Management of Patients With Neurologic Trauma Chapter 63 Neurology Management of Patients With Neurologic Trauma Chapter 63

Head Injuries TBI Traumatic Brain Injury

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

Pathophysiology Damage  Swelling  h ICP  Displacement  i Blood flow  i O2  Ischemia  Infarction Deathmosis

Scalp Injuries Clinical manifestation Bleeding Profusely!

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

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

Scalp Injuries Laceration The act of… Tearing

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

Scalp Injuries Complication Infection Clean Use procaine/Lidocaine Suture

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

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

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

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

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

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

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

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

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.”

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

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

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

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

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

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

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

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

Brain Injury Concussion S&S LOC Memory loss Headache

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

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

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

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

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

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

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

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

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

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

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

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

Brain Injury: Epidural hematoma Management Extreme emergency Burr Holes

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

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

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

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

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

Spinal Cord Injury Pathophysiology Transient concussion Contusion Laceration Compression Complete transection

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

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

Spinal Cord Injury Below neurologic level Loss of sensory and motor function Loss of B&B control Loss of sweating i in BP

Spinal Cord Injury Clinical Manifestations Pain Fear Paraplegia Paralysis of the lower body Quadriplegia Paralysis of all four extremities C7-T1 i Para h Quad

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 L3

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

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

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

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

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

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

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

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

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

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

SCI: Complications & Interventions Respiratory Weakness Vital capacity i Secretions Retention PaCO2 h Diaphragm controls C3-C5 Complications Resp Failure Pulm edema

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

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

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

SCI: Complications & Interventions Thermal Regulation Not perspire Fever?

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

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

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

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

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

SCI: Complications & Interventions Pressure Sores Turn Diet h protein h cal Low pressure cushions

SCI: Complications & Interventions Depression

SCI: Complications & Interventions Infections Respiratory UTI Wound

The Quadriplegic Patient See homework and reading Ch 63