1 sometimes: the lights are on…. but nobody’s home…
TRANSCRIPT
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1
Sometimes:The Lights are on…. But nobody’s home….
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Traumatic Brain Injury (TBI) 2
Adult Health IITraumatic Brain Injury—Part 1
Jerry Carley RN, MA, MSN, CNESummer 2010
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Concept Map: Selected Topics in Neurological Nursing
PATHOPHYSIOLOGY
Traumatic Brain Injury (TBI)Spinal Cord Injury
Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Huntington’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease
PHARMACOLOGY
--Decrease ICP--Disease Specific Meds
ASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation
ICP Monitoring“Neuro Checks” Lab Monitoring
Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…basedOn Nursing Process: A_D_O P_I_E
Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary
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Objectives4
Recall anatomy and physiology of the brain & cranial nerves
Explain pathophysiology of various brain (head) injuries
Detail signs, symptoms and prevention of Increased Intracranial Pressure (ICP)
Demonstrate effective use of Glasgow Coma Scale
Discuss medical & nursing management of brain injuries
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trauma nursing is not for everyone……and traumatic brain injury is one of the trauma nurse’s greatest challenges.
5
Nasal catheters toCombat epistaxis
Endotracheal tube
Dry sterileDressing over Ears (for CSF Leak)
“N-G Tube”Inserted orally(“orogastric tube”)
RigidCervicalCollar
Is this “just blood,”Or is thereSome leakedCSF FluidIn there?
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Anatomy & Physiology Review 6
OOOTTAFAGVSH
IIIIIIIVVVIVIIVIIIIXXXIXII
lfactorypticculomotorrochlearrigeminalbducensacialcousticlossopharyngealaguspinal accessoryypoglossal
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Cranial Nerve Function Structures Innervated
I Olfactory Smell Olfactory Bulb
II Optic Vision Retina
III Oculomotor Eyeball movementLens AccomodationPupil Constriction
4 eyeball muscles1 eyelid muscle
IV Trochlear Eyeball Movement Superior Oblique Muscles
V Trigeminal 1. Sensation2. General Sensory From Tongue3. Proprioception
1. Face, scalp, teeth, lips, eyeballs, nose, throat lining2. Anterior 2/3 of tongue3. Muscles of mastication
VI Abducens Eyeball movement Lateral Rectus muscle
VII Facial 1. Taste2. Proprioception3. Facial Expressions4. Salivation & Lacrimation
1. Face & Scalp2. Face & Scalp3. Muscles of face4. Salivary & Lacrimal Glands
VIII Acoustic 1. Balance2. Hearing
1. Vestibular apparatus2. Cochlea
IX Glossopharyngeal
1. Taste2. Proprioception for swallowing3. Blood pressure receptors4. Swallowing & gag reflex5. Tear production6. Saliva production
1. Posterior 2/3 of tongue2. Throat muscles3. Carotid sinuses4. Throat muscles5. Lacrimal glands6. Parotid glands
X Vagus 1. Chemoreceptors2. Pain receptors3. Sensations4. Taste5. Heart Rate & Stroke Volume6. Peristalsis7. Air Flow8. Speech & Swallowing
1. Blood O2 Concentration, Aortic bodies2. Respiratory & Digestive Tracts3. External ear, larynx, pharynx4. Tongue5. Pacemaker & Ventricular Muscles6. Smooth muscles of digestive tract7. Smooth muscles of bronchioles8. Muscles of larynx & pharynx
XI Spinal Accessory
1. Head rotation, upright position2. Shrugging shoulders
1. Trapezius & sternocleidomastoid muscles
XII Hypoglossal Speech & Swallowing Tongue & Throat muscles
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Brain Trauma8
Brain injury results in more trauma deaths than do injuries to any other body region!
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Primary Injury
9
Mechanical trauma that occurs at the moment of impact and may lead to irreversible cell damage from physical disruption of neurons or axons
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103 Top Causes
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Etiology of Traumatic Brain Injury (TBI) in the U.S.
OtherSportsAssaultsFallsMVC
Other 7%
11
Motor Vehicle Crashes50 %
Falls21 %
Sports10 %
Assaults12 %
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Mechanism of Closed Head Injury“Rear-Ended” – “Whiplash” Effect
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“Coup- Contrecoup”
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“Coup-Contre Coup”13
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14
Boxing:
Coup-
Contre Coup
Injury :
“The second collision”
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Risk Factors15
Highest in young people and the elderly
*Age 65 – 75 has highest incidence of HI of ALL age groups*
Occurs twice as often among males compared with females
Motor vehicle crashes account for the major proportion of head and brain injuries….and involve a disproportionately large number of young persons
Alcohol intoxication is a compounding factor in at least 30% to 50% of head injuries and is a contributing factor in almost ½ of all fatal motor vehicle crashes in the United States
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Did you Know ?16
Laws that require helmet use have been shown to
reduce deaths
in motorcyclists
by about 30%
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At the Scene: - EMS- First Responders
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18Spinal Injury
Assumed
With
Any
Head Injury
UntilProven
Otherwise
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1. Maintain ability to breathe
2. Prevent shock
3. Immobilization to prevent further spinal cord damage
(Backboard + C-Collar)
“ TheGoldenHour ”
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EMS type C- Collar20
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EMS Back Boards21
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Upon Arrival to ER…22
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Baseline Assessment23
Vital Signs
Glasgow Coma Score (GCS)
Prevent Further Injury!
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The GCS is the most widely used method of defining a patient's Level of Consciousness (LOC)
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“ Posturing ”26
Decorticate Rigidity:
*Upper arms held at the sides, with elbows, wrists , and fingers flexed. *Legs are extended & internally rotated.
