Head/Brain Injury

Question 1

Any injury or trauma to the
- Skull
- Scalp
- Brain

• Traumatic brain injury (TBI)
• High incidence

Answer 1

Causes
- Motor vehicle collisions & falls (most common)
- Firearm-related injuries
- Assaults
- Sports-related injuries
- Recreational accidents
- War-related injuries

Question 2

• High potential for poor outcome

Answer 2

• Deaths occur @ 3 time points > inj:
  1. Immediately > the inj (most common; either from the direct head trauma or from massive hemorrhage & shock)
  2. Within 2 hrs > the inj (c/b progressive worsening of the head inj or internal bleeding)
  3. 3 wks > the inj (result from multi-system failure)

Question 3

Types of Head Injuries

Scalp Lacerations
- External head trauma
- Scalp is highly vascular → profuse bleeding
- Major complications → blood loss & infection

Answer 3

Question 4

Types of Head Injuries

• Skull fx’s freq occur w/head trauma
• Linear or depressed
• Simple, comminuted, or compound
• Closed or open

Answer 4

• Location determines manifestations

Complications
- Infections
- Hematoma
- Tissue damage

Question 5

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Occurs when there’s a break in continuity of bone w/o alteration of relationship of parts

Is assoc w/low-velocity inj

Answer 5

Linear fx

Question 6

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Is an inward indentation of skull & is assoc w/a powerful blow

Answer 6

Depressed skull fx

Question 7

A simple linear or depressed skull fx is w/o fragmentation or communicating lacerations; c/b low to moderate impact

Question 8

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Occurs when there are multiple linear fx’s w/fragmentation of bone into many pieces; is assoc w/direct, high-momentum impact

Answer 8

Comminuted fx

Question 9

An example of a compound fx is a depressed skull fx & scalp laceration w/communicating pathway to intracranial cavity

• Assoc w/severe head inj

Answer 9

Fx’s may be closed or open, depending on the presence of a scalp laceration or extension of the fx into the air sinuses or dura

Location of the fx determines clinical manifestations

Question 10

• The major potential complications of skull fx’s are intracranial infections & hematoma, as well as meningeal & brain tissue damage

Answer 10

• Also important to note that in cases where a basal skull fx is suspected, an NG or oral gastric tube should be inserted under fluoroscopy

Question 11

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Is a specialized type of linear fx that occurs when the fx involves the base of the skull

• Manifestations can evolve over the course of several hrs, vary w/the location & severity of fx, & may incl CN deficits, Battle’s sign (post-auricular ecchymosis), & peri-orbital ecchymosis (raccoon eyes)

Answer 11

basilar skull fx

Question 12

• Is generally assoc w/a tear in the dura & subseq leakage of CSF
• Rhinorrhea (CSF leakage from the nose) or otorrhea (CSF leakage from the ear) generally cnfms that the fx has traversed the dura

Answer 12

• Rhinorrhea may also manifest as postnasal sinus drainage

! The significance of rhinorrhea may be overlooked unless the pt is spec assessed for this finding

Question 13

! Risk of meningitis is high w/a CSF leak, & abx should be admin to prevent the development of meningitis

Question 14

• 2 methods of testing can be used to determine whether the fluid leaking from the nose or ear is CSF

1. Test the leaking fluid w/a Dextrostix or Tes-Tape strip to determine whether glucose is present
   > CSF gives a positive glucose reading

Answer 14

2. If blood is present in the fluid, testing for the presence of glucose is unreliable b/c blood also contains glucose
   > Look for the halo or ring sign
   - Allow the leaking fluid to drip onto a white gauze pad (4x4) or towel, & then observe the drainage
   - Within a few min, the blood coalesces into the center, & a yellowish ring encircles the blood if CSF is present

! both tests can give false (+) results

Question 15

Types of Brain Injuries

1°

• Happens @ time of inj
• Focal or diffuse
• Open or closed
• Mild, moderate, severe

Answer 15

2°

• Occurs > the initial inj & worsens outcomes
• e.g., post-concussion synd, hypotension & hypoxia, IICP, hemorrhage, etc.

Question 16

Brain injuries are classified as diffuse (generalized) or focal (localized)

• In a diffuse inj (e.g., concussion, diffuse axonal), damage to the brain cannot be localized to one particular area of the brain

Answer 16

• In a focal inj (e.g., contusion, hematoma), damage can be localized to a spec area of the brain

Question 17

Classification

• Minor/Mild (GCS 13-15)
  > probably d/c’d to home w/teaching to have someone monitor for problems
• Moderate (GCS 9-12)
  > gets admitted to the hosp but on a reg med/surg floor, most likely, & is monitored for any complications

Answer 17

• Severe (GCS 3-8)
  > admitted to critical care

Question 18

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> a minor diffuse head inj
* Brief disruption in LOC
* Retrograde amnesia
* HA
* Short duration

Answer 18

Concussion

Question 19

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May develop in some pts & is usually seen anywhere from 2 wks to 2 mos > the inj

