Neuro Trauma Flashcards
What are they two categories of brain injuries
Primary
Secondary
Define Primary injury
Primary injury occurs at the time of the trauma
Define Secondary injury
The indirect additional complications that occur later on that plays a large role in brain damage and death
- hours or even days later
Primary injury examples (5)
Contusion
Epidural Hematoma
Subdural Hematoma
Traumatic Subarachnoid Hemorrhage
Diffuse Axonal Injury
Define Diffuse Axonal Injury
Brain rapidly shifts inside the skull and causes shearing of axons
What state are those with Diffuse Axonal Injury left in typically?
Coma
Doctor recommends to do a CT and MRI for diffuse axonal injury. What do you know about this and what does that mean for the nruse?
Diffuse axonal injury is hard to detect on MRI and CT - which means nurse assessment has to be really good.
Symptoms of diffuse axonal injury?
Coma
Confusion
N/V
T/F
Secondary brain injury is not preventable
False. We can prevent this
What is the focus of care when it comes to minimizing secondary injury?
Increasing oxygen blood to brain
Decreasing metabolic demands
Why do we want to prevent hypoxemia in a patient who has a primary head injury?
If there isn’t enough oxygen in the blood, it increases chance of secondary head injury.
Why avoid hypotension to avoid a secondary brain injury?
We don’t want there to be hypotension because that can affect how well we perfuse the brain and thus cause the secondary injury.
Why do we need to focus on the blood sugar needs after a patient has a primary head injury?
Focus on controlling blood sugar to avoid a secondary head injury
What is meant “respond to loss of auto regulatory mechanisms” if a patient has a primary head injury?
Sometimes people’s compensation skills don’t work, and so it is our job to use medications like pressors, diuretics, hypertonics, etc to try to manipulate it
- loss of compensation like temp, BP, Hr changes
Why do we want to avoid increased ICP after having a primary brain injury?
Increased ICP can cause a secondary injury to occur
Why do we want to control the Co2 levels after a patient has a primary head injury?
The CO2 dictates the constriction/dilation of the vessels and can cause a secondary head injury if not monitored.
What is the most important indicator of neuro severity and how do we assess it?
LOC changes - which we assess for with the Glasgow Coma Scale
Mild Traumatic Brain Injury GCS score
13-15 = mild
Moderate Traumatic Brain Injury GCS score
9-12 = moderate
Severe Traumatic Brain Injury GCS score
Less than 8
What is the nature of deficits for a mild TBI?
Functional deficits that lasts weeks or months but usually come back
Diagnostic testing for Hematomas
Blood pooling bruise. CT
Diagnostic testing for Hemorrhage/Bleeding
CT
Diagnostic testing for fractures
CT
Diagnostic testing for cerebral edema
CT
Diagnostic testing for severe diffuse axonal injury
MRI - but only if the DAI is severe. A lot of times they don’t show up.
Diagnostic testing for brain stem injury and hernation
MRI
Diagnostic testing for aneurysm
MRI - due to the vessel bulging
What is the danger of an aneurysm?
As the bulge grows, it can hemorrhage and then you have a stroke on your hands.
What other injuries do we use diagnostic testing for that can be related to the cause of the TBI?
Other bone fractures. Or really anything.
What nursing care will you provide to a patient with a TBI that address respiratory needs?
Airway Management
Oxygenation
Ventilation
Explain why you will be managing the patients airway for a TBI
Brain injuries can affect the patients ability to maintain their own airway - so again, we want to avoid secondary injury.
Why would you be giving a patient oxygen for a TBI?
The TBI may affect their ability to oxygenate themselves but also, the brain needs oxygen to avoid a secondary injury.
Why might a patient with a TBI be on a vent?
The TBI can affect someone’s ability to oxygenate themselves and it could be so bad that they need the vent to breathe but also avoid secondary injury.
What nursing care will you provide to a TBI patient that addresses the needs of the brain related to volume?
Manage fluids
Manage ICP
Support cerebral perfusion
TBI patient asks why they need to be on fluids. What do you tell them?
The fluids can be contributing to either their perfusion or it can be taking volume off.
- depends on what the brain needs atm
Why do you do ICP management on a TBI patient?
Increased ICP can contribute to injury and even death.
Why do we manage the cerebral perfusion?
Manage cerebral perfusion because it is what keeps the brain oxygenated and full of blood.
What med can support CPP?
Dopamine etc / pressors
Why will we want to prevent an increase in oxygen demand in an ICP patient?
Prevent the need for more oxygen because the brain is already working hard to keep itself oxygenated after a TBI
How can we prevent increased cerebral oxygen demand?
Sedation meds
What is a secondary complication that can come with any head injury - primary or secondary - related to care?
