TBI/SCI & ABD Flashcards
Traumatic brain and spinal cord injury
Explain how to do a neurological exam for a traumatic Brian injury
ABC
GCS : obj level of patients conscious state : eye opening, verbal response, motor response ( 8 or less is comatose)
Pupils:
Movement (in coma patient check for gag or corneal reflex)
observe for signs of trauma
what is motor strength scaling
range motor strngth out of 5
motor exam assessment is these results:
1 - no response
2 - abdominal extension
3- abdominal flexion
4 - withdraw from pain
5 - localizes pain
6 - obeys commands
what are the trauma signs of traumatic brain injury (posturing)
posturing = severe brain damage
flexor posturing (cerebral hemispheres)
extensor posture (deeper brain structures, including the midbrain, pons, and brain stem)
what are the mild vs severe signs of traumatic brain injuries?
mild:
- loss of consciousness for seconds to min
- headache
- nausea / vomiting
-fatigue
- speech problems
mod to servere:
- loss of consciousness for several minutes to hour s
-headache
- repeated nausea and vomitting
- seizures
- dilation of one or both pupils
- clear fluid from nose or ears
- weakness
- agitation
- slurred speech
What are the classification and types of injury (how are each presented and treated)
penetrating injury - a head injury in which the dura mate (outer layer of menaces is breached) :
- perforating - through and through injury
- tangential - victim of a blast injury
- penetrating - object is lodged in the skull
concussion : low velocity injury resulting in function deficit without pathology injury , balance and coordination may be affected. most common symptom is a headache
Acceleration & Deceleration Injuries
coup : site of impact
counter coup : when the brain hits the back of the head when it moves back after impact
Diffuse Axonal Injury - long connecting fibers in the brain are sheared as the brain accelerates and decelerates
bleeds :
epidural
subdural
subarachnoid
intracerebral :
- intraparenchymal - blood in brain tissues
- intraventricullar - blood in ventricles
decompress brain by removing skull
what are the 4 potential complications of a head injury
- cerebral edema & herniation
herniation is Cushing triad ,
treat the underlining edema first - seizures
- antiepileptic medication for prophylaxis ( keppra 500 mg BID)
- any suspicion for subclinical seizures requires continuous eeg
- hydrocephalus
normal flow of csf in brain is obstructed causing abuld up of fluid and inc size of ventricles
treated with a diversion of csf with conversion to a shunt is needed
- External Ventricular Drain
- alterations of neuroendocrine function of hypothalamus and pituitary system
- diabetes insipidus ( oc diuresis)
- syndrome of inappropriate antidiuretic hormone (makes body hold water)
what is Cushing triad and how do nurses manage it?
Acute herniation : EMERGENCY
- increased BP
pulse pressure: SYSTOLIC BP - DIASTOLIC
causes edema - Decreased HR
- Decreased RR or irregular pattern (compression of respiratory center in brain)
treat underlining cause of edema
traumatic vs non traumatic spinal cord injury
traumatic :
- flexion/extension/compression
- fractures
-hematomas
non traumatic:
- tumors
- infection
- stenosis (narrowing of blood vessel)
- ischemic injury
- AVMSs
Neuromuscular disease can present with weakness
etiology of a spinal cord injury
fractures
dislocation
tumors
hematomeas
abscesses
ischemic injuries (spinal stroke)
penetrating injuries accounts for half of spinal injuries in urban centers
major cause of death for spinal cord injury
aspiration and shock
mechanisms of injury for a SCI (what are the ways you can injure yourself)
- compression - weight of head driven into neck
- flexion - excess anterior movement of head to ches t
- extension - excess posterior movement of the head and neck
- rotation - forcefully rotation of head and neck
- lateral bending/stress - lateral force to spine
- distraction - hanging , extension of spine
- penetration
Explain the ASIA scoring
Determine motor and sensory through classification of preserved function
A = COMPLETE , no motor or sensory function is preserved in the sacral segment S4-S5
B - D IS INCOMPLETE
B = sensory but NO MOTOR
C = Motor function but not up to the req level. MORE THAN HALF of muscles have a muscle grade of 3 (active against gravity but not super strong)
D= motor function but not up to the req level. LESS THAN HALF of muscles have a muscle grade of 3 or more
E = youre normal baby
what are some spinal precautions
- dont over extend yourself.
watch out for motor vehicle crashes
be careful about falling
ex of spinal syndromes
incomplete injuries (still some residual sensory and motor function, not a complete spinal injury)
Central cord syndrome - MOST COMMON . Injury to the center portion of the cervical cord .
