1. Sometimes:
The Lights are on….
But nobody’s home….

2. Traumatic Brain Injury (TBI)
Adult Health II
Traumatic Brain Injury—Part 1
Jerry Carley RN, MA, MSN, CNE
Summer 2010

3. Concept Map: Selected Topics in Neurological Nursing
PATHOPHYSIOLOGY
Traumatic Brain Injury (TBI)
Spinal Cord Injury
Specific Disease Entities:
Amyotropic Lateral Sclerosis
Multiple Sclerosis
Huntington’s Disease
Alzheimer’s Disease
Myasthenia Gravis
Guillian-Barre’ Syndrome
Meningitis
Parkinson’s Disease
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
ICP Monitoring
“Neuro Checks”
Lab Monitoring
PHARMACOLOGY
--Decrease ICP
--Disease Specific Meds
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, more…based
On Nursing Process:
A_D_O P_I_E
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary

4. Objectives Recall anatomy and physiology of the brain & cranial nerves
Explain pathophysiology of various brain (head) injuries
Detail signs, symptoms and prevention of Increased Intracranial Pressure (ICP)
Demonstrate effective use of Glasgow Coma Scale
Discuss medical & nursing management of brain injuries

5. trauma nursing is not for everyone… …and traumatic brain injury is one of the trauma nurse’s greatest challenges.
Endotracheal tube
Nasal catheters to
Combat epistaxis
Is this
“just blood,”
Or is there
Some leaked
CSF Fluid
In there?
Rigid
Cervical
Collar
“N-G Tube”
Inserted orally
(“orogastric tube”)
Dry sterile
Dressing over
Ears
(for CSF Leak)

6. Anatomy & Physiology ReviewII
III IV V VI
VII
VIII IX X XI
XII O T A F G V S H
lfactory
ptic
culomotor
rochlear
rigeminal
bducens
acial
coustic
lossopharyngeal
agus
pinal accessory
ypoglossal

7. Structures Innervated
Cranial Nerve
Function
Structures Innervated
I Olfactory
Smell
Olfactory Bulb
II Optic
Vision
Retina
III Oculomotor
Eyeball movement
Lens Accomodation
Pupil Constriction
4 eyeball muscles
1 eyelid muscle
IV Trochlear
Eyeball Movement
Superior Oblique Muscles
V Trigeminal
Sensation
General Sensory From Tongue
Proprioception
Face, scalp, teeth, lips, eyeballs, nose, throat lining
Anterior 2/3 of tongue
Muscles of mastication
VI Abducens
Lateral Rectus muscle
VII Facial
Taste
Facial Expressions
Salivation & Lacrimation
Face & Scalp
Muscles of face
Salivary & Lacrimal Glands
VIII Acoustic
Balance
Hearing
Vestibular apparatus
Cochlea
IX Glossopharyngeal
Proprioception for swallowing
Blood pressure receptors
Swallowing & gag reflex
Tear production
Saliva production
Posterior 2/3 of tongue
Throat muscles
Carotid sinuses
Lacrimal glands
Parotid glands
X Vagus
Chemoreceptors
Pain receptors
Sensations
Heart Rate & Stroke Volume
Peristalsis
Air Flow
Speech & Swallowing
Blood O2 Concentration, Aortic bodies
Respiratory & Digestive Tracts
External ear, larynx, pharynx
Tongue
Pacemaker & Ventricular Muscles
Smooth muscles of digestive tract
Smooth muscles of bronchioles
Muscles of larynx & pharynx
XI Spinal Accessory
Head rotation, upright position
Shrugging shoulders
1. Trapezius & sternocleidomastoid muscles
XII Hypoglossal
Tongue & Throat muscles

8. Brain Trauma
Brain injury results in more trauma deaths than do injuries to any other body region!

9. Primary Injury
Mechanical trauma that occurs at the moment of impact and may lead to irreversible cell damage from physical disruption of neurons or axons

10. 3 Top Causes

11. Etiology of Traumatic Brain Injury (TBI) in the U.S.
Sports
10 %
Motor
Vehicle
Crashes
50 %
Assaults
12 %
Falls
21 %

12. Mechanism of Closed Head Injury “Rear-Ended” – “Whiplash” Effect
“Coup- Contrecoup”

13. “Coup-Contre Coup”

14. “The second collision”
Boxing:
Coup-
Contre Coup
Injury :
“The second collision”

15. Risk Factors Highest in young people and the elderly
*Age 65 – 75 has highest incidence of HI of ALL age groups*
Occurs twice as often among males compared with females
Motor vehicle crashes account for the major proportion of head and brain injuries….and involve a disproportionately large number of young persons
Alcohol intoxication is a compounding factor in at least 30% to 50% of head injuries and is a contributing factor in almost ½ of all fatal motor vehicle crashes in the United States

16. Laws that require helmet use have been shown to
Did you Know ?
Laws that require helmet use have been shown to
reduce deaths
in motorcyclists
by about 30%

17. At the Scene: - EMS - First Responders

18. Spinal Injury Assumed With Any Head Injury
Until
Proven
Otherwise

19. 1. Maintain ability to breathe
2. Prevent shock
3. Immobilization to prevent further spinal cord damage
(Backboard + C-Collar)
“ The
Golden
Hour ”

20. EMS type C- Collar

21. EMS Back Boards

22. Upon Arrival to ER…

23. Glasgow Coma Score (GCS)
Baseline Assessment
Vital Signs
Glasgow Coma Score (GCS)
Prevent Further Injury!

24. The GCS is the most widely used method of defining a patient's Level of Consciousness (LOC)

26. “ Posturing ” Decorticate Rigidity: Decerebrate Rigidity:
*Upper arms held at the sides, with elbows, wrists , and fingers flexed.
*Legs are extended & internally rotated.
Decerebrate Rigidity:
*Jaws are clenched & neck is extended.
*Arms are extended with wrists facing out.
*Legs are extended.