Pneumonia, PE, DVT, skin integrity
- just because they will be immobile
How do check for the pneumonia & PE?
Anticoagulation
Lung sound assessments
- especially if they’re sedated. Diminished lung sounds are bad
How often do we turn patients?
q2hrs
Why do we have to educate the family and be there for them with a TBI?
Brain injuries are often acute because of an accident
Linear fracture
Generally not displaced. More like a hairline fx that heals on its own
Depressed fracture
Inward depression of the bone which needs surgical removal
Basilar fracture
Symptom?
Back Base of the skull is involved.
Kiddo who hit the back of their head is complaining of runny nose and ears. What could this mean?
Basilar fracture - the runny nose and ears is cerebral spinal fluid from a dural tear.
If a kid is having CSF coming out of their nose and ear, what do you need to do?
Call the doctor so you can get a pH test for glucose
Little kid has bruising behind the ears. What is this and what do you need to be aware of?
Battles sign related to basilar fracture.
Caused by shaken baby syndrome.
Most common causes of Spinal Cord Injury?
Motor vehicle accidents (MVA)
Falls
Acts of violence
Sports-related injuries
Which gender has mores spinal cord injuries?
80% are males due to reckless behaviors
Who is the major population that gets spinal injuries from falls?
23% elderly
What is meant by acts of violence causing spinal cord injury?
Domestic abuse towards females
What mechanisms of injury are there for spinal cord injuries?
Hyperflexion
Hyperextension
Axial loading/compression
Rotation
Penetrating trauma
What causes the hyperflexion and hyperextension of a spinal cord injury?
Whiplash - it compresses the spine and causes bruises
What mechanism of injury causes axial loading?
Diving action
What action causes rotation related to the spinal cord injury?
From rolling
What causes the penetration spinal cord injury?
Knife or gunshot wound
What happens to the synapse if the spinal cord is pushed, bruised, or compressed from edema?
Whatever the case - it blocks the synapse from traveling and you have paralysis.
Concussion effects
Temporary loss of function
Symptoms of Concussion
Headache
Vomiting
Decrease LOC
Sensitive to light and sound
- common in athletes; guardian cap
Contusion Effecgts
Bruising and bleeding goes into spinal cord causing edema and possible neuronal death
Laceration effects
The tear in the cord causes a permanent injury
What are lacerations caused by?
What do laceration injuries usually involve in addition?
Stabbing wound
Can involve contusion, edema, & compression
Transection effects
Severing of whole cord w complete loss function below the injury
Explain how hemorrhage and blood vessel damage can occur with a spinal cord injury and its effects
Any injury can cause internal bleeding. Both issues involve bleeding/rupture which can create volume issues.
What is the secondary injury caused by in a spinal cord injury?
Vascular damage from the initial injury which decreases blood flow
Due to a decrease in blood flow often associated with cell and vascular damage with spinal cord injuries , what happens? (2)
Metabolic function changes
Cell membrane destruction therefore synapse not functioning
What symptoms do you see for a secondary injury to the spinal cord?
Respiratory changes
Headaches
What happens in the Neurogenic shock?
Spinal injury of some sort causes complete loss of autonomic nervous system; parasympathetic and sympathetic
What is the blood pressure and HR you see with Neurogenic shock?
How do we treat?
Hypotension + Bradycardia
Try fluid challenge
Use pressors; levophed
What measurements do we use to assess the Neurogenic shock?
CVP
MAP
CPP
What to assess with a spinal injury
Airway & Breathing
Circulation
Motor and sensory function q4hrs
When assessing someone with a spinal cord injury, what do you do position wise?
Immobilize spine with C spinal collar
Why is baseline assessment so important?
You need to be able to compare your findings.
What are the main 3 issues that cause decreased functioning related to the spinal cord injury?
Edema
Loss of vertebral alignment
Intrathecal hematoma
What is spinal shock?
Acute injury where there is temporary suppression of the reflexes
Is spinal shock caused by something that is repairable or permanent?
Repairable
What needs to be evaluated in spinal shock?
Degree of injury so keep your assessment up
Define Complete Spinal Cord injury
Total loss of sensory and motor functions caused by a complete interruption
Define Incomplete Spinal Cord Injury
Varying degree of sensory and motor function disruption due to some tracts being intact
Which types of spinal cord injuries are the most common ? (2)
Cervical
Lumbar
What level of spinal cord injury affects respiratory function?
The higher up the insult, the more likely respiratory is involved.
What diagnositic tests are there for spinal cord injuries?
Xray
CT
MRI
What does a CT diagnostic test exam for in relation to spinal cord injury?
Bone injury and cord compression
What does MRI diagnostic test exam for in relation to a spinal cord injury?
