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Acute Care Exam 3 > Neuro Trauma > Flashcards

Neuro Trauma Flashcards

1
Q

what is a head injury

A

Injury to scalp, skull, or brain
Skull is rigid = no ability for contents to expand

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2
Q

most serious form of brain injury

A

TBI

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3
Q

primary head injury and examples

A

initial damage = coup
Contusions, lacerations, torn vessels, accel/decel injury, or foreign object

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4
Q

secondary head injury and examples

A

damage that occurs after initial injury = countercoup
Edema, ischemia, seizures, infection, hyperthermia, hypovolemia, & hypoxia

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5
Q

causes of head injuries

A

Falls (40.5%)
MVAs (14.3%)
Collisions with objects (15.5%)
Assaults (10%)

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6
Q

those at risk for head injuries

A

Males 15-24 yo
Children under 5 yo
Older Adults over 75 yo
Many with long lasting chronic issues
Prevention is key!!!

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7
Q

patho of skull fracture

A

Trauma  Break in skull  with or without brain damage

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8
Q

types of skull fractures

A

Simple (AKA: Linear)- straight line
Comminuted – splintered fracture line
Depressed= dips down, fragments in brain
Basilar – base of skull area
Open- Scalp laceration to tear of dura
Closed- dura intact

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9
Q

the meninges layers

A

Dura  Under skull
Arachnoid  middle layer
Pia  layer over brain

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10
Q

clinical manifestations of head injuries

A

Depends on mechanism, severity, distribution etc…
Hemorrhage, ecchymosis (e.g., battle sign), CSF from ear or nose
Halo sign- Blood stain surrounded by yellow stain = CSF leak

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11
Q

focused assessment of head injuries

A

Obvious injuries
Check HEENT
- Eyes (don’t forget the conjunctiva, ears, nose, mouth
Check Neuro Status
- Are they A&O x 4?
ABCs

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12
Q

diagnostic imaging of head injuries

A

CT – More detail for skull injuries, for pts who can’t have MRI, w/ or without contrast (without better for looking for hemorrhage), faster in an emergency
MRI – More detailed for soft tissue issues, no-radiation used, w/ or w/out contrast

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13
Q

management of head injuries

A

Stabilize neck until injury of neck ruled out!
Observation for minor fractures
Surgery
Removal of foreign body
IV antibiotics if open
Blood Products prn
Test drainage from nose/ears for glucose (+ for glucose = CSF)

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14
Q

management of a CSF leak

A

Start even if suspected
Call provider ASAP
Education: Pt cannot blow nose
Elevate HOB to 30 degrees
No suction or nasogastric tubes

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15
Q

patho of a brain injury

A

We want to prevent or manage quickly to prevent long-term effects
Obstructed blood flow  decrease in tissue perfusion so O2 and glucose decrease  Neurons can’t work  Cells/tissue die (necrosis)

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16
Q

TBI focused assessment

A

LOC (Need a GCS every time taking VS/q5m)
A&O x 4
Pupils (PERRLA)
Sudden onset of deficits
Vision & Hearing
Sensory
HA
Seizure Precautions!!!

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17
Q

vital signs for brain injuries

A

Look for irregular respirations** - first indicators
Widened pulse pressure
- If pt is 160/70 for example
Brady or Tachycardia
- <60 BPM or >100 BPM
Hypo or Hyperthermia
- <95 F or >104 F (35 or 40 Celsius)

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18
Q

concussion components

A

AKA: Mild TBI
Loss of Consciousness- yes or no
Manifestations: HA, nausea, photophobia, amnesia, blurred vision, difficulty concentrating
Observation
Postconcussive syndrome
For first 24 hrs keep close check at home, wake Q2h
Educate pt and support person!

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19
Q

contusion components

A

> in severity; Bruise of the brain
Loss of Consciousness- yes!
Size of swelling = severity of deficits
Manifestations: unconscious, faint pulse, shallow resp., cool/pale skin, decreased BP and Temp
Cerebral irritability- keep stimulation to a minimum (lights, noise, etc…) when awakening
Restraints could lead to worse injury
Months of recovery w/ possible HA, vertigo, or impaired mental function/seizures if severe

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20
Q

Diffuse Axonal Injury

A

Axons are where the electrical impulses are conducted in a neuron
Mild/Moderate/Severe
Coma, global edema, posturing
DeCORticate- (hands to the core!) flexion of UE, extension LE = damage to upper midbrain
DecerEbrate- (hands make an e shape) extension of UE & LE, lower midbrain and upper pons (worse!!)

