NRSG 3013 Chapter 65: Neurologic Trauma Management

Management of Patients With Neurologic Trauma

Chapter 65 (4th ed.)
Adapted by J. Black RN, BScN, MN
NRSG 3013

Head Injury

Broad classification including injury to scalp, skull, or brain
Most common causes are falls, motor vehicle accidents, and assault
Prevention: see Chart 65-1

Other Definitions

Coma
Vegetative state
Brain death

Pathophysiology of Brain Damage

Primary injury: Result of initial damage (contusions, lacerations, external hematomas, skull fractures)
Secondary injury: Damage evolving after the initial insult (intracranial hemorrhage, cerebral edema, intracranial hypertension, hyperemia, seizures, vasospasm)
Death can occur immediately after injury, within 2 hours, or approximately 3 weeks after injury

Pathophysiology of Traumatic Brain Injury

Brain suffers traumatic injury
Brain swelling or bleeding increases intracranial volume
Rigid cranium prevents expansion of contents, increasing intracranial pressure
Pressure on blood vessels within the brain slows blood flow
Cerebral hypoxia and ischemia occur
Intracranial pressure continues to rise; brain may herniate
Cerebral blood flow ceases

Clinical Manifestations

Manifestations depend on severity and location of injury
Scalp wounds: Tend to bleed heavily; portals for infection
Skull fractures: Linear, comminuted, depressed, open, closed; usually have localized, persistent pain
Fractures of the base of the skull: Bleeding from nose, pharynx, or ears; Battle sign (ecchymosis behind the ear); CSF leak (halo sign—ring of fluid around blood stain from drainage)
Basilar fractures allow CSF to leak from nose and ears (Fig. 65-2)
Manifestations of Traumatic Brain Injury: Altered level of consciousness, pupillary abnormalities, sudden onset of neurologic deficits (changes in sense, movement, and reflexes), changes in vital signs (Cushing reflex/triad), headache, seizures. See Chart 65-2

Factors that Predict a Poor Outcome

Intracranial hematoma
Increasing age of patient
Abnormal motor responses (decorticate, decerebrate)
Impaired/absent eye responses
Early sustained hypotension, hypoxemia
ICP levels higher than 20 mm Hg

Types of Traumatic Brain Injury

Contusion: Bruised brain in specific areas
- Clinical manifestations depend on size, location, surrounding edema; commonly occur 18-36 hours after trauma; usually located in frontal and temporal lobes; characterized by loss of consciousness, stupor, and confusion; managed medically to prevent increased ICP
Intracranial hemorrhage
- Epidural hematoma: Bleeding between dura and inner surface of skull; often middle meningeal artery; usually severe medical emergency requiring immediate surgical intervention; unconsciousness at scene, often a brief lucid interval, followed by a decrease in level of consciousness.
- Subdural hematoma: Collection of blood between dura and brain; venous in nature; commonly caused by trauma but can be an aneurysm; often manifests with changes in level of consciousness, pupillary signs, hemiparesis; signs of increased intracranial pressure (ICP), and coma; area of bleeding rapidly enlarges; high mortality rate due to associated brain damage; can be acute or chronic (see pg. 2060).
- Intracerebral hemorrhage: Bleeding into parenchyma of brain; commonly seen in head injuries with force exerted to a small area (bullet, stab); systemic hypertension, aneurysm, intracranial tumors, bleeding disorders, and anticoagulant therapies.
Concussion: Temporary loss of neurologic function with no apparent structural damage; Mechanism of injury usually blunt trauma; Duration of mental status abnormalities indicates the grade of the concussion. Monitor for decreased levels of consciousness (LOC), increased headache, worsening neurological status, seizures, abnormal pupil response, irritability, vomiting, slurred speech, and numbness/weakness. Repeated concussive incidents can lead to chronic traumatic encephalopathy (CTE).
Diffuse axonal injury: Widespread axon damage in brain seen with head trauma; associated with prolonged traumatic coma; no lucid interval, immediate coma; decorticate/decerebrate posturing; global cerebral edema; poor prognosis; diagnosis by CT/MRI/clinical signs

Diagnostic Evaluation

Physical and neurologic examination
Skull and spinal x-rays
CT scan
MRI
PET scan (assess function)

