2 Statistics 80,000 have disability; 50,000 die from head injury Head injury profilesAge 15 to 24MaleCausesMotor vehicle accidentsFalls (especially in the young and older populations)Violence
3 Mechanism of InjuryImportant information to get from those at the sceneImportant in determining where the injury is located and the type of neurologic deficitsMechanism of injuryAcceleration – moving object hits nonmoving headDeceleration – moving head hits stationary objectCoup-contrecoup – damage from rebound effectRotational – twisting of brain in the skull(See Figure 36-1.)
4 QuestionWhich of the following predisposes an elderly patient to falls and possible head injury?A. An enlarged cerebrumB. Sinus arrhythmiaC. NocturiaD. The use of steroids in the elderly
5 AnswerC. NocturiaRationale: Nocturia (getting up to void at night) along with decreased visual acuity leads to falls. Cerebral atrophy, not enlargement, leads to more room for the brain to move, and therefore the brain would be subject to trauma against the bony skull. Steroids are not always used in the elderly, and complications are not associated with falls. Atrial fibrillation and flutter can lead to strokes or syncope and falls.
6 Pathophysiology: Types Primary (due to initial injury)TypesLacerationsSkull fractureBasilar skull fractureConcussionContusionHematomasSAH (subarachnoid hemorrhage)DAH (diffuse axonal injury)Cerebrovascular injurySecondary (generally due to response to injury)TypesCerebral edemaIschemiaHerniation syndromesComa
7 Primary Injuries Scalp lacerations Always a bit scary as they tend to bleed a lotSkull fracturesOpen/compoundLinearClosedDepressedBone fragments may enter the dura
8 Primary Injuries: Basilar Skull Fracture Classic signs, usually due to CSF leakage from the sinuses or bleeding in unusual areasOtorrheaPostauricular hematoma (Battle’s sign)RhinorrheaPeriocular ecchymosis (“raccoon’s eyes”)
9 QuestionWhich of the following symptoms indicates a fracture of the middle fossa in a basilar skull fracture?A. OtorrheaB. RhinorrheaC. Raccoon’s eyesD. Halo sign
10 AnswerA. OtorrheaRationale: A communicating fracture of the middle fossa in a basilar skull fracture manifests with otorrhea (CSF from the ear) or Battle’s sign (mastoid ecchymosis). A fracture of the anterior fossa or front of the skull usually produces raccoon’s eyes and rhinorrhea (CSF from the nose). The halo sign is a bloodstain surrounded by a yellowish “halo.” The halo sign can happen with any CSF drainage and is not limited to any one area of the brain.
11 QuestionIn a patient with a head injury, the endotracheal tube should be inserted through the nose.A. TrueB. False
12 AnswerB. FalseRationale: Nothing should be passed into the nose of a patient with head trauma, especially a basilar skull fracture. If a nasogastric or endotracheal tube is nasally inserted, the tube could pass into brain tissue because of the fracture and communication with the CSF.
13 Primary Brain Injuries ConcussionMild brain trauma causing an alteration in mental statusMay or may not have a change in LOCCan have memory deficits both before and after the accidentMay have residual effects that need to be monitoredContusionFocal injury usually due to microtrauma to the vascular systemSymptoms depend on depth of injury and amount of tissue contusedMortality can be from cerebral swellingUsually resolves within 24 to 72 hrs
14 Primary Brain Injuries: Hematomas Hematomas are lesions in the brain caused by traumatic bleeding. Types include:EpiduralSubduralIntracerebralTraumatic subdural hemorrhageDiffuse axonal InjuryCerebrovascular Injury(Refer to Figure 36-2.)
15 Secondary Brain Injury These are due to changes in the brain as a result of trauma. Types include:Cerebral edemaIschemiaHerniation syndromesComa
16 Secondary Injury: Edema and Ischemia Cerebral edema peaks in 72 hrsCytotoxicVasogenicIschemia – decreased blood flow and possible infarctionMajor cause of permanent injury and death
17 Secondary Injury: Herniation Syndromes Caused by the shifting of structures under pressure. Cushing’s triad is a late sign. There are four types:Uncal – supratentorial herniation; ipsilateral “blown pupil”; contralateral weaknessTonsillar – through foramen magnum; respiratory arrestCentral (transtentorial)Upward cerebellarThe first two are most commonly seen in critical care.
18 Secondary Injury: Coma Defined as a change in the LORRAS is disruptedPersistent vegetative stateArousal but no cognitive functionRole of the GCSCausesRefer to Box 36-2.
19 Nursing Assessment of the Brain-Injured Patient LOR is the most sensitive indicatorAVPU scalePainful stimuli typesGlasgow Coma ScaleTests for cognitive functionAlert and oriented x3Hand grasps and letting goRefer to Figure 36-5.
21 Nursing Assessment of the Brain-Injured Patient: Brain Stem Responses Corneal reflexCough/gag
22 Nursing Assessment of the Brain-Injured Patient: Motor Function Test all of these and record responses on both sides of the body:LocalizationWithdrawalDecorticateDecerebrateBabinski’s reflex
23 Nursing Assessment: Respiratory Function Cheyne-Stokes – periods of apnea slowly building in rate/depth till a peak is met (cerebral hemisphere trauma; normal age- related change)Central neurogenic hyperventilation – rapid, regular, sustained and deep (upper midbrain)Apneustic – long pauses with full inspiration/expiration (brain stem)Ataxic – irregular and unpredictable (medulla)Refer to Figure 36-6.
25 Medical Management and Nursing Care AirwayAlways #1 priorityKeep pCO2 35 to 45 mmHgAvoid hyperventilation in first 24 hrsFluid resuscitationTo keep ICP within normal range and BP stableICP monitoringPositioning
26 QuestionA nurse would see increased intracranial pressure during which of the following position changes?A. Logrolling the patientB. Extreme hip flexionC. Keeping the head of the bed at 30 degreesD. Placing sandbags on the side of the head to keepit in alignment
27 Answer B. Extreme hip flexion Rationale: Logrolling the patient, keeping the HOB at 30 degrees, and sandbagging each side of the head help lowering increased ICP. Extreme hip flexion increases intra-abdominal pressure, which can be transmitted to the cranial vault.
28 Medical Management and Nursing Care Prevention and treatment of seizuresMedications for prophylaxis in early phase onlyDilantin (phenytoin)General seizure precautionsTemperature maintenanceTherapeutic hypothermia doesn’t affect outcomesMonitoring fluids and electrolytesDiureticsMonitoring for SIADH, diabetes insipidus, glucose and salt- wasting syndrome
29 Medical Management and Nursing Care (cont.) CardiovascularMonitor for MI and rhythm disturbancesMonitor for DICUse of pulmonary artery catheterHazards of immobility (DVT, contractures)PulmonaryAspiration pneumoniaETT management, suctioning, tube feeding managementMonitor for ARDS and “flash” pulmonary edema
30 Medical Management and Nursing Care (cont.) NutritionNutrition ASAPProtein-rich formulasIntegumentary and musculoskeletal systemContracture preventionEarly PTFamily supportImportance of being honest and truthfulInformationActive involvementBehavioral changes
31 Brain Death Examination NormothermicComaNegative brain stem reflexesApneicOrgan procurement