Traumatic Brain Injury

Traumatic Brain Injury

1. Clinical Manifestations

   • Location determine manifestation
   • focal
     • associated with close head injury 
     • Contusion
       • Rebleeding! seizure FIRST 7days 
     • Coup & Contrecoup
   • Hemotoma Types
   • Basilar Fx (Linear)
     • Rhinorrhea & Ottorrhea
     • Raccoon Eyes
       • Periorbital edema
     • Battle Sign
       • postauricular ecchymosis
   • Diffuse Axonal Injury (12-24hrs)
     • Widespread axonal damage (Mild, moderate, severe) 
     • Decortication & Decerebration
     • increase ICP & decrease LOC
     • persistent Vegetative state
     • Global cerebral edema
   • Concussion (Diffuse)
     • Transient neurologic disturbances. Caused by (1)  rapid acceleration and deccelerations (2) Sharp blow to the head cause axonal injury, tens
     • Post concussion
       • 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  
     • Mild
       • No loss of cousciousness (brief period of diorientation or confusion)
       • may or may not have retrograde amnesia
     • Moderate
       • temporary loss of consciouness (usually less than 5 minutes)
       • No longer than 6hrs
       • Retrograde amnesia or posttraumatic amnesia ALWAYS present
       • Other S&S
         • H/A, dizziness, N&V, visual disturbances, diffficulty concentrating, poor behavior, memory disorders, irritability, anxiety & insomnia 
   • Scalp Lacerations
     • Hemorrhage
     • intracerebral dependes on space occupying- ipsilateral dilated pupil, contralateral hemipalegia & unconsciouness
   • Skull Fx
     • Hematoma
     • Depressed
       • Bruising Dura
     • Comminuted
     • Linear

2. Diagnostics

   • Dextrostix or Tes-tape strip
   • Test CSF fluid Halo Sign
     • Blood present will concentrate in the middle and halo yellowish ring encircles the Blood coalesces in the center  
   • CT scan (fastest)
   • Glocoma Scale <below 8 is severe loss of consciousness
     • GCS mild (13-15), moderate (9-12), less than 9 severe&nbsp; (a) eye opening&nbsp; (b) verbal response&nbsp; (c) motor response&nbsp;
   • ICP
   • MRI, PET, evoked Potential studies
   • Transcranial doppler
   • Cervical spine x-r

3. Interventions

   • Insert NG tube Basilar fracture
   • Administer antibiotics with postiive CSF fluid test
   • Surgery & invasive procedures- Subdural & epidrual hematoma
     • Subdural & epidural surgical evacuation
     • craniotomy, burr's holes
     • craniectomy if extreme swelling
   • COncussion & COntusions
     • Teach Post concussion Syndrome (2weeks- 2 months)
     • Advise to avoid activities (Quiet rest periods)
     • Managment of ICP & observation
   • Skull Fx
     • surgery if depresssed (conservative treatment for others)
   • Emergency Treatment
     • (1) patent airway (2) stabilize cervical spine&nbsp; (3) Oxygen&nbsp; (4) iV access&nbsp; (5) Intubate if GCS &lt;8&nbsp; (6) Control external bleeding&nbsp; (7) Remove patient clothing&nbsp;
   • Ongoing monitoring
     • (1) maintain warmth- warm blankets, warm IV fluids, warm humified o2, warm heating lamps (2) Monitor vital signs, LOC, cardiac rhythm,&nbsp; o2 sats, GCS scale, pupil size reactivity,&nbsp; (3) rinorrhea, otorrhea, scalp wounds (4) Administered fluids cautiously (Increase in ICP)&nbsp;
   • Gag reflex absent intubation
   • Initially assume neck injury until r/o immobilize
   • Primary
     • seatbelts &amp; helmets
   • Acute rehabiliation
     • motor &amp; sensory bowel and bladder management prevent DVT/hydrocephalus nutrtion dysphagia communication
     • seizure managment
     • teach no smaok, drive, alcohol
     • educate family, progressive recovery (mental & emotional difficulties)
   • pharmacotherapy
     • antiemetics
       • increases ICP
     • analegiscs
       • maintains temperature
   • acute measures
     • Eye problems
       • Eye drops, compress &amp; patch
     • Hyperthermia
       • prevent shivering!!!
     • CSF leak
       • loose collection pad
       • head of bed elevated
       • NO sneeze or blowing nose
       • no NG tube and No nasotracheal suctioning

4. Complications

   • Laceration
     • Hemorrhage
       • intracerebral, subarachnoid, and intraventricular&nbsp;
     • Infection
   • Hematoma
     • Epidural
       • collectuion of blood between skull and dura matter&nbsp; Arterial rapid, venous slow. meningeal artery tearig common cause&nbsp;&nbsp; (1) Brief loss of consciousness&nbsp; (2) Lucid period&nbsp; (3) decrease in LOC&nbsp; EMERGENCY&nbsp;brief loss of consciousnessRapid deterioration of neurologic system&nbsp;Needs surgery to evacuate hematoma&nbsp;
     • Subdural
       • Between dura and arachnoid. Majority is venous&nbsp;
       • Acute
         • 24-48hrs&nbsp; Symptoms related to ICP increased&nbsp; Decrease LOC, H/A Ipsiliateral pupil dilated and fixed if severe&nbsp;
       • Subacute
         • 2-14 days of injury may appear to enlarge over time&nbsp;
       • Chronic
         • weeks or months, More common in older adults,&nbsp; presents of focal symptoms, risk for misdiagnosis
     • Intracerebral
       • hemorrhage in the brain tissue (mass lesion)&nbsp;
   • contusion (Focal)
     • risk to rebleed especially 7 days after
     • Ask about anticoagulant therapy
     • "blossum on CT scan"
     • Seizure
   • Skull Fx
     • Infection, Hematoma & tissue damage

5. Chapter 57 Acute intracranial problems p.1367

6. Skull or brain injury serious enough to cause damage to normal functioning

7. Types

   • Secondary
     • Infection
     • Hypoxia
     • Fluid electrolyte imbalances
   • Primary
     • open or closed. Comminuted, linear, depressed and compound&nbsp;
     • Open or Closed
     • Skull fx- Comminuted, linear, depressed
   • Diffuse
     • Concussion
     • Diffuse axonal injury
   • Focal
     • Laceration
     • Contusion
     • cranial nerve damage
   • Coup & Countrecoup
     • more severe often cause of severe injury&nbsp;

8. Assessment

   • nursing Subjective &amp; Objective&nbsp; medications- need to know if they are on anticoagulants&nbsp; Respiratory- rhinorrhea, gag reflex, inability to maintain a patent airway, impending heriniation, altered/irregular respirations Cardiovascular- impending herniation, cushing triad&nbsp; GI vomiting, projectile vomiting, bowel incontinence&nbsp; urinary- bowel incontinence&nbsp; reproductive- uninhibited sexual expression Neurologic- Altered LOC, seizure activity, pupil dysfunction, cranial nerve deficit,&nbsp; Motor weakness, palmar drift, paralysis, spascitity, decorticate, decerbrate posturing, muscle ridgity, flaccidity, ataxia&nbsp;
   • LOC
   • Confusion, H/A, SEIZURES
   • Pupillary abnormalities
   • Altered or Absent Gag reflex
     • Glossopharyngeal Cranial Nerve 9&nbsp;
   • Sudden onset of neurologic deficits-Hearing, vision, sensory, motor
   • changes in VItal signs
     • Respiratory
     • Cushing Triad
       • Hypertension (widening pulse pressure) , Bradycardia, increase Respirations
   • Damage to pituitary DI or SIADH
   • projectile vomiity