Head Trauma Flashcards
Classification of Head Trauma According to Result of Force
Acceleration: moving object strives stationary force
I.e. someone hits a head with a bat
Deceleration: When a head in motion strives a stationary force
Head striking steering wheel in MV accident
Deformation: brain twists in the head
Seen under physical assault
Countercoup: shaken baby syndrome
Coup-contre-coup: when the brain is rotated from inside to the head (?)
Classification of Head Trauma According to the Injury
-Blunt Trauma- Damage to the brain without penetration of the skull; Results from acceleration and deceleration injuries
-Penetrating Trauma/Missile Trauma - Example: gun shot wound to the head is the most common
-Shearing Injury - Affects white matter in the brain
-Concussion - Long term effects result, especially with youths under 21 years old
-Contusion - Concussion with bruising
-Skull Fracture- Linear, depressed
Nursing Goals for Head Trauma
Reduce the risk of secondary damage
Stabilize vital signs
Prevent further Injury
REDUCE ICP (Most important)
Head Trauma Assessment
Baseline - Primary Survey
Secondary Survey
Neurological Survey
DERM
Depth of coma (confusion, lethargy, obtundation, stupor, coma)
Eyes
Respirations
Motor movement
Abnormal Posturing
Decorticate Posturing- flexion and internal rotation of extremities. Lesion above mid-brain.
Decerebrate Posturing- Abnormal extension- an extension and internal rotation of the upper and lower extremities.
Can indicate Brain herniation
Range of Glascow Coma Scale?
3-15 (add T if with trache)
Indications of cranial nerve
Vision Loss
Hearing Loss
Loss of sense of smell - Unilateral or bilateral; Testing olfactory nerve
Squint or fixed, dilated pupils for ocular nerve damage
Reflexes to assess
-corneal (blink)
-gag
-deep tendon
-babinski
-kernig’s sign - Pain in the neck when your leg is flexed on the abdomen and extended
-brudzinski’s sign - Involuntary hip flexion when the neck is flexed; sign of meningititis
-doll eyes
ICP Values
Normal: 4-15 mm. Hg.
Moderate Elevation: 15-40 mm. Hg.
Severe, life threatening: Greater than 40 mm. Hg.
Cerebral Perfusion Pressure
More accurate: It is the pressure required to perfuse the brain cells
CPP= MAP-ICP
Normal: 60-90 mmHg.
Decreased: less than 60 mmHg.
How is CPP measured?
-Catheter placed through the skull into the subarachnoid space or cerebral ventricle (preferred method)
-Changes in pressure are monitored, via a transducer, directly and continuously
-Changes in ICP can be treated before symptoms appear
otorrhea and rhinorrhea
Drainage of cerebral spinal fluid, one from the nose and one from the ear
If you see clear fluid, DO NOT suction until you are sure that this is not cerebral spinal fluid
Halo Test - put fluid down on any surface and this will result in a blue halo surrounding it
Diagnostic tools in head trauma
CAT scan is the number one tool for this
Lumbar puncture: Insertion of needle in lumbar space, between two lumbar vertebrae; Very risky to do when the ICP is increased; Patient lies still, maybe with their head down on the table; 18 Gauge needle;
120 mmHg is the normal pressure for adults; Clear fluid, colorless, not bloody, not cloudy; Bloody and cloudy would indicate infection
MRI - you see the change in the pictures within 5 minutes of someone having a stroke so gold standard for a stroke decreased perfusion
CAT Scan is for bleeds because you will not see signs of a stroke until 48 hours after, used to rule out hemorrhage before giving TPA - #1
Nursing Diagnoses for head trauma
Alteration in Tissue perfusion related to localized trauma and resulting increased ICP
Alteration in comfort related to head injury and inability to medicate initially
Potential for injury related to increased ICP
Ineffective Airway Clearance related to unconscious state
Impaired Gas exchange related to systemic results of head injury
Potential alteration in fluid volume: excess related to swelling of cerebral tissues
Impaired Thought Process
Signs and symptoms of increased ICP (early)
Early clinical manifestations:
-Change in Level of Consciousness ***
-Headache
-Nausea and Projectile Vomiting
-Cri-du-Ca (“cry of the cat” in infants)
Late clinical manifestations
Loss of motor and sensory functions
Pupillary Changes
Cushing’s Triad
-widening pulse pressure
-bradycardia,
-irregular respirations
Nursing Care of Patients with Head Trauma
-Maintain Patent Airway and Adequate Ventilation
-Neurologic Assessments every hour and more frequently with high risk patients.
-Position Patient to Promote Venous Return
-Minimize clustering of nursing care and do only what is necessary at that time
-Avoid activities that increase intra-abdominal and intra-thoracic pressures (shivering, posturing)
-Prevent infections that will increase metabolic rate
-Monitor fluids and electrolytes
-Maintain a quiet and dim environment
-Emotional support to both patient and family. Avoid emotional upset, noxious stimuli
-Avoid certain body positions
Signs and Symptoms of Impending Herniation
-Decreased LOC (Coma)
-PupillaryAbnormalities
-Motor dysfunction (hemiplegioa, decortication, decerebration)
-Impaired brain stem reflexes (corneal, gag, swallowing)
-Alterations in Vital signs
Spinal cord damage
Types: Primary vs. Secondary
THE GREATER THE MAGNITUDE OF THE FORCE APPLIED TO THE SPINAL CORD, THE GREATER THE ASSOCIATED DAMAGE
Tetraplegia, paraplegia, complete spinal cord injury, Incomplete injury
Neurological Assessment
Field Assessment
Ensure airway with jaw-thrust maneuver
Immobilize head and neck
Extricate patient if necessary
Triage
Emergency Room to do’s
-Primary Survey
-Secondary Survey
-Neurological Assessment
-Laboratory Assessment
-Radiographic Evaluation
-History of Accident and Circumstances of Injury
Nursing Diagnoses - critical phase
High risk for Ventilatory Insufficiency
Ineffective Airway Clearance
Alteration in Comfort
Risk for Injury
Impaired physical mobility
Ineffective individual, family coping
Nursing diagnoses - acute phase
Impaired Skin Integrity
Altered Nutrition
Self Care Deficit
Sexual Dysfunction
Body Image Disturbance
Altered Health Maintenance
Nursing interventions
-Respiratory Support
-Treatment of Life Threatening Rhythm disturbances
-Management of paralytic Ileus
-Management of atonic bladder
-Drug Therapy
-Invasive and Non-Invasive Monitoring
-Cervical Immobilization
-Use of Turning Frame
-Patient, Family Support
Spinal Shock
-Immediate Response
-Temporary Suppression of Reflexes
-Input of Impulses from Higher Centers Ceases
-Lasts from Hours to Months
-A “Jamming”
-Bulbacavernous, Peri-Anal Reflexes
Autonomic Hyperreflexia
Serious Emergency
Seen after Spinal Shock
Caused by Noxious Stimuli
Vasoconstrictive Symptomatology
Goal: To Remove Noxious stimuli and Lower the Blood Pressure
A MEDICAL EMERGENCY
