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Neurology Management of Patients With Neurologic Trauma Chapter 63.

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Presentation on theme: "Neurology Management of Patients With Neurologic Trauma Chapter 63."— Presentation transcript:

1 Neurology Management of Patients With Neurologic Trauma Chapter 63

2 Head Injuries TBI – Traumatic Brain Injury

3 General Information Involves injury to – Scalp – Skull – Brain High Risk Groups – Male vs. Female? Male – Age? < 30yrs – #1 Variable Alcohol

4 Pathophysiology Damage  Swelling   ICP  Displacement   Blood flow   O2  Ischemia  Infarction  Deathmosis

5 Scalp Injuries Clinical manifestation – Bleeding Profusely!

6 Scalp Injuries Abrasion: – Wound caused by Rubbing or Scrapping the skin

7 Scalp Injuries Contusion: – Injury to the tissue without… Breaking the skin

8 Scalp Injuries Laceration – The act of… Tearing

9 Scalp Injuries Avulsion – The… – Tearing away of a structure or part

10 Scalp Injuries Complication – Infection – Clean – Use procaine/Lidocaine – Suture

11 Skull Injuries / Fractures Classifications – Linear Line – Comminuted A bone is shattered into many pieces – Depressed Comminuted fx in which broken bones are displaced inward

12 Skull Injuries / Fractures Classifications – Basilar: Breaks in boned at the base of the skull – Open: The dura is torn – Closed The dura is intact

13 Skull Injuries / Fractures Clinical manifestations – Local injury – Pain Persistent – Swelling? Sometimes

14 Skull Injuries / Fractures Clinical Manifestations – Halo Sign Description – Blood stain surrounded by a yellowish ring Indication – CSF leak

15 Skull Injuries / Fractures Clinical Manifestations – Basilar Hemorrhage from – Nose – Pharynx – Ears Blood under the – Conjunctiva Battle’s sign CSF otorrhea CSF rhinorrhea

16 Skull Injuries / Fractures Diagnostic Tests – X-ray – CT – MRI – Angiography Hematoma

17 Skull Injuries / Fractures Medical Management – Non-depressed skull fractures Usually do no require – Surgical treatment Do require close – Observation

18 Skull Injuries / Fractures Medical Management – Depressed skull fractures May require surgery Surgical debridement Antibiotics

19 Quote from text “After the skull fragments are elevated, the area is debrided. Large defects can be repaired immediately with bone or artificial grafts; if significant cerebral edema is present, repair of the defect can be delayed for 3-6 months.”

20 Skull Injuries / Fractures Medical Management – Basilar skull fractures Usually open or closed? – OPEN Keep nose and ears – Clean Sterile cotton pad/ball – Loosely inserted Instruct pt not to – Blow nose HOB: – Up I-ICP protocol

21 Question?????? You notice the sheet under a patients head is red with blood, but the stain has a yellowish ring around it. What would be a priority nursing actions? – Notify MD – Infection control!! – Act first -- document last

22 Question???? How do you prevent infections in a patient with a head wound? – Clean – Inject antibiotic

23 A patient enters the ER following a MVA where he was thrown from the car. He has a major head wound. His vital signs show very low blood pressure. What does this indicate? – Hypovolemia – More than just head injury

24 Question???? An open skull fracture means what? What nursing measures do you implement? What are the risks? – Dura mater is torn – CSF leakage possible – Increase risk of infection

25 Question????? What kind of an injury produces hemorrhaging from the nose, pharynx and ears? – Basil skull fracture

26 Question???? Do you give morphine for pain to a patient with head injury? Why or why not? – NO – Interferes with accurate neuro assessment

27 Brain Injury Concussion – Pathophysiology Temporary loss of neurologic function with no apparent Structural damage – Closed / open? Closed – Duration of unconsciousness? Seconds to few minutes

28 Brain Injury Concussion – S&S LOC Memory loss Headache

29 Brain Injury Concussion – Emergency S&S Difficulty awakening Dysphasia Confusion Severe H/A Vomiting Weak on one side

30 Brain Injury Concussion – Diagnostic tests CT MRI X-ray Neuro checks

31 Brain Injury Concussion – Medical treatment Analgesics – Mild Observe for post- concussion syndrome Return to ER if you see any of the emergency S&S

32 Brain Injury Concussion – Gerontologic Considerations Will recover more Slowly with More complications

33 Brain Injury: Contusion Pathophysiology – The brain is bruised, with possible surface hemorrhage – Duration of unconsciousness: More than concussion – Potential of infarction & necrosis

34 Brain Injury: Contusion Contracoup/Contralateral Phenomenon – Damage to brain occurs opposite to impact

35 Brain Injury: Contusion Symptoms: Similar to shock – Activity Motionless – Pulse Faint – Respirations Shallow – Skin Cool & pale – Bowel & bladder Evacuation – BP  – Temp 

36 Question???? Is a concussion an open or closed head injury? – Closed Is a contusion an open or closed head injury? – Closed

37 Brain Injury: Intracranial Hemorrhage A collection of blood that develops within the cranial vault Small & fast vs. large & slow Symptoms are frequently delayed

38 Question???? Which is more fatal, a small hematoma that develops rapidly or a large hematoma that develops slowly? – Fast = Fatal

39 Brain Injury: Intracranial Hemorrhage Epidural hematoma / Extradural hematoma – Blood collects Btw the skull & dura – Usually due to Fx of skull – Type of blood vessel Arterial bleed – Onset of symptoms Rapid

