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Primary Brain Injury

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-Open head injury -Skull fracture or penetrated by object-brain matt expos

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Primary Brain Injury

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-Closed head injury-worst ICP -Blunt trauma -Skull integrity intact

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Primary Brain Injury

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-Mild injury -GCS 13-15 -0-15 minute LOC @ time inj

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Primary Brain Injury

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-Moderate -GCS 9-12 -Up to 6 hour LOC

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Primary Brain Injury

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-Severe -GCS 3-8 > 6 hour LOC

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Open Head Injury-Fractures

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-Linear-line -Depressed-bone pieces in brain matter -Open-bone pieces come off -Comminuted-compound-fragments -Basilar -CSF leakage from ears & nose ↑ RF hemorrhage

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Closed Head Injury-Blunt trauma leads to:

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-Concussion-short LOC -Diffuse axonal injury-acc/decel -Contusion-bruising frontal lobe -Laceration-shering forces, cause bleed-(worse than contusion, low BP-hypoxia-ischemia/edema/inflamm) -Countercoup-hits in front/back skull-shaken baby

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Closed Head Injury-Types of Force

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-Check for spinal cord/neck break -Acceleration injury -Deceleration injury

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NURSING FOCUS on the OLDER ADULT: Head Injury

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-5th leadng cause of death/older adults. ▪65-75yo age-group 2nd highest incidence head inj ▪Falls & MVA's most common cause of head injury.

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NURSING FOCUS on the OLDER ADULT: Head Injury

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▪Factors contribute to high mortality: -Falls caus subdural hematomas/clsd hd inj, chronic -Poorly tolerated systemic stress, which is increased by ad-mission to a high-stimuli environment -Medical comps: hypo/hypertension, cardiac probs

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NURSING FOCUS on the Older Adult: Head Injury-(cont)

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-Decreased protective mechanisms, which make clients susceptible to infections (espec pneumonia) -Decreased immunologic competence, which is further diminished by head injury

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Key Features TBI

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-Loss of memory-short term -Seizure-late sign -LOC/drowsiness -Restless/irritable-early -Disorientation

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Key Features TBI-(cont)

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-Scalp bruising/tenderness -Personality changes-erratic behav -Diplopia-doublevision -Gait changes

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Severe head injury-late

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-Pupil changes -Bradycardia -Papilledema-optic edema/ICP-late sign -HTN/wide pulse pressure-worry for brain perfusion -Hypotension & tachycardia -Hypovolemic shock -Nuchal rigidity -CSF leak

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Care of a Patient with Minor Head Injury

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-Wake every 3-4 hour X 2 days, Neuro assess-LOC -Expect C/O H/A, N/V, dizziness-Report if persist or worsen-NO MORE THAN 72HRS -Acetaminophen for headache as needed -Avoid sedatives & alcohol -No strenuous activity X 48 hours-dec ICP risk -No blowing nose or ear cleaning X 48 hours

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Care of a Patient with Minor Head Injury-(cont)

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-Return to ER for symptoms listed in Chart 47-10 -Blurred vision -Weakness inc sleep -Pupils changes- -Slurred speech

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Increased Intracranial Pressure (ICP)

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-ICP leads to: ↓ cerebral perfusion →Tissue hypoxia → ↓ pH and ↑CO2 → Cerebral vasodilation, edema → ↑ ICP →Brain stem herniation → Irreversible brain damage and death

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Types of Edema

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-Vasogenic edema ↑ brain tissue volume -Abnormal permeability of cerebral vessels smaller/rise of ICP-plasma B infil

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Types of Edema

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-Cytotoxic edema -Hypoxic insult -Disturbance in cellular metabolism-dec glucose/glycogen/O2=anaerobic metabolism -Abnormal fluid accumulation-in brain

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Types of Edema

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-Interstitial edema -Acute brain swelling due to HTN or ↑ CSF pressure.

