Acute Cranial Problems Flashcards
Head injury
refers to any trauma to scalp, skull, or brain
Head trauma
refers mainly to cranio-cerebral trauma, which includes alteration in consciousness, regardless of the duration.
Head trauma has high likelihood for poor outcome.
What are time periods of death from head trauma?
Immediately after the injury
Within 2 hrs after the injury
Approx. 3 weeks post injury
Majority of death from a head injury occur immediately after the injury
Types of head injury
Scalp lacerations
- most common type
- scalp is highly vascular (lots of bleeding)
- complications: blood loss and infection
Skull fractures
- Linear or depressed
- Simple, comminuted (3 or more pieces), or compound
- Closed or open
Skull fracture manifestations
Racoon eyes & rhinorrhea (CSF leaking from nose)
Battle sign (postauricular ecchymosis) with otorrhea (CSF from ear) - bruising behind ear
Halo or ring sign (double ring) -Yellowish ring encircles blood if CSF is present
What does CSF leak increase the risk of?
Meningitis
What are head traumas categorized as?
diffuse (several areas to brain) - concussion
focal (localized) – one area - contusion, hematoma
Classification of brain injury
Mild (GCS score 13-15)
Moderate (GCS 9-12)
Severe (GCS 3-8)
Concussions
diffuse injury
a sudden transient mechanical head injury with disruption of neural activity and a change in LOC
Postconcussion syndrome
seen 2 weeks to 2 months post concussion
Chronic traumatic encephalopathy (CTE)
Degeneration in brain from repeated concussions
Signs of concussions
Brief disruption in LOC
Amnesia
Headache
Short duration
Signs of postconcussion syndrome
Persistent headache
Lethargy
Personality & behavioral changes
↓ short-term memory, ↓ attention span
Changes in intellectual ability
Diffuse axonal injury (DAI)
Widespread axonal damage that occurs following mild, moderate, or severe traumatic brain injury (TBI)
Trauma changes the function of axon → results in axon swelling
signs & symptoms: decreased LOC, increased ICP, decorticate, decerebration, global cerebral edema
vegetative state is common
Focal injury
Can be mild to severe; localized to an area of injury
Consists of laceration, contusions, hematomas, and cranial nerve injury
Laceration
focal injury
tearing of brain tissue
Often associated with penetrating injuries
Severe tissue damage
Contusion
focal injury
Bruising of brain tissue within a local area
Coup-contrecoup injury
what is Coup-contrecoup injury>
Coup → contusions or lacerations occur both at the site of direct impact of brain on the skull
Contrecoup → at a secondary area of damage on opposite side away from injury, leading to multiple contused areas
Complications of head injury
Epidural hematoma
Subdural hematoma
Intraparenchymal hematoma
Traumatic subarachnoid hemorrhage
Epidural hematoma
From bleeding between dura & inner surface of skull
Often result of torn artery
Symptoms:
- unconsciousness at the scene
- A brief lucid interval followed by ↓ LOC
- Headache, N/V
Subdural hematoma
From bleeding between dura matter & arachnoid layer of brain
Usually venous in origin, thus, slower to develop
Types of subdural hematoma
Acute subdural hematoma
- signs within 48 hrs of injury
- ↑ ICP; ↓ LOC, headache
Subacute subdural hematoma
- Occur within 2- 14 days of injury
- Subdural hematoma may appear to enlarge over time
Chronic subdural hematoma
- Develops over weeks or months after a seemingly minor injury
- Peak incidence in 50s and 60s
- Alcoholics increased risk
Intraparenchymal hematoma
aka intracerebral hematoma
Collection of blood within parenchyma, from bleeding within brain tissue itself
Usually occurs in the frontal and temporal lobes
Traumatic subarachnoid hemorrhage
Result of traumatic forces damaging the superficial vascular structures in subarachnoid space
May dispose pts to cerebral vasospasm & ↓CBF
Functions of the brain
Frontal lobe
- behaviour, intelligence, memory, movement
Parietal lobe
- intelligence, language, reading, sensation
Occipital lobe
- vision
Temporal lobe
- behaviour, hearing, memory, speech, vision
Cerebellum
- balance, coordination
Brain stem
- blood pressure, breathing, consciousness, HR, swallowing
Brain tumors
Primary- arising from tissues in the brain
Secondary- resulting from a malignant neoplasm located somewhere else in the body. These are the most common kind.
