Transcript LWW PPT Slide Template Master

Chapter 36:
Traumatic Brain Injury
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Statistics
• 80,000 have disability; 50,000 die from head injury
• Head injury profiles
– Age 15 to 24
– Male
• Causes
– Motor vehicle accidents
– Falls (especially in the young and older populations)
– Violence
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Mechanism of Injury
• Important information to get from those at the scene
• Important in determining where the injury is located and the
type of neurologic deficits
• Mechanism of injury
– Acceleration – moving object hits nonmoving head
– Deceleration – moving head hits stationary object
– Coup-contrecoup – damage from rebound effect
– Rotational – twisting of brain in the skull
(See Figure 36-1.)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following predisposes an elderly patient to
falls and possible head injury?
A. An enlarged cerebrum
B. Sinus arrhythmia
C. Nocturia
D. The use of steroids in the elderly
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
C. Nocturia
Rationale: Nocturia (getting up to void at night) along with
decreased visual acuity leads to falls. Cerebral atrophy,
not enlargement, leads to more room for the brain to
move, and therefore the brain would be subject to
trauma against the bony skull. Steroids are not always
used in the elderly, and complications are not associated
with falls. Atrial fibrillation and flutter can lead to strokes
or syncope and falls.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pathophysiology: Types
• Primary (due to initial injury)
–
Types
• Lacerations
• Secondary (generally due to
response to injury)
–
Types
• Skull fracture
• Cerebral edema
• Basilar skull fracture
• Ischemia
• Concussion
• Herniation syndromes
• Contusion
• Coma
• Hematomas
• SAH (subarachnoid
hemorrhage)
• DAH (diffuse axonal
injury)
• Cerebrovascular injury
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Primary Injuries
• Scalp lacerations
– Always a bit scary as they tend to bleed a lot
• Skull fractures
– Open/compound
– Linear
– Closed
– Depressed
• Bone fragments may enter the dura
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Primary Injuries: Basilar Skull Fracture
• Classic signs, usually due to CSF leakage from the
sinuses or bleeding in unusual areas
– Otorrhea
– Postauricular hematoma (Battle’s sign)
– Rhinorrhea
– Periocular ecchymosis (“raccoon’s eyes”)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following symptoms indicates a fracture of the
middle fossa in a basilar skull fracture?
A. Otorrhea
B. Rhinorrhea
C. Raccoon’s eyes
D. Halo sign
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
A. Otorrhea
Rationale: A communicating fracture of the middle fossa in
a basilar skull fracture manifests with otorrhea (CSF from
the ear) or Battle’s sign (mastoid ecchymosis). A fracture
of the anterior fossa or front of the skull usually produces
raccoon’s eyes and rhinorrhea (CSF from the nose). The
halo sign is a bloodstain surrounded by a yellowish
“halo.” The halo sign can happen with any CSF drainage
and is not limited to any one area of the brain.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
In a patient with a head injury, the endotracheal tube
should be inserted through the nose.
