T9: Head Injury TBI (Traumatic Brain Injury) Flashcards
Traumatic Brain Injury
a blow to the head or a penetrating head injury that damages the brain
majority of deaths after a head injury occur immediately after the injury, either from
*the direct head trauma or from massive hemorrhage and shock.
Deaths occurring within a few hours of the trauma are caused by
*progressive worsening of the brain injury or internal bleeding.
Deaths occurring 3 weeks or more after the injury result from
multisystem failure.
Linear fracture occurs when
*there is a break in continuity of bone without alteration of relationship of parts. It is associated with low-velocity injuries.
depressed skull fracture
inward indentation of skull and is associated with a powerful blow
simple linear or depressed skull fracture
*without fragmentation or communicating lacerations. It is caused by low to moderate impact.
comminuted fracture occurs
*occurs when there are multiple linear fractures with fragmentation of bone into many pieces. It is associated with direct, high-momentum impact.
r potential complications of skull fractures
*intracranial infections, hematoma, and meningeal and brain tissue damage.
The location of the fracture determines
*the clinical manifestations.
Basilar Skull Fracture
a specialized type of linear fracture that occurs when the fracture involves the base of the skull. Manifestations can evolve over the course of several hours, vary with the location and severity of fracture
clinical manifestations of basilar skull fracture
cranial nerve deficits, Battle’s sign (postauricular ecchymosis), and periorbital ecchymosis (raccoon eyes).
Brain injuries are categorized as
diffuse (generalized) or focal (localized).
diffuse injury
*damage to the brain cannot be localized to one particular area of the brain.
(e.g., concussion, diffuse axonal)
focal injury
damage can be localized to a specific area of the brain.
(e.g., contusion, hematoma)
Brain injury can be classified as
minor: GCS 13 to 15
moderate: GCS 9 to 12
severe: (GCS 3 to 8).
signs of concussion
*brief disruption in LOC, amnesia regarding the event (retrograde amnesia), and headache. The manifestations are generally of short duration.
Postconcussion syndrome can occur
anywhere from 2 weeks to 2 months after the injury.
Postconcussion syndrome s/s
*Persistent headache
*Lethargy
*Personality and behavior changes
*Shortened attention span, decreased short-term memory
*Changes in intellectual ability
Diffuse Axonal Injury
*widespread axonal damage occurring after a mild, moderate, or severe TBI.
s/s of diffuse axonal injury
*varied but may include a decreased LOC, increased ICP, decortication or decerebration, and global cerebral edema.
Lacerations
involve actual tearing of the brain tissue and often occur in association with depressed and open fractures and penetrating injuries.
contusion
*bruising of the brain tissue within a focal area.
what do we ask a patient with a contusion?
ARE YOU ON ANY ANITCOAGULANTS??? BECAUSE THEY HAVE A BRUISING WHICH IS BLEEDING!!
Coup-Contrecoup Injury
Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds
with contusion what are we monitoring for
*Monitor for seizures
*Potential for increased hemorrhage if on anticoagulants
Epidural and Subdural Hematoma intervention
Subdural Hematoma intervention
Evacuate these (suck them up) and try to decrease ICP in surgery
epidural hematoma
*results from bleeding between the dura and inner surface of the skull. neurological emergency
Classic signs of an epidural hematoma
an initial period of unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC.
*Headache, nausea, vomiting
*Focal findings
intervention for epidural hematoma
Rapid surgical intervention to evacuate the hematoma and prevent cerebral herniation, along with medical management for increasing ICP
subdural hematoma
occurs from bleeding between the dura mater and arachnoid layer of the meninges
*Acute Subdural Hematoma
*Within 24 to 48 hours of injury
*Symptoms related to increased ICP
*↓ LOC, headache
*Ipsilateral pupil dilated and fixed if severe
*Subacute Subdural Hematoma
*Within 2 to 14 days of the injury
*May appear to enlarge over time
*Chronic Subdural Hematoma
*Weeks or months after injury
*More common in older adults
*Presents as focal symptoms
*↑ Risk for misdiagnosis
*ETOH-atrophy and falling high percentage
*Subtle symptoms-mimic TIA,dementia somnolence,confusion,lethargy,memory
Delay in diagnosis of a subdural hematoma in the older adult can be attributed to
symptoms that mimic other health problems in persons of this age group, such as somnolence, confusion, lethargy, and memory loss.
