Topic: TBI/Brain Death/Organ Donation (Ch. 56, 9, & 46) (Unit 4)

Intracerebral hematoma

An _______________ occurs from bleeding within the brain tissue. It occurs in about 16% of head injuries and usually happens in the frontal and temporal lobes, possibly from rupture of the intracerebral vessels at the time of injury. The size and location of the hematoma are key in determining the patient's outcome.

Epidural hematoma

An ________________ results from bleeding between the dura and the inner surface of the skull. An ___________ is a neurological emergency. It usually is associated with a linear fracture crossing a major artery in the dura, causing a ear. It can have a venous or an arterial origin.

Neurosurgical emergency; linear fracture

An epidural hematoma results from bleeding between the dura and the inner surface of the skull. This is a ___________. It usually is associated with a _________ crossing a major artery in the dura, causing a ear. It can have a venous or an arterial origin.

Frontal; temporal lobes

An intracerebral hematoma occurs from bleeding within the brain tissue. It occurs in about 16% of head injuries and usually happens in the _____ and ________, possibly from rupture of the intracerebral vessels at the time of injury. The size and location of the hematoma are key in determining the patient's outcome.

Postauricular bruising

Battle's sign consists of what?

Permanent vegetative state

Brain death criteria do not address patients in a ________________ since the brainstem activity in these patients is adequate to maintain heart and lung function.

Diffuse injury

Brain injuries are categorized as diffuse (generalized) or focal (localized). In a __________ injury (e.g., concussion, axonal injury) damage to the brain is not localized to one area.

Focal injury

Brain injuries are categorized as diffuse (generalized) or focal (localized). In a ____________ (e.g., contusion, hematoma), damage is localized to a specific area.

13-15

Brain injury can be classified as minor with a GCS of _______ - ________

9 to 12

Brain injury can be classified as moderate with a GCS of _______ - _______

3 to 8

Brain injury can be classified as severe with a GCS of _______ - _______

Epidural hematoma

Classic signs of an ____________ include: - Initial period of unconsciousness at the scene - Followed by a brief lucid interval - Followed by a decrease in LOC. Other findings may include: - Headache - Nausea and vomiting - Focal findings Rapid surgical intervention to evacuate it and prevent cerebral herniation, along with medical management for increasing ICP dramatically improves outcomes.

Unconsciousness; brief lucid; decrease in LOC; Rapid surgical intervention

Classic signs of an epidural hematoma include: - Initial period of ___________ at the scene - Followed by a __________ interval - Followed by a ___________. Other findings may include: - Headache - Nausea and vomiting - Focal findings __________ to evacuate it and prevent cerebral herniation, along with medical management for increasing ICP dramatically improves outcomes.

Benign

Concussion is generally considered _________ and usually resolves spontaneously. For some, the signs and symptoms may be the beginning of a more serious, progressive problem, especially in a patient with a history of prior concussion or head injury. At the time of discharge, it is important to give the patient and the caregiver instructions for observation and accurate reporting of symptoms or changes in neurological status.

Multisystem failure

Deaths occurring 3 weeks or more after the injury result from ____________. Expert nursing care in the weeks after injury is crucial in decreasing mortality risk and in optimizing patient outcomes.

Subdural hematoma

Diagnosis of ____________ in older adults may be delayed because symptoms mimic other health problems in this age group such as: - Somnolence - Confusion - Lethargy - Memory loss The manifestations of a ____________ are often attributed to vascular disease (stroke, TIA) or dementia.

Concussion and contusion

For patients with a _________ and ________, observation and management of increased ICP are the main strategies of management.

Immediately, within 2 hours, 3 weeks after

Head trauma has a high potential for a poor outcome. Deaths from head trauma occur at 3 points after injury: _____________ after injury, ___________ after injury, and about _________ after injury.

Halo Ring Sign

If blood is present in the patient with rhinorrhea or otorrhea, assess for halo/ring's sign: Allow the leaking fluid to drip onto the white gauze pad (4x4) or towel, and then observe the drainage. Within a few minutes, the blood coalesces into the center and a yellowish ring encircles the blood. If CSF is present, note the color, appearance, and amount of the leaking fluid because both tests can give false-positive results.

