Traumatic Brain Injury

FALSE (risk for hernia and loss of CSF)

(true or false) you can use a lumbar puncture for patients with brain injuries?

Open skull fracture

--fracture of the skull with an associated open wound to the scalp. --allows for bacteria and infection to enter the skull and infect the brain.

Cushing's triad

-Increased SBP -Widening pulse pressure -Altered respirations are all signs/symptoms of?

nursing assessment: objective data for brain injury

-LOC/altered mental status -GCS -vitals -pupils -respiratory effort -integument assessment -otorrhea/ rhinorrhea -vomiting -exposed brain

Emergent care for head injury

-Patent airway (Intubate if GCS <8) -Oxygen -Stabilize cervical spine -IV access -HOB elevated 30 degrees -Control external bleeding -monitor (vitals, ICP, Cerebral perfusion, EEG) -prevent secondary injury

factors that influence ICP

-arterial pressure -venous pressure -intraabdominal and intrathoracic pressure -posture -temperature -blood gases (CO2 levels)

contusion

-bruising of brain tissue within a focal area -watch for recurrent bleeds, focal/generalized manifestations, seizures

rehab/long term care/home care

-communication -motor/sensory deficits -memory and intellectual functioning -nutrition -bowel and bladder management -dysphagia -DVT prophylaxis -personality changes -emotional support -role changes -financial support return to baseline or optimal functioning

skull fracture inter professional care

-conservative treatment -surgery if depressed (craniotomy to remove small fragment or elevate depressed bone)

clinical manifestations of head injuries

-cranial nerve deficits -battle's sign -perioribital ecchymosis -rhinorrhea -otorrhea -decorticate or decerebrate posture

causes of TBI

-falls -motor vehicle accident (falls and MVA are 2 most common causes) -assault -sports injuries -recreational injuries -firearms

Overall nursing goals for pt w/ brain injury

-maintain patent airway -ICP within normal limits -Normal fluid & electrolyte balance -prevent complications secondary to immobility and decreased level of consciousness

nursing assessment: subjective data for brain injury

-mechanism of injury(scene) -pertinent past history (alcohol/drug use, risk-taking behaviors) -headache mood/behavior changes -mentation changes; impaired judgement -aphasia; dysphagia -fear, denial, anger, aggression, depression -medications: anticoagulants

concussion

-minor diffuse head injury -brief disruption in level of consciousness -retrograde amnesia -headache -short duration

scalp laceration

-most easily recognized type of external head trauma -large amount of blood loss/profuse bleeding due to highly vascular head -complications: blood loss/infection

epidural hematoma

-neurologic emergencies -signs: initial period of unconsciousness, brief lucid interval, then another decrease in consciousness; headache, nausea, vomiting -rapid surgical intervention necessary to evacuate that hematoma and prevent cerebral herniation -manage increased ICP

health promotion/ teaching for TBI

-prevent car and motorcycle accidents -use seat belts and child car seats -wear safety helmets -home safety/fall prevention

diffuse axonal injury

-severe diffuse injury -widespread axonal damage -decreased level of consciousness -increased ICP -decortication, decerebration -global cerebral edema -occurs 12-24 hours after injury

subdural and epidural hematoma inter professional care

-surgical evacuation (of blood) -craniotomy, burr-holes -craniectomy if extreme swelling

treatment for brain injuries

1) identify cause of increased ICP (history, accident, fall, trauma) 2) Glascow Coma Score (watch for scores less than 8) 3) support brain function, maintain CPP 4) HOB @ 30 degrees 5) decrease intraabdominal and intrathroacic pressure 6) decrease stimulation (alarms, visitors)

Acute care of patient with increased ICP

1) maintain patent airway (intubate) 2) monitor respiratory function (mechanical ventilation if GCS <8) 3) elevate HOB 30 degrees 4) suctioning 5) minimize abdominal distention 6) monitor ABGs 7) total patient care (skin, hygiene, nutrition, elimination)

post-concussion syndrome (PCS)

A concussion may result in _______ which develops 2 weeks to 2 months after concussion and involves persistent headaches, lethargy, behavior changes, shortened attention span, decrease in short term memory, and changes in intellectual ability

Decerebrate posturing

All four extremities in ridged extension with hyperpronation of forearms and planter flexion of feet

