Neuro Trauma Outline Fall 2024 PDF

# Neuro Trauma Chap 45 ## Neuro - Neurologic trauma can be life-threatening or life-altering. - Neurologic trauma affects the patient, the family, the health care system and society. - The nurse collaborates with many members of the health care team. ## Head injuries - Includes injury to scalp, sk...

# Neuro Trauma Chap 45 ## Neuro - Neurologic trauma can be life-threatening or life-altering. - Neurologic trauma affects the patient, the family, the health care system and society. - The nurse collaborates with many members of the health care team. ## Head injuries - Includes injury to scalp, skull, or brain - Most common cause of death from trauma in US - Most common cause of TBI are falls - Males 15-24 yo are highest risk ## Patho - TBI takes 2 forms - **Primary injury**- initial damage results from the traumatic event - **Secondary**- evolves hours or days after an initial injury. This usually occurs due to cerebral edema, ischemia, seizures, infection, hyperthermia, hypovolemia and hypoxia. ## Skull fractures - Break in skull that may occur with or without damage to brain - May be simple, comminuted, depressed or basilar - **Simple**- break in bone - **Comminuted** - splintered fracture line - **Depressed**- bone fragments are embedded into brain tissue - **Basilar**- fracture at the base of the skull - Fractures can be open or closed ## Clinical manifestations - depends on severity and distribution of injury - Basilar fx- tend to transverse the paranasal sinus and there may be hemorrhage from the nose, pharynx, ears, or blood may appear in the conjunctiva. Basilar skill fractures are suspected when CSF escapes from the ears and the nose. ## Assess & Diagnosis - X ray and physical and neurologic exam. MRI when stable. ## Nursing care - Close observation for change in Neurological status. - Depressed fx usually require surgery. - Basilar fx: do not blow or suction nose (use oral NG tube if needed), HOB 30 degrees. Monitor for infection. CSF from nose for 3-5 days may not need surgery but 7 or more days usually needs surgery. CSF from ears usually no surgery needed. # Brain Injury - The major factor in head injury is whether or not the brain is injured. Minor head injuries can have significant brain damage. - **Open brain injury** -object penetrates skull and enters the brain and tissue. Or when blunt trauma is so severe it opens the skull, scalp, and dura to expose brain tissue. - **Closed brain injury** -no opening in skull or dura ## Types of brain injury - **Concussion**- alteration in mental status, may or may not have loss of consciousness. Last 24 hours or less. May have H/A, N&V, photophobia, amnesia, blurry vision, difficulty speaking, difficulty in awakening, seizures, weakness on one side of the body. - Treatment: observation, awaken every 2 hours, resume normal activities slowly. - **Contusion** more severe injury. Involves bruising of brain with possible surface hemorrhage. - They may be unconscious for more than a few seconds or minutes. The symptoms depend on the size of the injury and brain swelling. May be motionless with faint pule, shallow respirations, and cool, pale skin.(similar to shock) They may arouse and go back to unconsciousness. BP and temp may be abnormal. Patients may gain consciousness but have cerebral irritability. (easily disturbed by stimulation, sound, light and may be hyperactive). Full recovery can take months. May have long term residual H/A, vertigo, impaired mental function or seizures - **Diffuse Axonal injury**- widespread damage to multiple areas of brain. - The patient experiences immediate coma, cerebral edema, decorticate and decerebrate rigidity or posturing. - Diagnosis- Clinical signs, CT and MRI. These tests may be normal. - Recovery depends on the severity of the axonal injury - **Intracranial hemorrhage**- Hematomas that develop in the cranial vault. - Symptoms may be delayed until the hematoma is large enough to cause pressure or increase ICP. - Clinical manifestations depend on which vital areas are affected and area of injury. - **Intracerebral hemorrhage and hematoma**- bleeding into the parenchyma of brain. - Force, bullet wounds, and stabbings). Onset may begin with neuro deficits and follow by HA - Supportive care, control ICP or surgical intervention. ## Management of Brain injuries - Cervical collars and back boards should be used until C spine injuries are ruled out. - All therapy is directed to prevent secondary brain injury. This is done by stabilizing cardiovascular and respiratory function. ## Altered level of consciousness - **Not oriented**, do not follow commands and needs persistent stimuli to achieve alertness. - **Coma** - clinical state of unarousable unresponsiveness with no purposeful responses to internal or external stimuli. Usually last 2-4 weeks. - **Persistent vegetative state**- unresponsive patient resumes sleep-wake cycles after a coma but has no cognitive or affective mental function. - **Lacked in syndrome**- lesion affecting the pons or midbrain and results in tetraplegia (used to be quadriplegia) and inability to speak but vertical eye movements and lid elevation remain intact and are used to indicate responsiveness. - **LOC IS The MOST IMPORTANT INDICATOR OF THE PATIENTS CONDITION!!!!!!!