Return of spontaneous circulation (ROSC); 30 minutes

In absence of mitigating factors, prolonged resuscitative efforts are unlikely to be successful and can be stopped if there is no ______________ at any time during ___________ of cumulative advanced live support

Craniectomy

In cases in which extreme swelling is expected, such as direct axonal injury (DAI) or hemorrhage, a ______________ may be done. This involves removing a piece of skull to reduce pressure inside the cranial vault. It reduces the risk for herniation.

Surgical evacuation; craniotomy; burr holes

In cases of a large acute subdural and epidural hematomas or those associated with severe neurological impairment, the blood must be removed through _____________. A _____________ is generally done to see and allow control of bleeding vessels. ______________ may be used in an extreme emergency for a more rapid decompression, followed by a craniotomy. A drain may be placed after surgery for several days to prevent blood from reaccumulating.

Head injury

Respiratory findings of a _____________ include: - Central neurogenic hyperventilation - Cheyne-stokes respirations - Decreased O2 saturation - Pulmonary edema

Profuse bleeding; blood loss; infection

Scalp lacerations are an easily recognized type of external head trauma. Because the scalp contains many blood vessels with poor constrictive abilities, most injuries are associated with _________. Even relatively small wounds can bleed significantly. The major complications associated with this are: - ___________ - ___________

Head trauma

Subarachnoid hemorrhage and intraventricular hemorrhage can occur from ___________.

Head injury

Surface findings of a ____________ include: - Bruises or contusions on face; Battle's sign (behind ears) - Fracture or depressions in skull - Raccoon eyes - Scalp lacerations

True

T/F: In a situation in which the professional responsible for determining a state of brain death is in remote contact with the patient, but the monitoring devices available provide virtual contact with the patient, a remote diagnosis of death may be legally acceptable.

Glucose

The first method is testing the leaking fluid with a Dextrostix or Tes-Tape strip to determine whether ________is present, which would be positive. However, if blood is present in the fluid, testing for ________ is unreliable because blood also contains glucose. In this event, look for the halo or ring sign.

Blood; halo or ring sign

The first method is testing the leaking fluid with a Dextrostix or Tes-Tape strip to determine whether glucose is present, which would be positive. However, if _______ is present in the fluid, testing for glucose is unreliable because ________ also contains glucose. In this event, look for the __________

Scalp lacerations

___________ are an easily recognized type of external head trauma. Because the ______ contains many blood vessels with poor constrictive abilities, most injuries are associated with profuse bleeding. Even relatively small wounds can bleed significantly. The major complications associated with this are: - Blood loss - Infection

Concussion

___________ is a sudden transient mechanical head injury with disruption of neural activity and a change in LOC. It is considered a minor diffuse head injury. The patient may or may not lose total consciousness with this injury.

Venous epidural hematomas

____________ are associated with a tear of the dural venous sinus and develop slowly.

Linear skull fracture

____________ is a type of skull fracture: Description - Break in continuity of bone without change of relationship of parts Causes - Low velocity injuries

Compound skull fracture

____________ is a type of skull fracture: Description - Depressed skull fracture and scalp laceration with communicating pathway into the intracranial cavity Causes - Severe head injury

Depressed

____________ is a type of skull fracture: Description - Inward indentation of skull Causes - Powerful blow

Simple skull fracture

____________ is a type of skull fracture: Description - Linear or depressed skull fracture without fragmentation or communicating lacerations Causes - Low to moderate impact

Comminuted

____________ is a type of skull fracture: Description - Multiple linear fractures with fragmented bone into many pieces Causes - Direct, high momentum impact

Rhinorrhea; otorrhea

_____________ (CSF leakage from the nose) or ___________ (CSF leakage from the ear) generally confirms that a fracture has a transversed the dura. This may often be overlooked unless the patient is specifically assessed for this finding.

Focal injury

_____________ can be minor to severe and localized to an area of injury. These consists of: - Lacerations - Hematomas - Cranial nerve injuries

Head injury

_____________ includes any injury or trauma to the scalp, skull, or brain.

Blunt force injuries

______________ that produce acute subdural hematomas may cause significant underlying brain injury, resulting in cerebral edema that can increase morbidity and mortality despite surgery to evacuate the hematoma.

