% to adequately perfuse the patient.

Why is it important to maintain hypotension greater than 90 mmHG?

Hypotension is usually associated with severe blood loss and therefore should be treated quickly to maintain a SBP greater than 90mmHg and therefore prevent secondary injury.

___________ fluids should not be used as they can cross the blood brain barrier, increase brain water and worsen cerebral edema.

Hypotonic

__________________ remains to be the first line of fluid choice for resuscitation as per Advanced Trauma Life Support guidelines however current evidence recommends the immediate use of blood products for hemorrhagic shock has shown to improve patient outcomes.

Normal saline or Lactate Ringers

Nursing Interventions (TBI)

Ongoing assessment and monitoring are vital •LOC •Vital signs •Maintenance of airway •Motor function •Assess I/O daily weight (bladder and urinary output) •Assess dressings and casts for constriction • Assess oxygenation • monitor blood and urine electrolytes and osmolality and blood glucose • measures to promote adequate nutrition • strategies to prevent injury • strategies to maintain body temp •Pad side rails •Mittens to prevent self-injury; avoid restraints • support cognitive function • support family • provide patient and family education

Can a patient have arousal without awareness?

Patient w/ severe brain disorder may have arousal but not awareness w/ sleep wake cycles: "Lights on, nobody home"

TBI Initial Management - CIRCULATION

Prevent Hypoxia & Hypotension •Maintain SBP > 90mmHg •Establish euvolemia •Stop hemorrhage •Restore volume •Maintain Hct 30% •CPP > 60 mmHg

Primary injury vs secondary injury in TBI

Primary Injury • direct contact to head/brain during injury Secondary Injury • damages that evolves post injury

What part of the brain controls arousal?

Reticular Activating System in diencephalon

What is "awareness" in regards to LOC?

State of interaction with and reaction to stimuli from environment; from cerebrum

Capnography and TBI

Use of capnography is to be used to maintain end tidal CO2 between 35 and 40mmHg

What is the foramen magnum?

opening in base of skull where spinal cord joins brain stem

Where does blood collect in epidural hematoma?

•Blood collection in the space between the skull and the dura

Where does blood collect in subdural hematoma?

•Collection of blood between the dura and the brain

chronic subdural hematoma

•Develops over weeks to months •Causative injury may be minor and forgotten •Clinical signs and symptoms may fluctuate •Treatment is evacuation of the clot

The Brain Injury Association of American defines TBI as:

"an insult to the brain... by an external physical force that may produce a diminished or altered state of consciousness, which results in impairments of cognitive abilities or physical functioning.

TBI Initial Management - AIRWAY

1. Airway protection and C-Spine immobilization 2. Endotracheal Intubate for GCS < 8 •Rapid Sequence Intubation (RSI) •Maintain head and neck in straight alignment •"less than 8, intubate"

Management of the Patient With TBI

1. Assume Cervical Spine Injury Until ruled out 2. Therapy to preserve brain homeostasis and prevent secondary damage •Treat cerebral edema •Maintain cerebral perfusion; treat hypotension, hypovolemia, and bleeding; monitor and manage ICP •Maintain oxygenation; cardiovascular and respiratory function •Manage fluid and electrolyte balance

3 types of Intracranial bleeding

1. Epidural hematoma 2. Subdural hematoma •Acute and subacute •Chronic 3. Intracerebral hemorrhage and hematoma

Late Signs of Elevated ICP

1. LOC (increasing confusion, decreasing LOC, eventual coma) 2. Pupillary changes (dilate, eventually fixed, may be unilateral) 3. Vital Sign Changes • Pressure on brainstem; EKG changes, labile BP and HR; changes in resp pattern • Hypothalamus dysfunction; altered body temp, and diabetes insipidus 4. Abnormal Reflexes • Babinski, Rooting, Sucking, Grasp 5. Loss of Brainstem Reflexes • Sluggish, then loss of corneal, cough, gag 6. Posturing & Seizures • Abnormal flexion and extension; finally flaccid

Early Signs of Elevated ICP

1. LOC (irritable, restless, mild confusion, can't concentrate) 2. Pupillary changes (oval shape, sluggish response) 3. Headache (due to pressure on the meninges) 4. Speech (slurring, trouble finding words or completing sentences)

What to do if TBI is suspected?

1. Prehospital transport, maintain vital signs, breathing 2. ABCDE management 3. mitigate secondary injury

TBI Supportive Measures

1. Respiratory support; intubation and mechanical ventilation 2. Seizure precautions and prevention •• padding bedrails •• central line for IV access 3. NG tube to manage reduced gastric motility and prevent aspiration 4. Fluid and electrolyte maintenance 5. Pain and anxiety management 6. Nutrition

18% TBI = _____1___ 22% TBI = ____2___

1. ages 0-4 2. ages 75+

What to observe if concussion suspected?

