Neurologic Trauma

Traumatic Brain Injury

Traumatic Brain Injury (TBI)

• Primary brain injury– Two classifications

• Open head injury (penetrating)• Closed head injury (blunt)

• Secondary brain injury– Any neurological damage that occurs after the

initial injury

TBI: Types of Forces

• Acceleration injury

• Deceleration injury

• Shearing

• Straining

• Distortion of brain tissue

• Destruction of adjacent brain tissue

TBI: Secondary Brain Injury

• Increased intracranial pressure (ICP)• Hemorrhage• Epidural hemorrhage• Subdural hematoma• Intracerebral hemorrhage• Loss of autoregulation• Hydrocephalus• Herniation

Types of Brain Injury

• Concussion• Contusion• Diffuse axonal injury• Intracranial

hemorrhage

Describe the injuries.

Compare and contrast the types of injury.

Pathophysiology

Create a concept map flow chart of the pathophysiology of a brain injury.

Hemorrhage

• Caused by vascular damage from shearing force

• Potentially life threatening– Epidural: bleeding into space between the

dura and inner table of the skull– Subdural: venous bleeding into space

beneath dura and above the arachnoid– Intracerebral: accumulation of blood within the

brain tissue

Loss of Autoregulation

• Causes cerebral blood flow to fluctuate passively with the systemic blood pressure

• Increases ICP and potential for vasogenic edema

• Hypoxemia and hypercapnia cause marked cerebral vasodilation

Hydrocephalus and Herniation

Hydrocephalus• Abnormal increase in CSF volume• Results from impairment of CSF absorption or

blockage of the CSF circulation pathwayHerniation• With ↑ ICP, brain tissue may shift and herniate

downward• Several herniation syndromes• Uncal (transtentorial) herniation is life

threatening

History

• Client may experience amnesia• Client may be unconscious• Obtain history from others• Obtain information about events immediately

after injury• Determine whether client experienced seizure

activity before or after the injury• What were the circumstances of the fall• Past medical history• Allergies (esp. allergy to seafood)

Clinical Manifestations

What do clinical manifestations depend upon?

Why is drainage of CSF a serious problem?

What do the following manifestations indicate?

• Hemorrhage from nose, pharynx, or ears

• Blood under conjunctiva• Echymosis over mastoid• CSF otorrhea, rhinorrhea• Halo sign

Physical Assessment

• Goals of Nursing Assessment– Establishment of baseline data– Early detection and prevention of ↑ ICP, systemic

hypotension, hypoxia, or hypercapnia

• Treat all head injuries as though they have a spinal injury – Assess for indicators of spinal cord injury

• Loss of motor and sensory function• Tenderness along spine and abnormal head tilt• Respiratory difficulties• Diminished or absent reflexes

Physical Assessments

• Airway and breathing pattern– 1st priority– ABG’s

• Vital signs– Blood pressure and pulse – Cushing reflex

• Neurological – GCS or similar scale– Neuro assessment (pupillary response, motor

function, LOC, intactness of cranial nerves, signs of CSF leakage, posturing, papilledema)

Diagnostics

Lab• No labs to diagnose, can be used to diagnose or prevent

secondary brain insult• ABG’s, CBC, and serum glucose, electrolytes and

osmolality

Radiographic• CT scan• Cervical spine and skull xray• MRI• Cerebral angiography

TBI Interventions

• Monitoring for declining neurological function• Maintaining airway • Maintaining fluid and electrolyte balance• Promoting adequate nutrition• Preventing injury• Maintaining body temperature• Maintaining skin integrity• Improving cognitive functioning• Preventing sleep pattern disturbance• Supporting family coping• Monitoring and managing potential complications

TBI Interventions:Drug Therapy

– Glucocorticoids and steroids ineffective– Mannitol (osmotic diuretic) to treat cerebral edema– Furosemide as an adjunctive therapy– Codeine and fentanyl to ↓agitation and control

restlessness of ventilated patients

TBI: Interventions

Surgical management• Intracranial pressure monitoring

– Intraventricular catheter (can drain CSF)– Subarachnoid screw or bolt (less invasive, CSF

cannot be drained)– Epidural catheter or sensor – Subdural catheter– Fiberoptic transducer tipped pressure sensor (most

common device for ICP monitoring)

• Craniotomy