Postconcussion syndrome (PCS)

_______________ may develop in some patients usually from 2 weeks to 2 months after the injury. Manifestations include: - Persistent headache - Lethargy - Personality and behavioral changes - Shortened attention span - Decreased short term memory - Changes in intellectual ability This syndrome can significantly affect the patient's ability to perform ADLs.

Skull fractures

_______________ often occur with head trauma. These are described in several ways: - Linear - Depressed - Simple - Comminuted - Compound - Closed or open The type and severity all depend on the: - Velocity - Momentum - Direction - Shape (blunt or sharp) of the injuring agent. - Site of impact

Acute subdural hematoma

An ____________ manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression in increased ICP. They include: - Decreasing LOC - Headache The size of the hematoma determines the patient's presentation and prognosis. The patient's appearance may range from drowsy and confused to unconscious. The patient's ipsilateral pupil dilates and becomes fixed if the ICP is significantly increased.

Intracerebral hemorrhage

An __________ is generally associated with a cerebral laceration. This manifests as a space-occupying lesion accompanied by: - Unconsciousness - Hemiplegia on the contraleteral side - Dilated pupil on the ipsilateral side As the hematoma expands, signs and symptoms of increased ICP become more severe.

Parietal fracture

Manifestations of a ___________ include: - Deafness - CSF or brain otorrhea - Bulging of tympanic membrane caused by blood or CSF - Facial paralysis - Loss of taste - Battle's sign

Frontal fracture

Manifestations of a ___________ include: - Exposure of brain to contaminates through frontal air sinus - Possible air in forehead tissue - CSF rhinorrhea - Pneumocranium (air between cranium and dura mater)

Posterior fossa fracture

Manifestations of a ___________ include: - Occipital bruising resulting in cortical blindness - Visual field defects - Rare appearance of ataxia - Other cerebellar signs

Orbital fracture

Manifestations of a ___________ include: - Periorbital bruising (raccoon eyes) - Optic nerve injury

Subdural hematoma

A __________ may be acute, subacute, or chronic.

Diffuse axonal injury (DAI)

A ___________ is a widespread axonal damage occurring after a mild, moderate, or severe TBI. The damage occurs primarily around the axons in the subcortical white matter of the cerebral hemispheres, basal ganglia, thalamus, and brainstem. Initially, we thought ________ occurred because of the tensile forces of trauma sheared the axons, resulting in axonal disconnection. There is increasing evidence that the axonal damage is not preceded by an immediate tearing of the axon, but instead the trauma changes the function of the axon, resulting in swelling and disconnection. This process take 12 to 24 hours to develop and may persist longer.

Transcranial doppler

A ____________ allows for the measurement of cerebral blood flow velocity.

Basilar skull fracture

A ____________ is a specialized type of linear fracture. Manifestations can evolve over the course of several hours and vary with the location and the severity. These may include: - Cranial nerve deficits - Battle's sign (postauricular bruising) - Periorbital bruising (racoon eyes) This fracture is also associated with a tear in the dura and subsequent leakage of CSF.

Subacute subdural hematoma

A _____________ can occur within 2-14 days after the injury. After the initial bleeding, this hematoma may appear to enlarge over time as the breakdown of blood products draw fluid into the subdural space.

Contusion

A _____________ is bruising of the brain tissue within a focal area. It usually is associated with a closed head injury and often occurs at a fracture site. A _____________ may have areas of: - Hemorrhage - Infarction - Necrosis - Edema

Head injury

A ______________ can occur due to: Blunt causes: - Assault - Fall - MVA collison - Sports injury Penetrating: - Arrow - Gunshot - Knife

Chronic subdural hematoma

A ______________ develops over weeks or months after a seemingly minor head injury. They are more common in older adults because of a potentially larger subdural space from the brain atrophy. With atrophy, the brain stays attached to the supportive structures and the tension is increase. This makes it subject to tearing. Because the subdural space is larger, the presenting problem is focal symptoms (specific to a certain area), rather than signs of increased ICP.

