Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries (Nursing prospective) Hayek. M Nursing College / Medical complex Najah National University

Definition Head injury: is a general term used to describe any trauma to the head, and most specifically to the brain itself. A head injury is classified by brain injury types: fracture, hemorrhage, or trauma.

KEY WORDS: traumatic brain injury (TBI), intracranial pressure (ICP), Glasgow Coma Scale (GCS), cerebral blood flow (CBF), cerebral perfusion pressure (CPP),

Epidemiologic Aspects 80,000 survivors of head injury annually 125,000 children <15yo head injured annually 40-60% of head injured patients have extremity injury 32,000-48,000 head injury survivors with orthopaedic injuries annually

Overview Initial evaluation Prognosis Management of Head Injury Orthopaedic Issues –Operative vs. nonoperative treatment Timing of surgery methods – Fracture healing in head injury –Associated injuries –Complications

Evaluation ATLS—ABC’s History –loss of consciousness Physical exam –Glasgow Coma Scale Radiographic studies –CT Scan

Evaluation Must exclude head injury by evaluation if –history of loss of consciousness –significant amnesia –confusion, combativeness Cannot be simply attributed to drug or alcohol use –neurologic deficits on exam of cranial nerves or extremities

Physical Exam Exam of head and cranial nerves for lateralizing signs –dilated or sluggish pupil(s) Extremities –unilateral weakness –posturing decorticate (flexor) decerebrate (extensor)

Glasgow Coma Scale Eye opening: 1-4 Motor response: 1-6 Verbal response: 1-5

Glasgow Coma Scale Eye opening –Spontaneous 4 –To speech 3 –To pain 2 –None1

Glasgow Coma Scale Motor response –Obeys commands6 –Purposeful response to pain5 –Withdrawal to pain 4 –Flexion response to pain 3 –Extension response to pain 2 –None1

Glasgow Coma Scale Verbal response –Oriented 5 –Confused 4 –Inappropriate 3 –Incomprehensible 2 –None 1

Glasgow Coma Scale Sum scores (3-15) –<9 considered severe –9-12 moderate –13-15 mild* Modifiers—xT– if intubated (Best score possible 11T) xTP – if intubated and paralyzed (Best score possible is 3TP) Done in the field but best in trauma bay following initial resuscitation

Treatment Initial –Intubation if unresponsive or combative to give controlled ventilation –pharmacologic paralysis after neurologic exam is completed –Blood pressure and O 2 saturation monitoring keep systolic > 90 mm Hg 100% O 2 saturation

Management Based on physical and neurological examination, Xray CT Scan MRI Treatment of increased ICP - Supportive measures – - Ventilatory Support - Fluid and Electrolyte maintenance - Nutritional support - Pain and Anxiety management.

Nursing Assessment - History of Trauma - Time, cause, direction and force of the blow - Loss of consciousness, duration Assess LOC - Glasgow Coma Scale - Response to verbal commands or tactile stimuli - Pupillary response to light - Motor Function Vital Signs - Monitor for signs of increased ICP Motor Function - Move extremities, hand grasp, pedal push, speech

Nursing Mg or care with patient with HT are divided on the several levels including prevention, pre-hospital (first aid), immediate hospital care, acute hospital care and rehabilitation. The nurse should understand the principles behind medical treatment The nursing management of head injury aimed to preserve brain homeostasis, prevent secondary injury and to provide psychosocial support

Nursing Management. (1) Monitor vital signs closely. (a) Accurately assess and document neurological status. (b) Evaluation of alterations of consciousness is crucial since symptoms progress rapidly. (2) Maintain patent airway. (a) Intubation and hyperventilation. (b) If patient is not intubated, maintain agood sposition. (c) Be aware that stimulation of coughing when suctioning increases intracranial pressure and may precipitate seizure activity.

Nursing Management. (3) Administer medications as ordered. (4) Elevate head of bed (30º). (5) Administer hypertonic I.V. solutions as ordered Be alert for all signs and symptoms for pts who have brain trauma.

Nursing Management. (6) Protect patient from injury if seizures occur. (7) Maintain normal body temperature. Should readmission if : (1) Fever greater than 100ºF. (2) Pulse less than 50 beats per minute. (3) Vomiting. (4) Slurred speech. (5) Dizziness. (6) Blurred or double vision. (7) Unequal pupil size. (8) Blood or fluid discharge from ears or nose. (9) Increased sleepiness. (10) Inability to move extremities. (11) Convulsions. (12) Unconsciousness

ICP Monitoring (Nursing prospective) Indications –severe head injury (GCS < 9) abnormal head CT or normal CT and at least two of the following –age over 40 –uni- or bilateral flexor or extensor posturing

ICU Management Goals (nursing intervention) O 2 saturation 100% Mean arterial pressure mm Hg ICP < 20 mm Hg Cerebral Perfusion Pressure (CPP=MAP- ICP) >70 mm Hg

ICU Adjuncts ___be Attentions HCT~ 30-33% PaCO 2 = 35±2 mm Hg CVP= 8-14 mm Hg avoid dextrose IV maintain euthermia or mild hypothermia

Factors Influencing Prognosis Age –Younger pts have greatest potential for survival and recovery –61-75% mortality if over 65 –90% mortality in elderly with ICP >20 and coma for more than 3 days –100% mortality if GCS < 5, uni- or bilateral dilated pupils, and age over 75 survival and recovery not predictable except in old pts

Factors Influencing Prognosis Hypotension--50% increase in mortality with single episode of hypotension Hypoxia Delay in treatment –prolonged transport –surgical delay when lateralizing signs present Potentially controllable!!

Outcome Glasgow Outcome Score: –1-dead –2-vegetative –3-cannot self care –4-deficits but able to self care –5-return to preinjury level of function

Nonoperative Management Treatment of choice when –nonoperative means best treat that particular fracture –operative risks outweigh potential benefits Modalities –splint –brace –cast –traction Caveat –device must be removed periodically to inspect underlying skin for decubiti

Health care team roles First aid may be given by emergency medical technicians. Physicians trained in emergency medicine often provide initial care in a hospital. Neurosurgeons and neurologists may be asked to assist with care. Rehabilitation specialists such as physicians, physical therapists, speech therapists, or occupational therapists may provide rehabilitation. Nurses provide supportive care throughout, including 24- hour care, home nursing care, and patient education. Preventions…… Rehab…. Cope….. Advocate and help……

Summary Orthopaedic injuries are common in head injured polytrauma patients Head injury outcome is difficult to predict Management requires multidisciplinary approach Operative management is safe and often improves functional outcome if secondary brain insults are avoided –Hypotension, hypoxia, increased ICP |* Holistic nursing intervention approach must be done to maximize chance of survival