1. Neuro Traumas Gail Lupica PhD, RN, CNE Nurs 211

2. Neurons in the brain and spinal cord do not regenerate after they die? (Outside the CNS, injured nerve fibers are able to regenerate because they grow within a protective covering- the myelin sheath) What should that mean to you?

3. Preserve the Neuron!

5. The CNS is a structure comprised of the brain and spinal chord. Each part of the cerebral cortex is responsible to control a certain function for the body.

6. Having a basic understanding of what is controlled by what part of the brain allows us clues as to what part of the brain has an alteration and allows for more accurate and helpful documentation of the neurologic client.

10. Cranial nerves Twelve cranial nerves: (3-12 are located in the brainstem, only 1 & 2 are not) 1. Olfactory (smell) 2. Optic (read) 3. Oculomotor 4. Trochlear 5. Trigeminal 6. Abducens (3, 4, and 6 are tested together)

11. 7. Facial (touch face) 8. Acoustic (hear words) 9. Glossopharyngeal 10. Vagus (very important!!) -WHY? 11. Accessory (shrug shoulders) 12. Hypoglossal (stick out tongue)

12. Meninges The brain relies upon the CSF for cushion, and the skull, and Meninges for protection. There are three layers of meninges 1. Dura 2. Arachnoid 3. pia

13. Meninges  Dura: outer layer, tough, below skull, forms the extension between the cerebrum, and cerebellum: the tentorium  Also lines the spinal column (passes through the foramen magnum) Epidural space : Space between the skull and the dura mater. The middle meningeal artery lies here. Subdural space : Space between the dura and arachnoid space. This is the site of acute, sub acute, and chronic subdural hematomas.

14. Meninges Arachnoid: Middle layer where CSF circulates.  Subarachnoid space : Below the arachnoid space where CSF is reabsorbed. = arachnoid villi

15. Meninges Pia: Delicate membrane directly adherent to brain, and spinal cord.

17. Subdural hematoma- a hematoma located below the dura mater. There are three types classified according to how quickly they develop/ how serious they are for the patient. 1. Acute 2. Subacute 3. chronic

18. Epidural hematoma- a hematoma located above the dura mater. Most often associated with a fracture in the temporal/parietal region. This is where the middle meningeal artery runs. What happens when you tear an arterial vessel? This is a medical emergency requiring immediate evacuation of the hematoma?

22. Uncal herniation A problem where a hematoma (or something) forms on ONE side of the cerebral hemispheres (R or L). The result is the pushing down on the uncus ( wall that separates the cerebrum from the cerebellum. The THIRD cranial nerve is compressed obstructing parasympathetic outflow. This causes one sided (unilateral) pupil dilation.

24. Critical Thinking What would happen if the brainstem was compressed on both sides, instead of only on one side?

25. Let’s talk about..CSF CEREBROSPINAL FLUID (CSF): Acts as a shock absorber to the brain and spinal cord. Decreases when brain tissue or blood flow increases to compensate Bathes neurons in electrolytes and fluid

26. CSF Constantly produced in the lateral ventricles from the choroid plexus It is an ultra filtrate of blood 20cc/h is produced (135cc is present at any one time) Clear Colorless No RBCs No microorganisms Glucose is present (2/3 the amount as in serum)

28. It’s continually fluctuating. Transient increases are OK, sustained increases are life threatening!

29. There’s 3 contents of the skull: BRAIN CSF BLOOD When there’s an increase in any one of these three things there needs to be a corresponding decrease, or else you have increased ICP.

32. ICP NORMAL= 1-15mmHg The most sensitive indicator of increased ICP is level of consciousness. Assess baselines every 2 hours if critical patient. How? Don’t label. Describe!

33. How to document? Example #1- Describe- DO NOT LABEL! M.B. opens eyes to verbal stimuli. Pupil on right is 5mm, round, positioned to midline, reactive to light, and accommodates. Pupil on left is 3mm, round, positioned to midline, reactive to light, and accommodates. Conversant, but unable to focus thoughts on one topic. States: “My breakfast is not here yet. I’m gonna go gamble. My bed is hard.” Oriented to person, but not time, or place. Follows command on right side to hold up two fingers, and flex wrist. Left arm flaccid, although withdraws to painful stimuli of fingernail pressure applied under fingernail. No spontaneous movements of lower extremities noted, although withdraws to painful stimuli of fingernail pressure applied under toenail beds bilaterally.