Subdural hematoma

A _______________ occurs from bleeding between the dura mater and arachnoid mater of the meninges. This usually results from injury to the brain tissue and its blood vessels. The veins that drain from the surface of the brain into the sagittal sinus are the source of most _______________. Because it usually is venous in origin, a __________ may be slower to develop. However, an arterial hemorrhage can cause a ________, in which it develops more rapidly.

Increased ICP

A patient with a head injury always has the potential to develop ____________, which is associated with a higher mortality rate and poorer functional ouctomes.

Traumatic brain injury (TBI)

A serious form of head injury is the -.

Dura mater; arachnoid mater; Brain tissue; blood vessels;

A subdural hematoma occurs from bleeding between the dura mater and arachnoid mater of the meninges. This usually results from injury to the brain tissue and its blood vessels. The veins that drain from the surface of the brain into the sagittal sinus are the source of most subdural hematoma. Because it usually is venous in origin, a subdural hematoma may be slower to develop. However, an arterial hemorrhage can cause a subdural hematoma, in which it develops more rapidly.

MRI

An _______ is more sensitive in detecting small lesions in the patient with head trauma than a CT scan.

Arterial epidural hematomas

__________ the middle meningeal artery lying under the temporal bone is often torn. Hemorrhage occurs in to the epidural space which lies between the dura and the inner surface of the skull. Because this is an _________, the hematoma develops rapidly.

Head injury

CNS findings of a ____________ include: - Asymmetric face movements - Combativeness - Confusion - CSF leaking from ears or nose - Decerebrate or decorticate posturing - Decreased LOC - Depressed or hyperactive reflexes - Dilated or unequal pupils, photophobia - Flaccidity - Garbled, abusive speech - Incontinence - Involuntary movments - Seizures

Anticoagulant use; coagulopathy

___________ and ___________ are in the patient with a contusion is associated with: - Increased hemorrhage - More severe head injury - Increased mortality rate This is especially important with older adults who are on these, if they fall, their contusion is likely to be more severe. Assess for risks for falls in all patients on these.

Coma or unresponsiveness, absence of brainstem reflexes, apnea

Criteria for brain death include ____________, _____________, and _____________.

CT scan

In general the diagnostic studies are similar to those used for a patient with increased ICP. _____________ is the best diagnostic test to evaluate head trauma. It allows for rapid diagnosis and intervention in the acute care setting. MRI, PET, and evoked potential studies may be used to diagnose head injuries. A cervical spine x-ray series, CT scan, or MRI of the spine may be done since the cervical spine trauma often occurs at the same time as a head injury.

Head injury

Initial measures for a ______________ include: • If unresponsive, assess circulation, airway, and breathing. • If responsive, monitor airway, breathing, and circulation. • Assume neck injury with head injury. • Stabilize cervical spine. • Apply O2 via nonrebreather mask. • Establish IV access with 2 large-bore catheters to infuse normal saline or lactated Ringer's solution. • Intubate if GCS score <8. • Control external bleeding with sterile pressure dressing. • Remove patient's clothing.

Temporal fracture

Manifestations of a ___________ include: - Boggy temporal muscle due to extravasation of blood - Oval-shaped bruise behind ear in mastoid region (Battle's sign) - CSF otorrhea - Middle meningeal artery disruption - Epidural hematoma

Basilar fracture

Manifestations of a ___________ include: - CSF or brain otorrhea - Bulging of tympanic membrane caused by blood or CSF - Battle's sign - Tinnitus or hearing difficulty - Rhinorrhea - Facial paralysis - Conjugated deviation of gaze - Vertigo

Immediately after

Most deaths occur ___________ either from the direct head trauma or from massive hemorrhage and shock.