1. arouse and assess frequently 2. report the following immediately •changes in LOC •Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety •Difficulty in speaking or movement •Severe headache •Vomiting

Pathophysiology of TBI

1. brain suffers TBI 2. swelling or bleeding increases intracranial volume 3. no room to expand so pressure increases 4. pressure on blood vessels slows blood flow to brain 5. cerebral hypoxia and ischemia occur 6. intracranial pressure increases. Brain may herniate. 7. Cerebral blood flow ceases

2 classifications of TBI

1. closed head injury 2. open had injury

What 3 categories are accessed for GCS?

1. eye opening 2. verbal response 3. motor response

Diagnostic evaluation of intracerebral hemorrhage?

1. physical and neurological exam 2. skull and spinal radiography 3. CT scan 4. MRI 5. PET

Rapid Sequence Intubation (5 Ps)

1.Prepare equipment/ patient 2.Preoxygenate 3.Premedicate 4.Paralysis 5.Post intubation

5 year outcome of persons with TBI?

22% died 30% worse 22% stayed the same 26% improved

b) moderate

A client sustained a closed head injury from a fall from a tree that happened 2 hours ago. There is MRI evidence of a contusion. The client has just begun to regain consciousness and presents by opening eyes when asked, inappropriately responds to questions, and has purposeful movement to painful stimuli. Based on the GCS, the nurse should plan care for a client with which level of injury from this contusion. a) mild b) moderate c) severe d) extreme

Collaborative Problems and Potential Complications TBI

Decreased cerebral perfusion Cerebral edema and herniation Impaired oxygenation and ventilation Impaired fluid, electrolyte, and nutritional balance Risk of posttraumatic seizures & storming

ABCDE management

Airway Breathing Circulation Disability Exposure/Environment approach to the assessment

Why is it important to not overload TBI patient with fluid?

Care should be taken not to overload the patient with fluid as this can cause edema of the brain and further worsen the patient's condition

Draw levels of brain injury.

Inner to outer Concussion Contusion DAI SDH/EDH ICB

What is the most sensitive early indicator of elevated ICP?

LOC (irritable, restless, mild confusion, can't concentrate)

Leading cause of TBI resulting in hospitalization?

MVA

What is a mild, moderate and severe GCS score?

Mild = 13-15 Moderate = 9-12 Severe = 3-8

Concussion:

a temporary loss of consciousness with no apparent structural damage

Closed brain injury (blunt trauma):

acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue

What is always assumed about TBI until it is ruled out?

assume cervical spine injury until ruled out

In order to be conscious, must have both ________ and _______.

awareness and arousal

How does patient's LOC present with epidural hematoma?

brief loss of consciousness → return of lucid state → as hematoma expands, increased ICP will often suddenly reduce LOC

CPP

cerebral perfusion pressure

What part of the brain controls awareness?

cerebrum

What age groups are at the highest risk for brain trauma?

children 0-4 adolescents 15-19 adults 65+

Herniation & Brain Death •As ICP continues to rise, contents move from areas of higher pressure to areas of lower pressure causing ___________.

cingulate and uncal/transtentorial herniation

Secondary injury (TBI)

damage that evolves post injury caused by: - cerebral edema - ischemia - chemical changes associated w/trauma

lateralization

deficits only on one side of brain

Why is GCS sometimes hard to assess?

difficult to grade patients who are intubated, trached, or receiving sedation

If a patient has a concussion, are they admitted or sent home?

either/both

Leading cause of TBI

falls

Primary injury (TBI)

initial injury to the brain sustained by impact - contusions - lacerations - external hematomas - skull fractures - subdural hematomas - concussion - diffuse axonal

A client with TBI presents with a temperature of 98.2, BP of 83/51, PaO2 of 62 mmHg, and Glasgow Coma Scale (GCS) of 11. Which of the following nursing interventions is the most appropriate to perform initially?

initiate fluid replacement with normal saline

When is a TBI patient intubated?

less than 8 intubate (GCS ≤ 8)

74% TBI in male or female?

male

Contusion:

more severe injury with possible surface hemorrhage

Is hypovolemic shock caused by intracranial hemorrhage?

no

Open brain injury:

object penetrates the brain or trauma is so severe that the scalp and skull are opened

If a client presents to ER with head injury from fall at home and initial Glasgow Coma Scale (GCS) score is 12, but 20 minutes later falls to 8, what should the nurse to first?

prepare client for intubation

What is the goal for TBI patients for nurses?

prevent Hypoxia and HYPOTENSION!

What is best approach to TBI?

prevention

What kind of motor response should be present at birth?

primitive and spastic

capnography

procedure to record carbon dioxide levels

How does the control of motor neurons change as a child develops?

upper motor neurons take over and spastic reflexes are lost

Diffuse axonal injury:

widespread axon damage in the brain seen with head trauma. Patient develops immediate coma.

Is epidural hematoma an emergency?

yes

What is "arousal" in regards to LOC?

• State of wakefulness • eyes open and ready able to receive input • comes from Reticular Activating System in diencephalon

TBI symptoms and recovery depend on...

• amount of damage and cerebral edema •Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs

Nursing Interventions for epidural hemotoma?

• monitor & support vital body functions • respiratory support

Motor responses are controlled where?