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Brain Hemorrhage

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-Subdural-slower -Venous bleeding beneath dura & above arachnoid -Acute SDH -within 48 hours of injury -Subacute - 48- 2 weeks -Chronic - 2 weeks to several months

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Brain Hemorrhage

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-Epidural hematoma-fast -Arterial bleeding between dura & skull -Lucidity/momentary unconscness w/i mins of injury -Emergent surgical intervention-eval hematoma

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Brain Hemorrhage

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-Intracerebral hemorrhage -Accumulation of blood within the brain tissue in white matter

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Brain Herniation

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-ICP caused brain tissue to shift & herniate downward

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Brain Herniation

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-Uncal herniation -Life threatening -Pressure to 3rd cranial nerve -Late findings - fixed/dialated pupils & rapid ↓ LOC

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Brain Herniation

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-Central herniation -Downward shift of brainstem -Cheyne-Stokes respiration, pinpoint/nonreactive pupils, hemodynamically unstable

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Irreversible Brain Damage

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-Glasgow Coma Scale <3 -Apnea -No pupillary response -No gag or cough reflex -No oculovestibular reflex, corneal reflex -No oculocephalic reflex

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Irreversible Brain Damage

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-Withdrawal or withholding of life support -Flat EEG -Removal of life support -Organ donation

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Nursing Care

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-Airway Management - first priority

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Nursing Care

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-Vital Sign Assessment -Cushing reflex (triad) -Late sign for ICP -Hypertension -Widening pulse pressure -Bradycardia

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Nursing Care

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-Neuro Assessment -Most important to assess LOC ↓or change in LOC 1st sign in deterioration

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Nursing Care

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-Glasgow coma scale (Figure 43-10 pg 941) -Eye opening -Motor response -Verbal response

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Nursing Care

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-Pupillary response -PERRLA -Pinpoint/nonresponsive - brainstem dysfunction -Ovoid pupil - development of ↑ ICP -Fixed/dilated - poor prognosis, marked ↑ ICP

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Nursing Care

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-Motor response -Assess for bilateral motor function

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Nursing Care

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-Posturing (Figure 44-13, pg 939) -Decerebrate-brainstem dysfunction-extension/extremities, pronation/arms, plantar flexion/opisthotonos (tetanic spasm)

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Nursing Care

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-Decorticate-interruption in corticospinal pathways -Arms, wrists, fingers flexed/internally rotated, plantar flexion legs

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KEY FEATURES of Increased Intracranial Pressure

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-Decreased level of consciousness (lethargy/coma) -Behavior chnges: restlessness, irritability, confusion -Headache -Nausea and vomiting -Change in speech pattern -Aphasia -Slurred speech

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KEY FEATURES of Increased Intracranial Pressure (cont)

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-Change in sensorimotor status -Pupil chngs: dilated/nonreactive pupils ("blown pupils") or constricted and nonreactive pupils -Cranial nerve dysfunction -Ataxia -Seizures -Cushing's triad (reflex) -Abnormal posturing (decorticate, decerebrate)

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Goals for Management

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-Preventing or detecting ↑ ICP -Promoting fluid & electrolyte balance -Monitoring treatment & drug therapy effects -Emotional support for patient/family

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ICP Prevention/Detection-Non-surgical management-

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-Vital signs minimally every 1-2 hours -Fever on admission -Defense mechanism to trauma -Indication of inflammatory response -May indicate hypothalamic damage -No sweating -No diurenal (day & night) temperature variation

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ICP Prevention/Detection-Non-surgical management-

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-Respiratory management -Maintain PaCO2 35-38 mm Hg -Prevent hypercarbia → vasodilation → ↑ ICP -Avoid aggress hyperventilation with ENT suctioning -Allow rest b/t suction, minimal suction if possible

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ICP Prevention/Detection-Non-surgical management-

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-Positioning -Avoid extreme flexion or extension of neck -Maintain neutral midline position -Avoid extreme hip flexion -HOB ↑ > 30⁰

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ICP Prevention/Detection-Non-surgical management-

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-Monitor for CSF leakage -Watch at ears & nose -Halo sign, presence of glucose

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