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21
Q

decorticate

A

(hands to the core!) flexion of UE, extension LE = damage to upper midbrain

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22
Q

decerebrate

A

(hands make an e shape) extension of UE & LE, lower midbrain and upper pons (worse!!)

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23
Q

3 types of Intracranial Hemorrhage (AKA: Hematoma)

A

Intracerebral: Inside brain, deficits depend on area and severity
Epidural: Above dura, EMERGENCY!!!
Subdural: Below dura, acute vs. subacute and chronic types

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24
Q

intercerebral hematoma

A

Insidious symptom onset
Bleeding into parenchyma
Where it happens and severity = major symptoms
Increased Intracranial Pressure (ICP)
Causes: GSW, Stabbings, hemorrhages from bleeding/vasc d/o

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25
Q

epidural hematoma

A

Immediate LOC
Skull fx  Rupture or laceration of middle meningeal artery = huge amount of bleeding = Emergency!!!
ICP rapidly increases
LOC at first, then might be lucid, then rapid decline = classic symptoms
Tx: Burr Holes
Causes: Accidents (ski, motorcycle, skateboarding etc…)

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26
Q

subdural hematoma

A

Symptoms over 24-48 hours if acute/subacute, high mortality
Chronic- 3 weeks +
Causes: Bleeding d/o, aneurysm rupture, injury
Most common, Chronic common in older adults (all types most often in 60’s/70’s)
CT scan to diagnose
Can reabsorb if small (1 cm)

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27
Q

management of brain injury

A

Assume cervical spine injury until ruled out = initiate c-spine
immobilization/precautions
C-spine injuries 1.7 – 8% of the time in TBI
Suspect if GCS 8 or less, motorcycle accident, or skull base fracture
C-spine immobilization/precautions= maintain head and neck midline,
hard cervical collar, back board for transport. X-ray to diagnose
Time is brain! Preserve as much as possible
Secondary Injury = cerebral edema, hypotension, resp. depression

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28
Q

treatment for brain injury management

A

Focus on stabilizing CV and Resp. function, perfusion to brain, control hemorrhage, hypovolemia, blood gas values

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29
Q

altered LOC

A

Disoriented, not following commands, persistent need for stimuli

30
Q

spectrum of level of consciousness

A

alert and oriented to coma

31
Q

3 main causes of altered LOC and ICP

A

Neuro (e.g., CVA)
Toxicologic (e.g., intoxication)
Metabolic (e.g., kidney failure)

32
Q

status of a coma

A

unarousable, no “purposeful” responses to stimuli, 2-4 weeks duration (varies!)

33
Q

status of persistent vegetative state

A

unresponsive but after coma resumes sleep-wake cycles, no cognitive function

34
Q

locked in syndrome

A

lesion on pons or midbrain  tetraplegia

Non-verbal, vertical eye movement and lid elevation remain intact
LOC most important indicator of condition

35
Q

herniation and types

A

Can cause brain to shift against hard surface of skull and blood supply is decreased which causes…
Ischemia (decrease of blood supply) then…
Infarction (no blood supply) then…
Necrosis (brain tissue death)

36
Q

cranial vault composition

A

80% brain tissue, 10% intravascular blood, 10% CSF

37
Q

ICP range and when to start treatment

A

ICP Normal Range: 5-15 mm Hg
Treatment starts at 20 mm Hg

38
Q

early ischemia signs

A

slow bounding pulses, resp. irreg., systemic BP increased

39
Q

cushing triad

A

Bad sign!!!
Bradycardia + HTN + Bradypnea  leads to herniation of brainstem if not treated ASAP

40
Q

ALOC and ICP manifestations

A

Depends on how far along in the process
Subtle changes in behavior (Restless)
Sluggish pupillary response  fixed
Decreased alertness  coma

41
Q

ALOC and ICP assessment

A

Mental status
Cranial nerves (I through XII)
Cerebellar function (Balance/coordination)
Reflexes
Motor/Sensory Function
GCS: Score 3 (coma), 8 (unconscious), 15 (normal)
- Eye opening
- Best Verbal response
- Best Motor response