Decerebrate Rigidity:
*Jaws are clenched & neck is extended.*Arms are extended with wrists facing out.*Legs are extended.
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C – Spine X-Ray“Cross-Table Lat”
Before removal of ANY immobilization devices
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As Much as Possible In ER28
Instruct client to avoid sneezing or coughing
Provide calm environment
Maintain immobilization
Avoid meds the decrease LOC such as analgesics
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Severity of Head Injury29
GCS 3 – 8 : Severe Head
InjuryGCS 9 – 12: Moderate Head
InjuryGCS 13 -15: Mild Head
Injury
GCSSCORE< 8 =COMA
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The best guide to the severity of head
injury is the level of
consciousness(LOC)
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History of Injury32
Loss of Consciousness?
Other victims seriously hurt?
Mechanism of injury?
Driver / passenger / seatbelt ?Fall height / what caused fall?Hit where and with what?Gunshot / impaled object ?
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Open or Closed Injury ?33
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Diagnostics34
Damaged areas of the brain have a reduced or no blood flow or glucose metabolism. This can be seen in the images below where there has been a blow to the head by a rock
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Skull Fractures35
Present on CT scans in about two thirds of patients after head injury
Skull fractures can be linear, depressed, or diastatic and may involve the cranial vault or skull base
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Depressed Skull Fractures36
A portion of the skull is extending into the intracranial space
Often results in pressure on the brain or direct injury to the brain
In addition, the bone fragment may cause a laceration of the dura mater resulting in a cerebrospinal fluid leak
Outcome is based upon the underlying brain injury. If no brain injury is present the surgery represents a cosmetic procedure and the outcome is generally quite good
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Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving
Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli
Occipital Lobe- associated with visual processing
Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech
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Basal (Basilar) Skull Fractures
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1 frontal2 ethmoid3 sphenoid4 temporal5 parietal6 occipital
Involve the floor of the skull and include fractures of the cribriform plate, frontal bones, sphenoid bones, temporal bone and occipital bones
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1. Frontal sinus
2. Crista galli
3. Cribriform plate
4. Lesser wing of sphenoid
5. Superior orbital fissure
6. Superior border of petrous part of temporal bone
7. Dense shadow of petrous part of temporal bone
8. Perpendicular plate of the ethmoid
9. Vomer
10. Maxillary sinus
11. Inferior concha
12. Ramus of mandible
13. Body of mandible
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Basal (Basilar) Skull Fractures40
• Most basal skull fractures do not require treatment and heal themselves
• Persistent CSF leakage may warrant operative repair of the leakage, particularly CSF leaks related to frontal bone and cribiform plate fractures
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Basal Skull Fractures41
Clinical Clues may include:
CSF leakage through the ear or nose (otorrhea or rhinorrhea)
Hemotympanum (blood behind the eardrum)
Bruising behind the ears (postauricular ecchymoses) “Battle Sign”
Bruising around the eyes (periorbital ecchymoses) “Raccoon Eyes” “Panda Eyes”
Injury to cranial nerves:
VII Facial nerve - weakness of the face VIII Acoustic nerve - loss of hearing I Olfactory nerve - loss of smell II Optic nerve - vision loss VI Abducens nerve - double vision
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CSF Leakage44
Rhinorrhea and otorrhea are clinical signs of cerebrospinal fluid (CSF) leakage in patients with skull fracture
Presence of glucose (CSF) in otorrhea and rhinorrhea detected by Beta-2 transferrin. Nasal/ear discharge (glucostix) was traditionally used to diagnose CSF leak at the bedside, but has fallen into disuse as it has poor positive predictive value
CSF leakage opens the brain & spinal canal to infection
CSF is needed to cushion the brain, maintain pressure within the eye and cleanse the CNS (like the lymphatic system serves the same function in the rest of the body)
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45The Halo Effect
of Leaking
Serosanguinous
Cerebrospinal Fluid (CSF)
Filter Paper
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Prevent Infection !46
Cover any suspected source of CSF leakage with a
Sterile Dressing STAT !
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CSF Infection 47
Nuchal Rigidity
CSF has WBCs
Increased Temperature
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(Sometimes) Associated with Brain Injury48
Blood on Ocular Surface : Subconjunctival Hemorrhage
Blood in the anterior chamber of the eye (hyphema) as a complication of blunt trauma. Eyes with hyphema may show other signs of damage
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Another Clue….49
Avulsed eye and lacerations to the forehead
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Penetrating Brain Injury50
MRI of 19 y.o Melbourne, Australia resident involved in bar fight. That’s a metal chair leg going into the left orbit. Patient survived. Not only that, the left eye was salvaged with only slight loss of visual acuity.
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Attempted suicide with a crossbow. Patient survived, though he did lose sight in one eye, since the arrow partially severed one of his optic nerves.
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Head Injury Assessment52
Obvious Skull Fractures?
Lacerations?
Deformities? (bumps / indentations)
Facial Injuries?
Blood and/or CSF drainage from nostrils? (rhinorrhea)
Blood and/or CSF drainage from ear canals? (otorrhea)
Blood and/or CSF drainage from mouth?
Blood and/or CSF drainage from eyes?
Pain?
Headache?
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Collaborative Treatment Goals 53
Maintain AirwayBreathingCirculation
Maintain cerebral perfusionMaintain electrolyte balanceMaintain fluid balanceMaintain cognitive function
HOW ????
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Prevent Secondary Injury !!!
Meaningful recovery of function after head injury is possible IF
secondary injuries are prevented or minimized
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