34. Documentation sample Example # 2: G. D. responsive only to painful stimuli. Pupils equal, round, fixed at 3mm, and positioned at midline. Pressure applied under nail bed of right hand causes patient to withdraw the extremity. No spontaneous movements noted. Unable to elicit withdrawal response to pain on the left side. Dorsiflexion of great toe, and fanning of other toes occurs bilaterally when sole of foot scraped with heel of scissor handle from middle of foot to ball of foot.

35. Factors that influence ICP 1. Changes in arterial pressure - (blood pressure) 2. Venous pressure (How do you make sure venous outflow is not occluded?) 3. Intra-abdominal/intrathoracic pressure (What activities increase these pressures?) 4. Posture (What does this mean?)

36. Factors that influence ICP 5. Blood gases … 6. Temperature (How would this affect ICP?)

38. Monitoring ICP Epidural sensor : fiberoptic transducer in the epidural space; least accurate, least invasive Subdural subarachnoid bolt: decreased accuracy at high pressures Intraventricular catheters : associated with highest risk of infection; allows for drainage of CSF, most accurate (All carry a risk of infection. Atbx are prescribed. CSF samples are taken routinely.)

41. Autoregulation The brain has the ability to alter the diameter of the cerebral blood vessels in order to maintain a constant blood flow despite arterial pressure changes. CPP = MAP - ICP Cerebral perfusion pressure equals the mean arterial pressure minus the intracranial pressure.

42. Autoregulation Autoregulation is lost when the CPP falls below the 50mmHg or exceeds 150mmHg. In that case CPP is totally dependent upon blood pressure.

43. Cushing’s Triad When you see: Increasing BP Bradycardia Wide pulse pressure This means there’s pressure on the vasomotor center in the brainstem! Very LATE sign. Very BAD sign.

44. Posturing Decorticate (pressure on the cortical structures) elbows flexed/legs extended/wrists pronated Decerebrate (pressure on the cerebellum)arms extended/legs extended/wrists pronated May have a combination of both

47. Case Study: Neuro Trauma Bob Klutz is a 24-year-old construction worker. While working on a first floor patio deck for a friend, he took one step backward too far while admiring his work. He fell four feet to the ground and hit his head on a rock. His wife nearby, Jane, lucky a registered nurse, discovered him two minutes later and found that his eyes were opening spontaneously. He was able to follow the command to extend his arm and he was talking about how lovely Jane looked on their wedding day.

48. 1. What should Jane do now? Why?

50. Eyes open Best verbal response Best motor response* Spontaneously (4) To speech (3) To pain (2) None (1) Orientated (5) Confused (4) Inappropriate words (3) Incomprehensible sounds (2) None (1) Obeys commands (6) Localizes pain (5) Withdraws to pain (4) Flexion (abnormal) to pain (3) Extension to pain (2) none(1) Glasgow coma scale = *Original description of Glasgow Coma Scale (see first reference) did not distinguish "Flexion (abnormal) to pain (3 points)" and "Withdraws to pain (4 points)". Consequently, maximum score for Best motor response was 5 and maximum score for Glasgow Coma Scale was 14. Description of actual Glasgow Coma Scale first (?) appears in second reference.

51. Five minutes later Bob’s eyes would only flicker to speech, he would withdraw to painful stimuli, and would mumble words that no one, not even Jane could understand. 2.What should Jane do now? Why?

52. The paramedics arrived on the scene eight minutes later. At this point Jane noted he had right temporal scalp swelling and ecchymosis, and a clear drainage coming from his right ear. His right pupil was 5mm and sluggishly reactive to light, and his left pupil was 3mm and reacted briskly. HR 106, BP 110/70, RR 14.

55. 3. What intervention is appropriate upon finding that there’s clear drainage coming from the ear. Why?

56. Bob arrived at the hospital 10 minutes later. He was immediately intubated, hyperventilated, and rushed to CT scan. He was then rushed to OR. 4. While Bob was being rushed everywhere Jane was giving a history of what happened to Bob. What should Jane be sure to include in her history.

57. 5. What type of neuro trauma did Bob suffer from? What events from the history lead you to this conclusion? Explain the differences in the manifestations of symptoms between the subdural hematomas (3 types) and the epidural hematomas