27. C – Spine X-Ray “Cross-Table Lat” Before removal of ANY immobilization devices

28. As Much as Possible In ER
Instruct client to avoid sneezing or coughing
Provide calm environment
Maintain immobilization
Avoid meds the decrease LOC such as analgesics

29. Severity of Head Injury
GCS 3 – 8 : Severe Head Injury GCS 9 – 12: Moderate Head Injury GCS : Mild Head Injury
GCS SCORE
< 8 =
COMA

30. the severity of head injury is the level of consciousness
The best guide to
the severity of head injury is the
level of consciousness
(LOC)

32. History of Injury Loss of Consciousness? Other victims seriously hurt?
Mechanism of injury?
Driver / passenger / seatbelt ?
Fall height / what caused fall?
Hit where and with what?
Gunshot / impaled object ?

33. Open or Closed Injury ?

34. Diagnostics
Damaged areas of the brain have a reduced or no blood flow or glucose metabolism. This can be seen in the images below where there has been a blow to the head by a rock

35. Skull Fractures
Present on CT scans in about two thirds of patients after head injury
Skull fractures can be linear, depressed, or diastatic and may involve the cranial vault or skull base

36. Depressed Skull Fractures
A portion of the skull is extending into the intracranial space
Often results in pressure on the brain or direct injury to the brain
In addition, the bone fragment may cause a laceration of the dura mater resulting in a cerebrospinal fluid leak
Outcome is based upon the underlying brain injury. If no brain injury is present the surgery represents a cosmetic procedure and the outcome is generally quite good

37. Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving
Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli
Occipital Lobe- associated with visual processing
Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech

38. Basal (Basilar) Skull Fractures
Involve the floor of the skull and include fractures of the cribriform plate, frontal bones, sphenoid bones, temporal bone and occipital bones
1 frontal 2 ethmoid 3 sphenoid 4 temporal 5 parietal 6 occipital

39. 1. Frontal sinus 2. Crista galli 3. Cribriform plate 4
1. Frontal sinus 2. Crista galli 3. Cribriform plate 4. Lesser wing of sphenoid 5. Superior orbital fissure 6. Superior border of petrous part of temporal bone 7. Dense shadow of petrous part of temporal bone 8. Perpendicular plate of the ethmoid 9. Vomer 10. Maxillary sinus 11. Inferior concha 12. Ramus of mandible 13. Body of mandible

40. Basal (Basilar) Skull Fractures
Most basal skull fractures do not require treatment and heal themselves
Persistent CSF leakage may warrant operative repair of the leakage, particularly CSF leaks related to frontal bone and cribiform plate fractures

41. Basal Skull Fractures Clinical Clues may include:
CSF leakage through the ear or nose (otorrhea or rhinorrhea)
Hemotympanum (blood behind the eardrum)
Bruising behind the ears (postauricular ecchymoses)
“Battle Sign”
Bruising around the eyes (periorbital ecchymoses)
“Raccoon Eyes” “Panda Eyes”
Injury to cranial nerves:
VII Facial nerve - weakness of the face
VIII Acoustic nerve - loss of hearing
I Olfactory nerve - loss of smell
II Optic nerve - vision loss
VI Abducens nerve - double vision

44. CSF Leakage
Rhinorrhea and otorrhea are clinical signs of cerebrospinal fluid (CSF) leakage in patients with skull fracture
Presence of glucose (CSF) in otorrhea and rhinorrhea detected by Beta-2 transferrin. Nasal/ear discharge (glucostix) was traditionally used to diagnose CSF leak at the bedside, but has fallen into disuse as it has poor positive predictive value
CSF leakage opens the brain & spinal canal to infection
CSF is needed to cushion the brain, maintain pressure within the eye and cleanse the CNS (like the lymphatic system serves the same function in the rest of the body) 

45. The Halo Effect of Leaking Cerebrospinal Fluid (CSF)
Serosanguinous
Cerebrospinal Fluid (CSF)
Filter Paper

46. Prevent Infection !
Cover any suspected source of CSF leakage with a Sterile Dressing STAT !

47. CSF Infection
Nuchal Rigidity
CSF has WBCs
Increased Temperature

48. (Sometimes) Associated with Brain Injury
Blood in the anterior chamber of the eye (hyphema) as a complication of blunt trauma. Eyes with hyphema may show other signs of damage
Blood on Ocular Surface : Subconjunctival Hemorrhage

49. Another Clue….
Avulsed eye and lacerations to the forehead

50. Penetrating Brain Injury
MRI of 19 y.o Melbourne, Australia resident involved in bar fight.
That’s a metal chair leg going into the left orbit.
Patient survived. Not only that, the left eye was salvaged with only slight loss
of visual acuity.

51. Attempted suicide with a crossbow.
Patient survived, though he did lose sight in one eye, since the arrow partially
severed one of his optic nerves.

52. Head Injury Assessment
Obvious Skull Fractures?
Lacerations?
Deformities? (bumps / indentations)
Facial Injuries?
Blood and/or CSF drainage from nostrils? (rhinorrhea)
Blood and/or CSF drainage from ear canals? (otorrhea)
Blood and/or CSF drainage from mouth?
Blood and/or CSF drainage from eyes?
Pain?
Headache?

53. Collaborative Treatment Goals
Maintain
Airway
Breathing
Circulation
Maintain cerebral perfusion
Maintain electrolyte balance
Maintain fluid balance
Maintain cognitive function
HOW ????

54. Prevent Secondary Injury !!!
Meaningful recovery of function after head injury is possible IF secondary injuries are prevented or minimized