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