• persistent HA
• lethargy
• personality & behavior changes
• shortened attention span, decr short-term memory
• changes in intellectual ability

Answer 19

postconcussion syndrome

Question 20

Diffuse Axonal Injury (DAI)

• Widespread axonal damage > a mild, moderate, or severe TBI
• Decr LOC
• IICP
• Decortication, decerebration
• Global cerebral edema

Answer 20

• Approx 90% of pts w/DAI remain in a persistent vegetative state

Question 21

Focal

Focal injury
- Lacerations
- Contusions
- Hematomas
- CN injuries

Answer 21

Lacerations

• Involve actual tearing of brain tissue & often occur in assoc w/ depressed & open fx’s & penetrating injuries

Intracerebral / Subarachnoid / Intraventricular (the latter 2 can occur 2° to head trauma)

Question 22

____ hemorrhage

Is generally assoc w/cerebral laceration

Manifests as a space-occupying lesion accompanied by unconsciousness, hemiplegia on the contralateral side, & a dilated pupil on the ipsilateral side

Answer 22

Intracerebral

Question 23

Contusions

• Bruising of brain tissue within a focal area
• Usually assoc w/closed head inj
• Can cause hemorrhage, infarction, necrosis, edema; freq occurs @ a fx site

Question 24

Coup-Contrecoup aka Acceleration-Deceleration Injury

• Occurs when the brain moves inside the skull d/t high-energy or high-impact inj mechanisms
• Contusions or lacerations occur both @ the site of the direct impact of the brain and on the opposite side away from inj (contrecoup), leading to multiple contused areas

Answer 24

• Contrecoup inj tend to be more severe, & overall pt prognosis depends on the amt of bleeding around the contusion site
• Also called acceleration-deceleration inj

Question 25

Types of Head Injuries

Answer 25

Contusion - Can rebleed - Focal & generalized manifestations - Monitor for seizures - Potential for incr hemorrhage if on anticoags

Question 26

? Results from bleeding between the dura & the inner surface of the skull ! neurologic emergency - venous → slow origin - arterial → fast origin

Answer 26

Epidural hematoma

Question 27

Epidural Hematoma - Initial period of unconsciousness - Brief lucid interval followed by decr in LOC - HA, n/v - Focal findings - Requires rapid evacuation

Answer 27

Question 28

? Bleeding between the dura mater & arachnoid layer of the meninges - Most common source is the veins that drain the brain surface into the sagittal sinus - Can also be arterial - May be acute, subacute, or chronic

Answer 28

Subdural hematoma

Question 29

___ ___ hematoma - within 24-48 hrs of the inj - sx's r/t incr ICP - ↓ LOC, HA - Ipsilateral pupil dilated & fixed if severe

Answer 29

acute subdural

Question 30

___ ___ hematoma - within 2-14 days of the inj - may appear to enlarge over time

Answer 30

subacute subdural

Question 31

___ ___ hematoma - wks or mos > inj - more common in older adults - presents as focal sx's - ↑ risk for misdiagnosis (manifestations are misinterpreted as vasc dz [stroke, TIA, & dementia])

Answer 31

chronic subdural

Question 32

____ hematoma - bleeding within the brain tissue - usually within frontal & temporal lobes - size & location of hematoma determine pt outcome

Answer 32

Intracerebral

Question 33

Answer 33

Brain Death *Criteria to determine brain death:* ✓ Coma of known cause as est by hx, clinical exam, lab testing, & neuro imaging ✓ Normal/near normal core body temp (> 96.8°F) ✓ Normal systolic BP (≥100 mmHg) ✓ Neuro exam (1-2 dep on state)

Question 34

Diagnostic Studies * CT scan > Best diagnostic test to determine craniocerebral trauma * MRI, PET, evoked potential studies > MRI more sensitive for small lesions * Functional MRI > To identify anoxic inj to the brain

Answer 34

* Transcranial Doppler studies > To measure CBF velocity * c/s x-ray * GCS

Question 35

Collaborative Care - *Emergency Treatment* ✓ Patent airway ✓ Stabilize c/s ✓ O2 via non-rebreather mask ✓ IV access via 2 large-bore catheters ✓ Intubate if GCS <8 ✓ Control external bleeding w/sterile pressure dressing ✓ Remove pt's clothing

Answer 35

✓ Maintain pt warmth ✓ Ongoing monitoring - of VS, LOC, O2, cardiac rhythm, GCS, pupil size & reactivity ✓ Anticipate poss intubation if gag reflex is impaired or absent ✓ Assume neck inj w/head inj ✓ Admin fluids cautiously to prevent fluid overload & IICP

Question 36

Treatment Principles - Prevent 2° inj (by treating cerebral edema & managing IICP) - Timely dx - Surgery if necessary