Acute subdural hematoma

Name this type of subdural hematoma: Occurrence after injury: 24-48 hours after severe trauma Progression of symptoms: Immediate deterioration Treatment Craniotomy, evacuation, and decompression

Subacute subdural hematoma

Name this type of subdural hematoma: Occurrence after injury: 48 hours to 2 weeks after severe trauma Progression of symptoms Decline in mental status as it develops. Progression depends on size and location of the hematoma. Treatment Evacuation and decompression

Chronic subdural hematoma

Name this type of subdural hematoma: Occurrence after injury: Weeks or months, usually >20 days after injury. Often injury seemed trivial or was forgotten by the patient. Progression of symptoms Nonspecific, nonlocalizing progression. Progressive change in LOC Treatment: - Evacuation and decompression - Membranectomy

Subjective data

Nursing assessment for the patient with a head injury includes collecting ___________ such as: Past health history: - Mechanism of injury - MVA - Sports injury - Industrial accident - Assaults, falls Medications - Anticoagulant drugs Health-perception-health management: - Alcohol or recreational drugs - Risk taking behaviors Cognitive perceptual - Headache, mood or behavioral change - Mentation changes - Aphasia - Dysphasia - Impaired judgement Coping-stress tolerance: - Fear, denial, anger, aggression, depression

Objective data

Nursing assessment for the patient with a head injury includes collecting ___________ such as: - Altered mental status - Lacerations, contusions - Abraision - Hematoma - Battle's sign - Periorbital edema and bruising - Otorrhea - Exposed brain matter - Rhinorrhea - Impaired gag reflex - Inability to maintain a patent airway - Impending herniation, altered respiratory rate and pattern - Cushings triad - Vomiting/projectile vomiting - Bowel and bladder incontinence - Uninhibited sexual expression - Altered LOC, seizures, pupillary dysfunction, cranial nerve deficits - Motor deficit/impairment - Weakness, palmar drift, spascticty, paralysis - Decorticate/decerebrate - Muscular rigidity or increased tone - Flaccidity - Ataxia Diagnostic findings - Location and type of hematoma - Edema - Skull fracture - Foreign body on CT and/or MRI - Abnormal EEG - Positive toxicology screen - Decreased or increased blood glucose - Increased ICP

Head injury

Nursing diagnosis for the patient who has sustained a _____________ may include: - Decreased intracranial adaptive capacity - Ineffective tissue perfusion - Hyperthermia - Risk for injury - Anxiety

Head injury

Objective data are obtained in the patient with a head injury by: - Applying the GCS - Assessing and monitoring the neurological status - Determining whether a CSF leak has occurred.

MVAs

One of the best ways to prevent head injuries is to prevent _______________. Be active in campaigns that promote safety.

Head injury

Ongoing monitoring for a ____________ includes: • Maintain normothermia using blankets, warm IV fluids, as needed. • Monitor vital signs, level of consciousness, O2 saturation, cardiac rhythm, GCS score, pupil size and reactivity. • Expect intubation if gag reflex is impaired or absent. • Assess for rhinorrhea, otorrhea, scalp wounds. • Give fluids cautiously to prevent fluid overload and increasing ICP.

Alcohol use

Patients with a history of ___________ are more prone to subdural hematomas because of an increased risk for falls.

2 weeks to 2 months

Postconcussion syndrome develop in some patients usually from _______ to _______ after the injury. Manifestations include: - Persistent headache - Lethargy - Personality and behavioral changes - Shortened attention span - Decreased short term memory - Changes in intellectual ability This syndrome can significantly affect the patient's ability to perform ADLs.

Head injury

The following instructions should be given when teaching the patient and the care giver about care during the first 2 to 3 days after a _________________: 1. Notify your HCP immediately if you have signs and symptoms that may indicate complications. These include: • Increased drowsiness (e.g., difficulty arousing, confusion) • Nausea or vomiting • Worsening headache or stiff neck • Seizures • Vision difficulties (e.g., blurring) or sensitivity to light (photophobia) • Behavioral changes (e.g., irritability, anger) • Motor problems (e.g., clumsiness, difficulty walking, slurred speech, weakness in arms or legs) • Sensory problems (e.g., numbness) • A heart rate <60 beats/min 2.) Have someone to stay with you. 3.) Abstain from alcohol 4.) Check with HCP before taking drugs that may increase drowsiness, including muscle relaxants, tranquilizers and opioid analgesia 5.) Avoid driving, using heavy machinery, playing contact sports, taking hot baths

Maintain cerebral oxygenation and perfusion; prevent secondary cerebral ischemia

The general goal of nursing management of the patient with a head injury is to _________________ and ________________.

