Class 8: Traumatic Brain Injury, Spinal Cord Injury

Spinal Cord Injury: Primary Injury

At time of impact Cervical area most frequently involved Spinal cord damage associated with vertebral damage Spinal cord may be contused, compressed, or dislocated

Subdural Hematoma: Acute

Due to trauma within 48 hours of injury Large: surgery to evacuate, via Burr holes (drill hole in skull) Small: hope to reabsorb on it's own: so send to PCU for monitoring 24 hrs - if lucky, no surgery, if grows, surgery OBSERVATION KEY!! Need neuro checks q 1hr

TBI: Penetration Injury

EX: gun shot or knife through skull and penetrate tissue

Table 45-6 Postoperative Complications of Craniotomy

Early: increased intracranial pressure (ICP) hematomas (subdural, epidural) subarachnoid hematomas hypovolemic shock hydrocephalus (too muc fluid on ventricles) respiratory complications (atelectasis, hypoxia, pneumonia, neurogenic pulmonary edema) Late: wound infection meningitis fluid and electrolyte imbalance (dehydration, hyponatremia, hypernatremia) seizures cerebrospinal fluid (CSF) leak cerebral edema

Linear Skull Fracture

Easy to deal with Heal on own Nothing to do

3 Types of Hematomas

Epidural Subdural (acute, subacute, & chronic) Intracerebral hemorrhage *Based on location in brain

Halo Device

Especially with cervical spine injuries/fractures Helps spine heal/decrease compression wear for 4-12 weeks * wrench velcored to it at hospital Concerns: SAFETY HUGE Can not drive because they can't turn head Pins needs cleaning and site care Worry about skin breakdown from vest Don't pull up in bed by device

Brain Death: Evaluation Includes...

Evaluate pupillary responses Corneal reflex Cough and gag Apnea testing Oculocephalic reflex (doll's eyes) Oculovestibular reflex (caloric ice water test)

Secondary Brain Injury: Seizures

First 7 days after TBI/surgery Common with brain tumor/traumatic stroke "Disrupt normal neuron pattern" Prophylactic's TX of Seizures: Antiepileptics - Keppra, Depakote, Dilantin/Cerebyx * on about a week; longer if had an actual seizure

Managing Increased ICP: CSF Drainage

Goal: decrease pressure to prevent drainage (don't want to stimulate pt) External ventricular drainage placement - EVD Intermittent vs continuous

Central Cord Syndrome

Greater involvement of upper extremities Loss of motor function SOME sensation

Autonomic Dysfunction: Spinal Shock

Happens w/in a few hours of injury 48hr to 6 weeks regain function, some may not regain Neuromuscular Flaccid paralysis below level of injury r/t swelling * First few weeks critical

TBI: Acceleration-Deceleration Injury

Head in motion strikes stationary object EX: striking head on a table

Brain Tumor: Assessment

Headache Seizures Nausea - projectile vomiting Papilledema (optic nerve becomes swollen) Mental status changes Cognitive changes *Symptoms correlate to location (olfactory - hearing loss, near eye - vision loss) *Duration, frequency, and severity varies

Quad Cough

Help diaphragm As they cough, push up like Heimlich maneuver to promote coughing

Define Cheyne Stoking

Hyperventilation and abnormal breathing --> apnea with brain injury

Secondary Brain Injury: Causes

Hypoxemia Hypotension Anemia Cerebral edema (BIG ONE) Cerebral ischemia Increased ICP Hypercarbia (too much CO2) Hyperthermia Seizures Hyperglycemia Infection

Spinal Cord Injury

Most common : 16-30 years old Classified by: MOI: penetrating/blunt Type of vertebral injury: fracture, dislocation, both Level of Injury: cervical, thoracic, lumbar, sacral

Anterior Cord Syndrome

Motor paralysis Loss of pain and temperature below level of injury

TBI: Acceleration Injury

Moving object strikes stationary head EX: baseball, hand

IICP: Signs and Symptoms continued

Nausea and projectile vomiting Pupils sluggish/fixed: pinpoint (early), dilated (late), ipsilateral (early - where one is bigger than other; usually side of injury) Neuro first, then Motor function decline: posturing (late/rigid body movements & abnormal positions of body: Ex: decorticate & decerebrate) VS changes: Cushing's triad (late)