- Weakness of the arms
- from HYPEREXTENSION with CERVICAL STENOSIS
Brown Squared Syndrome - Rare
- Weakness or paralysis on one side of the body and loss of sensation on the opposite side
- Damage to half of the spinal cord FROM TUMOR, TRAUMA , infection, disc herniation, inflammation disease
Anterior Cord Syndrome -
Complete motor paralysis and loss of temp and pain perception distal to the lesion which some sensory
- caused by COMPRESSION of anterior spinal artery
- ASSOCIATED WITH BURST FRAACTURES
Cauda Equina Syndrome - nerve roots of the caudal equine are compressed
symptoms : weakness, difficulty urinating, loss of rectal tone, saddle anesthesia
MEDICAL EMERGENCY
different types of spinal cord injuries
Complete
- no residual function more than three levels below the injury affecting both sides equally
Incomplete
- any residual sensory or motor function below the injured level
acute complications of SCI
1.) Spinal Shock - transient depression or loss of reflex activity below the level of the injury. Neurogenic Shock - CAN BE LIFE THREATENING form of distributive shock. SUDDEN loss of autonomic tone due to spinal injury.
causes hypotension and bradycardia
1. Neurogenic Shock management :
Fluids and vasopressors obviously girl they’re BRADYCARDIC ,
inc perfusion to spinal cord after injury (Have a high MAP GOAL >65)
atropine for bradycardia (inc HR) OR PACEMAKERS
Airway support if needed
2.) Autonomic Dysreflexia - the sympathetic system works but the parasympathetic system signals are blocked from the site of injury to calm it down (HTN, Bradycardia) typically starts with a headache
- Dysreflexia Management :
- remove cause of stimulation (drain bladder)
- position position upright
- loosen tight clothing
- antihypertensive drugs
- recognize triggers and avoid stimuli to prevent attacks
Nursing and medical management of spinal cord injuries
- stabilization of spine (surgery, brace, traction)
C spine - take 2 to 3 nurses to turn
T spine - no bending at the waist , or using arms to support
Full spine - log roll,
- distraction shock management : fluids, resuscitation, atropine to inc hr , vasopressors as needed d
-steroids (DONT GIVE)
- intensive support card
Management:
Neuro assessments
Pain Management (neuropathic pain)
Resp ( manage secretions, watch for pulmonary toileting)
CV
GI/GU
Skin - freq turns
DVT Prophylaxis
cause of spinal tumors
- viruses
- exposure to certain chemicals and hazardous materials
- genetic diseases such as tuberous sclerosis
clinical manifestations of SCI
- obvious spine deformitive
- pain or absence of sensation on spine
- trouble walking
- numbness
- bladder and bowel dysfunction
Diagnostic approaches of SCI
ASIA Score
Motor Strength Exam
MRI
Management of spinal tumors
- surgical resection and stabilization of spine
-radiation therapy
- chemo
- steroids to reduce swelling
Lead cause of death in spinal cord injury after initial injury
pneumonia, pulmonary embolism and sepsis
primary prevention of abdominal trauma
- seatbelts
- helmets
golden hour vs platinum 10 ABD Trauma
golden hour: the critical time immediately after injury (first hour)
platinum 10 minutes: restrict the time of prehospital care at that location of injury for no more than 10 minutes. they should just stabilize the patient and bring them to the local trauma center IMMEDIATELY. however some life saving things in the field can be done.
