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Etiology of Trauma To The Brain

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This can occur due to a number of reasons, which include: - Motor Vehicle/Motorcycle Accident - Falls - Acts of violence - Team sports - Alcohol and Drug Use

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Common Demographic for Brain Injury

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This mostly occurs with Males ages 18-34. They take more risks when driving, drink alcohol, and tend to play more sports.

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Forces of Impact

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These can vary, and influence the type of head injury you can have: - Acceleration - Deceleration

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Acceleration Impact

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This type of impact deals with an immobile head struck by a moving object (Head moves back)

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Deceleration Impact

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This type of impact deals with the head pushing forward and hitting a stationary object (steering wheel, windshield) - Frontal and temporal are most commonly involved with personality changes.

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Primary Brain Injury

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This is damage that occurs at the time of an injury. Examples of this include: - Open Head Injury - Closed Head Injury

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Primary Brain Injury: Open Head Injury

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This is when the skull is fractured or when it is pierced by a penetrating object. Three examples include: - Linear Fracture - Depressed Fracture - Basilar Skull Fracture

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Open Head Injury: Linear Fracture

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This is a type of open head fracture where a *clean break* occurs. It makes up 80% of all skull fractures.

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Open Head Injury: Depressed Fracture

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This is a type of open head fracture where the bone is pressed inward into the brain tissue. Fragments of the bone penetrates brain tissue.

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Open Head Injury: Basilar Skull Fracture

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This is a type of open head fracture that occurs at the base of the skull. Evidence of this includes: - CSF leakage from the nose or ear - Rhinorrhea or Otorrhea - Potential for hemorrhage - Battle Sign - Raccoon eyes

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Battle Sign

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This is a sign that occurs when the meninges tear and there is bruising around the mastoid process. (Bruising behind the ears)

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Raccoon Eyes

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This is a sign of brain injury that appears as black and blue around the eyes.

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Primary Brain Injury: Closed Head Injury

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This is a brain injury that is a result of blunt trauma; the integrity of the skull is not violated. This leads to concussions, contusions, and lacerations of the brain. Examples include: - Concussion - Contusion

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Concussion

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This is a shaken movement of the brain. At times, there can be a brief loss of consciousness, some however, do not loss consciousness. The severity of this depends on the length of time the patient has lost consciousness.

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Contusion

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This is a bruising of the brain tissue most often at the site of impact. This manifests according to the area involved. - If this occurs in the brain stem: Unresponsiveness

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Laceration

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This is an actual tearing of the cortical surface vessels which may lead to secondary hemorrhage and significant cerebral edema and inflammation.

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Secondary Brain Injury

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This is any neurological damage that occurs after the initial injury. Examples include. - Increased ICP - Hemorrhage - Herniation

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Secondary Brain Injury: Increased ICP

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This is the leading cause of death of head injury patients that reached the hospital alive.

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10 - 15 mg/hg

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This is the normal ICP. Ideally, you definitely want this to be less than 20 mg/hg

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Cranial Contents

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These include: - Brain Tissue - Blood - CSF Any increase in volume in one component must be compensated for by an decrease in another component. Normally the brain responds by displacing CSF, so the ICP doesn't increase. However, when compliance doesn't occur, the brain doesn't accommodate, then ICP will increase.

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Increased ICP Manifestations

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As this increases, cerebral perfusion decreases, leading to tissue hypoxia, and an increase in CO2. This causes cerebral vasodilation, edema, and a further increase in this, and the cycle continues.

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Untreated ICP

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If this condition remains untreated, the brain may herniate downwards toward the brain stem (Uncal Herniation) causing irreversible brain damage and possibly death.

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Secondary Brain Injury: Hemorrhage

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This is a secondary injury that can cause brain hematomas (collection of blood) or clots. All hematomas are potentially life threatening because they act s space-occupying lesions and are surrounded by edema.

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Epidural Hematoma

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This is a hemorrhage that results from an arterial bleed. It is a neurological emergency. There is a temporary loss of consciousness, followed by a *return* of consciousness, then followed by a loss of consciousness again. - Symptoms progress very quickly - Creates increased ICP

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Subdural Hematoma

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This is a hemorrhage that results from a venous bleed. With this, bleeding occurs more slowly than with an epidural hematoma. This type as the highest mortality rate.

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Intracerebral Hemorrhage

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This is a hemorrhage that has an accumulation of blood within the brain tissue.

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Herniation

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All forms of these are life threatening. Notify the MD immediately when you suspect this. Examples include: - Transtentorial (Uncal) " " - Central " "

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Transtentorial (Uncal) Herniation

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Here, in the presence of increased ICP, the brain tissue may shift and herniate downward. - Shift of the Uncus (One or two areas of the temporal lobe)

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Signs and Symptoms of a Transtentorial (Uncal) Herniation

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These signs and symptoms include: - Dilated and non-reactive pupils - Ptosis (drooping eyelids) - Rapid deterioration in LOC

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Central Herniation

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This is a downward shift of the brainstem and the diencephalon.

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Signs and Symptoms of a Central Herniation

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These signs and symptoms include: - Cheyne-Stokes Respiration's - Pinpoint and nonreactive pupils

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Cheyne-Stokes Breathing

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This is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.