MAP (mean arterial pressure) - ICP

CPP=

cerebrospinal fluid, intravascular blood, brain tissue

Components of brain that make up the ICP

-muscle of throat and larynx -taste

Cranial Nerve IX: Glossopharyngeal function

-hearing -balance

Cranial Nerve VIII: Auditory

-sensory face -sinuses, teeth -jaw muscles

Cranial nerve V: Trigeminal function

-face muscle -taste

Cranial nerve VII: Facial function

internal organs

Cranial nerve X:Vagus function

muscles of the neck and upper back

Cranial nerve XI: Spinal accessory function

tongue movement

Cranial nerve XII: Hypoglossal function

Mannitol (Osmitrol)

Drug for increased ICP: -Osmotic diuretic: causes fluid to move from cerebral tissue to blood which causes plasma expansion -monitor fluid & electrolyte status

Hypertonic saline

Drug for increased ICP: -shifts fluid from cells to blood vessels -Monitor BP and Serum Sodium Levels (b/c intravascular fluid volume excess can occur)

corticosteroids: dexamethasone (Decadron)

Drug for increased ICP: used to treat vasogenic edema surrounding tumors and abscesses.

coup-contrecoup injury

Dual impacting of the brain into the skull; one injury occurs at the point of impact; another injury occurs on the opposite side of impact, as the brain rebounds.

eye opening, verbal response, motor response

Glasgow coma scale assess what 3 components?

you don't, you get this value from the monitor!

How do you calculate the ICP?

yes. "Brain dead" declared when no function, no EEG wave; Time of death is when cardiac and ventilation is deceased

Is brain death different from time of death?

(DBP x 2) + SBP/3

MAP=

epidural, intraparenchymal, subarachnoid, ventricular, and subdural space

Potential Locations where the ICP monitor may be placed

Mental status change (earliest sign; restless, confused, not responding appropriately) Irregular breathing (Cheyne-Stoke: hyperventilation then apnea) Nerve changes to optic and oculomotor nerves (double vision, swelling of optic nerve "pipilledema"; increased/decreased/unequal pupils, abnormal dolls eye "oculocephalic reflex") Decerebrate or Decorticate posturing or Flaccid Cushing's Triad (LATE sign) Reflex positive babinski (toes fan out) Unconscious (LATE) Seizures (precautions) Headache Emesis (vomiting w/out nausea) Deterioration of motor function

Signs and Symptoms of Increased ICP (MINDCRUSHED)

1) immediately after injury 2) within 2 hours after injury 3) 3 weeks after the injury

The three points in time after a traumatic brain injury where death occurs

Neuromuscular blocking agents (Vecuronium- Norcurom)

This is a paralytic; will only be used if a person is on a ventilator

>20

What ICP level indicates increased ICP and warrants immediate intervention?

hyperglycemia and GI bleed/ulcers

What are risks of corticosteroids?

-dextrose strips to see if glucose is present -collect drops on clean white gauze, let it sit, and you will observe a small red dot of blood in middle of fluid (halo sign)

What are two tests to see if fluid leaking from Nose or Ear is CSF?

60-100

What is the normal Cerebral Perfusion Pressure (CPP) level?

5-15

What is the normal ICP?

ICU

What setting are mannitol and hypertonic saline used?

A

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as: a) decorticate b) decerebrate c) localization of pain d) flexion withdrawal

Because you do not want to alter the patient's Glasgow coma scale

Why should you be careful not to overdose on opioids?

venous; arterial

____ hematoma develop slowly, and ______ develop rapidly

24-48 hours; 2-14 days; weeks to months

acute subdural hematoma manifests within ______ of injury. Subacute occurs _______ after injury, and chronic develops in ________

Anti-seizure medications

additional medication taken with ICP in which you must monitor seizure activity and may be treated prophylactically

Cerebral Perfusion Pressure (CPP)

amount of blood that passes through 100 gm of brain tissue per minute; pressure that pushes blood to brain so it will influence cerebral blood flow

head injury

any trauma or injury to the scalp, skull, or brain

prevention

best treatment for TBI's is

ominous sign

bilateral dilated, fixed pupils indicate

Linear skull fracture

break in continuity of bone without alteration of relationship of parts. cause: low-velosity injuries

infections, hematoma, tissue damage, increased ICP

complications of head injuries include

smell

cranial nerve I: Olfactory function

eye movement

cranial nerve III: Oculomotor, IV: Trochlear, and VI:Abducens function.

vision

cranial never II: Optic function

Compound skull fracture

depressed skull fracture and scalp laceration with communicating pathway to intracranial cavity. cause: severe head injury

-CT -MRI -EEG -cerebral angiography -intracranial pressure monitoring

diagnostic studies for brain injuries

chronic hematoma can be a small slow leakage into the subdural space

difference between chronic and acute subdural hematoma?

males

do males or females experience TBI's more?