Soft tissue involvement
- can identify ligamentous injury without bone abnormality
What steps do we take to manage a spinal cord injury and avoid the secondary injury?
Immobilize them
Manage the airway
Add on Respiratory management
Hemodynamic support
Neuroprotection
How do we immobilize the patient for an SCI?
Hard cervical collar
Bed rest
Log roll
How do maintain the airway management if we intubate them for a SCI?
Keep them immobilized
Tracheostomy (hole in neck) for severe injuries
What happens to patients who have impaired diaphragmatic innervation?
What are concerned about?
C2 - decreased cough strength and inability to clear secretions
Aspiration risk
Main goal of management for an SCI?
Prevent secondary injury
How do we provide hemodynamic support for an SCI?
Maintain adequate oxygenation and ventilation
Adequate fluids
Rule out any other injuries that could lead to hemodynamic shock!
Neurogenic shock can cause bradycardia and hypotension
What do we use for neuroprotection for an SCI?
Methylprednisone (steroid) administration for anti inflammatory action
An SCI can lead to neurogenic shock. What does this mean for the hemodynamics?
We need to treat the hypotension and bradycardia that comes with it
How do we treat the hemodynamic instability that can come from a SCI?
Adequate oxygenation - vent
Rule out any other injuries that can cause hemodynamic shock
Give adequate fluids
What is one way we can supply the brain with glucose tho?
Steroids technically since they raise BG
- point is, there is a balance
What meds do we give in addition to the high dose steroids for the SCI neuroprotection?
Protonix, Prilosec for the GI ulcers
Blood glucose monitoring for the skyrocketing BS
Neurogenic shocks unique presentation includes?
Instant hypotension with bradycardia
Warm flushed skin
Your patient with neurogenic shock has the injury below the 5th cervical vertebrae. What symptoms will be illicited?
Diaphragmatic breathing - due to the loss of control over the intercostal muscles.
Neurogenic shock patient has their injury above the 3rd cervical vertebrae. What are the symptoms associated with it?
Patient will go into respiratory arrest immediately from loss of control of diaphragm
What meds will we use for neurogenic shock?
Dopamine
Vasopressin
Levophed
Atropine
Phenylephrine
(trying to drive the pressure)
First line treatment for neurogenic SCI patient?
Phenylephrine
- definitely for those who don’t respond to dopamine
What bladder and bowel management do you anticipate for a patient with neurogenic shock rt SCI?
And why?
Foley insertion hourly output
We want to monitor their output because of the hypotension in neurogenic shock leading need to monitor for the acute renal failure.
Patient with history of neurogenic shock , what do we need to monitor if they make it to the point they void on their own?
Monitor for residuals. May have to straight cath them.
What do you anticipate for a neurogenic shock rt SCI patient who is not able to stool?
Stool softener
Digital stimulation
Stool softener meds
Colace
Miralax
What meds can often cause the constipation??
Pain meds
- gabapentin , opiods
What pain meds do you anticipate for neurogenic shock patient rt to SCI?
Opiates
Muscle relaxants
What meds can we use to treat the neuropathic pain from neurogenic shock rt SCI?
Antidepressants and anticonvulsants
- gabapentin
Explain the difference between Autonomic Dysreflexia and Neurogenic shock
Neurogenic shock is caused by loss of control of the sympathetic and parasympathetic with a SCI - hypotension. .
Autonomic Dysreflexia is due to an insult at or above T6 and is caused by over-distention or other reasons - hypertension.
Autonomic Dysreflexia over-distention examples
Distended bladder
Full rectum
Infection
Pressure sores
Cause examples of Autonomic Dysreflexia
Distended bladder
Full rectum
Infection
Pressure sores
What BP do you expect for Autonomic Dysreflexia?
Hypertension
What does Autonomic Dysreflexia often preciptate/lead to?
When does it usually occur?
Precipitates Seizure & Stroke
- put on anticonvulsants
Can actually occur anytime after spinal shock resolves but usually within the first year
What position do you move Autonomic Dysreflexia patient
Put them in a sitting position to decrease pressure
What to vitals monitor in Autonomic Dysreflexia patient?
What medication would you use?
BP
Pulse
3-4x a day
How is Autonomic Dysreflexia treated?
Key is to treat the underlying cause
- bladder distention, full rectum, infection, pressure sores, pain
How to best prevent the Autonomic Dysreflexia
Pay careful attention to bladder and bowel - to avoid the distention
Be consistent on turning the patient - to avoid sores
Watch labs and temp - to monitor for infection
Since the there is hypertension with Autonomic Dysreflexia, what meds do you anticipate?
Antihypertensives
- beta blockers
- CCB