Intracerebral Hematoma
*occurs from bleeding within the brain tissue and occurs in approximately 16% of head injuries.
Diagnostic Studies
*CT scan (Best diagnostic test to determine craniocerebral trauma)
*MRI, PET, evoked potential studies
*Transcranial Doppler studies
*Cervical spine x-ray
*Glasgow Coma Scale (GCS)
head injury treatment principles
*Prevent secondary injury
*Timely diagnosis
*Surgery if necessary
For the patient with concussion and contusion interventions include
observation and management of increased ICP are the primary management strategies.
intervention for depressed skull fracture
*a craniotomy is necessary to elevate the depressed bone and remove the free fragments. If large amounts of bone are destroyed, the bone may be removed (craniectomy), and a cranioplasty will be needed at a later time.
craniotomy
incision of the skull performed to visualize and allow control of the bleeding vessels
burr-hole
used in an extreme emergency for a more rapid decompression, followed by a craniotomy.
emergent treatment for patients with head injury
*Stabilize cervical spine. REMAIN HEAD IN NEUTRAL POSTION
*Administer O2 via non-rebreather mask.
*Establish IV access with two large-bore catheters to infuse normal saline or lactated Ringer’s solution.
*Intubate if GCS <8.
*Control external bleeding with sterile pressure dressing.
*Remove patient’s clothing.
maintain patients warmth by
warmth using blankets, warm IV fluids, overhead warming lights, warm humidified O2
what GCS indicates intubation
GCS <8
objective data for head injury
*Altered mental status
*Lacerations, contusions, abrasions
*Hematoma
*Battle’s sign
*Periorbital edema and ecchymosis
*Otorrhea
*Exposed brain
otorrhea
CSF leaking from the ear
rhinorrhea
CSF leakage from the nose
Cushing’s triad indicates
impending herniation
cushings triad
systolic hypertension with widening pulse pressure, bradycardia with full and bounding pulse, irregular respirations
GI/GU objective data for head injury
-Vomiting, projectile vomiting, bowel incontinence
-Bladder incontinence
neuro objective data for head injury
Altered level of consciousness, seizure activity, pupil dysfunction, cranial nerve deficit(s)
muscoloskeletal system objective data for head injury
Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity/increased tone, flaccidity, ataxia
overal all goals for head injury
*Cerebral oxygenation and perfusion
*Normothermic
*Control pain and discomfort
*Free of infection
*Adequate nutrition
*Maximal cognitive, motor, and sensory function
*Hyperthermia-hypothalamus damage goals
*Goal 36°to 37° C
*Prevent shivering
Eye problems may include
corneal reflex, periorbital ecchymosis and edema, and diplopia.
interventions or eye problems
-Loss of the corneal reflex may necessitate administering lubricating eye drops or taping the eyes shut to prevent abrasion.
-Periorbital ecchymosis and edema decrease with time, but cold and, later, warm compresses provide comfort and hasten the process.
-Diplopia can be relieved by use of an eye patch
*Measures for patients leaking CSF
*Head of bed elevated
*Loose collection pad under nose/over ear
*No sneezing or blowing nose
*No NG tube
*No nasotracheal suctioning
*Acute rehabilitation
*Motor and sensory deficits
*Communication issues
*Memory and intellectual functioning
*Nutrition
*Bowel and bladder management
what may occur in patients with nonpenetrating head injury
Seizure disorders so Antiseizure drugs may be used prophylactically to manage posttraumatic seizure activity
what is often the most incapacitating problem after head injury
*Mental and emotional difficulties-personality changes with progressive coma
*Health Promotion -Secondary Prevention
*Prevent car and motorcycle accidents
*Wear safety helmets
*Use seat belts and child car seats
*Home safety to prevent falls