42
Q

nursing management and treatment of ALOC and ICP

A

Maintain Airway!!!
May need ventilator
BP/Heart rate = cerebral perfusion
IV for fluids/meds/antibiotics
Increased ICP is an emergency!!!
Goal: Decreased edema, lower volume of CSF, maintain adequate perfusion
Treatment: Diuretics (osmotic = mannitol), restrict fluids, drain CSF, control fever, maintain O2/BP

43
Q

ICP monitoring

A

Frequent Neuro assessments
Report signs of Increasing ICP:

44
Q

signs of increasing ICP

A

Change in LOC (Earliest sign) = disorientation, restless, anxious, increased resp. purposeless movements, confusion
Pupils – CN II, III, IV, V
Weak extremities on 1 side or 1 extremity only
HA constant, increasing, with movement/straining

45
Q

Later signs of ICP leads to:

A

brain death

46
Q

later signs of ICP

A

Stupor or coma, irreg. resp., BP/Temp increase
widened pulse pressure, brady to tachy and varies quickly
Cheyne-stokes breathing (differing rate, depth, periods of apnea)
Ataxic breathing (Irreg. with random deep/shallow breaths + apnea)
vomiting (projectile), posturing, flaccidity before death
loss of reflexes (pupil, corneal, gag, swallowing)

47
Q

management of increased ICP

A

Need to know baseline, watch trends closely
Ventriculostomy (catheter in ventricle)
VP Shunt (ventriculoperitoneal)
Subarachnoid Bolt/Screw
External Ventricular Drain (EVD)

48
Q

complications and nursing management of altered ICP

A

Meningitis, infection, clot (blood or tissue), ICP excessive reduction  ventricular collapse and herniation
Altered LOC  pneumonia, resp. failure, pressure ulcers, aspiration, GI decreased function, musculoskeletal atrophy, DVT etc…
DI (pee too much) SIADH (retain) from TBI
Monitor electrolytes
Good oral hygiene! Good Nutrition 
Clean environment, still describe steps of care to pt in ALOC, advocate for patient, be vigilant! 1:1 or 1:2 care
Fever  Nursing management
- Removing bedding (drape or light sheet only)
- Acetaminophen
- Cool sponge baths, fans, hypothermia blanket
- Frequently monitor, shivering = increase in work of body/demand
- Rectal or skin continual monitor can be used
BP & O2
- Maintain Systolic greater than 100 mm Hg
- Maintain O2 Sat > 90%
Keep patient calm and comfy (sedation/analgesia)
Seizure Precautions
Bladder- scan, foley prn
Nutrition- Higher caloric needs, begin up to 72 hrs after injury
- Protein 15% of all calories, glucose monitored (hyper=worse outcomes), consult dietician
Bowel Function- assess! Diarrhea (infection, fluids, feedings) or constipation (meds/lack of fiber)
- Straining increases ICP!
May need or have Craniectomy to decompress. If flap is stored in abdomen for replacement, need to be aware to assess and protect!

49
Q

Osmotic diuretics for increased ICP

A

(Mannitol)
Draws water across intact membranes to decrease swelling  decrease blood viscosity (check hematocrit), and ultimately increase blood flow
If serum osmolality > 320 mOsm = not effective!
We can use hypERtonic saline [3% NaCl] (not hypOtonic  more swelling); newer approach

50
Q

3 main findings for brain death

A

Coma/unresponsiveness
Absence of brainstem reflexes
Apnea

51
Q

criteria for brain death

A

Irreversible condition with known cause, pt not on CNS depressant or paralytic, no severe electrolyte/acid-base/endocrine abnormality, the 3 above, core body temp >90 F, SBP at least 100 mm Hg, neuroimage of catastrophic CNS damage
Possible preparation for organ donation

52
Q

spinal cord injury patho

A

Damage to spinal cord can be minor (concussive, contusion) to transection of cord (severed)
Young people 16-30 yo > half of new SCIs annually
Most common: MVAs

53
Q

primary vs secondary spinal cord injury

A

Primary- initial trauma
Secondary- usually from contusion or tear where nerve fibers swell/die
- Secondary reaction- ischemia, hypoxia, edema, hemorrhage damages myelin and axons
- Try to prevent permanent damage within 4-6 hrs after injury

54
Q

most frequent areas for spinal cord injury

A

Most frequent at C 5,6,7 T 12, L1 (greatest range of mobility in these)