Intracranial infections; hematoma; meningeal and brain tissue damage

The major complications of skull fractures are: - _______________ - _______________ - _______________

Diffuse axonal injury

The manifestations of a __________ can vary. They may include: - Decreased LOC - Increased ICP - Decortication or decerebration - Global cerebral edema About 90% of patients with ________ stay in a persistent vegetative state. Patients with a ________ who survive the initial event, are rapidly triaged to the ICU. There, they will be vigilantly watched for signs and symptoms of increased ICP and treated accordingly.

Falls and MVA

The most common causes of head injury are _________ and ________. Other causes include: - Firearms - Assaults - Sports-related trauma - Recreational injuries - War-related injuries Men are 2x as likely to sustain TBI as wwomen.

Head injury

The overall goals for the patient with a _____________ are: 1.) Maintain adequate cerebral oxygenation and perfusion 2.) Stay afebrile 3.) Be free of discomfort 4.) Be free from infection 5.) Have adequate nutrition 6.) Attain maximal cognitive, motor, and sensory function

Cerebral edema; increased ICP

The principal treatment of head injuries is prompt diagnosis and surgery (if needed). In addition, we institute measures to prevent secondary injury by treating ______________ and managing ____________.

Meningitis; antibiotics

The risk for _________ is high with a CSF leak. _______ should be given as a preventative measure.

Conservative; craniotomy; craniectomy

Treatment of skull fractures is usually _______________. For depressed fractures and fractures with loose fragments, a __________ is done to elevate the depressed bone and remove the free fragments. If large amounts of bone are destroyed, the bone may be removed (__________) and a cranioplasty will be needed later.

CSF leak

Two methods of testing can be used to determine whether there is a ______________: The first method is testing the leaking fluid with a Dextrostix or Tes-Tape strip to determine whether glucose is present, which would be positive. However, if blood is present in the fluid, testing for glucose is unreliable because blood also contains glucose. In this event, look for the halo or ring sign.

Concussion

Typical signs of a _________ include: - Brief disruption in LOC - Amnesia about the event (retrograde) - Headache The manifestations are generally of short duration. If the patient has not lost consciousness, or if the loss of consciousness lasts less than 5 minutes, the patient is usually discharged with instructions to notify the HCP if symptoms persist or if the behavior changes.

Orogastric tube; NG

When a basilar skull fracture is suspected, an ___________ rather than ________ tube should be inserted.

Major head trauma

With __________, many delayed responses can occur, which include: - Hemorrhage - Hematoma formation - Seizures - Cerebral edema

Croup-contrecoup injury

With a contusion, the phenomenon of ___________ is often noted. Injuries can range from minor to severe. Damage from ___________ occurs when the brain moves inside of the skull due to high-energy or high impact injury mechanisms. Contusions or lacerations occur at both at the site of direct impact of the brain on the skull (________) and at the second area of damage on the opposite side away (______), leading to multiple contused areas.

Croup; Contrecroup; Contrecroup

With a contusion, the phenomenon of croup-contrecroup injuryis often noted. Injuries can range from minor to severe. Damage from this occurs when the brain moves inside of the skull due to high-energy or high impact injury mechanisms. Contusions or lacerations occur at both at the site of direct impact of the brain on the skull (_______) and at the second area of damage on the opposite side away (__________), leading to multiple contused areas. ___________ injuries tend to be more severe. The overall prognosis depends on the amount of bleeding around the contusion site.

Seizures

_________ can occur because of a brain contusions, particularly when the injury involves the frontal or temporal lobes.

Lacerations

__________ involve actual tearing of brain tissue. They often occur in association with depressed and open fractures, as well as penetrating injuries. Tissue damage is severe and surgical repair of the laceration is impossible due to the nature of the brain tissue. Medical management consists of: - Antibiotics (until meningitis is ruled out) - Preventing secondary injury related to increased ICP. If bleeding is deep into the brain tissue, focal and generalized signs develop. Intracerebral hemorrhage is generally associated with ______________.

Contusions

__________ may continue to bleed or rebleed and appear to "blossom" on subsequent CT scans of the brain. Bleeding worsens the neurological outcome. Neurological assessment may show focal and generalized manifestations depending on the ____________ size and location. Seizures can occur because of a brain _________, particularly when the injury involves the frontal or temporal lobes.