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Management of Patients With Neurologic Trauma Chapter 63

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Presentation on theme: "Management of Patients With Neurologic Trauma Chapter 63"— Presentation transcript:

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

2 Head Injuries TBI Traumatic Brain Injury

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

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

5 Scalp Injuries Clinical manifestation Bleeding Profusely!

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

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

8 Scalp Injuries Laceration The act of… Tearing

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

10 Scalp Injuries Complication Infection Clean Use procaine/Lidocaine
Suture

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

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

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

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

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

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

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

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

19 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.”

20 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

21 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

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

23 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

24 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

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

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

27 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

28 Brain Injury Concussion S&S LOC Memory loss Headache

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

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

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

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

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

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

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

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

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

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

39 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

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

41 Brain Injury: Epidural hematoma
Management Extreme emergency Burr Holes

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

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

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

45 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

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

47 Spinal Cord Injury Pathophysiology Transient concussion Contusion
Laceration Compression Complete transection

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

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

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

51 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

52 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

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

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

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

56 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

57 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

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

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

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

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

62 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

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

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

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

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

67 SCI: Complications & Interventions Thermal Regulation
Not perspire Fever?

68 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

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

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

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

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

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

74 SCI: Complications & Interventions Depression

75 SCI: Complications & Interventions Infections
Respiratory UTI Wound

76 The Quadriplegic Patient
See homework and reading Ch 63

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