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

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

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

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

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)

Anatomy & Physiology Review II 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

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

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

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

3 Top Causes

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

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

“Coup-Contre Coup”

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

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

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%

At the Scene: - EMS - First Responders

Spinal Injury Assumed With Any Head Injury Until Proven Otherwise

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

EMS type C- Collar

EMS Back Boards

Upon Arrival to ER…

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

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

“ 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.

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

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

Severity of Head Injury GCS 3 – 8 : Severe Head Injury GCS 9 – 12: Moderate Head Injury GCS 13 -15: Mild Head Injury GCS SCORE < 8 = COMA

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)

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 ?

Open or Closed Injury ?

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

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

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

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

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

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

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

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

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) 

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

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

CSF Infection Nuchal Rigidity CSF has WBCs Increased Temperature

(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

Another Clue…. Avulsed eye and lacerations to the forehead

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.

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.

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?

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

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