40 Brain Injury: Epidural hematoma Clinical manifestations – Time of injury Momentary loss of consciousness – Lucid interval Compensation – Sudden S&S of compression

41 Brain Injury: Epidural hematoma Management – Extreme emergency – Burr Holes

42 Brain Injury: Subdural Hematoma Collection of blood – Btw dura & brain Usually due to – Trauma – Venous blood

43 Brain Injury: Intracerebral Hemorrhage & Hematoma Bleeding into – Brain Usually due to – Aneurysm – Missile injuries

44 Management of Brain Injuries Treatment of I-ICP Assume spinal injury Baseline neurological assessment Brain Death

45 Question? What type of hematoma’s are usually associated with arterial bleeds? – Epidural What type of hematoma’s are usually associated with venous bleeds? – Subdural

46 Spinal Cord Injury Etiology – Male vs Female Male – Variable MVA – Age < 30 yrs – Most frequently involved area C-5,6,7 T12-L1

47 Spinal Cord Injury Pathophysiology – Transient concussion – Contusion – Laceration – Compression – Complete transection

48 Spinal Cord Injury Clinical manifestations – Incomplete spinal cord lesions – Neurologic Level Lowest level where sensory & motor function are normal

49 Question????? Is it possible to break your back (vertebrae) without damaging your spinal cord? – Yes

50 Spinal Cord Injury Below neurologic level – Loss of sensory and motor function – Loss of B&B control – Loss of sweating –  in BP

51 Spinal Cord Injury Clinical Manifestations – Pain – Fear – Paraplegia Paralysis of the lower body – Quadriplegia Paralysis of all four extremities – C7-T1  Para  Quad

52 Question?????? If a person has a complete spinal cord injury at the following level will they be a para or a quadriplegic? C7? – Quad T4? – Para C4 – Quad L3 – Para

53 Spinal Cord Injury Emergency Management Rapid assessment Immobilization – Back board – Cervical collar – Positioning Head & Neck neutral – Handling Assign Head 4 person – Traction Extrications Stabilize

54 Spinal Cord Injury Management of Acute SCI Rx – Corticosteroids – Mannitol – IM? Not below level of injury Respiratory therapy –  O2 – Intubate carefully

55 Question???? Which of the following are appropriate site to give a paraplegic an IM injection? – Abdomen ? – Deltoid Yes – Dorsogluteal No – Vastus lateralis No – Ventrogluteal No

56 Spinal Cord Injury Management of Acute SCI Skeletal reduction & traction – Immobilization – Reduction – Gardner-Well tongs No predrilled holes – Crutchfield & Vinke tongs Holes into the skull – Halo vest Surgical interventions

57 SCI: Complications & Interventions Spinal Shock A sudden depression of reflex activity in the spinal cord below the level of injury due to the loss of autonomic nervous system function

58 SCI: Complications & Interventions Spinal Shock S&S Areflexia Vasodilitations  – ______tension Hypotension – ______ cardia Bradycardia  in cardiac output Venous pooling

59 SCI: Complications & Interventions Spinal Shock S&S Muscle completely – Flaccid – Loss of temp regulating mech Below level of injury Duration – Days – weeks

60 Question????? How will you know when a patient is no longer in spinal shock? – Reflexes return

61 SCI: Complications & Interventions Deep Vein Thrombosis / DVT S&S Treatment

62 SCI: Complications & Interventions Orthostatic Hypotension  venous return +  vasoconstriction  Pooling of blood in the legs  HOB  faint Gradually  HOB Reclining W/C

63 SCI: Complications & Interventions Respiratory Weakness Vital capacity –– Secretions – Retention PaCO2 –– Diaphragm controls – C3-C5 Complications – Resp Failure – Pulm edema

64 If a patient developed a Pulmonary embolism due to immobility and what would their ABG’s look like? – PaCO2 increased – PaO2 Decreased – pH Decreased

65 Question????? The cord segments involved with maintaining respiratory function are? – Cervical level 3 - 5

66 SCI: Complications & Interventions Bowel & Bladder Neurogenic bladder – Incontinent Bowel distention Treatment –  bulk –  fluid – Stool softener – Disimpaction

67 SCI: Complications & Interventions Thermal Regulation Not perspire Fever?

68 SCI: Complications & Interventions Autonomic Hyperflexia /dysreflexia Injury impairs normal equilibrium between the sympathetic and parasympathetic system – Vasoconstriction below the level of injury – Vasodilation above the level of injury Common cause – Noxious Stimuli – Below level of injury

69 SCI: Complications & Interventions Autonomic Hyperflexia /dysreflexia S&S Above injury – Vasodilation – Pounding H/A – Profuse diaphoresis – Nasal congestion Bradycardia Hypertension – > 300 mmHg systolic

70 SCI: Complications & Interventions Autonomic Hyperflexia /dysreflexia Treatment Monitor BP How  BP fast? –  HOB Find & remove noxious stimuli If med with apresoline  – crash

71 Question????? What can lead to autonomic hypereflexia? – Bowel impaction – Hang nail

72 Question????? What is the major danger of a patient suffering form autonomic dysreflexia? – Hypertension

73 SCI: Complications & Interventions Pressure Sores Turn Diet –  protein –  cal Low pressure cushions

74 SCI: Complications & Interventions Depression

75 SCI: Complications & Interventions Infections Respiratory UTI Wound

76 The Quadriplegic Patient See homework and reading Ch 63

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