Neuro: Traumatic Injury Flashcards
Neurological Assessment
cornerstone of trauma care
basis for resuscitation efforts
tests nasal/ear drainage (halo sign) = basilar skull fracture
ABCDE Approach
airway breathing circulation disability exposure/envirnment
Disability Survey
glasgow coma scale
ABC Assessment
airway (skin color, capillary refill, oxygen saturation) cervical spine examination severe bleeding stopped breathing assessed/managed circulation assessed/managed
Opening an airway
maintain cervical spine stability
avoid hyperextending neck
assess for cervical stenosis or osteoarthritis
spinal cord injury
anaerobic glycollysis atp depletion increased intracellular calcium arachidonic acid cascade potassium depletion spinal cord cellular death (ascending up)
Chest Trauma
Pediatric
Pregnant Women
Older Adults
varied breathing patterns, diaphragmatic breathers
increased normal tidal bolume, increased respiratory rate, decreased residual volume & functional residual capacity
less pliable lung tissue, reduced pulmonary compliance
Injuries to pleura
pneumothorax (collapsed lung, can lead to hemothorax)
Hemothorax
blood accumulates in pleural cavity
type of pleural cavity
Bleeding/Shock
compromises perfusion/oxygenation
at risk for hypovolemic shock
class IV shock = unsurvivable
death isn’t always immediate, secondary trauma causes organ failure
Bleeding/Shock II
look for uncontrolled sources of bleeding
stop all external bleeding
treat hypovolemia
Head Trauma/Acute Brain Injury Primary vs Secondary
brain initially injured on impact
injured brain cells swell/reduce blood supply to cells
causes secondary brain death
Monro-Kellie hypothesis
brain resides inside fixed skull/contents are constant
Brain conditions caused by trauma
basilar skull fractures brain herniations cerebral contusion coup-contrecoup injury brain hemorrage
cerebral perfusion causes
decreased ATP production
depletion of cellular energy
cellular death
Exposure assessment
all areas of body
look for hidden bruises/lacerations/impaled objects/bullet wounds/bleeding/open fractures
Envinment TX
controlled avoid hypothermia continuous temperature monitoring warm blankets warm fluids
unilateral dilated pupil
one dilated, one small
CNIII compression
bilateral fixed, dilated pupils
pupils are stuck dilated
brain herniation
Positive Babinski
great toe extends upward and fan out
abnormal
damage to spinal cord thoracic or lumbar
anoxic brain injury or tumor
Aphasia types
Broca (expressive) sparse and nonfluent but preserved comprehension
Wenicke (receptive) fluent and voluminous but comprehension greatly diminished)
Unconscious Patient Causes
head trauma cerebral toxins shock hemorrhage tumor infection (meningitis)
Unconscious Patient Assessment
unresponsive
primitive/no response to painful stimuli
altered respirations
decreased cranial nerve/reflex activity
posturing (decorticate, decerebrate, flaccid)
bilateral, dilated, fixed pupils
pinpoint pupils (pons damage/druge overdose)
Unconscious Patient DX
CT
MRI
Lumbar Puncture (needle inserted into subarachnoid space, sample of CSF for suspected meningitis, contra for increased ICP could lead to herniation of brain)
cerebral/arterial angiography (Ids vascular malformations w/ contrast dye through femoral artery)
EEG
Caloric Testing (dx brainstem/cerebellar lesions, cool water infused into ear)
Unconscious Patient Interventions
patency of airway
keep emergency equipment ready
monitor BP, pulse, heart sounds, respirations, pulse ox
assess body temp (increased could be hypothalamus/brainstem issue, increased metabolic rate of brain, or infection)
assess reflexes (cranial, cough, gag, corneal blink)
assess autonomic system (SNS/PNS)
monitor I/O
maintain nutrition (IV/enteral)
provide range of motion to prevent contractures
Intracranial Pressure Normal/Monitoring
5-15 mmHg
monitoring is invasive
Intracranial Pressure Assessment
altered LOC pupillary changes fever headache nausea vomiting abnormal respirations elevated SBP widened pulse pressure bradycardia Late: positive babinski, decorticate/decerebrate, seizures
ICP Interventions
management of underlying causes adequate airway avoid increasing intra pressure (straining/coughing/deep breathing/incentive spirometry) head of bed to 30-40 degrees avoid flexion of neck/hops no bright lights limit visitors quiet nonstimulating environment keep close to patient ventriculoperitoneal shunt
ICP Meds
anticonvulsants (increase ICP) Antipyretics/Muscle Relaxants (decrease ICP) Blood pressure meds corticosteroids IV fluids Hyperosmotic agents (mannitol)
Head Trauma Immediate Complications
cerebral bleeding hematomas uncontrolled increased ICP infections seizures
Head Injuries Long Term
changes in personality and behavior
CN deficits
