Download - TRAUMATIC BRAIN INJURY (TBI)
TRAUMATIC BRAIN INJURY (TBI)
Written by: Beth Frisby, RN, BSN, CEN, CCRN, CFRN, RNC-OB
Julia Sandoval RN, BSN, CFRN, CCRN
06/20/2019
Objectives
1. Discuss common mechanism of TBI.
2. Identify common TBI.
3. Identify clinical presentation of the patient
with a TBI.
4. Discuss medical management of patient
diagnosed with TBI.
5. Scenario training.
Common mechanisms in TBI
• MVC
• Falls
• Occupational
• Recreational
• Assaults
• Risk factor: Being male
ABRUPT SYMPTOMS and RISK FACTORS. • Unwitnessed or unrecognized Seizure with post-ictal deficits
• Migraines
• Systemic Infections
• Tumors (more often a slower presentation)
• Psychogenic Paralysis (Diagnosis of exclusion) (Conversion disorder)
• Chronic SDH
• Cardiac Failure
• Toxic-metabolic disturbances (Hyperglycemia; Hypoglycemia< 45mg/dl,often improves with glucose; Hyponatremia, Hepatic Encephalopathy)
• Syncope
• Vertigo
Differential Diagnosis
Concussion
No identifiable lesion;
N/V, confusion,
disorientation, memory
loss, seizure
• Post-concussion
syndrome: symptoms
remain for an
extended time;
• Head CT: Negative
Post Concussion Symptoms
• Neuropsychiatric Impairments– Headaches
– Slow/difficulty responding to questions
– Inability to focus attention
– Emotionally labile
– Memory deficits
– Disruption in speech
– Must have resolution of all impairments before returning to sport• Second impact syndrome
Assessment for CT scan
• Canadian CT head Rule (CCHR)
• New Orleans/Charity Head Trauma/Injury
Rule (NOC)
• National Emergency X-Radiography
Utilization Study II (NEXUS II)
• Pediatric Emergency Care Applied
Research Network (PECARN)
Pediatric Emergency Care Applied Research
Network PECARNS
https://www.aliem.com/2017/06/pecarn-pediatric-head-trauma-official-visual-decision-aid/
• Etiology: acceleration-
deceleration thus the
shearing of axons
• A widespread disruption
of neurologic function
without focal lesions
• 12-24hrs later tiny
punctate lesions are seen
on CT
• Diffuse swelling, white
matter degeneration,
axon damage
• Immediate LOC, last days
to months with normal
ICP
• Posturing
• Loss of brainstem
reflexes
Diffuse Axonal Injury
Epidural
• Hemorrhage between skull and dura mater
• Most common is temporal impact, middle meningeal artery
• (+) LOC, can have brief lucid period then rapid decline
• Need evacuation emergent
• Prognosis if bleed
evac’d early can be
good! Delays bring
mortality rate to 50%.
• Often Lens shaped in
appearance on CT
scan
Epidural Hemorrhage
• Cranial fractures are present in 70% to
90% of cases.
• 90% of epidural hematomas are caused
by head trauma with a skull fracture that
crosses a portion of the middle meningeal
artery or vein.
• The middle meningeal artery is torn in
60% of cases.
• Collection of blood between the dura mater and the arachnoid layer of the meninges
• Bridging veins torn
1. Acute (48hrs)
2. Subacute (2-14days)
3. Chronic (>14days)
Generally needs emergent evacuation
Subdural Hemorrhage
Subarachnoid Hemorrhage
• A diffuse collection of
blood between the
arachnoid mater and
the pia mater, from
SA vessels
• Seizure, vomiting,
LOC?
• 50% of traumatic
bleeds have SAH
Brain Stem Hemorrhage
• Primary: direct blow or torsion
• Secondary: Compression from elevated
ICP’s, edema
– Midbrain: deep coma, fixed pupils at midpoint,
posturing (decerebration)
– Pons: Coma, small (pinpoint) nonreactive
pupils, opthalmophlegia, decerebration.
