Traumatic Brain Injury (TBI) Flashcards
What is a Head Injury?
any trauma to the;
- skull
- brain
- scalp
Causes of head injury
- motor vehicle accident**
- falls**
- firearm-related injuries
- assaults
- sports-related injuries
- recreational accidents
- war-related injuries
Head Injury
3 points in time after injury
high potential for poor outcome
deaths occur at three points in time after injury:
- immediately after the injury (r/t hemorrhage and shock)
- within 2 hrs after the injury (r/t hemorrhage)
- 3 weeks after the injury (r/t multi system failure)
Types of Head Injuries: Scalp Lacerations
- external head trauma
- scalp is highly vascular- profuse bleeding
- major complication- blood loss and infection
Types of Head Injuries: Skull Fractures
- frequently occur with head trauma
- linear or depressed
- simple, comminuted, or compound
- closed or open
Linear Fracture
Simple linear or depressed fracture
- associated with LOW-VELOCITY IMPACT
- when there is a break in continnuty of bone without alterations of parts
simple linear or depressed fracture:
- without fragmentation or communicating lacerations.
- caused by low to MODERATE IMPACT
Depressed skull fracture
associated with POWERFUL BLOW
inward indentation
Comminuted Fracture
- multiple linear fractures with fragmentation of many bone in many pieces.
- associated with DIRECT HIGH-MOMENTUM IMPACT
Compound Fracture example
depressed skull fracture and laceration with communicating pathway to intracranial cavity
associated with SEVERE head injury
Skull Fractures: manifestations, complications
-Location determines manifestations
-complications:
infection
hematoma
tissue damage: meningeal/ brain tissue
Basilar Skull Fracture &
Basal Skull Fracture Suspicion
Basilar skull fracture: specialized type of linear skull fracture that occurs involving the base of the skull.
Generally associated with tear in the dura and subsequent leakage of CSF.
- Rinorrhea- CSF leakage from nose
- Otorrhea- CSF leakage from ear
(CSF leakage increases risk for meningitis. Antibiotics should be given) test for glucose unless there’s blood then use 4x4
nasogastric or nasal tube should be inserted under fluoroscopy
Signs of Basilar Skull Fractures
may include cranial nerve deficits
- Raccoon eyes- periorbital ecchymosis
- Battle’s sign- postauricular ecchymosis
- Halo sign- stain of blood with white ring around
Types of Head Injuries
categorized as;
Diffuse (generalized)- concussion, diffuse
Focal (localized)- contusion, hematoma
classified as;
Minor (GCS 13-15)
Moderate (GCS 9-12)
Severe (GCS 3-8)
Diffuse injury (Concussion)
- Brief disruption in LOC
- Retrograde amnesia
- Headache
- Short duration
- May result in postconcussion syndrome
- may or may not lose total consciousness
if patient didn’t lose consciousness or it’s <5 min, patient is discharged
Focal Injury
- Lacerations
- contusions
- hematomas
- cranial nerve injuries
Post-concussion Syndrome
usually from 2 weeks to 2 months after injury
Persistent headache
Lethargy
Personality and behavior changes
Shortened attention span, decreased short-term memory
Changes in intellectual ability
Diffuse Axonal Injury (general)
MASSIVE TRAUMA TO BRAIN
- widespread axonal damage from mild, mod., severe TBI
- decreased LOC
- increased ICP
- decortication/ decerebration
- global cerebral edema
- about 90% remain in vegetable state
Lacerations
- tearing of brain tissue
- with depressed and open fractures and penetrating injuries
- intracerebral hemorrhage- cerebral laceration. Manifested by unconsciousness, hemiplegia on contralateral side, and dilated pupil on ipsilateral side
- subarachnoid hemorrhage
- intraventricular hemorrhage
- surgical repair is impossible
Medical management of lacerations
antibiotics until meningitis is ruled out
preventing secondary injury r/t ICP
Contusion (focal)
bruising of brain within a focal area
- bruising of brain tissue
- associated with closed head injury
- can cause hemorrhage, infarction, necrosis, edema
- frequently occurs at fracture site
Contusions (cont.)