Types of Head Injuries
open: scalp lacerations, fractures in skull, interruption of dura mater
closed: concussions, contusions (bruising of brain tissue), fractures
Hematoma
collection of blood in tissues as a result of subarachnoid hemorrage
Concussion signs
brief disruption in LOC
amnesia regarding event (retrograde amnesia)
headache
Concussion serious s/s
worsening headaches vomiting excessive sleep/confusion visual changes weakness/numbness
Concussion Reccomendations
don’t participate in strenuous or athletic activities min 1-2 days
rest/light diet
observed closely
Diffuse Axonal Injury
extensive tearing of nerve tissue throughout brain
tearing disrupts brain’s regular communication/chemical processes
result of acceleration/deceleration motion (not really impact)
axons are stretched & damaged when parts of brain of differing density slide over one another
major cause of unconsciousness & persistent vegetative state after head trauma
Diffuse Axonal Injury DX
difficult to detect (not really present on injury)
suspected in pts w/ normal CT scans but still unconscious
Diffuse Axonal Injury Tx/Prognosis
lacks a specific TX
varies depending on damage
Coup-Contreoup
head strikes an object, brain injured under area of impact (coup), brain rebounds to opposite side of skull, second injury (contrecoup
common in motor vehicle accidents/shaken brain syndrome
usually frontal/occipital lobes (executive fx, memory, speech, motor skills, vision)
Epidural Hematomas
most serious
forms rapidly
result of arterial bleed
forms between dura/skull from tear in meningeal artery
associated w/ temp loss of consciousness then lucid then progress to coma
surgical emrgency
Subdural Hematoma
forms slowly from venous bleed
under dura from tears in veins crossing subdural space
Intracerebral hemorrhage
blood vessels w/in brain ruptures
blood leaks inside brain
Subarachnoid Hemorrhage
bleeding into subarachnoid space
head trauma/spontaneous
ruptured cerebral aneurysm
Hematoma Assessment
s/s usually result of increased ICP look for seizure activity assess airway/breathing patterns asses VS changes N/V/Headache/visual disturbances/pupil changes nuchal rigidity weakness/paralysis/posturing CSF drainage from ears or nose blood fluid surrounded by yellowish stain (halo sign) when on white background \+ for glucose (fluid)
Subdural Hematoma Etiology/TX
from high-speed impact/injury
spontaneous
sugery
Subdural Hematoma s/s
headache confusion changes in behavior dizziness n v lethargy excessive drowsiness weakness apathy seizures
Subdural v Epidural Progression
S: slow collection of blood, s/s usually w/in 48 hrs, slow progression of mental deterioration, can become chronic
E: brief loss of consciousness, lucid interval (hallmark), rapid deterioration, increasing ICP, death w/in hours if hematoma not drained
Hematoma/TBI Interventions
monitor respiratory status/airway (increased CO2 = cerebral edema/dilated cerebral arteries) monitor VS/temp/ICP head elevation seizure precautions maintain normothermia assess CN fx/reflexes/motor/sensory fx monitor for CSF drainage monitor for infection morphine sulfate (decreases agitation but can worsen condition) surgical interventions
Brain Herniations Causes
brain tissue, blood and CSF shifted from normal position head injury stroke bleeding tumor medical emergency
Brain Herniations s/s
dilated pupils headache altered LOC (drowsy > coma) high blood pressure bradycardia seizures cardiac arrest
Brain Herniation Interventions
surgery ventriculostomy craniectomy osmotic diuretics corticosteroids
Head Injury Teaching
ensure responsible adult will check LOC brain edema/increased ICP may not be evident immediately return to Ed/HCP if these s/s in 2-3 days change in LOC worsening headache stiff neck visual changes motor problems sensory disturbances seizures n/v bradycardia abstain from alcohol, watch meds, avoid driving
Spinal Cord Injury
trauma causes partial/complete disruption of nerve tracts/neurons
contusions, laceration, compression
loss of motor fx/sensation/reflex
loss of bowel/bladder control
Spinal Cord Injury Causes & Complications
falls, accidents, gunshot/stab wounds
respiratory failure
autonomic dysreflexia
death
Transection
spinal cord is damaged or severed partially w/ symptoms depending on place/extent
Brown-Sequard Syndrome
hemidisection of spinal cord that affects half of spinal cord
fx/vibration/proprioception/deep sesation on same side of body as damaged = lost
opposite side of body from damage, pain/temp/light touch =lost
Spinal Assessment
respiratory status
motor/sensory changes
loss of bowel/bladder control (urinary retention/distension)
no sweat produced on paralyzed areas
injury above C4 causes respiratory difficulty/paralysis of all extremities