Barbiturates (pentobarbital, thiopental)

drugs that decrease cerebral edema to decrease intracerebral pressure

Decorticate posturing

flexion of arms, wrists, and fingers with adduction in upper extremities. Extension, internal rotation, and plantar flexion in lower extremities.

CT scan

gold standard diagnostic study to determine craniocerebral trauma

diffuse (generalized) head injury

head injury in which that damage is not confined to one area (concussion, diffuse axonal injury)

focal (localized) head injury

head injury in which the damage is localized to a specific area (laceration, contusion, hematoma, cranial nerve injury)

epidural hematoma

hematoma between surface of skull and duramater

subdural hematoma

hematoma located between duramater and arachnoid mater -usually results results from injury to brain tissue and/or blood vessels in brain

Monroe-Kellie Doctrine

if cerebrospinal fluid, intravascular blood, brain tissue is elevated then one or more of the remaining components must be decreased to maintain the balance within the skull

craniotomy

incision of the skull

closed skull fracture

injury in which the skull is fractured but there is no open wound to the overlying scalp.

secondary injury

injury that occurs as result of initial injury (hypoxia, ischemia, hypertension, edema, increased ICP)

primary injury

injury that occurs at time of initial impact (blunt forced trauma, bruising)

depressed skull fracture

inward indentation of skull. cause: powerful blow

contrecoup

is coup or contrecoup more severe?

otorrhea

leaking of CSF from ear

rhinorrhea

leaking of CSF from nose

simple skull fracture

linear or depressed skull fracture without fragmentation or communicating lacerations. cause: low-to-moderate impact

-MRI, PET -Transcranial Doppler Studies (measure cerebral blood flow) -Cervical spine x-ray

look for additional injuries with brain injuries

brain death

loss of all brain function or brain activity including voluntary and involuntary

nursing implementation for head injuries

maintain airway/breathing -cerebral perfusion/oxygenation -mechanical ventilation -trach care, suctioning monitoring -vitals, ICP, LOCm EEG -GCS, pupil response HOB 30 degree Fluid/electrolytes -TPN or enteral Protect from injury -IV site carem restraints, DVT prophylaxis, skin care, foley Cath care

analgesics (opioids-morphine sulfate, fentanyl)

medication used to manage pain.

sedatives (propofol (deprival), dexmedetomidine (precedex))

medications that help patient's with anxiety/agitation

13-15

minor injury has Glasgow coma scale of _______

9-12

moderate injury has Glasgow coma scale of _______

Comminuted skull fracture

multiple linear fractures with fragmentation of bone into many pieces. cause: direct, high-momentum impact

intracerebral hematoma

occur from bleeding that occurs within the brain

Antipyretics (Acetaminophen)

patient's fever should be well controlled to maintain a temp of 96.8 to 98.6F by using _________; also may use cooling blankets, cool baths, or ice packs

Cheyne-Stokes respiration

periods of rapid or deep breathing followed by period of apnea

raccoon eyes

periorbital ecchymosis is also known as

pons damage or drugs

pinpoint pupils indicate

battle's sign

post oracle echomosis (behind and below ear)

Intracranial Pressure (ICP)

pressure within compartment of skull

3-8

severe injury has Glasgow coma scale of _______

compressed cranial nerve III

single dilated pupil indicates

laceration

tearing of actual brain tissue; generally in association with depressed or open skull fractures and penetrating injuries -will see hemorrhaging

craniectomy

the surgical removal of a portion of the skull

vasopressor

used to help with the vasoconstriction that increases the ICP

antihypertensives

used to manage hypertensions

fluid intake, serum sodium and glucose

what do you monitor when patients are taking corticosteroid: dexamethasone?

anticoagulants

with a contusion, _______ use can be associated with more severe head injuries and an increased mortality rate for those using these long term

surgery; increased ICP

with a laceration resulting in hemorrhaging, patients may have _____ to remove blood, monitory and manage __________ and prevent secondary injury

coup

with coup-contrecoup injury, ________ injury occurs at the point of impact

contrecoup

with coup-contrecoup injury, ______injury occurs on the opposite side of impact, as the brain rebounds.

BB, fluid/electrolytes, renal function, and ICP (should be decreasing)

with mannitol and hypertonic saline, you want to make sure you monitor what?