Skull Fractures
• Depressed
– Pushes the skull into the brain
• Basilar
– Occurs most commonly in temporal bone
• Middle meningial artery and vein
– Raccoon eyes
– Rhinorrhea or Otorrhea
– Hemotympanum
– Facial nerve palsies
• Linear
Pneumocephalus and CSF leak
• Most often seen with Basilar skull fracture
– CSF leak is slightly increased risk of
meningitis
• Not usually given antibiotic prophylaxis
• Usually resolve in 7 days
• Elevated ICP
• Low CPP
• Systemic hypotension/shock
• Hypoventilation/hypoxemia
• Hyperventilation
• Brain edema
• Brain herniation
• Brain hemorrhage
• Cerebral arterial vasospasm
• Inflammation
• Hyperthemia
• Chronic systemic illness
Secondary Brain Injury
• Inadequate fluid or blood
resuscitation
• Inadequate oxygen
delivery
• Hyperventilation
• Nosocomial infections
• Alcohol and other drug
intoxication
• Anticoagulants
Intrinsic Extrinsic or Iatrogenic
Primary Survey
• A irway: Patent?
• B reathing: tachypnea common, SpO2>94%
• C irculation: normotensive
• D isability: (before medication/RSI)
Directed Neuro: GCS, Pupils, motor Strength, gross sensory
• E xposure: Trauma?
• Comatose?
• Posturing: abnormal flexion or extension of extremities in response to pain (Brainstem)
• Preferential gaze?
• Abnormal changes in breathing
• VS changes: CUSHINGS TRIAD:
– HTN with widened pulse pressure, BRADY-CARDIA, RESPIRATORY CHANGES (decreased) (Brainstem). (THIS IS A SIGN OF IMPENDING HERNIATION!!!! )
RSI
• Place pt on high flow
N/C for intubation can
increase reservoir
and buy you extra
time during intubation.
• Lidocaine
– May decrease ICP
– May do nothing
• Ketamine/Etomidate
• Succinylcholine/
• Rocuronium
Management of TBI
• HOB elevated
• Neck aligned, no knee / hip flexion
• C-collar (too tight??)
• Keep ETCO2 35
• PaCO2 35-38
• Normothermic
• Sat’s >94% (avoid hypoxia / hyperventilation)
• Control Pain / Keep sedated
• Mannitol if needed
• Euvolemic– Foley
• Normotensive
• Benzodiazepines – Levetiracetam (Keppra)
– 1000mg IVPB over 15min
then Q12hr.
– Fosphenytoin (Cerebryx)
load (15mg/kg, max
150mg) then Q 8hr. OR
Seizure
Prevention
Coagulopathies
• Release of
thromblplastin and
tissue-activating
proteins from TBI.
• PT, PTT
• treat with FFP
• S/S of elevated ICP? Intubate and control ETCO2
• Maintain neck alignment
• HOB 30
• Analgesics IVP or gtts
• Midazolam IVP or gtt
• Proprofol gtt
• Paralyze (Nimbex, rocuronium)
• Mannitol if showing S/S of potential herniation. – 1mg/kg
Manage Increase Cerebral Pressure (ICP)
https://www.iemoji.com/view/emoji/2493/smileys-people/exploding-head
Hyperventilation and TBI
• Decrease in PaCO2 leads to decrease in
cerebral blood flow
• Linked to worse outcomes
• Goal is to have PaCO2 at 35
Hypotension and TBI
• Spaite et al
– Increased mortality with decreased blood
pressure
– Threshold of 90mmHg may be too low
– Increased mortality with every 10 point
grouping decrease in blood pressure
– Prevent secondary injury
• Even one low blood pressure can increase
mortality as blood flow to brain decreases.
