Traumatic Brain Injury

1. Location determine manifestation
2. focal

   Nota:

   • associated with close head injury 
   1. Contusion

      Nota:

      • Rebleeding! seizure FIRST 7days 
   2. Coup & Contrecoup
3. Hemotoma Types
4. Basilar Fx (Linear)
   1. Rhinorrhea & Ottorrhea
   2. Raccoon Eyes

      Nota:

      • Periorbital edema
   3. Battle Sign

      Nota:

      • postauricular ecchymosis
5. Diffuse Axonal Injury (12-24hrs)

   Nota:

   • Widespread axonal damage (Mild, moderate, severe) 
   1. Decortication & Decerebration
   2. increase ICP & decrease LOC
   3. persistent Vegetative state
   4. Global cerebral edema
6. Concussion (Diffuse)

   Nota:

   • Transient neurologic disturbances. Caused by (1)  rapid acceleration and deccelerations (2) Sharp blow to the head cause axonal injury, tens
   1. Post concussion

      Nota:

      • Teach Caregiver when patient is discharged home! 2weeks to 2months  S&S persistent headache lethargy  personality & behavior changes  shortened attention span decreased short term  memory  intellectual changes ability interfere with ADLs  
   2. Mild
      1. No loss of cousciousness (brief period of diorientation or confusion)
      2. may or may not have retrograde amnesia
   3. Moderate
      1. temporary loss of consciouness (usually less than 5 minutes)
      2. No longer than 6hrs
      3. Retrograde amnesia or posttraumatic amnesia ALWAYS present
      4. Other S&S

         Nota:

         • H/A, dizziness, N&V, visual disturbances, diffficulty concentrating, poor behavior, memory disorders, irritability, anxiety & insomnia 
7. Scalp Lacerations
   1. Hemorrhage
   2. intracerebral dependes on space occupying- ipsilateral dilated pupil, contralateral hemipalegia & unconsciouness
8. Skull Fx

   Nota:

   • Hematoma
   1. Depressed
      1. Bruising Dura
   2. Comminuted
   3. Linear

1. Dextrostix or Tes-tape strip
2. Test CSF fluid Halo Sign

   Nota:

   • Blood present will concentrate in the middle and halo yellowish ring encircles the Blood coalesces in the center  
3. CT scan (fastest)
4. Glocoma Scale <below 8 is severe loss of consciousness

   Nota:

   • GCS mild (13-15), moderate (9-12), less than 9 severe  (a) eye opening  (b) verbal response  (c) motor response 
5. ICP
6. MRI, PET, evoked Potential studies
7. Transcranial doppler
8. Cervical spine x-r

1. Insert NG tube Basilar fracture
2. Administer antibiotics with postiive CSF fluid test
3. Surgery & invasive procedures- Subdural & epidrual hematoma
   1. Subdural & epidural surgical evacuation
   2. craniotomy, burr's holes
   3. craniectomy if extreme swelling
4. COncussion & COntusions
   1. Teach Post concussion Syndrome (2weeks- 2 months)
   2. Advise to avoid activities (Quiet rest periods)
   3. Managment of ICP & observation
5. Skull Fx
   1. surgery if depresssed (conservative treatment for others)
6. Emergency Treatment

   Nota:

   • (1) patent airway (2) stabilize cervical spine  (3) Oxygen  (4) iV access  (5) Intubate if GCS &lt;8  (6) Control external bleeding  (7) Remove patient clothing 
7. Ongoing monitoring

   Nota:

   • (1) maintain warmth- warm blankets, warm IV fluids, warm humified o2, warm heating lamps (2) Monitor vital signs, LOC, cardiac rhythm,  o2 sats, GCS scale, pupil size reactivity,  (3) rinorrhea, otorrhea, scalp wounds (4) Administered fluids cautiously (Increase in ICP) 
8. Gag reflex absent intubation
9. Initially assume neck injury until r/o immobilize
10. Primary