Concussion: Signs and Symptoms

Nausea/Vomiting Off balance Altered mental status Blurred vision Headache *Can last 72 hours or more *May not be obvious: irritable, decreased attention span * Multiple can lead to CTE (chronic traumatic encephalopathy)

Brain Death Evaluation: Cough and Gag

No response to tongue depressor, moving tube, or suction

EVD: Troubleshooting

No waveform: call provider Too low: too high Too high: too low *Look at fluid volume and BP...if patient appears okay, probably not accurate *NEVER EVER FLUSH

IICP Monitoring

Normal ICP - 0 to 15 mm Hg >20 is elevated ICP Warns of impending herniation (downward) Used to calculate cerebral perfusion pressure (CPP)

Open Skull Fracture vs Closed Skull Fracture

Open - Means break in skin from bone and open wound near fracture. Closed - Bone did not penetrate the skin

Brain Death Evaluation: Oculocephalic Reflex (Doll's Eyes)

Open eyes --> move head back and forth --> pupils stay fixed = DEAD

Nursing Care Plan For Patient with a Traumatic Brain Injury, Increased Cranial Pressure, and Acute Stroke

Page 359-361 SOLE

Spinal Cord Injury: Lumbar Region Signs and Symptoms

Pain Paresis Lower extremity atrophy Loss of sphincter control Footdrop

Brown Sequard Cord Syndrome

Partial Injury Ipsilateral: motor paralysis on affected side Contralateral: sensation lost on opposite side

Spinal Cord Injury: Nursing Managment

Patient assessment: establish a baseline Manage sensory and motor deficits (explain) control pain Manage sphincter disturbances ROM, positioning, splints, high top tennis shoes, alternating pressure mattress, accurate I&O, force fluids, accept behavior, listen and be supportive

Autonomic Dysfunction: Neurogenic Shock

Perfusion, Cardiovascular Shock Loss of sympathetic control of heart and vasculature Above T6 Give fluids and pressors Decreased BP and HR, lose respirations and temp control (sympathetic tanks)

Brain Death Evaluation: Oculovestibular Reflex (Caloric Ice Water Test)

Pour cold water in ear --> pupils should go toward water if NOT DEAD

Brain Tumors

Primary vs metastatic Many are benign BIGGEST CONCERN: cerebral edema, which increases ICP May have to cut good tissue to excise

Brain Injury: Management

Rapid assessment/airway management: Cheyne stoking Prevent secondary injury: neuro checks hourly - Glascow coma scale: < 8 intubate/AVPU Monitor circulation and perfusion - BP/HR Monitor fluid and electrolyte balance - NA big deal Provide mobility and safety: impulsive Prevent and manage complications

Brain Death Evaluation: Time of Death

Recorded at time brain death declared Go into the Organ saving mode

Managing ICP: Sedation and Analgesia

Reduces agitation, discomfort, and pain Facilitates mechanical ventilation Limits response to stimuli Seizure prophylaxis

Intracranial Surgery: Craniotomy (any type of brain surgery)

Removes: tumors cysts vascular malformations Could be to: clip aneurysms evacuate hematomas reverse herniation Take out as much as possible Place burr holes * can do chemo/radiation/palliative care with this

Define Neurogenic Shock

Results from loss of disruption of sympathetic tone most often due to severe cervical or upper thoracic spinal cord injury (T6). S&S: hypotension severe bradycardia warm and dry skin TX: volume resuscitation vasopressors

Spinal Cord Injury: Thoracic Region Signs and Symptoms

Sensory loss Sphincter impairment + Babinski (when it does react in adults-fans out)

Brain Injury Complications: Coma

Short or long term vegetative state Medially induced: decreased O2 demand and stimulation, let brain sleep, don't rub head or feet, don't play music, teach family why *Trach and PEG most likely needed