Answer 36

Concussion & contusion - Observation & management of ICP

Question 37

Rx's Diuretics - Mannitol, Lasix > glucocorticoids would NOT be used as they have no ICP decr mechanisms Sedatives - Propofol Opioids - Morphine sulfate, fentanyl

Answer 37

Anti-epileptics - phenytoin Antipyretics - acetaminophen (APAP) Barbiturates - coma-inducing (pentobarbital) > to decr metabolic demands & decr IH NSAIDs - potentially for anti-inflammatory effects (salicylates preferred r/t decr risk of bleeding)

Question 38

Skull Fractures - Conservative treatment - Surgery if depressed

Answer 38

Subdural & epidural hematomas - Surgical evacuation > Craniotomy, burr holes > Craniectomy if extreme swelling

Question 39

Nursing Assessment: Subjective Data Past medical history - mechanism of injury Rx's - Anticoagulants

Answer 39

*Health perception - health management*: use of alcohol or recreational drugs; risk-taking behaviors *Cognitive-perceptual*: HA, mood or behavioral change, mentation changes, aphasia, dysphasia, impaired judgement *Coping-stress tolerance*: fear, denial, anger, aggression, depression

Question 40

General - AMS Integumentary - Lacerations, contusions, abrasions, hematoma, Battle's sign, periorbital edema & ecchymosis, otorrhea, exposed brain matter

Answer 40

Respiratory - Rhinorrhea, impaired gag reflex, inability to maintain a patent airway - Impending herniation: altered/irregular RR & pattern

Question 41

Cardiovascular - Impending herniation: Cushing's triad What are its 3 signs?

Answer 41

systolic HTN w/ widening PP bradycardia w/full & bounding pulse irregular resp

Question 42

GI - Vomiting, projectile vomiting, bowel incontinence Urinary - Bladder incontinence Reproductive - Uninhibited sexual expression

Answer 42

Neurologic - Altered LOC, seizure activity, pupil dysfunction, CN deficit(s) Musculoskeletal - Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity/incr tone, flaccidity, ataxia

Question 43

*Possible diagnostic findings* - Location & type of hematoma, edema, skull fx, and/or foreign body on CT scan &/or MRI - Abn EEG; (+) toxicology screen or alcohol lvl - ↓ or ↑ blood glucose lvl - ↑ ICP

Question 44

Nursing Diagnoses ★ Risk for ineffective cerebral tissue perfusion r/t interruption of CBF assoc w/cerebral hemorrhage, hematoma, & edema ★ Hyperthermia r/t incr metabolism, infection, & hypothalamic inj ★ Impaired physical mobility r/t decr LOC

Answer 44

★ Anxiety r/t abrupt change in health status, hosp environment, & uncertain future ★ Potential complication: increased ICP r/t cerebral edema & hemorrhage

Question 45

Nursing: Planning - Overall Goals - Maintain adequate cerebral oxygenation & perfusion - Remain normothermic - Achieve control of pain & discomfort - Be free from infection - Have adequate nutrition - Attain maximal cognitive, motor, & sensory function

Answer 45

Nursing: Implementation

Question 46

Health Promotion - Prevent car & motorcycle accidents - Wear safety helmets - Use seat belts & child car seats - Home safety to prevent falls

Answer 46

Acute Intervention - Maintain cerebral perfusion - Prevent 2° cerebral ischemia - Monitor for changes in neurologic status - Pt & family teaching

Question 47

Major focus of nursing care r/t IICP Eye problems * Eye drops, compresses, patch Hyperthermia * Goal temp 96-98.6°F * Prevent shivering

Answer 47

Measures for pts leaking CSF ! *If CSF rhinorrhea or otorrhea occurs, inform MD immediately* - HOB elevated - Loosen collection pad - No sneezing or blowing nose - No NG tube - No nasotracheal suctioning (d/t the high risk of meningitis)

Question 48

* Measures for immobilized pts > Bowel & bladder function, skin care, & infection * Anti-emetics

Answer 48

* Analgesics * Pre-op preparation, if needed

Question 49

Ambulatory & Home Care * Motor & sensory deficits * Communication issues * Memory & intellectual functioning * Nutrition * Bowel & bladder management * "no" policies

Answer 49

* Seizure disorders * Mental & emotional difficulties * Progressive recovery * Family participation & education

Question 50

Nursing Evaluation: Expected Outcomes - Maintain normal cerebral perfusion pressure - Achieve maximal cognitive, motor, & sensory function - Experience no infection or hyperthermia

Answer 50

- Achieve pain control - Ability to adapt/compensate to altered mobility or sensory perception or cognitive changes

Question 51

Chronic Traumatic Encephalopathy (CTE) ! Repetitive brain trauma > symptomatic concussions > asymptomatic sub-concussive hits

Answer 51

Triggers progressive degeneration of the brain tissue incl buildup of abn protein tau > assoc w/memory loss, confusion, impaired judgement, impulse control problems, aggression, depression, & eventually, progressive dementia Can only be dx'd through post-mortem tissue neuropathological analysis