    Nota:

    • seatbelts &amp; helmets
11. Acute rehabiliation

    Nota:

    • motor &amp; sensory bowel and bladder management prevent DVT/hydrocephalus nutrtion dysphagia communication
    1. seizure managment
    2. teach no smaok, drive, alcohol
    3. educate family, progressive recovery (mental & emotional difficulties)
12. pharmacotherapy
    1. antiemetics

       Nota:

       • increases ICP
    2. analegiscs

       Nota:

       • maintains temperature
13. acute measures
    1. Eye problems

       Nota:

       • Eye drops, compress &amp; patch
    2. Hyperthermia

       Nota:

       • prevent shivering!!!
    3. CSF leak

       Nota:

       • loose collection pad
       1. head of bed elevated
       2. NO sneeze or blowing nose
       3. no NG tube and No nasotracheal suctioning

1. Laceration
   1. Hemorrhage

      Nota:

      • intracerebral, subarachnoid, and intraventricular 
   2. Infection
2. Hematoma
   1. Epidural

      Nota:

      • collectuion of blood between skull and dura matter  Arterial rapid, venous slow. meningeal artery tearig common cause   (1) Brief loss of consciousness  (2) Lucid period  (3) decrease in LOC  EMERGENCY brief loss of consciousnessRapid deterioration of neurologic system Needs surgery to evacuate hematoma 
   2. Subdural

      Nota:

      • Between dura and arachnoid. Majority is venous 
      1. Acute

         Nota:

         • 24-48hrs  Symptoms related to ICP increased  Decrease LOC, H/A Ipsiliateral pupil dilated and fixed if severe 
      2. Subacute

         Nota:

         • 2-14 days of injury may appear to enlarge over time 
      3. Chronic

         Nota:

         • weeks or months, More common in older adults,  presents of focal symptoms, risk for misdiagnosis
   3. Intracerebral

      Nota:

      • hemorrhage in the brain tissue (mass lesion) 
3. contusion (Focal)
   1. risk to rebleed especially 7 days after
   2. Ask about anticoagulant therapy
   3. "blossum on CT scan"
   4. Seizure
4. Skull Fx
   1. Infection, Hematoma & tissue damage

1. Secondary
   1. Infection
   2. Hypoxia
   3. Fluid electrolyte imbalances
2. Primary

   Nota:

   • open or closed. Comminuted, linear, depressed and compound 
   1. Open or Closed
   2. Skull fx- Comminuted, linear, depressed
3. Diffuse
   1. Concussion
   2. Diffuse axonal injury
4. Focal
   1. Laceration
   2. Contusion
   3. cranial nerve damage
5. Coup & Countrecoup

   Nota:

   • more severe often cause of severe injury 

Nota:

• nursing Subjective &amp; Objective  medications- need to know if they are on anticoagulants  Respiratory- rhinorrhea, gag reflex, inability to maintain a patent airway, impending heriniation, altered/irregular respirations Cardiovascular- impending herniation, cushing triad  GI vomiting, projectile vomiting, bowel incontinence  urinary- bowel incontinence  reproductive- uninhibited sexual expression Neurologic- Altered LOC, seizure activity, pupil dysfunction, cranial nerve deficit,  Motor weakness, palmar drift, paralysis, spascitity, decorticate, decerbrate posturing, muscle ridgity, flaccidity, ataxia 

1. LOC
2. Confusion, H/A, SEIZURES
3. Pupillary abnormalities
4. Altered or Absent Gag reflex

   Nota:

   • Glossopharyngeal Cranial Nerve 9 
5. Sudden onset of neurologic deficits-Hearing, vision, sensory, motor
6. changes in VItal signs

   Nota:

   • Respiratory
   1. Cushing Triad

      Nota:

      • Hypertension (widening pulse pressure) , Bradycardia, increase Respirations
7. Damage to pituitary DI or SIADH
8. projectile vomiity