Head Trauma Emergency

Question 1

What is primary head trauma?

Answer 1

Direct damage to the brain parenchyma, such as contusions,lacerations and punctures.

Question 2

What is secondary head trauma?

Answer 2

This results from increased intracranial pressure that exerts itself on the brain. This causes further damage by activating various biochemical pathways producing primary mediators such as nitric oxide, free radicals and glutamate.

Question 3

Name 4 types of Cerebral Edema?

Answer 3

1. Cytotoxic- damaged cellular membranes, failure of ion pumps.
2. Interstitial- rupture of the CSF-brain barrier.
3. Osmotic abnormal pressure gradient within the brain such as water moving into brain.
4. Vasogenic- vasodilation and failure of the blood brain barrier.

Question 4

How to initially stabilize a head trauma patient?

Answer 4

Stabilize the ABC’s. Airway, breathing, circulation and pain.

Question 5

What are signs of intracranially pressure?

Answer 5

1. Increased blood pressure with bradycardia.
2. Miotic or pinpoint pupils.
   3, Decreasing mentation.

Question 6

What is the goal blood pressure in a head trauma patient?

Answer 6

Blood pressure should be at MAP of 80-100mmHg and systolic of 120- 150mmHg.

Question 7

What medications aid in lowering ICP?

Answer 7

1. Mannitol, furosemide, hypertonic saline,

Question 8

What should pulseox read in a respiratory stable patient?

Answer 8

Pulse Ox over %95

Question 9

What typical abnormal breathing patterns can be observed in a head trauma patient?

Answer 9

1. Cheyne-Stokes breathing pattern (hyperpnea with phases of apnea)
2. Hyperventilation
3. Irregular breathing patterns with periods of apnea
4. Rapid and Shallow breathing pattern

Question 10

Where is the brain lesion in a patient displaying chyene-stokes breathing pattern?

Answer 10

Severe cerebral or rostral brainstem lesions.

Question 11

Where is the brain lesion in a patient displaying hyperventilation?

Answer 11

Midbrain lesion

Question 12

Where is the brain lesion in a patient displaying irregular breathing and patterns of apnea?

Answer 12

Medulla oblongata

Question 13

Where is the brain lesion in a patient displaying rapid shallow breathing?

Answer 13

Pontine lesions

Question 14

After the head trauma patient is stable what assessments should be made?

Answer 14

Assessments in;

1. Fractures
2. Bloodwork
3. Level of consciousness
4. Patients eyes such as PLR, menace, stribismus, pupil size and behavior.
5. Body posture such as Opisthotonus, Schiff-sherrington, Decerebellate, Decerebrate
6. Evaluate chest and abdomen such as contusions, pneumothorax, fractures

Question 15

Name the levels of consciousness?

Answer 15

1. Alert and responsive- Normal behavior
2. Obtunded= response to stimuli is decreased and patient awake
3. Stuperous- response to painful and noxious stimuli limited
4. Comatose- response to stimuli nonexistent; patient unconscious

Question 16

What is opisthotonus posture?

Answer 16

head and neck are stretched in sever hyperextension- this is a grave prognosis

Question 17

What is schiff-sherrington posture?

Answer 17

Thoracic limb extensor rigidity this usally means thoracolumbar lesion is present

Question 18

What is Decerebellate posture?

Answer 18

Extension of thoracic limbs and flexion of the pelvic limbs, can indicate cerebellar lesions and herniation

Question 19

What is decerebrate rigidity?

Answer 19

Combined extension of head and neck and all limbs with stuperous and comatose mental status, poor prognosis.

Question 20

What could strabismus mean in an head trauma patient?

Answer 20

Cranial nerve or brainstem damage.

Question 21

What does the absence of physiological nystagmus

mean?

Answer 21

Severe brainstem damage can be possible. If comatose this may not apply.

Question 22

What may miotic pupils mean in head trauma patient?

Answer 22

This may mean cerebral edema or lesion- guarded to fair prognosis.

Question 23

What may mydriatic pupils mean in a head trauma patient?

Answer 23

may indicate stress, certain medications such as atropine and sometimes cardiac arrest.

Question 24

If a head trauma patient had unilateral mydriatic puil that became bilateral and non-responsive to light what kind of prognosis would that give the patient?

Answer 24

poor prognosis, worse than miotic pupils.

Question 25

What nursing care should be provided for head patient?

Answer 25

1. Placement of IV catheter.
2. Elevate the cranial end of the body by 30-40 degrees.
3. Ample bedding and flipping every 4 hours.
4. Range of motion exercises every 6 to 8 hours
5. Treat eyes with wash wash and lube every 4 to 6 hours
6. Wipe and moisten oral cavity every 4 to 6 hours
7. Express bladder every 3 to 6 hours
8. Hand feed patients every 4 to 6 hours

Question 26

What kind of brainstem integrity tests can be performed?

Answer 26

1. caloric test- lavage warm water intoexternal ear to invoke physiological nystagmus, if present medulla,pons and midbrain are intact.
2. BAER testing- checks electrical activity in th ecochlea and auditory pathways and if absent may indicate damage to brainstem
3. EEG helps determine integrity of the cerebral cortex and brain death

Question 27

The use of mannitol for increased ICP?

Answer 27

Dose- 0.25 to 2g/kg in an IV bolus over 10 tp 20minutes. Can be repeated every 4 to 6 hours.
Prepared by warming and through a filter between syringe and needle.
This will cause diuresis
Should only be used in cardiac stable patients- may ovewhelhm circulatory system, but can be used with furosemide to lessen stress on heart

Question 28

The use of hypertonic saline for increased ICP?

Answer 28

4ml/kg dilute in colloid solution to create7.5% solution

Should not be used in hyper or hyponatremic pateints, may increase sodium levels in brain.

Question 29

What should be monitored in head trauma patient?

Answer 29

1. Monitor blood pressure- hypotension may result in decrease in brain perfusion and result in ischemia, hypertension may mean increased ICP
2. Check body temperature- brain trauma patients have a hard time regulating body temp.
3. Monitor level of awareness, pupil size, PLR