Depressed Skull Fracture

Skull pushed in Swelling on soft tissue Pop bone back out

Sympathetic Storming: TREATMENT

Sympathetic Blockers: Antihypertensive Reglan Low dose beta blocker ("lol") Benzos for anxiety (Ativan)

Subdural Hematoma

Venous bleed - slower Blood below dura and above arachnoid covering the brain "INSIDE" Acute, subacute, chronic

Comminuted Skull Fracture

WORST because fragments

Subdural Hematoma: Chronic

Weeks - months after Large: surgery to evacuate, via Burr holes (drill hole in skull) Small: reabsorb so send to PCU for monitoring 24 hrs EX: elderly/alcoholics

Subdural Hematoma: Subacute

48hr - 2 weeks of injury Large: surgery to evacuate, via Burr holes (drill hole in skull) Small: reabsorb so send to PCU for monitoring 24 hrs Blood takes longer to accumulate EX: usually elderly with AMS due to fall and on blood thinners / alcoholics due to alcohol thinning blood * Need good history, med list, etc.

Craniotomy: PostOp

Monitor neuro changes from baseline (hourly) Early ambulation PT/OT - esp. if function loss Speech assessment/ST DVT prophylaxis Wound care *ICU/PCU 24-48 hours for OBSERVATION

Spinal Cord Injury: Signs and Symptoms by General Location

C3-5 = involves the diaphragm = respiratory failure (keep diaphragm alive) Below C-4 = pain/atrophy/weakness in the shoulder, arm or hand constriction of pupils

Cerebral Perfusion Pressure Formula

CPP = MAP - ICP (MAP = 2 x DBP + SBP / 3) - ICP = Want between 60 - 100; If > 70 doing well

IICP: External Ventricular Drain (EVD)

Cath sits in brain and monitors pressure Leveled and zeroed with transducer with waveform Allows drainage of CSF to lower ICP NO pressure on the bag Maintain aseptic techinique

What is Bolt?

Catheter in the brain just used for monitoring ICP only - DOES NOT DRAIN

Spinal Cord Injury: Secondary Injury

Cellular damage secondary to inflammatory response Hypoperfusion Edema: worst case because pressure

Spinal Cord Syndromes: 3 Types

Central cord syndrome Brown sequard cord syndrome Anterior cord syndrome

Table 11-2 Prerequisites for Clinical Evaluation of Brain Death

- establish irreversible coma and cause (not a result of meds) - achieve normal core temp (warm blanket) - achieve normal systolic bp - neuro checks

Secondary Brain Injuries: Cerebral Edema

24-48 hours after TBI/surgery Peak: 72 hours Never let person lie flat: head above heart - (reverse Trendelenburg) decreases perfusion, causes tissue death

Secondary Brain Injury: Cerebral Ischemia

24-48 hours after TBI/surgery Poor perfusion r/t edema (pressure)

Managing ICP: Neuromuscular Blockage

" Last Resort" Concurrent analgesia and sedation EX: succinylcholine

Define Concussion

"Mild TBI" Temporary alteration in mental status from trauma May or may not include LOC May have short/long term effects Hard to diagnose

Determination of Brain Death

"Patient condition must be normalized": ABGs, off all sedatives, BP, temp (clear of infection) No standard policy May need one or two exams Could be a Neurologist or Neurosurgeon to make call Needs to be established before Organ Donation (will need O2 perfusion to maintain organ and call gift of life asap)

Diffuse Axonal Injury (DAI) - (girl hit by train)

"Scrambled egg syndrome" Petechial hemorrhage - pinpoint bleeds all over brain Often due to high speed brain injury Doesn't show up on head CT Pt usually comatose immediately after injury for 24 hours to months Diagnose by exclusion/rule out Mild (in pic): a small amount of bleed, out of it first 24 hrs, can see small hemorrhages on MRI until reabsorbed(but with devices hard to get one) Moderate: coma more than 24 hrs w/o presence of decerebrate posturing Severe: permanent / vegetative state - presence of decerebrate posturing (rigid/flexed/hyperextension)