Injured thoracic level can mean paralysis of movement of chest/trunk/bowel/bladder and legs
T6 or above = autonomic autonomic dysreflexia (^ sweating, bradycardia, hypertension, nasal stuffiness, gooseflesh)
Lumbar/Sacral Injuries (loss of fx of lower extremities)
s2/3 center on urination (bladder contracts but won’t empty)
-plegia
stroke/paralysis
-paresis
weakness
-hmi/semi
both limbs on one side
di-/para-
both upper limbs (di) or both lower limbs (para)
quadri/tetra
all four limbs
Quadriplegia
lower limbs completely paralyzed complete/partial paralysis of upper limbs
usually due to injury of cervical spinal cord
Quadriplegia Assessment
frequently assess breath sounds, accessory muscle use, vital capacity, tidal volume, arterial blood gas values
Quadriplegia Interventions
ROM exercises to affected joints
turning necessary
bladder/bowel training programs
Turn every 2 hours
Emergency Management of Spinal Cord Injuries
always suspect spinal cord injury until ruled out
immobilize patient
head in neutral position
improper movement can cause further damage
assess resp pattern/maintain airway
don’t twist/turn body
don’t allow in sitting posotion
cervical fracture: c-collar, halo traction
Spinal Cord CV
monitor for dysrhythmias
assess for hemorrhage/bleeding around fracture site
look for signs of shock
assess lower extremities for DVTs
Spinal Cord Injuries GI/GU
assess for distention/hemorrhage monitor bowel sounds high fiber diet admin stool softeners as needed maybe catheterization
Spinal Shock
complete but temporary loss of motor/sensory/reflex/autonomic fx
immediately after injury
Spinal Shock s/s
flaccid paralysis loss of reflex below injury bradycardia hypotension paralytic ileus usually 48 hours but up to several weeks absent bulbocavernosus reflex
Neurogenic Shock
most common in injuries above T6 soon after injury massive vasodilation pooling of blood in BV tissue hypoperfusion impaired cellular metabolism
Autonomic Dysreflexia
common cause
high spinal cord injury T6 and above
uncompensated sympathetic nervous system stimulation
bladder irritation due to distention, bowel impaction
Autonomic Dysreflexia Classic Signs
hypertension (up to 300 SBP) throbbing headache diaphoresis above level of injury bradycardia (30-40) piloerection (goose bumps) flushing nausea
Autonomic Dysreflexia Life-Threatening Condition
hypertensive stroke
seizures
Autonomic Dysreflexia Interventions
check bp when headache reported assess urination (may need catheter) assess constipation (digital rectal examination) remove constrictive clothing notify HCP alpha-adrenergic blocker arteriolar vasodilator (amlodipine) HOB to 45 degrees or high Fowler's to lower BP don't have patient flat/side-lying
Meningitis
inflammation of meninges covering brain &spinal cord
Bacterial meningitis
classic
s/s
testing
fever, severe headache, n/v, nuchal rigidity
photophobia, AMS, other signs of increased ICP
Brudzinski & Kernig’s
Meningitis in Infants/Children
fever, restlessness, high-pitched cry
bulging fontanels
increasing head circumference
Acute Complications of Bacterial Meningitis
hydrcephalus increased ICP from CSF obstruction permanent hearing loss learning disabilities brain damage
pulse pressure
difference between sBP & DBP
Cushing’s Triad
systolic HTN w/ widened pulse pressure, bradycardia, respiratory depression
occur very late if increased ICP not treated
Brudzinski/Kernig’s
severe neck stiffness cause hips/knees to flex when neck is flared
stiffness of hamstring causes inability to straighten the leg when hip is flexed to 90 degrees
Lumbar Puncture
CSF assess for color/contents/pressure
Normal CSF
clear colorless small amount of protein, glucose, WBCs no RBCs/microorganism pressure is 60 -150 in water
Contraindication to Lumbar Puncture
Increased ICP
Highest Priority Meningitis Intervention
fluid resuscitation to counter hypotension
Sepsis & Meningitis
vasopressors (norepinephrine, phenylephrine, vasopressin, dopamine) once fluid resuscitation adequate
obtain labs & blood cultures prior to admin ABX
administer empiric ABX (w/in 30 min of admin)
prior to a lumbar puncture head CT scan
assist w/ LP for CSF examination & cultures (usually purulent/turbid in clients w/ bacterial meningitis)
Bacterial meningitis interventions
medical emergency
high mortality (25%) if untreated
empriric ABX started immediately
need peripheral IV to remain in place
Viral Meningitis
self-limiting
ABX not effective
usually not serious
s/s leave in 2 weeks
If suspected bacterial miningitis
droplet precaution until bac id’d and tx started
Miningococcal meningitis & Haemophilus influenzae type B meningitis
highly transmissible to others
precautions discontinued after 24 hours post ABX
viral meningitis usually does not require droplet