- can rebleed
- focal & generalized manifestations
- monitor for seizures (especially first 7 days)
- potential for increased hemorrhage if on anticoags. (higher mortality rate)
Coup- Contrecoup injury
coup- primary impact
contrecoup- secondary impact, tend to be more serious
can range from minor to severe
Hematomas: Epidural, Subdural, Subarachnoid
dura matter is attached to skull
epidural- above dura matter
subdural- below dura matter
subarachnoid- under subdural and under arachnoid space
Epidural Hematoma complications
bleeding between the dura and the inner surface of the skull
neuro. emergency
venous origin slow
arterial origin rapid
Findings in Epidural Hematoma
- initial period of unconsciousness (ask)
- brief lucid interval followed by decrease LOC
- headache, nausea, vomiting
- focal findings
- requires rapid evacuation (surgery/ drill hole)
Glascow Coma Scale
Eye opening response
Best verbal response
Motor response
13-14: mild
9-12: mod
3-8 severe
Eye opening response (4 is highest)
4- opens eyes spontaneously
3- opens eyes to speech
2- opens eyes to pain
1- no response
Best Verbal Response (5 is highest)
5- oriented to time, place, and person
4- confused
3- inappropriate words
2- in-comprehensive sounds
1- no response
Best Motor Response (6 is highest)
6- obeys commands
5- moves to localized pain
4- flexion withdrawal from pain
3- abnormal flexion (decortication)
2- abnormal extension (decerebrate)
1- no response
Subdural Hematoma
bleeding between the dura mater and the arachnoid
- most common source is the veins that drain the brain surface into the sagittal sinus
- Can also be arterial
- may be acute, subacute or chronic
Subdural Hematoma manifestations
- within 24 to 48 hours of the injury
- symptoms r/t ICP
- decreased LOC, headache
- **ipsilateral pupil dilated and fixed if severe: ipsilateral means same side of body as injury
- blunt force injuries that cause subdural hematomas cause sig. brain injury, increased cerebral edema. Prognosis is poor; morbidity and mortality are high
Subacute vs. Chronic Hematoma
Subacute subdural Hematoma:
- within 2 to 14 days of the injury (after initial bleeding)
- may appear to enlarge over time
Chronic subdural hematoma
- weeks or months after injury
- more common in older adults (more space due to brain atrophy)
- presents as focal symptoms
- increased risk for misdiagnosis
- ETOHers (due to clotting factors impaired, brain atrophy, falls)
sometimes symptoms are confused for stroke/ TIA. Symptoms are the same like; somnolence, confusion, lethargy, memory loss
Intracerebral Hematoma
- bleeding within brain tissue
- usually within frontal and temporal lobes
- sz and location of hematoma determine patient outcome
Intracranial Pressure (ICP)
Cerebral Perfusion Pressure (CPP)
ICP- amount of pressure in the brain and spinal fluid
CCP- amount of pressure required to get a sufficient enough amount of blood to the brain.
normal: 60-100 mg/hg
Cerebral Perfusion Pressure and oxygenation
it is recommended to keep CPP between 50-70
too low may cause ischemia (60 to prevent oxygen desaturation)
too high may cause acute respiratory distress syndrome
increase in edema & tissue pressure → increase in ICP → decrease in CPP → decrease in CBF → increase in ischemia
Cushing’s Triad (severe ICP)
- irregular, decreased respirations (caused by impaired brainstem function: cheyne-stokes)
- Bradycardia
- Systolic HTN (widening pulse pressure)
confusion will be evident
Calculating Cerebral Perfusion Pressure
an unconscious patient with traumatic head injury has a BP of 170/80, ICP of 30 mmHg. what is CPP?