what is the trauma primary survey and the trauma secondary survey
primary survey: access and treat life changing injuries rapidly. for injued but stable patients
Airway ( w/ cervical spine protection)
Breathing (w/ ventilation)
Circulation (with hemorrhage control - stop bleeding)
Diability (neuro status)
Exposure and Environmental control (completely undress patient to ensure that do injuries are missed, then recover to avoid risk of hypothermia)
secondary survey: rapid but thorough head to toe assessment, performed after primary and initial stabilization AMPLE
A allergies
M medications
P Past medical history
L last meal
E events surrounding injury
then do physical assessment in all parts of the body ( head , jaw, neck , chest and, perineum, tubes and fingers etc)
with is the etiology of abdominal trauma : blunt vs penetrating
blunt:
- motor vehicle crash
- motorcycle crash
- pedestrian vs car
- assault with blunt force
- fall
penetrating
- foreign object perceiving skin and entering the body
- stab wound
- gun shot
what is the pre op nursing management
pre op:
- prep for OR
- fluid resuscitation
- ABCs
- management of pain
- freq abd assessments (distention, pain & firmness) - could be is signs of intrabdominal hypertension —> and compartilazation )
- prevent the lethal triad
severe blood loss/ dec perfusion to the tissues leads to hypothermia which leads to decreased coagulation ( blood clotting problem), hemorrhaging can cause this aswell — coagulopathy leads to inc lactic acid in the blood (acidosis) and decreased heart performance, leads to hypothermia again
3 most common complications from pre and post op abdominal surgery
abdominal compartment syndrome -
sustained abdominal HTN
- abnormally increased pressure within the abdomen that is associated with multiple organ dysfunction ( brain ischemia, impairing venous return/ blood flow etc)
clinical manifestations - abdominal distension , oc pain, tachypnea or dyspnea
Treatment: RELIEVE THE PRESSURE
renal injury -
AKI (prerenal secondary to hypovolemia)
intra renal (toxins from iv dye and antibiotics, prolonged hypotension)
monitor urine output
0.5mL/kg/hour
monitor creatine, bun , electrolytes
infection -
monitor for sepsis
S- shivering or fevre
E extreme pain
P paleness
S sleepy
I feel like I might die
S SOB
give a infection prophylaxis or exact med
what is the FAST exam?
focuses assessment with sonography and trauma , access for peritoneal bleeding. its important to do it FAST ( less than 5 minutes)
postivit fast exam in an unstable patient means patient is going to the OR IMMEDIATELY , if its neg, then do a CT scan
6 common injuries in blunt abdominal trauma (dont need to know management)
Lacerations:
- liver
- spleen
- renal
hematoma:
- bowel
- pelvic
- retroperitoneal
what is the post op nurse management for abdominal surgery?
respiratory - monitor and protect AB , monitor vitals esp pluse ox and respiratory, monitor lung expansion , monitor vitals
CV - systolic bp above 90 , neuropathy checks, fluid resuscitation
crystalloid for IV fluids like saline
colloid remain introvascular longer, so use for bleeding (albumin, frozen plasma)
I& O’s
Vasopressors
Hematologic
- prevent trauma triad of death (stop the bleeding ) , WAM BLANKETS, ROOM TEMP HIGH , WARM FLUIDS, MAX OUT O2
GI
Frey assessments
palpate for pain or tenderness
BLADDER PRESSURE - used to identify intraabdomianl HTN and potential abdominal compartment syndrome. measure with urinary Cather.
decreased gastric motility ,
give protein , weigh patient daily, replace electrolytes
Skin/surgical sight itself
- incision assessment
dec cap refill , cold extremities
how to treat intracrhail hypertension
- track Increased IntraCranialPressure Multimodality Monitors : monitors the pressure . If its more than 15 mmHg,
to reduce:
elevate head of med
minimize hip flexion
proper neck alignment
hyperventilation (rescue measure, not more than 15 minutes)
- Hyperosmolar Therapy , give hypertonic saline, mannitol or lassie
Sodium HIGH brain will FRY
Sodium low brain will BLOW - Surgical Decompression , take out a piece of the skull