Brain Injury Complications: Sympathetic Storming

(Later occurrence) Increased risk of overactivation of SNS INCREASE: HR, RR, glucose, temp (sweaty) Restless, agitated DECREASE: GI, UOP (foley)

Intracerebral Hemorrhage Hematoma

(aka hemorrhagic stroke) Causes: Depressed skull fractures Penetrating injuries May need surgery or craniotomy

Spinal Cord Injury: Managment

* Airway/C spine Circulatory Neuro Spine XRay Rectal tone Assess associated injury CT/MRI High dose steroids in ED Cervical traction: rod placement, fusion, laminectomy (one or more vertebrae removed) Supportive care - relearning ADLS Prevent respiratory/cardiovascular compromise Pain management Thermoregulation Mobilize/position Urinary/bowel management (regimen): NG tube first 72 hours Sexual help Psych help

IICP: Mannitol

* Give EARLY Decrease Cerebral Edema by increasing intravascular osmolality Induces diuresis, may need to replace fluids Need filter, IV Watch Na and K+ (Keep ICP < 20 ) Standing order

Herniation

* Worst case scenario Swelling compression pushes on brain stem into skull into spinal cord area (BRAIN DEATH occurs) NO COMING BACK

Brain Injury Complications: Sodium Imbalance

*Damage to pituitary DI: Increased UOP and Na, give Desmopressin/Ddavp and fluids per mL w/ bolus NS, check serum osmolarity SIADH/Schwartz Barter Syndrome: Hypervolemia: Edema, decreased UOP and Na, Diuretic: Lasix (at risk for seizures) Cerebral Salt Wasting: Decrease Na, normovolemic, watch I/O and electrolytes, seizure risk, give 3% Na Chloride Bolus

Primary Brain Injury

*Occur at time of trauma immediately Scalp laceration Skull fracture (linear, depressed, open, comminuted) Concussion (caused by blow to head or violent shaking of head/body) Contusion (blood or bleeding under-bruised appearance) Hemorrhage (bleeding inside or outside body) Hematoma (collection of blood outside of bld vessels) Diffuse axonal injury (severe injury affecting white matter in the brain, neuro dysfunction, < 8 GCS)

Chart 45-7 Nursing Focus on Older Adult - Traumatic Brain Injury

- Brain injury is 5th leading cause of death in older adults - 65 to 75 yo have 2nd highest incidence of brain injury than all other age groups - falls and motor vehicle crashes are most common causes of brain injury - factors that contribute to high mortality rate . falls causing subdural hematomas (closed head injuries), esp. chronic subdural hematomas . poorly tolerated systemic stress, which is increased by admission to a high-stimuli environment . medical complications, such as < BP, > BP, and cardiac problems . decreased protective mechanisms, which make patients susceptible to infections (esp. pneumonia) . decreased immunologic competence, which is further diminished by brain injury

Traumatic Brain Injury: Mechanisms of Injury

Acceleration injuries Acceleration-deceleration injuries Coup contracoup injuries Rotation injuries Penetration injuries

Brain Tumors: Diagnosis

CT (cat scan) MRI (magnetic resonance imaging) MRA (magnetic resonance angiography) PET (positron emission tomography) Stereotactic biopsy (uses a computer and imaging performed in at least two planes to localize target lesion in three-dimensional space and guide removal of tissue)

Brain Death Evaluation: Corneal Reflex

Blink to threat Rub cotton swab on cornea and don't blink

Epidural Hematoma

Blood between dura and inside skull surface Could be a period of lucidity and then out cold Life threatening due to Arterial bleed Presses on brain = pass out so get to surgery STAT no time for head CT, call OR, page Neurosurgeon with high suspicion due to mechanism of injury: CT sooner than later

Basilar Skull Fracture

Boxer/fighter Hits from back --> brain goes forward --> smashes into skull Battle sign (bruising behind ear) and Raccoon eyes