- CPP- mean arterial pressure [MAP]- ICP
- MAP = DBP x 2 + SBP divided by 3
- 170 + 160 = 320 divided by 3 = 110 minus ICP of 30 = 80 mmHg
- (target CPP 50-70 mmHg)
Diagnostic Studies
- ***CT scan: best test to determine initial extent of craniocerebral trauma
- MRI, PET: more detailed
- Evoked potential studies (measure brain activity)
- Transcranial Doppler studies
- Cervical spine x-ray, CT scan, MRI
- GCS
diagnostic studies similar to ICP
Nursing care for head injury
- VS
- BP
- pulse
- respiration
(think Cushing’s triad)
Emergency Treatment for head injury (subdural hematoma)
***- patient airway
***- stabilize cervical spine
- oxygen (administer via non-rebreather)
- IV access (two large bore catheters NS/LR)
- intubate if GCS <8
- control external bleeding with sterile dressing
- remove patient’s clothing but maintain warm
Emergency treatment cont.
- keep patient warm (warm IV, overhead lights, warm humidified O2)
- ongoing monitoring (VS, LOC, O2 sats., cardiac rhythm, GCS, pupil sz and reactivity)
- anticipate possible intubation
- assume neck injury
- administer fluids cautiously
Tx PRINCIPALS
- prevent secondary injury
- timely diagnosis
- surgery if necessary (craniectomy, or burr holes)
- concussion and contusion: observation and ICP management
Nursing Assessment (subjective)
- mechanisms of injury
- alcohol/ drug use; risk-taking behaviors
- headache
- mentation changes; impaired judgement
- aphasia, dysphasia
- fear, denial, anger, aggression, depression
- ***anticoags. use
Nursing Assessment (objective)
- altered mental status
- lacerations, contusion, abrasions
- hematoma
- Battle’s sign
- Periorbital edema and ecchymosis
- otorrhea
- exposed brain
Objective data cont. 1
- rhinorrhea
- impaired gag reflex
- altered/ irregular respirations
- Cushing’s triad
- Vomiting
- Bowel and bladder incontinence
Objective data (cont. 2)
- uninhibited sexual expression
- altered LOC
- seizures
- pupil dysfunction (dilated pupils is a late sign)
- cranial nerve deficits
- increased ICP, high or low blood sugar, toxicology
Objective date (cont. 3)
- motor deficit
- palmar drift
- paralysis
- spasticity
- posturing
- rigidity or flaccidity
- ataxia; mimic being drunk
Objective data (cont. 4)
- abnormal CT scan or MRI; location, type of hematoma, edema, skull fracture, foreign body
- abnormal EEG
- positive toxicology screen or alcohol level
- increased or decreased glucose level
- increased ICP
Manitol
it is an osmotic diuretic. decreased ICP
Anisocoria
irregular pupils (different shapes or size)
Overall Goals for head injury
- maintain cerebral oxygenation & perfusion
- remain normothermic
- control pain and discomfort
- free of infection
- adequate nutrition
- attain maximal cognitive, motor, and sensory function
Acute Interventions
- maintain cerebral perfusion
- prevent secondary cerebral ischemia
- monitor for changes in neuro. status
- patient and family teaching
- *** major focus of nursing care r/t ICP: to prevent shift of brain and herniation
- eye problems: eye drops, compresses, patch
- hyperthermia: goal 36 to 37 C, prevent shivering
Acute interventions (cont. 1)
***acute interventions:
Measures for patients leaking CSF
- head of bed elevated
- loose collection pad
- no sneezing or blowing nose
- ***no NG tube
- no nasotracheal suctioning
if rhinorrhea or otorrhea occur, notify provider immediately!
Acute interventions (cont. 2)
- measures for immobilized patients (bowel, bladder function, skin care, infection prevention)
- antiemetics
- analgesics
- antibiotics
- diuretics
- pre-op preparation, if needed
Ambulatory and Home Care
- rehab: motor and sensory deficits, communication issues, memory and intellectual functioning, nutrition, bowel and bladder management
- seizure disorders may occur
- mental and emotional difficulties
- progressive recovery
- family participation and education
first RED FLAG indicative of a problem
change LOC/ mental status
