Exam 2: TBI Flashcards
Head injury
Broad classification, injury to scalp, skull, or brain
Most common cause of death from trauma
Most common cause of brain trauma = falls
Open: Gun shot wound, stabbed
Closed: Car accident, fell and hit head
Scalp wounds
Bleed a lot, portals for infection
Extra pressure and extra gauze needed
Skull fractures
Localized, persistent pain
Base of skull fracture signs:
Bleeding from nose, pharynx, ears
Battle sign: Ecchymosis behind ear (postauricular)
Halo sign: Ring of fluid around blood stain from drainage = CSF leak
Closed brain injury
Blunt trauma
Acceleration/deceleration damages brain tissue. More commonly damages back part of brain
First 24 hours priority is to stabilize patient and stop bleed, after 24 hours worry about brain swelling
Diffuse axonal injury
Widespread axon damage in the brain seen with head trauma, patient develops immediate coma
CT scan is diagnostic choice for someone admitted with possible brain bleed, faster than MRI
Open brain injury
Object penetrates brain or trauma is so severe that the scalp and skull are opened
Epidural Hematoma
Blood collection in space between skull and the dura
Patient may have brief loss of consciousness with return to lucid state, as hematoma expands increased ICP will often suddenly reduce LOC
EMERGENCY, in and out of consciousness
Don’t want systolic BP above 150 or bleed could get bigger
Treatment: Decrease ICP, removal of clot in OR, stop bleeding (decrease BP and burr holes), pain medicine, turn lights off, be calm, ICU patient
Subdural Hematoma (acute)
Collection of blood between dura and the brain
Acute: 24-48 hours
Subacute: 48 hours-2 weeks
Can require immediate craniotomy and control of ICP
Common in patients with blood thinners
Subdural hematoma (chronic)
Develops over weeks to months
Causative injury may be minor and forgotten
S/S may fluctuate: Dull headache, alternating neuro changes that fluctuate, focal seizures, gradual confusion
Treatment: Evacuation of clot, skull stays on post-op if not worried about swelling
Intracerebral hemorrhage
Hemorrhage in substance of brain, may be caused by trauma or non-traumatic cause (high BP)
Treatment: Control ICP, administer fluids, electrolytes, anti-hypertensives, craniotomy or craniectomy to remove clot and control hemorrhage not common, can take off skull flap to relieve pressure
Neuro assessments every hour, ANY change in MS (including vomiting) must be reported to provider
Manifestations of brain injury
Altered LOC need Glasgow coma scale/neuro assessments every hour
Pupillary abnormalities (late sign)
Sudden onset of neuro deficits and changes (change in sense, movement, reflexes, strength)
Change in VS
Headache
Seizures
Monroe-Kellie Hypothesis
Normal state ICP <20
Compensated state = Normal ICP
Decompensated state = elevated ICP
Management of PT with head injury
Assume cervical spine injury until it’s ruled out
Preserve brain homeostasis and prevent secondary damage: Treat cerebral edema, maintain cerebral perfusion, treat hypotension/hypovolemia/bleeding, monitor/manage ICP, maintain oxygenation/CV and resp function, manage fluid and electrolytes
GCS < 8 = INTUBATE
CPP
CPP = most important value, adequate oxygen getting to brain
CPP = MAP - ICP
Normal ICP: <20
Normal CPP: >60
Order: SBP <150, MAP>60, ICP<20, and CPP >60
ICP obtainted through ventriculostomy
Supportive measures
Respiratory support, intubation/mechanical ventilation
Seizure precautions/prevention
NG tube
Fluid and electrolytes
Pain and anxiety
Nutrition
Cerebral Salt Wasting (CSW)
Body compensates by going into diabetes insipidus
Decreased Serum Sodium
Increased Urine Sodium
Increased Urine Output
Concussion
Temporary loss of consciousness with no apparent structural damage
NO head bleed
Grade 1: Transient confusion, no loss of consciousness, symptoms resolve in less than 15 minutes
Grade 2: Transient confusion, no loss of consciousness, symptoms resolve in greater than 15 minutes
Grade 3: LOSS OF CONSCIOUSNESS from seconds to minutes, worsening headache, dizziness, seizure, abnormal pupil response, vomiting, irritability, slurred speech
Concussion management
Observation after head trauma, report immediately:
Any change in LOC or mental status
Difficulty awakening, lethargy, dizziness, confusion, irritability, anxiety, difficulty in speaking/movement, severe headache, n/v
PT should be aroused and assessed frequently, never skip a neuro assessment
Diagnostic evaluation of concussion
Physical and neuro exam
Skull and spinal radiography
CT scan
MRI
Complete body assessment to make sure they didn’t hit anything else
Cushing’s Triad
3 Symptoms someone is about to herniate (brain is so swollen going into brain stem, if you get herniated into brain stem = brain dead = EMERGENCY)
- Bradycardia
- Widening pulse pressure
- Irregular respirations
Assessment of PT with brain injury
Health history with focus on immediate injury, time, cause, direction, force of blow
LOC - Glasgow Coma Scale (GCS) worst GCS is 3
Cranial nerves
ICP monitoring (Ventriculostomy/EVD or Camino Bolt)
Multisystem assessment
Pupil Assessment
PERRLA (Pupils equal, round, reactive to light accommodation)
Know PT’s baseline
Complications of TBI
Decreased cerebral perfusion
Cerebral edema and herniation
Impaired oxygen and ventilation
Impaired fluid, electrolyte, nutritional balance
Risk of post-traumatic seizures
Infection from leakage of CSF from nose or ear
Mannitol
Osmotic diuretic
Treatment of elevated ICP, decreases ICP through diuresis
Nursing considerations: VS, weight, I&O, renal function, serum sodium and potassium
Major goals of care of PT with TBI
Maintenance of patent airway
Fluid and electrolyte
Adequate nutritional status
Prevent secondary injury
Maintain normal temperature
Maintain skin integrity
Improve cognitive function
Effective family coping
