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Apr 03, 2018

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    Traumatic Brain Injury

    A Case Study

    Lisa Randall, RN, MSN, ACNS-BC

    RNSG 2432

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    Demographics/CC

    23 y.o. AAM

    Auto vs. ped

    8/10/08

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    HPI

    Dancing on I-35 under the influence ofcrack cocaine and ETOH.

    Hit by 2 cars > 50mph

    GCS 12 on arrival, but declined to 4

    Eyes 4>1

    Verbal 3>1

    Motor 5>2

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    History

    PMH Denies, but GSW (metallic pellets CXR)

    PSH Denies

    Social Hx Single, no children, unemployed, unfunded +ETOH, +amphetamines, +cannibis

    Recently released from jail for drug possession Meds

    Denies

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    Diagnostics

    Normal CT

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    Subdural Hematoma

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    Diagnostics

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    Diagnostics

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    Focused A/P

    R frontotemporoparietal SDH Craniectomy

    EVD

    Monitor/treat ICP

    Paraplegia/paresis

    L2 burst fracture c subluxation L2-L3

    T11 lamina/TP fracture T10-L3 posterior fusion when stable

    PT/OT/STrehab

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    A/P cont

    10th & 11th rib fractures

    R femur fracture

    Acetabular fracture

    Mediastinal hematoma

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    Post-Op

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    Post-Op

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    Nursing Concerns

    Neuro checks/VS q1h ICP monitoring

    Mannitol CSF drainage

    CPP monitoring IVF Vasopressors

    MAP monitoring Sedation/analgesia

    Seizure prophylaxis Infection prophylaxis Skin care

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    Interdisciplinary

    Collaboration Trauma

    Pulmonary/CC

    Orthopedics ID

    SW/CM

    Nursing

    PT/OT/ST/RT

    WOCN Dietary

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    Evaluation

    Rehabilitation

    Assessment Decreased short

    term memory

    Paraparesis

    DF 2/5, PF 2/5, HF4-/5

    Cranioplasty

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    Epidemiology of Head

    Trauma Occurs every 15

    seconds 500,000 annual ED

    visits Most common causes:

    MVAs, falls, assaults Males 15-24, elderly

    > 75 Accounts for 40% of

    traumatic deaths

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    Pathophysiology of TBI

    1st

    Primary Injury: initial insult i.e. from bleed

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    Second

    Secondary Injury: delayed injury from hypoxia,ischemia, and release of neurotoxins

    Excitatory amino acids can cause swelling and

    neuronal death Endogenous opioids cause increased metabolism,

    using glucose supplies

    Increased ICP, especially > 40 leads to brain

    hypoxia, ischemia, hydrocephalus, herniation Hydrocephalus: clotted blood obstructs CSF outflow

    tracts and absorption of CSF, disrupts blood-brainbarrier

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    Head Trauma

    Concussion

    Contusion

    Epidural hematoma (EDH)

    Subdural hematoma (SDH)

    Basilar skull fracture Diffuse axonal injury (DAI)

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    Epidural

    Basilar skull

    fractureDepressed skull

    Fracture

    Contusions

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    Types of Injuries

    Mild Traumatic Brain Injury: Concussion: brief change in mental

    status with axonal swelling Moderate to Severe Brain Injury:

    Contusion:bruising

    Fractures: linear,comminuted,depressed, basalar

    Bleeds: epidural, subdural,intracerebral

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    Mild Traumatic Brain

    Injury1. Period of LOC < 30 mins with a GCS

    of 13-15 after this LOC

    2. Amnesia to the event3. Alteration in mental status at the

    time of the event (dazed and

    confused)

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    Types of Concussion

    Grade I (confusion, no amnesia, no LOC) Remove from activity (may return when asymptomatic) 3 concussions in 3 months: no activity that risks head

    trauma for 3 months

    Grade II (confusion and amnesia) Remove from activity for day Recheck in 24 hours No activity for 1 week Two grade II concussions in 3 months, no activity for 3

    months Grade III (LOC)

    To ED for CT Symptom free for 2 weeks, then another 30 days Two grade III concussions, no activity for 3 months

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    Post-Concussive

    Syndrome Somatic symptoms: headache, sleep

    disturbance, dizziness, vertigo,

    nausea, fatigue, sensitivity to light ornoise

    Cognitive: attention, concentration,

    memory problemsAffective: irritability, depression,

    anxiety, emotional lability

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    Moderate andSevere Brain Injury

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    Contusion

    Small bleeds

    Cerebral Edema

    Deficits are basedon lobe involved

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    Fractures

    Linear

    Comminuted

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    Depressed Skull Fracture