A. True
B. False
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. False
Rationale: Nothing should be passed into the nose of a
patient with head trauma, especially a basilar skull
fracture. If a nasogastric or endotracheal tube is nasally
inserted, the tube could pass into brain tissue because of
the fracture and communication with the CSF.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Primary Brain Injuries
• Concussion
• Contusion
–
Mild brain trauma causing
an alteration in mental
status
–
Focal injury usually due to
microtrauma to the
vascular system
–
May or may not have a
change in LOC
–
–
Can have memory deficits
both before and after the
accident
Symptoms depend on
depth of injury and amount
of tissue contused
–
Mortality can be from
cerebral swelling
–
May have residual effects
that need to be monitored
–
Usually resolves within 24
to 72 hrs
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Primary Brain Injuries: Hematomas
• Hematomas are lesions in the brain caused by traumatic
bleeding. Types include:
– Epidural
– Subdural
– Intracerebral
– Traumatic subdural hemorrhage
– Diffuse axonal Injury
– Cerebrovascular Injury
(Refer to Figure 36-2.)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Secondary Brain Injury
These are due to changes in the brain as a result of
trauma. Types include:
Cerebral edema
Ischemia
Herniation syndromes
Coma
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Secondary Injury: Edema and Ischemia
• Cerebral edema peaks in 72 hrs
– Cytotoxic
– Vasogenic
• Ischemia – decreased blood flow and possible infarction
– Major cause of permanent injury and death
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Secondary Injury: Herniation Syndromes
Caused by the shifting of structures under pressure. Cushing’s
triad is a late sign. There are four types:
Uncal – supratentorial herniation; ipsilateral “blown
pupil”; contralateral weakness
Tonsillar – through foramen magnum; respiratory arrest
Central (transtentorial)
Upward cerebellar
The first two are most commonly seen in critical care.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Secondary Injury: Coma
• Defined as a change in the LOR
– RAS is disrupted
– Persistent vegetative state
• Arousal but no cognitive function
– Role of the GCS
– Causes
• Refer to Box 36-2.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Assessment of the Brain-Injured
Patient
• LOR is the most sensitive indicator
– AVPU scale
– Painful stimuli types
– Glasgow Coma Scale
• Tests for cognitive function
– Alert and oriented x3
– Hand grasps and letting go
• Refer to Figure 36-5.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Eye Changes
– Extraocular movements
– PERRLA
– Oculocephalic
– Oculovestibular
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Assessment of the Brain-Injured
Patient: Brain Stem Responses
• Corneal reflex
• Cough/gag
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Assessment of the Brain-Injured
Patient: Motor Function
Test all of these and record responses on both sides of the
body:
• Localization
• Withdrawal
• Decorticate
• Decerebrate
• Babinski’s reflex
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Assessment: Respiratory Function
• Cheyne-Stokes – periods of apnea slowly building in rate/depth
till a peak is met (cerebral hemisphere trauma; normal agerelated change)
• Central neurogenic hyperventilation – rapid, regular, sustained
and deep (upper midbrain)
• Apneustic – long pauses with full inspiration/expiration (brain
stem)
• Ataxic – irregular and unpredictable (medulla)
• Refer to Figure 36-6.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnostic Testing
• CT
• MRI
• Angiography
• Transcranial Doppler ultrasonography
• EEG
• Jugular bulb catheter
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Medical Management and Nursing Care
• Airway
– Always #1 priority
– Keep pCO2 35 to 45 mmHg
– Avoid hyperventilation in first 24 hrs
• Fluid resuscitation
– To keep ICP within normal range and BP stable
• ICP monitoring
– Positioning
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
A nurse would see increased intracranial pressure during
which of the following position changes?
A. Logrolling the patient
B. Extreme hip flexion
C. Keeping the head of the bed at 30 degrees
D. Placing sandbags on the side of the head to keep
it in alignment
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. Extreme hip flexion
Rationale: Logrolling the patient, keeping the HOB at 30
degrees, and sandbagging each side of the head help
lowering increased ICP. Extreme hip flexion increases
intra-abdominal pressure, which can be transmitted to
the cranial vault.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Medical Management and Nursing Care
• Prevention and treatment of seizures
–
Medications for prophylaxis in early phase only
–
Dilantin (phenytoin)
–
General seizure precautions
• Temperature maintenance
–
Therapeutic hypothermia doesn’t affect outcomes
• Monitoring fluids and electrolytes
–
Diuretics
–
Monitoring for SIADH, diabetes insipidus, glucose and saltwasting syndrome
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Medical Management and Nursing Care
(cont.)
• Cardiovascular
– Monitor for MI and rhythm disturbances
– Monitor for DIC
– Use of pulmonary artery catheter
– Hazards of immobility (DVT, contractures)
• Pulmonary
– Aspiration pneumonia
• ETT management, suctioning, tube feeding
management
– Monitor for ARDS and “flash” pulmonary edema
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Medical Management and Nursing Care
(cont.)
• Nutrition
– Nutrition ASAP
– Protein-rich formulas
• Integumentary and musculoskeletal system
– Contracture prevention
– Early PT
• Family support
– Importance of being honest and truthful
– Information
– Active involvement
– Behavioral changes
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Brain Death Examination
• Normothermic
• Coma
• Negative brain stem reflexes
• Apneic
• Organ procurement
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins