Brain Injury Flashcards by Daphmy Francois

Headache
Dizziness
Insomnia
Impaired learning

Post concussion syndrome

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Mild traumatic injury 
Temporary loss of neuro function 
With or without LOC 
amnesia common 
Headache

Concussion

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Normal pressure found in the brain is 10-15mm/Hg

ICP

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Cerebral blood flow decreases significantly
Triggers increase in arterial pressure with widening pulse pressure
Bradycardia
Bradypnea

Cushings reflex

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Mannitol/diuretics
Decreasing cerebral edema 
Lowering CSF volume 
Controlling fever 
Maintaining B/P
Oxygenation 
Reducing cellular demands

Medical management Of ICP

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Ventricular catheter monitoring ICP

Ventriculostomy

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Brain stem herniation
Diabetes insipidious
SIADH
anoxic brain death

Complications of ICP

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Deceased secretion of ADH
Excessive urine output 
Decreased serum osmolality 
• Adminster fluids
• electrolyte replacement
• vasopressin

Diabetes Insipidus

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Increased secretion of ADH 
patient become fluid overloaded 
Urine output diminishes 
Serum sodium becomes dilute 
• fluid restriction

SIADH

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Changes in pupillary response
Changes in behavior, restlessness, increased anxiety,
Sluggish pupil response

Clinical manifestations of AMS

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is an area of skin associated with a pair of dorsal roots from the spine
o The significance of dermatomic regions is important as pain in a dermatomic area may indicate spinal damage or neurological stenosis.

Dermatome

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A. Mental status
B. Cranial nerves
C. Motor system
D. Sensory system
E. Reflexes

Neuro assessment

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Intentional: Pt can’t pick up item because he develops tremor due to demyelinization of peripheral seen in

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Tremor at rest as seen
is due to absence of dopamine, therefore the muscle cannot relax, causing muscle tremors in relaxed state
▪ Tremors decrease when moving

Parkinson’s

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• 1˚ injury - coup and counter coup injury
o Contusions lacerations damage to blood vessels
• 2˚ injury - when cells are killed off they continue to kill surrounding cells
o Chemical Cascade Effect
• There is a chemical cascade that will continue to kill surrounding tissue

Brain injury

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Blood collects between the dura mater & arachnoid layer

Venous

Subdural hematoma

Headache 
Drowsiness
Slowed thinking 
Confusion 
~ Tx: craniotomy

Subdural hematoma

Arterial bleed 
Between skull and dura
* requires rapid intervention 
* STAT BURR HOLES 
LOC
SEIZURES
HEADACHES 
HEMIPARESIS 
IPSILATERAL 
CUSHINGS

Epidural hematoma

Coughing 
Sneezing 
Valsalva
Suctioning 
Increased metabolic rate 
Prone position 
Seizure 
Stressors- pain bright lights

Causes of ICP

Pressure on brainstem
Lack of blood and oxygen
Not treated causes herniation.

Pathophysiology of brainstem

• Put pt on ventilator
• Hyperventilate pt to keep CO2 btw 25-35 (hypocapnia)
• Hypocapnia vasoconstricts the blood vessels in the brain
• It will maintain pressure in the brain
• IICP monitoring:
o High level neuro units will use catheters that can remove CSF pressure
o Pressure of 30mm/Hg means that pt is about to herniaten

Nursing Interventions ICP

Blown pupils
At this point 25-50cc CSF will be removed
Pt will develop spinal h/a, but will survive due to dec. brain capacity

S/S of herniation:

o Change in LOC/alertness – Mentation (mental status)
o Irritability – most common sign – the 1st sign
o Confusion, disorientation and agitation – later sign - most severe s/s

Early signs of ICP

posture is an abnormal postering that involves rigidity, flexion of the arms, clenched fists, and extended legs (held out straight). The arms are bent inward toward the body with the wrists and fingers bent and held on the chest

Decorticate

posture is an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain.

Decerebrate

``` Ipsilateral dilation Contrahemiparesis Neurological posturing Decorticorte Decebrate ```

Mild sign ICP

``` CUSHINGS triad 1. Systolic HTN 2. Widening pulse pressure 3 bradycardia Cheyenne stokes respirations Headache Projectile vomiting Papilledema ```

Late sign of ICP

``` • Mean Arterial Pressure – MAP • Measure arterial pressure – optimally 70-100mg/Hg o CPP: MAP – ICP = CPP EX: map 100-icp 15 =cpp 85 o As ICP incr. CCP dec. o Keep at 70mm/Hg ```

Cerebral perfusion pressure

Protects brain by decreasing cerebral metabolic rate

Barbiturate coma

It is an osmotic diuretic o Contains large glucose molecules/ osmotic pull o It will pull water from brain into intervascular compartment ▪ This will cause hypovolemia ▪ This will cause diuresis - unusually large urine output ▪ Mannitiol dehydrates pt ▪ Dec. BP ▪ Inc. HR ▪ Dec. urine ▪ Watch pt carefully – we can’t give fluids since fluid is going directly back to brain • Pt must be monitored extra carefully for hypovolemic shock ▪ Mannitol will remove Na and K ▪ Pt is NPO • Give pt supplements to restore what has diuresed out ▪will halt herniation

Manitol

``` o HOB elevated 30 ˚ Hyperventilation- increase RR pt of CO2 in blood to prevent swelling ▪ Neck must be straight ▪ No flexing o Osmotic therapy ▪ Have mannitol ready ▪ Prepare IV and poly catheter o Ventilator for hyperventilation o Ventricular drainage for ICP ```

1st line of management ICP

▪ Comes in a tube ▪ It crystallizes over time over 15% concentration ▪ Must melt it in warm water for 20 min ▪ Put filter when hanging from IV ▪ The above takes time, prepare in advance

Mannitol preparation

o Barbiturate coma ▪ Use pentobarbitol ▪ Snow pt ▪ All metabolism red. – dec. HR, dec. temp ▪ If metabolism is down 4-5 days, swelling will not destroy brain ▪ When pt comes out of coma, swelling should be resolved o Hypothermia – pt temp dropped to 92-94˚F o Emergency burr holes

2nd tier of management of ICP

``` • ABC – assess q 2 h: o Monitor pt carefully o Make sure pt is breathing o Color is good o Listen to respiration • Airway adjust prn • Administer O2 as necessary • HOB > 30˚ • Keep PaCO2 25-30mm/Hg – hypocapnea ```

Ineffective breathing pattern r/t LOC increased ICP

``` • Pt neuro WNL • ICP – WNL • Monitor ICP q 1-2 hrs • Neuro assess q 15 -30 min • HOB 30˚ • No flexing neck • Pt teaching • Administer meds on time – have Mannitol ready to go • Monitor hypothermia • No suctioning unless necessary • Calm environment o Laying of hands or touch therapy found to dec. ICP • With Mannitol, we look for dehydration ```

Altered cerebral tissue perfusion r/t IICP

• Cluster nursing activity • Plan nursing activity around low trend in ICP • Allow rest periods for ICP to return to baseline • Dec. environmental stimuli • Plan care w/ minimal disturbance to pt o Difficult since neuro check is done q 15 mins. • Monitor airway • Prevent seizure • Nutrition o Mouth care is #1 NI to prevent pneumonia when is pt on ventilator o Pt on tube feedings 24-48 hours after initial insult will have a dramatic positive effect on their brain • DVT