Classified from the tissue they arise from for ex meningiomas.
Over half of all brain tumours are malignant.
Unless treated all will eventually cause death by tumour volume leading to increased ICP.
Manifestations of brain tumors
Depend on location, rate of growth and size.
headache common symptom (worse at night). Dull and constant.
Seizures especially in gliomas and brain metastases.
Nausea and vomiting from increased ICP
Cognitive and motor dysfunctions and sensory deficits depending on location of the tumour.
What does tx of brain tumors aim to do?
- Identifying the tumour
- Removing or decreasing tumour mass.
- Preventing or managing increased ICP
What is the care of brain tumors?
meds - steriods
sx - risk of removing part of the brain that is functional (removes tumor)
Ventricular shunts (fluid in ventricles- risk of infection and displacement)
Radiation
Chemo (systemic) and targeted therapy (difficulty d/t BBB)
Neurosurgery reasons
The removal or repair of brain tissue to prevent more harm
To give palliative relief of distressing symptoms when the cause cannot be removed
Trauma
- Fractured skull, Traumatic brain injury
Infection
- Cerebral and spinal abscesses
Vascular disorders
- Cerebral aneurysm, Arteriovenous malformation
Spinal disorders
- tumors of spine
Congenial abnormalities
- hydrocephalus
Cerebral and spinal tumors
- glioma
Degenerative disorders
- Arthritic changes in the spine
Surgical approaches
Burr Holes
- Holes drilled into skull and is used for
- Insertion of brain needles to remove tissue for biopsy, or subdural hematoma
- To insert Gigli’s saw to create a bone flap in a craniotomy
Craniotomy - bone flap is surgical removed and then returned after sx. performed so brain can be accessed for further sx
Decompressive craniectomy - bone flap is removed but us not returned to skull after sx. performed to relieve pressure on brain
Hypophysectomy - removal of pituitary gland
Post craniotomy care
Safe recovery from anesthesia
Monitoring for signs of increased ICP & its clinical management
Provide nursing care based on pt’s degree of dependency
Promote rehabilitation
Management of Increased ICP
Hourly neurological observations, e.g., Glasgow Coma Scale
VS per protocol, e.g., q1h
Full neurological assessment
Report any change in pt’s condition immediately
Admin ordered meds to increased ICP
Likely caused by hemorrhage into wound site, cerebral edema, or hydrocephalus
- increase HOB to 30-40 degrees
- Chin and sternum should be aligned
- Pace nursing activities to frequency of stimulation
- Prevent constipation (don’t want straining)
- Pain control
- Require good oxygen supply and sufficient CO2 to stimulate respiration
- If cerebral edema is causing deterioration of neurological status,
May need to administer Mannitol
Wound care
Inspect incision to ensure edges remain well approximated and staples/sutures intact
Monitor for redness, discharge, signs of infection
Incision usually left open to air
Removal of sutures, usually in 2 wks
Cover incision when going outside
Safety considerations
Support positioning with towels and pillows to prevent pressure on surgical site
Sign at bedside e.g, “No right bone flap”
Keep bed at lowest level – risk of falling
Bacterial meningitis
Acute inflammation of meningeal tissues surrounding brain & spinal cord
Medical emergency
Clinical manifestations of bacterial meningitis
Fever, severe headache
N/V
Nuchal rigidity (resistance to flexion of the neck)
+ve Kernig sign (pain when hip flexed to 90º and extension of the knee)
Complications of bacterial meningitis
↑ ICP (major cause of altered mental status)
Encephalitis
acute inflammation of brain (from virus)
Manifestations of encephalitis
Onset is typically nonspecific
Fever, headache, N/V
Signs appear on day 2 or 3
Signs may vary from min. to coma
Hemiparesis, seizures, tremors, cranial nerve palsies, personality changes, memory impairment, amnesia