• neurons in the spinal cord (lower motor neurons) • not the brain

Herniation & Brain Death As pressure continues to rise causing contents to move from areas of high pressure to areas of low pressure, where does the contents go?

• pressure continues to push contents down until base of brain (cerebellum) and brain stem are pushed thru foramen magnum resulting in central herniation and brain death

How to treat epidural hematoma?

• reduce ICP • remove the clot • stop bleeding (burr holes or craniotomy)

Acute vs. Subacute subdural hematoma

•Acute: symptoms develop over 24 to 48 hours •Subacute: symptoms develop over 48 hours to 2 weeks •Requires immediate craniotomy and control of ICP

Manifestations of Brain Injury

•Altered LOC •Pupillary abnormalities •Sudden onset of neurologic deficits and neurologic changes; changes in sense, movement, reflexes , posturing •Changes in vital signs •Headache •Seizures •Paroxysmal Sympathetic Hyperactivity (PSH)

Monroe-Kelly Hypothesis/Doctrine

•Doctrine: the cranial compartment is encased in a nonexpandable case of bone → the volume inside the cranium is fixed. •In an incompressible cranium, the blood, CSF, and brain tissue exist in a state of volume equilibrium, such that any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another. •ICP is generally measured in mm Hg to allow for comparison with MAP and to enable quick calculation of CPP. •7-15 mm Hg in adults who are supine (lower in children), with pressures over 20 mm Hg considered pathological

What is GCS not able to show?

•Does not show lateralization (deficits only on one side);

TBI Initial Management - EXPOSURE/ENVIRONMENT

•Goal is to maintain normothermia

Nursing Assessment of intracerebral hemorrhage?

•Health history with focus on the immediate injury, time, cause, and the direction and force of the blow; refer to Figure 68-4 and Table 68-1 •Baseline assessment: refer to Chart 68-3 •LOC—Glasgow Coma Scale: refer to Chart 68-2 •Frequent and ongoing neurologic assessment •Multisystem assessment

Intracerebral Hemorrhage

•Hemorrhage occurs into the substance of the brain

TBI Initial Management -BREATHING

•Inspect, Auscultate, Palpate •O2 saturation > 90% •PaO2 > 60 mmHg •ETCO2 - 35 mmHg •Avoid HYPERVENTILATION

Glasgow Coma Scale (GCS)

•International scale to assess LOC •Grades 3 different categories and assigns best score 1. Eye opening 2. verbal response 3. motor response •Lowest score = 3 • highest score = 15 •Score < 8 = coma •Does not show lateralization (deficits only on one side); difficult to grade patients who are intubated, trached, or receiving sedation

Strategies to maintain body temp

•Maintain appropriate environmental temperature •Use of coverings: sheets, blankets to patient needs •Administration of acetaminophen for fever •Cooling blankets or cool baths; avoid shivering

Plan of Care for Intracerevral Hemorrhage

•Maintenance of patent airway and adequate CPP •Fluid and electrolyte balance •Adequate nutritional status •Prevention of secondary injury •Maintenance of normal temperature •Maintenance of skin integrity •Improvement of cognitive function •Prevention of sleep deprivation •Effective family coping •Increased knowledge about rehabilitation process •Absence of complications

Causes of intracerebral hemorrhage

•May be caused by trauma or a nontraumatic cause

Classification of TBI

•Mild •Moderate •Severe

TBI Initial Management - DISABILITY

•Neurologic Assessment •Glasgow Coma Scale •Pupils

Open Head Injury

•Occurs when the skull is penetrated (i.e. knife, bullet) •Tissue damage occurs at the point of penetration and surrounding the path of the intruding object •Potential consequences: swelling, lacerations from skull fragments, infection, etc.

Closed Head Injury (CHI)

•Primarily caused by a blunt impact or blow to the head without any fracture to the skull •The most common form of brain damage is due to a CHI. •Potential consequences of CHI: swelling, increased intra cranial pressure (ICP), tissue compression, and bleeding

How nurse can support family of TBI patients.

•Provide and reinforce information (PE) •Measures to promote effective coping •Setting of realistic, well-defined short-term goals •Referral for counseling •Support groups

Strategies to prevent injury

•Reduce environmental stimuli •Adequate lighting to reduce visual hallucinations •Measures to minimize disruption of sleep-wake cycles •Skin care •Measures to prevent infection

How to treat subdural hematoma?

•Requires immediate craniotomy and control of ICP

How to treat intracerebral hemorrhage?

•Supportive care •Control of ICP •Administration of fluids, electrolytes, and antihypertensive medications •Craniotomy or craniectomy to remove clot and control hemorrhage; this may not be possible because of the location or lack of circumscribed area of hemorrhage

Why is prevention of hypotension crucial for TBI patients?

•The literature states that one episode of SBP less than 90mmHg can worsen the patients outcome. Hypotension causes secondary brain injury therefore prevention of hypotension is crucial for a TBI patient. • Fluid resuscitation in a patient who is in hypovolemic shock is crucial in stabilizing and replacing blood loss. • If the patient is bleeding then blood should be given ASAP.