Management of the Patient With a Traumatic Head Injury

Assume cervical spine injury until ruled out
Therapy to preserve brain homeostasis and prevent secondary damage:
- Treat cerebral edema (mannitol)
- Maintain cerebral perfusion (treat hypotension, hypovolemia, and bleeding; monitor and manage ICP)
- Maintain oxygenation and cardiovascular/respiratory function
- Manage fluid and electrolyte balance

Supportive Measures

Respiratory support (intubation, mechanical ventilation)
Seizure precautions and prevention
NG tube to manage reduced gastric motility and prevent aspiration
Fluid and electrolyte maintenance
Pain and anxiety management
Nutrition

Brain Death

Three cardinal signs: coma, absence of brainstem reflexes, apnea
Other tests: cerebral blood flow studies, EEG, transcranial Doppler

Nursing Process—Assessment of the Patient With Traumatic Brain Injury

Health history (focus on immediate injury, time, cause, direction and force of blow)
Baseline assessment (Glasgow Coma Scale for level of consciousness)
Frequent/ongoing neurologic assessment
Multisystem assessment (see Table 65-1)

System-Specific Considerations

Neurologic system: severe TBI results in unconsciousness and altered neurologic functions, all bodily functions need support, increased ICP and herniation syndromes are life-threatening (measures instituted to control elevated ICP)
Integumentary system (skin and mucous membranes): immobility secondary to TBI and unconsciousness contribute to pressure areas and skin breakdown, intubation causes irritation; assessment of skin integrity and character, oral mucous membranes, and oral health
Musculoskeletal system: immobility contributes to musculoskeletal changes, decerebrate or decorticate posturing makes positioning difficult; assessment of range of motion of joints, and development of deformities or spasticity
Gastrointestinal system: injury to GI tract can result in paralytic ileus, constipation from bed rest/NPO status/fluid restriction/opioids; assessment of abdomen for bowel sounds and distention/monitoring for decreased hemoglobin. Bowel incontinence is related to the patient’s unconscious state or altered mental state
Genitourinary system: fluid restriction or diuretic agents can alter urinary output; intake/output records

Nursing Process—Diagnosis of the Patient With Traumatic Brain Injury

Airway clearance
Ineffective cerebral tissue perfusion
Deficient fluid volume
Nutrition
Injury prevention
Body temperature imbalance
Prevention of pressure injuries

Nursing Process—Diagnosis of the Patient With Traumatic Brain Injury (continued)

Disturbed thought patterns
Disturbed sleep pattern
Interrupted family process
Deficient knowledge

Collaborative Problems and Potential Complications

Decreased cerebral perfusion
Cerebral edema and herniation
Impaired oxygenation and ventilation
Impaired fluid, electrolyte, and nutritional balance
Risk of posttraumatic seizures

Nursing Process—Planning the Care of the Patient With Traumatic Brain Injury

Major goals include maintenance of patent airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, normal temperature, maintaining skin integrity, cognitive function and sleep, preventing deprivation, effective family coping, increased knowledge about rehabilitation process/absence of complications

Interventions

Ongoing assessment (monitoring vital signs)
Maintain airway (positioning: HOB elevated; suctioning with caution; prevention of aspiration and respiratory insufficiency; monitoring ABGs, ventilation, and mechanical ventilation; monitoring for pulmonary complications/potential ARDS)
Monitor I&O and daily weights; blood/urine electrolytes/osmolality/blood glucose
Implement measures to promote adequate nutrition
Implement strategies to prevent injury (reduce environmental stimulus; adequate lighting; minimize disruption of sleep-wake cycles; provide skin care; prevent infection)
Maintain body temperature (environmental temperature; coverings; administer acetaminophen; cooling blankets/cool baths; prevent shivering)
Support cognitive function, support family (provide information, coping measures, realistic/short-term goals; refer to counseling/support groups), and patient/family teaching (see Chart 65-6).

References

Prince, R. (2020). Management of patients with neurologic trauma. In M. El Hussein and J. Osuji (Eds.), Brunner & Suddarth's Canadian textbook of medical-surgical nursing (4th ed., pp. 2056-2087). Wolters Kluwer.