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.

This quiz covers Chapter 65 of NRSG 3013, focusing on the management of patients with neurologic trauma, including definitions, types of head injuries, and the pathophysiology of brain injuries. It also discusses the primary and secondary injuries and conditions that can arise from traumatic brain injury. Ideal for nursing students and professionals addressing critical care scenarios.