Traumatic Brain Injury Flashcards
Skull has 3 essential components
Brain tissue, blood and cerebrospinal fluid
Primary injury
Injury from car crash or impact
Happens then and there
Secondary injury
Will come from swelling , hypoxia , hypotension , etc
Monro-Kellie doctrine
When the volume of something in our head goes up .. the volume of something else has to go down
The head stays at 100 %
Which volume in the skull goes down first
CSF
It can be displaced into one of the cisterns in the head and even stop manufacturing
Next thing in the skull that would go down
Blood supply in the brain
It can’t be pushed anywhere and then the vessels will be compressed and the blood is not going to circulate
Once this happens then the pt starts becoming hypoxic leading to ischemia
Last thing that goes up in the skull
The brain tissue swells up leading to herniation
Cerebral blood flow is
Amount of blood in mL passing through 100 g brain tissue in 1 minute
Autoregulation of cerebral blood flow
So we can have a consistent amount of blood in the brain
MAP goal
At least 65 preferably 70
Map of greater than or equal to 150
Causes all of the autoregulation to shut down in the brain
Vessels lose their elasticity
Normal ICP
5-15 mmhg
Sustained intracranial of 20 or greater
Considered abnormal and must be treated
What happens when the brain loses its autoregulation
We can drain the pt head
CPP
Map- ICP
MAP formula
Systolic +diastolic x2 / 3
Why is diastolic pressure multiplied by two
The diastolic pressure last longer than my systolic
Normal ICP
5-15 mmhg
When do people posture?
If we go in and mess with them but they may be posturing the whole time
ICP increase .. Cushing triad
Systolic BP increase
Decrease pulshe
Altered resp pattern (kussmauhs , Cheyenne strokes, etc)
Indicated increased intracranial pressure (question in class)
Headache
Vomiting
Posturing
Pupillary changes’
Cushing triad ICP
Increased systolic BP
Decrease pulse
Decrease resp
Neuro issue
How do we support brain function in increased ICP
providing o2
Why is nutritional support important during increase ICP
The body needs more calories becuase it uses so many to heal .. we also do not want the gi to release endotoxins..
Even if it is just a trickle feed
Death occurs at three point in time after injury. When is this?
Immediately after injury
Within 2 hours after injury
3 weeks after injury
People who have multiple concussions such as football players and boxers..what do they lose?
Their language skills
Skull fractures
Linear or depressed
Simple , communituted or compound
Closed or open
Diffuse injury
Concussion
Diffuse atonal injury
Focal injury
Lacerations
Contusion
Coup -contrecoup
Contusion
Bruise
Diffuse axonal injury
Widespread damage of brain
Unconscious and unresponsive
Jello consistency
A pt falls 10 ft and has a basilar skull fracture.. what is our major concern?
If this break tore the dura and have a meningeal leak (CSF) which could set them up for a big infection
Epidural hematoma
Medical emergency bleeding inbetween the dura and the skull
Typically an arterial bleed ( fast)
Comes from the middle meningeal artery
O.R ASAPPPPPPP!!!!!!!!
Faster in the O.R it dramatically changes their outcome
Classic signs of epidural hematoma
Walking dead
Brief onset of unconsciousness at the scene
Immediately after it happen
Followed by a lucid period of consciousness then knocked out again
Acute Subdural hematoma
Similar signs and symptoms to compression in increased ICP
Don’t go to the OR .. they wait a moment to see if they’ll seal them selves up and reabsorb
Venous blood (much slower) ( breaching veins in the head)
Subacute subdural
After initial bleeding, may appear to enlarge over time
When they go in for 2nd CT or MRI it will look bigger than what they came in then we will have to do something
S/s of increase ICP
Chronic subdural
Peak incidence in sixth and seventh decades of life
( alcoholics at risk, elderly people)
Intracerebral hemorrhage
Bleeding in the parechyma
Treat pt symptomatically and let the blood reabsorb
The outcome depends on how bad the bleed was
Subarachoid hemorrhage
Present in the ER with a headache
Sometimes mistaken as a migraine
So dont shew off s/s because it “might “ be a migraine..
Bleeding into the subarachnoid space
What causes a subarachnoid hemorrhage
Uncontrolled hypertension , trauma, uncontrolled BP
Vasospasm
In about 3-14 days is when a pt can have a vasospasm in head after original bleed
Dangerous and can cause hypoxia leading to ischemia leading to permanent damage =cell death
Treatment for vasospasm
Make them hypervolemic
Let them be permissibly hypertensive
Nimodipine(calcium channel blocker )
Battle signs from head injury
Periorbital edema and ecchymoisis
Rhinorrhea
Ottorhea
Postaurcular ecchymosis
CSF
Very sticky and sweet
If CSF if dripping from nose and ears
Grab a gauze pad and let it drip on .. change it when needed
Never pack ears or nose because we dont want it trapped anywhere besides the dura and we run the risk of it becoming infected
Why do we question an NG tube with head injury
Because it scoots up and down the nose and runs the risk of meningitis
And document that you questioned the order
GCS
Best eye response
Best verbal response
Best motor response
When we need to do a neuro assessment and the pt is sedated .. what do we do
Let the physician tell you to bring them up from sedation to do neuro assessment
What is important to remember in GCS
To quantify what the pt can do in their limit like if they can only squeeze your hand they obey command but quantify it
If a person is intubated but can write you notes
Oriented ..but writes note
Non verbal but wrote a note
QUANTIFY
When giving report what is important to keep in mind when going over GCS
Do it at bed side with new nurse so she knows what ur looking at
Take into consideration what the pt family saw when you weren’t in the room
Nerve I
Olfaction
Test using an alcohol pad
Nerve II
Vision
Test with a vision chart
Nerve III
Most eye muscles
“Follow the moving finger”
Some ICP can’t .. have odd eye movement
What if someone can’t see
Verbalize where things are.. put them in the same spot .. tell them when you move something
How we monitor ICP
Epidural
Intraparenchymal
Subarachnoid
Ventricular
Gold standard monitoring for ICP
Ventricular
Goes in into the drainage pressure into the brain
How are we going to monitor drainage system with ICP
Maintain temp control and watch for infection- watch labs, hot , flushed , running fever , maintain sterility
How to keep sterility safe with drainage system
Biopatch and dressing over
How can we support brain oxygenation w increase ICP
Oxygenation pao2 100%
Interprofessional care increase ICP
Identify and treat the underlying cause
Support brain function
Drug therapy
Nutrition therapy
What can someone with a concussion tell us
Everything but not about the accident
Biggest concern of basilar skull fracture
Leak in meningeal , CSF leak, leading to a major infection
What vessel bled for pt to have a subdurral
Bridging veins
What. Is a GCS looking at
The best a pt can do