** ## ICP - Increased ICP from any cause decreases cerebral prefusion, stimulates further swelling, and may shift brain tissue trough openings and cause herniation. - Increased ICP may reduce cerebral blood flow causing ischemia and cell death. Early stages of cerebral ischemia stimulates vasomotor centers which increase systemic pressure to maintain blood flow. This may be seen by a slow bounding pulse and respiratory irregularities. - Cushing response is seen when cerebral blood flow decreases significantly. It is seen by an increased systolic BP with a widening pulse pressure and cardiac slowing. This is a late sign and needs IMMEDIATE INTERVENTION!! - At a certain point the brain cannot compensate and ischemia and infarction begins. The patient will significant changes in mental status and vital signs. - The bradycardia, hypertension and bradypnea with this are known as cushing triad. (Grave sign!!) and herniation and occlusion of blood flow occur if no intervention is initiated immediately. ## Glasgow Coma Scale | Eye opening and response | Best verbal response | Best motor response | Total | |---|---|---|---| | Spontaneous – 4 <br> To voice -3 <br> To pain - 2 <br> None – 1 | Oriented -5 <br> Confused -4 <br> Inappropriate words – 3 <br> Incomprehensible sounds – 2 <br> None - 1 | Obey command – 6 <br> Localized pain – 5 <br> Withdraws – 4 <br> Flexion - 3 <br> Extension - 2 <br> None - 1 | 3 to 15 | ## Treatment for altered LOC - FIRST PRIORITY is maintaining patent airway!!!!! - Then circulatory status BP and HR to ensure perfusion - Increased ICP is a true emergency and must be treated promptly (invasive monitoring are important) ## Management of increased ICP - decrease Cerebral edema - lowering volume of CSF - Decreasing cerebral blood flow while maintaining perfusion ## You can meet these goals by - administering osmotic diuretics - Mannitol generates an osmotic pressure difference across the BBB, driving the movement of water from the brain tissue into the bloodstream. This leads to brain dehydration and a subsequent reduction in ICP. - Side effects of mannitol - allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue. - confusion. - seizures. - signs and symptoms of electrolyte imbalance like severe diarrhea; unusual sweating; vomiting; loss of appetite; increased thirst. - Mannitol becomes ineffective when the serum osmolality exceeds 320 mOsm - Restricting fluids - Draining CSF - Controlling fever and decreasing metabolic demands - Maintain systolic BP and oxygenation ## Monitoring ICP - **Early signs of increased ICP**- disorientation, restlessness, increased resp effort, purposeless movements and mental confusion. - **Late signs of increased ICP**- pupil changes, impaired extraocular movements, weakness in one extremity or one side of body, HA that is constant or increasing in intensity or aggravated by movement or straining. - As ICP increases LOC continues to decrease until comatose, Resp rate decreases or becomes erratic, BP and temp increase, pulse fluctuates rapidly, altered resp patterns develop to Cheyne stokes or ataxic breathing, projectile vomiting, hemiplegia, and loss of brainstem reflexes (pupil, gag and swallowing) ## Ventriculostomy - is used for monitoring ICP, a fine-bore catheter is inserted into a lateral ventricle, preferably in the nondominant hemisphere of the brain. The catheter is connected by a fluid-filled system to a transducer, which records the pressure in the form of an electrical impulse. In addition to obtaining continuous ICP recordings, the ventricular catheter allows CSF to drain, particularly during acute increases in pressure. The ventriculostomy can also be used to drain blood from the ventricle. - Sterile ## Brain death - When a patient has sustained a severe neurologic injury not compatible with life. - Guidelines for brain death cessation of all brain function resulting from an irreversible cause. - Reversible conditions must be excluded (shock, hypothermia and drug intoxication)