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Physical Assessment: Any Patient w/ Head Trauma

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This patient should be assessed for a spinal cord injury - Always look at the spinal cord - Loss of motor/sensory function - Tenderness along the spine

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Physical Assessment: ABC's and Vital Signs

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Any injury to the brain stem - think breathing. Also, be concerned with any signs and symptoms of increased ICP. If missed, the patients condition can advance to cushing's triade. Assess for: - LOC Change - Dyspnea (Increased RR) - Vertigo - Confusion, Delirium, or Disorientation - Seizures - Ataxia - Amnesia to events before the injury - Abnormal Posturing (Decorticate & Decerebrate)

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Physical Assessment: CSF Leak

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This can come out of the ears and nose. Glucose, a yellow ring surrounding with bloody drainage - *Halo Sign - If this occurs, assess for *nuchal rigidity* which indicates meningitis, after cervical injury is ruled out.

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ICP Increase: Change in level of Responsiveness

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This is the first indication of an increase in ICP. Signs and Symptoms include: - Restlessness - Irritability - The patient wants to sleep

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ICP Increase: Change in Vital Signs

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These signs and symptoms include: - Increased or decreased pulse - Widening or narrowing pulse pressure - Increased Temperature

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ICP Increase: Additional Signs and Symptoms

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These include: - Headache - *Projectile* Vomiting - Pupillary Changes - Cushing's Triad

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Cushing Reflex (Cushing's Triad)

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This is a late manifestation of an increase in ICP. The body is trying to re-perfuse the brain. Assess the patient and call the MD stat.

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Cushing's Triad Signs and Symptoms

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These signs and symptoms include: - Severe hypertension w/ widened pulse pressure - Bradycardia - Bradypena - As ICP increases, the pulse becomes thready (very fine and scarcely perceptible), irregular, and rapid.

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Colace

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This is given to patients with an increased ICP to avoid a strain in bowel movements, as this can further increase ICP.

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Brain Trauma Nursing Interventions: Patient w/ Severe Head Trauma

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This type of patient is admitted to the critical care unit or a trauma center.

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Brain Trauma Nursing Interventions: Patient w/ a Moderate Head Trauma

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This type of patient is admitted to either the general nursing unit or the critical care unit where they are closely observed for at least 24 hours.

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Brain Trauma Nursing Interventions: Patient w/ a Mild Head Trauma

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This type of patient may be sent home from the ER with head trauma instructions (wake every 2 hours for 8 hours, etc..)

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Brain Trauma Nursing Interventions: ABC's

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With this intervention, ensure adequate airway & ventilation.

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Brain Trauma Nursing Interventions: Vital Sign Assessment

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With this intervention, monitor V/S Q 1-2 hours. - Patients can have a fever early (Defense Mechanism) Treat the fever immediately because it increases cerebral blood flow, which increases ICP. Give Tylenol. Be concerned with an infection risk if there is a late fever.

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Brain Trauma Nursing Interventions: Positioning

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With this intervention, things to consider: - Avoid any extreme flexion or extension of neck especially with increased ICP - Maintain the head in midline, with the neck in the neutral position. - Log Rolll - no draw sheet. This requires 2 people, moving the patient as one unit. - Avoid hip flexion: This is *NOT* allowed with patients with increased ICP.

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Brain Trauma Nursing Interventions: Hyperventilation

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Patients should avoid this 24 hours as it causes ischemia which leads to ICP. - Sometimes this is necessary if the patient is deteriorating - but only for a short time. - If the patients PaCO2 is increased 55-60, then do this to decreased CO2 - Ideally, you want patients who are vented to have PaCO2 between 35-38; on the low side. As close to normal as possible, not too low. Too low can cause vasoconstriction leading to hypoxia.

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Brain Trauma Nursing Interventions: Induced Barbituate Coma

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With this intervention, you don't want the brain to perform any work, and you want to prevent more damage from occurring. Any stimuli can increase ICP. With this, the brain is at rest.

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Brain Trauma Nursing Interventions: Drug Therapy

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With this intervention, you would use medications such as Mannitol, Lasix and Neuromuscular Blocking Agents (NMBA) like Pavulon.

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Mannitol

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This is an Osmotic Diuretic used for the treatment of cerebral edema. It is most effective if given as a bolus rather than as a continuous infusion. It is administered through a filtered IV and needle. It is also used for a very short term. - Frequent I&O (For osmotic and loop diuretics): Foley Cathter - Do *NOT* give to a patient with no urine output

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Lasix

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This medication is often given as an adjunctive therapy to Mannitol.

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Neuromusclar Blocking Agents (NMBA) - Pavulon

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This is a strong muscle relaxant. An MD *must* administer this medication. Also, it must *NEVER* be used without aggressive sedation - NEVER when patient is awake.

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Brain Trauma Nursing Interventions: Fluid & Electrolyte Management

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With this nursing intervention, consider pituitary gland damage, if it has been injured, and what that can cause: - SIADH - Diabetes Insipidus (W/ this give, Vasopressin) Weigh the patient daily, and check urine output.

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Vasopressin

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This medication is responsible for increasing water absorption in the collecting ducts of the kidney nephrons. It is given to patients w/ Diabetes Insipidus (as it relates to the topic of pituitary glad damage from trauma)

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Brain Trauma Nursing Interventions: ICP Monitoring

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With this intervention, you must consider: - reduced stimulation to the patient (avoid sensory overload) - Space out your nursing care, one task at a time so as not to over stimulate the patient - Allow the patient to rest in a calm, quiet environment - Low lighting - No vigorous suctioning and ALWAYS pre-oxygenate the patient beforehand - Think safety if they have a seizure - If they are restless, mittens on their hands - If the patients feet become flaccid, get a foot board or high top sneakers.

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Surgical Management: ICP Device

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With this surgical managment, you want the ICP less than 20. (Normally 10 - 15)

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Surgical Management: Goal

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With this, you want a normal ICP, you want the patient A&Ox4, and have them return to baseline.

Nursing 22: Oncology – Exam 3 (Traumatic Brain Injury) – Flashcards

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