TBI: Coup Contracoup Injury

Brain bounces back and forth EX: shaken baby syndrome

TBI: Rotation Injury

Brain twists within the skull EX: whip lash

Brain Death Evaluation: Apnea Testing

Done LAST Take off vent --> wait 10 minutes --> if dead won't take a breath --> draw ABGs and if CO2 >20 over baseline they are DEAD

Concussion: Cognitive Rehab

Decrease activity/stimulation for about a 1 week and then slowly bring back

Managing IICP: Hypothermia

Decrease brains metabolic demands *Shivering increases ICP (can give Benzos) *Induce HTN to combat low ICP and force blood flow to the brain

Managing ICP: Barbiturate Coma

Decrease metabolic activity and preserve brain function Must be monitoring: Mechanical ventilation ICP < 20 BP cardiac monitoring continuous EEG EX: pentobarbital coma (BARB) *3 days to wear off

Managing IICP: CO2

Decreased PaCO2 = vasoconstriction and decreased ICP TX: Oxygenate Hypocapnic

What is Cushing's Triad?

Decreased Respirations Bradycardia (decreased pulse) Increased SBP - Widened pulse pressure (>SBP <DBP)

Define Hydrocephalus

Increased fluid (CSF) in ventricles which causes brain to squish against side of skull Causes: change of mentation, change in pupils (due to compression of optic nerve), and Cushing's triad.

Managing IICP: Decompressive Craniectomy

LAST RESORT Part of skull removed to relieve swelling Put bone flap in abdomen/refrigerator Worried about further trauma *Can no longer get ICP because brain skull no longer closed

Treatment for Subdural hematoma

Large: surgery to evacuate, via Burr holes (drill hole in skull) Small: reabsorb so send to PCU for monitoring 24 hrs MONITOR 1 CSF 2 INFECTION 3 REACCUMULATION OF BLOOD (neuro-checks-q1h)

Scalp Laceration

Least concerning Vascular area - lots of bleeding Need tetanus shots

Spinal Cord Injury: Recovery Depends On

Location and extent of injury

Autonomic Dysfunction: Orthostatic Hypotension

Long-term injury Can't compensate for changes in position EX: person in w/c that is reclined because if they sit up, they will pass out

Increased Intracranial Pressure (IICP) Symptoms

MOST sensitive sign: change in LOC (as edema rises, pressure goes up and becomes stuck in rigid body; concern for increased brain damage) Restless --> confused --> combative --> lethargy --> obtundation (less than full alertness) --> coma Measure indirectly thru mental status

Managing ICP: Respiratory Support

Mechanical ventilation Positive Pressure Ventilation and PEEP (positive end-expiratory pressure) increase ICP; also worry about coughing/suctioning Suctioning limited to no more than 5-10 seconds (hyper-oxygenate before suction) *IF PRESSURE IS STILL VERY HIGH: leave alone for 24-48 hours - decrease stimuli, sit straight up in bed, and sedate and paralyze

Autonomic Dysreflexia (also 43-2 Key Features)

Medical emergency Stimulus below level of injury produces QUICK sympathetic discharge, extreme HTN (both systolic/diastolic), and a throbbing headache Sweating (esp neck, face, shoulders), goose bumps below lesion, flushing of skin above lesion, blurred vision, spots in visual field, nasal congestion, pale skin below lesion, feeling of apprehension TX: sit up to decrease BP, then assess EX: kinked foley, fecal impaction, too hot/cold

EVD: Leveling

To the external auditory canal (ear) OR outer canthus of eye The EVD system must remain upright and not be lying flat on the bed due to impairing drainage

Brain Death Evaluation: Pupillary Response

fixed, dilated

What is Secondary Brain injury?

refers to the "after effects" of the primary injury results from processes initiated by trauma * MOST DETREMENTAL

CSF Halo

yellow halo outside of blood (can be collected on 4X4 and tested for glucose to determine if positive) Can come from head, nose, ears Don't blow nose or cough...caused ICP Great injury underneath Perform neuro exam and get to CT No way to fix You want it to slow, may stop on its own