In Summary
• Treat primary injury and prevent
secondary injury
• Rememer the "H" Bombs
– Hypotension
– Hyperventilation
– Hypoxia
Bibliography
• https://www.uptodate.com/contents/emergency-airway-management-in-the-patient-with-elevated-
icp?source=history_widget
• https://www.uptodate.com/contents/management-of-acute-severe-traumatic-brain-
injury?source=history_widget
• https://www.uptodate.com/contents/pretreatment-medications-for-rapid-sequence-intubation-in-
adults-outside-the-operating-room?source=history_widget
• https://www.uptodate.com/contents/cerebrospinal-fluid-physiology-and-utility-of-an-examination-in-
disease-states?source=history_widget
• https://www.uptodate.com/contents/skull-fractures-in-children-clinical-manifestations-diagnosis-
and-management?source=history_widget
• https://www.uptodate.com/contents/acute-mild-traumatic-brain-injury-concussion-in-
adults?source=history_widget
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637731/
• https://www.uptodate.com/contents/severe-traumatic-brain-injury-in-children-initial-evaluation-and-
management?search=blood%20pressure%20traumatic%20brain%20injury&source=search_result
&selectedTitle=1~150&usage_type=default&display_rank=1
• https://www.uptodate.com/contents/management-of-acute-severe-traumatic-brain-
injury?search=blood%20pressure%20traumatic%20brain%20injury&source=search_result&select
edTitle=2~150&usage_type=default&display_rank=2
• https://www.uptodate.com/contents/sequelae-of-mild-traumatic-brain-
injury?sectionName=Second%20impact%20syndrome&search=second%20impact%20syndrome
&topicRef=91282&anchor=H4093484671&source=see_link#H4093484671
Bibliography
• https://canadiem.org/head-injuries-getting-it-right/
• https://www.aliem.com/2017/06/pecarn-pediatric-head-trauma-official-visual-decision-aid/
• https://www.uptodate.com/contents/evaluation-of-stupor-and-coma-in-
children?search=uncal%20herniation%20and%20pupils&source=search_result&selectedTitle=1~150&usage_type
=default&display_rank=1
• https://www.uptodate.com/contents/minor-head-trauma-in-infants-and-children-
evaluation?search=pecarn%20rules&source=search_result&selectedTitle=1~150&usage_type=default&display_ra
nk=1
• https://www.uptodate.com/contents/internuclear-
ophthalmoparesis?search=external%20ophthalmoplegia%20and%20trauma&source=search_result&selectedTitle
=1~150&usage_type=default&display_rank=1#H15
• https://www.uptodate.com/contents/intracranial-subdural-hematoma-in-children-epidemiology-anatomy-and-
pathophysiology?search=traumatic%20subdural%20hematoma%20injuries&source=search_result&selectedTitle=
1~150&usage_type=default&display_rank=1
• https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-children-clinical-features-diagnosis-and-
management?search=traumatic%20epidural%20hematoma%20injuries&source=search_result&selectedTitle=1~1
50&usage_type=default&display_rank=1
TRANSEXAMIC ACID (TXA)
Written by: Beth Frisby, RN,BSN, CEN, CCRN, CFRN, RNC-OB
Julia Sandoval RN, BSN, CFRN, CCRN
06/20/2019
Objectives
1. Discuss the history of TXA.
2. How does TXA work?
3. Identify clinical applications of TXA.
4. Overview of dosing of TXA.
5. Take home points.
History of TXA administration in Trauma
• 1962- A Japanese husband
and wife team publish in
Keio Journal of Medicine
• 2010- CRASH-2 in Lancet
• 2012- MATTERs
• 2017- WHO updates
recommendations based
on WOMAN trial
How does TXA work?
• TXA binds to
plasminogen’s lysine
receptor site
• Blocks the conversion
of plasminogen to
plasmin
• Less plasmin, thus
less fibrin (clot) break
down occurs https://hipandkneebook.com/hemostasis
Applications
Approved use in US
• Tooth extraction in
patients with
hemophilias
• menorrhagia
“Off-label” use in the US
• Traumatic
hemorrhage
• Total joint arthroplasty
• Cardiac surgery
• Post partum
hemorrhage
http://s.hswstatic.com/gif/tooth-extraction-1.jpg
https://www.springermedizin.de/polytrauma/755660-themenseite/11070372
Administration
Adult:
• 1gram in 100mL of NS/LR over 10 min WITHIN 3 HOURS of INJURY
• Followed by…
• 1gram in 1000mL NS over 8 hours within 6 hours of first dose
Pediatric:
• 15 mg/kg to a max of 1 gram over 10 min WITHIN 3 HOURS of INJURY
• Followed by…
• 2mg/kg/hour – within 6 hours of first
dose
– For at least 8 hours or until bleeding subsides
Traumatic hemorrhage with SBP<90
Contraindications/precautions
• Greater than 3 hours
since injury
• Hypersensitivity to
TXA
http://clipart-library.com/images/6ir5b8MBT.jpg
Take home points
• Traumatic hemorrhage
• SBP<90
• 1st dose MUST be given WITHIN 3 hours
• Don’t forget the 2nd dose within 6 hours
Bibliography
• https://www.ncbi.nlm.nih.gov/books/NBK532909/
• http://www.txacentral.org/history
• https://maternova.net/blogs/news/txa-recommended-by-who-for-pph-treatment
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086904/
• https://www.ncbi.nlm.nih.gov/pubmed/23477634