55
Q

spinal cord injury manifestations

A

Depends on level of injury
Sensory/Motor/Both types of fibers
Neurologic level- lowest level that sensory and motor function is normal
Complete spinal cord lesion- total loss of sensation/voluntary muscle control below lesion)
- loss of spinal reflexes, loss of ability to perspire, dysfunction bowel/bladder, absent visceral/somatic sensations below level of lesion (all)
Paraplegia – paralysis of lower body
Tetraplegia- (AKA: Quadriplegia) all 4 extremities paralyzed

56
Q

assessment of spinal cord injury

A

Respiratory – frequently
VS
Neuro (sensory/motor)
Pain
Bowel and bladder - indwelling catheter, loss of control
Other injuries (head/chest)
Cardiac (brady/asystole common in acute)

57
Q

diagnostics of spinal cord injury

A

X-rays (Cervical spine especially)
CT initial
MRI- later if ligaments injured or suspected

58
Q

spinal cord injury management

A

Emergency! Time is also spine 
MVA, sports, falls, violence = suspect SCI until ruled out
Rapid assessment, immobilization, extrication, stabilization, transportation
Spine board (back board), head/neck neutral = 1 person at head
4-person transfer preferred
Log roll
Cervical collar

Goal- prevent progressive neuro deficits
Reduction and traction (tongs, calipers, halo device, chin strap and weighted sandbags)
Surgery- for compression, unstable vertebral body, penetrating wound, bone fragments, poor neuro status
Laminectomy most common
Spinal fusion

59
Q

Areflexia below injury level

A

spinal shock
need NG tube for GI decompression

60
Q

spinal shock

A
  • Occurs immediately or within hours of an SCI
  • Caused by sudden cessation of impulses from the higher brain
    centers
  • Massive vasodilation; decreased preload, stroke volume, and heart
    rate, hypotension
  • Loss of motor, sensory, reflex, and autonomic function below the level
    of injury with flaccid paralysis
  • Loss of bowel and bladder function
  • Loss of temperature control
61
Q

loss of autonomic nervous system below lesion

A

neurogenic shock
* Form of distributive shock in severe cervical and upper thoracic injury
* Loss of sympathetic input to the systemic vasculature of the heart;
decreased peripheral vascular resistance
* Hypotension, severe bradycardia, loss of the ability to sweat below the
level of injury
Vital organs! BP and HR decrease, peripheral vasodilation and pooling, warm skin
No perspiration (sympathetic activity blocked)

62
Q
A
63
Q

DVT treatment

A

Need SCDs, compression stockings, or anticoagulant therapy (if no head injury). Use compression devises for 2 weeks after injury

64
Q

orthostatic hypotension

A

drop in SBP of 20 mm Hg or drop in DBP of at least 10 mm Hg
Vasopressors and abdominal binders can help, slow movement when position changes

65
Q

autonomic dysreflexia

A

Acute emergency!!!
Hyperresponsive to stimuli (anything like a crease in the bed sheet!)
Severe pounding HA, paroxysmal HTN, diaphoresis, nausea, nasal congestion, bradycardia
Sudden BP increase could rupture a blood vessel in the brain  ICP increase
Stimuli- bowel, bladder, skin
Nursing Management: HOB raised, rapid assessment, empty bladder (in & out cath), rectum check, skin, environment (cold blowing air)
May need hydralazine via IV (slow push)
Flag in EMR

66
Q

trauma patient with head injury - want O2 sats above:

A

95%

67
Q

CPP=MAP-ICP

Monroe Kellen

A

Cerebral Perfusion Pressure (CPP)
* 60‒100 mm Hg
Mean Arterial Pressure (MAP)
* 50‒150 mm Hg
* In the setting of increased ICP, the MAP may need to be higher to
maintain CPP
Intracranial Pressure (ICP)
* Normal is 0‒15 mm Hg
* Increased ICP caused by
* -Cerebral edema
* -Hemorrhage/hematoma/mass
* -Excess CSF (hydrocephalus)

68
Q

VIPP

A

Vitals
Interventions
Primary Exam
Pain

Prevents hypotension and hypoxia

69
Q

incomplete vs complete spinal cord injury

A

complete -Injuries that result in total loss of all sensory and motor function
below the level of injury
incomplete - Recognizable neurological syndromes that are classified
according to the area damaged

70
Q

SCI respiratory compromise with inspiration

A

Diaphram = C3, 4, 5
Accessory muscles = C2-7
External intercostals - T1-11

71
Q

SCI respiratory compromise with expiration

A

Internal intercostals
T1-11
Abdominal muscles
T6-12

Acute Care Exam 3 (4 decks)

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