    95% go to surgery

    Antibitoics for

    infection Brain tissue is

    involved

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    Treatment for CSF leak

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    Epidural Hematoma

    Laceration of duralarteries or veins

    Classically laceration ofmiddle meningeal artery

    Temporal bone fractures

    Lucid interval followedby rapid deterioration

    Acute bleed

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    Subdural Hematoma

    60-80% mortality

    Tearing of bridging

    veins, pial artery, orcortical veins

    Acute vs chronic

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    Traumatic Subarachnoid

    Hemorrhage Lacerations of vessels

    in subarachnoid space

    TSAH SAH

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    Intraventricular and

    Intraparenchymal Hemorrhage Intraventricular

    hemorrhage

    Very severe TBI

    Poor prognosis

    Intracerebral hemorrhage

    Parenchymal injuries from

    lacerations or contusions Large deep cerebral vessel

    injury

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    Coup and Contrecoup

    Injuries Coup: direct skull

    impact

    Contrecoup:opposite side ofimpact

    Due to negative

    pressure forcescausing bothvascular and tissuedamage

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    DAIDiffuse Axonal

    Injury

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    Neurologic Exam

    Decreasedneurologic function

    is best predictor ofbrain injury

    Pay attention tocranial nerves

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    Management of Acute BrainTrauma

    Labs: CBC, electrolytes, type andscreen, tox and ETOH screen

    CT Brain

    CT angiography or cerebralangiography (penetrating)

    MRI contraindicated if metallicfragments

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    Management Continued.

    . . Intubate GCS 8 or less or airway

    protection issue (Cricothyroidotomy if

    necessary) Maintain BP 90 mmHg systolic

    C-spine precautions

    Tetanus prophylaxis Sterile dressing to wounds

    Antibiotics in penetrating injury

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    ICP Management is the

    Key ICP monitor in patients with GCS < 8 Hyperventilation not routinely recommended Elevate head of bed to 30 degrees Sedation

    Propofol Barbiturate Induced Coma

    Contraindicated in hypotension

    Mannitol Reduces ICP by reducing blood viscosity, improves cerebral blood

    flow Serum osmolality should not be > 320 Bolus dosing

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    To Image or Not to

    Image? GCS < 15

    Intoxicated

    Age > 55 or < 2

    Amnesia to events

    Witnessed LOC (> 15 minutes)

    Repeated vomiting

    Evidence of basilar skull fracture

    Inability to recall 3 of 5 objects

    Coagulopathy

    Penetrating head injury

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    Ventriculostomy

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    Evidenced Based MedicalGuidelines for TBI Management

    BP and oxygenation

    Hyperosmolar

    therapy ICP monitoring

    CPP

    Infectionprophylaxis

    DVT prophylaxis http://youtu.be/YQ609Tk-qQI

    PbtO2

    Analgesic/sedatives

    Nutrition Antiseizure

    prophylaxis

    Hyperventilation Steroids

    Hypothermia

    http://youtu.be/YQ609Tk-qQIhttp://youtu.be/YQ609Tk-qQIhttp://youtu.be/YQ609Tk-qQIhttp://youtu.be/YQ609Tk-qQI
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    New Therapy

    Stem Cell Therapy

    Neural/Glial differentiation

    Neurogenesis Neuroplasticity

    Improve motor function

    Improve cognitive function

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    AANN Core Curriculum for Neuroscience Louis, MO.Nursing, 4th Ed. 2004. Saunders. St.

    Davis, F.A. (2001). Tabers Cyclopedic MedicalDictionary. F.A. Davis, Philadelphia.

    Greenberg, Mark. (2006). Handbook of Neurosurgery.Greenberg Graphics, Tampa, Florida.

    Lewis, S., Heitkemper, M., OBrien, P., Bucher, L.(2007). Medical-Surgical Nursign. Assessment of

    Management of Medical Problems. Mosby

    Elsevier, St. Louis, Missouri Silvestri, Linda. (2008). Comprehensive review for theNCLEX-RN Examination. Saunders Elsevier, St.Louis, Missouri.

    References

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    Introduction

    YouTube - Brain Plasticity

    http://www.youtube.com/watch?v=TSu9HGnlMV0http://www.youtube.com/watch?v=TSu9HGnlMV0http://www.youtube.com/watch?v=TSu9HGnlMV0http://www.youtube.com/watch?v=TSu9HGnlMV0http://www.youtube.com/watch?v=TSu9HGnlMV0
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    Neuroplasticity

    Organizational changes caused by experience

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    Neurogenesis

    Formation of new nerve cells

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    http:///reader/full/traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbrain 53/55

    Nature vs. Nurture

    Genetics

    2500 connections

    major highways

    Environment

    15000avenues & side roads

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    http:///reader/full/traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbrain 54/55

    Future

    Directed Neuroplasticity

    http://www.newsweek.com/id/163924http://www.newsweek.com/id/163924
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    http:///reader/full/traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbraininjury000traumaticbrain 55/55

    Brain Fitness Program

    YouTube - The Brain Fitness Program(1/8)

    http://www.youtube.com/watch?v=CRldD_Z9l2s&feature=emailhttp://www.youtube.com/watch?v=CRldD_Z9l2s&feature=emailhttp://www.youtube.com/watch?v=CRldD_Z9l2s&feature=emailhttp://www.youtube.com/watch?v=CRldD_Z9l2s&feature=emailhttp://www.youtube.com/watch?v=CRldD_Z9l2s&feature=emailhttp://www.youtube.com/watch?v=CRldD_Z9l2s&feature=emailhttp://www.youtube.com/watch?v=CRldD_Z9l2s&feature=email