Traumatic Brain Injury Flashcards
Managing Increased Intracranial pressure
- Elevate head of bed to improve perfusion
- O2 therapy to prevent hypoxia for SpO2 95% or less
- Place head in a midline, neutral position to promote venous drainage from brain
- Avoid sudden hip or neck flexion- can further increase ICP
- Avoid clustering of procedures
- Hyperoxygenate before and after suctioning
- Manage airway to prevent unnecessary suctioning or coughing
- Quiet environment is a must
- Keep lights low
- Monitor BP, heart rhythm, O2 saturation, blood glucose and body temp to prevent secondary brain injury
Pathophysiology of a Traumatic Brain Injury (TBI)
Damage to the brain from an external mechanical force and not caused by neurodegenerative or congenital conditions
Distinguish between a primary and secondary TBI
Primary: Occur at the time of injury and results from the physical stress (force) within the tissue caused by blunt or penetrating force
Secondary: Injury to the brain after the initial injury and worsens or negatively influence patient outcomes
Sign/Symptoms of TBI
Physical Findings:
1. Appears dazed or stunned
2. Loss of consciousness <30 mins
3. Headache
4. Nausea
5. Vomiting
6. Balance/gait problems
7. Visual problems
8. Fatigue
9. Sensitivity to light and noise
Cognitive Findings:
1. Feeling mentally foggy
2. Feeling slowed down
3. Difficulty concentrating
4. Difficulty remembering
5. Amnesia about the events around the time of injury
Sleep Disturbances:
1. Drowsiness
2. Sleeping less than usual
3. Sleeping more than usual
4. Trouble falling asleep
Emotional Changes:
1. Irritability
2. Sadness
3. Nervousness
4. More “emotional”
5. Depression
Mild TBI
Characterized by a blow to the head, transient confusion or feeling dazed/disoriented and one or more of these conditions:
(1) possible loss of consciousness for up to 30 minutes
(2) loss of memory for events
(3) focal neurologic deficit(s) that may not be transient
Loss of consciousness DOES NOT have to occur for a person to be diagnosed with mild TBI
No evidence of brain damage on a CT or MRI scan
Symptoms usually resolve within 72 hour. Symptoms may persist and last days, weeks or months. Persistent symptoms following a Mild TBI are referred to as a post concussion syndrome
Either sent home or 23 hours observation
Moderate TBI
Characterized by:
(1) a period of loss of consciousness (LOC) for 30 mins to 6 hour
(2) GCS score of 9-12
Often, but not always, focal or diffuse brain injury can be seen with a diagnostic CT or MRI scan
Post traumatic amnesia (memory loss) may last up to 24 hours. May occur with either closed or open brain injury
A short acute or critical care stay may be needed for close monitoring and to prevent secondary injury from brain edema, intracranial bleeding, or inadequate cerebral perfusion
Med-Surg unit or Critical Care Unit
Severe TBI
A severe TBI is defined by:
(1) A Glasgow Coma Scale score of 3-8
(2) Loss of consciousness for longer than 6 hours
Focal and diffuse damage to brain, cerebrovascular vessels, and/or ventricles is common. Both open and closed injuries can cause severe TBI, and injury can be focal or diffuse
CT and MRI scans can capture images of tissue damage quite early in the course of this illness
*Patients with severe TBI require management in critical care, including monitoring of:
(1) hemodynamics
(2) neurologic status
(3) possibly intracranial pressure
*Patients with severe TBI are at HIGH risk for secondary brain injury from:
(1) cerebral edema
(2) hemorrhage
(3) reduced perfusion
(4) bimolecular cascade
Prioritize assessment needs for patients experiencing a TBI
- Airway and Breathing Assessment
- Spine precautions
- Vital signs assessment
- Neurologic Assessment
Diagnostic Tests that are indicative of TBI
- CT- extent and scope of injury
- MRI- detect subtle changes in brain tissue and show more specific detail of the brain injury
Interventions to Maintaining Cerebral Tissue Perfusion
PRIORITY: MAINTAIN ABCs
(1) Vital signs based on acuity, but at least every 1-2 hours
(2) Cardiac monitoring
(3) Monitor for fever
> Therapeutic hypothermia can be started- this reduces brain metabolism and prevents events that cause secondary TBI
(4) Monitor/evaluate respiratory status using ABG values, SpO2 values, and ETCO2 values
(5) Determining brain death
(6) Drug therapy
> Mannitol
> Opioids for pain (fentanyl)
> Propofol and midazolam for sedation
Maintaining Cognition, Sensory Perception and Mobility
(1) Cognitive Rehabilitation
(2) Hazard-free environment
(3) Sensory stimulation
(4) Seizure precautions
Introduce yourself before any interaction
Keep explanations of procedures and activities short and simple
Maintain sleep-wake cycle with scheduled rest periods
Orient patient to time (day, month, year)
Reassure patient that they are safe
Ask family to bring in familiar objects (pictures)
Provide orientation cues (large clock with numbers or single-date calendar)
Brain Death Prerequisites
(1) Coma of known cause as established by history, clinical examination, laboratory testing, and neuro-imaging
(2). Normal or near-normal core body temp (higher than 96.8)
(3) Normal systolic blood pressure (higher than or equal to 100 mm Hg)
(4) At least one neurologic examination
Self-Management Education
(1) Collaborate with the case manager
(2) Explain drug therapy
(3) Encourage patient to participate in activities as tolerated
(4) Follow-up visits
(5) Develop home routine that provides structure, repetition and consistency
(6) Reinforce positive behavior
(7) Provide encouragement to patient and family to help them get through each day
(8) Teach importance of regular respite
(9) Join local support groups
Sign/Symptoms of Increased Cranial Pressure
(1) Decreased LOC (EARLIEST sign)
(2) Constricted and nonreactive pupillary changes (VERY LATE SIGN)
(3) Cushing Triad (VERY LATE SIGN)
(4) Abnormal posturing (VERY LATE SIGN)
