Traumatic Brain Injury

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• Traumatic Brain Injury
• Professor Deborah Cary,RN,MSN

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INCIDENCE

• Open or Closed Head or Brain Injury
• Skull fractures, brain concussions, cerebral
  contusions/lacerations, and hemorrhage
• (subarachnoid, subdural, epidural, intracerebral,
  brain stem)
• Primary or Secondary Injury

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Types of Insults

• Intracranial Hemorrhages

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Causes of Head Injury

• MVA
• Sports
• Cerebral Bleeds
  
• Concussions
• Masses/Lesions

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• Whiplash
• a Coup contre coup
• injury causes injury
• to neck/cerebrum

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• The leading cause of death in head
• trauma patients who reach hospital alive
• is increased intracranial pressure

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Initial Interventions

• Cervical collar
• Assess for bleeding
• ABCs
• CVA 6hr window for TPA to minimize
  complications
• Protect from further injury

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THE BRAIN FACTS

• Composed of tissue, blood and cerebrospinal fluid
  (CSF)
• Encased within a rigid structure (skull)
• Little room for brain components to increase in
  size/volume, expand

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AUTOCOMPLIANCE

• Dynamic process of Accomodation
• and Compliance----gt
• ICP maintained at 10-15mm/Hg (Normal)
• Range maintained despite normal pressure

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MONROE-KELLY HYPOTHESIS

• Any increase in the volume of one
• component must be compensated for by
• a decrease in the volume of other
• components

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Response to Increased Volume

• CSF shunted to spinal arachnoid space
• OR
• The rate of CSF absorption is increased

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ADDITIONAL RESPONSE

• If needed a decrease in blood volume occurs
  secondary to the displacement of
• venous blood into the sinuses
• Minimal ICP increases as long as brain able to
  compensate

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FACTS

• AS ICP increases, Cerebral blood flow
• decreases (CPP) ---gt tissue hypoxia
• decrease in serum
  pH
• increase in CO2
  levels

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AS THE PROCESS CONTINUES---gt

• Cerebral vasodilation.
• Cerebral edema
• Further ICP

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IF THE PROCESS CONTINUES-----gt

• The brain herniates downwards towards the brain
  stem------gt
• Irreversible brain damage----gt
• Death

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Determining CPP

• CPP pressure gradient that is needed to supply
  adequate blood to brain
• Difference between MAP and ICP
• SBP (2x DBP)
• 3

Norm80-100mmH
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Clinical Manifestations

• Level of consciousness (LOC)
• subtle or rapid
• Etiology From impaired cerebral flow affecting
  the RAS - the area that wakes you up
• Seizures

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VITAL SIGNS

• Increasing Systolic BP
• Widening Pulse Pressure
• Bradycardia
• Irregular Respiratory Pattern

Cushings Triad or Cushings Reflex
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Etiology

• Increasing pressure on the
• Thalamus
• Hypothalamus
• Pons/ Medulla

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OCULAR SIGNS

• Etiology Shifting of brain from
  midline---gtcompression of CN III----gtparalysis of
  pupil sphincter
• Dilation of ipsilateral pupil (one side)
• Sluggish response to light
• Inability to move eyes upward
• Ptosis of eyelid

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OCULAR 2

• Blurred vision
• Diplopia
• Changes in Extraocular Movement
• Papilledema
• Choked Optic Disc

Opthalmoscope
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NEUROSENSORY

• Unequal, weak hand grasps
• Facial asymmetry (drooping)
• Loss muscle tone, muscle spasticity
• Absent/weak deep tendon reflexes (DTR)
• Apraxia, hemiplegia/hemiparesis
• behavior changes
• clumsiness, loss of balance
• Posturing - decerebrate and decorticate

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Decorticate Posturing
Ominous Sign brainstem injury
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Decerebrate Posturing
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SYMPTOMS cont.

• Flaccidity
• Headache - due to compression vessels/nerves
• Vomiting can be projectile

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Dx cont.

• Cerebral Angiography use contrast dx AV
  malformations, venous spasm and thrombus
• EEG
• EMG
• Evoked Potentials to detect lesions in cerebral
  cortex might predict
• coma outcome

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Diagnosis

• Neuro exam
• CAT Scans best initially
• Later MRI or PET
• ICP monitoring via LP
• Intraventricular catheter Gold Standard for
  monitoring ICP

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Medical

• Goal decrease ICP and maintain cerebral
  perfusion (CPP) poor prognosis ICP lt3
• Ventilation - ABCs!!!
• Monitor cardiac
• Hypothermia
• Sedation if extremely agitated (can ICP)

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Medications

• Ticlix
• Plavix
• Heparin
• Coumadin antidotes check labs
• Osmotic diuretics Mannitol
• Corticosteroids
• Anticonvulsants
• Sedatives
• Antipyretics

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Nursing Interventions

• Neurological checks/document - may be q1hr -
  chart on Glascow Coma scale
• Analysis of vital signs changes?
• Pad siderails \
• Eye Care
• Assess reflexes
• Assess for nuchal rigidity (stiff neck)
• Quiet environment
• Darkened room
• HOB - some controversy re position recent
• thought is flat

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Nursing cont.

• Observe for otorrhea / rhinorrhea
• No valsalva maneuvers
• Suctioning only if necessary
• 10 and only 2 passes since inc.ICP
• SCDs
• Never forcibly restrain ICP increases
• With TIA sx assess for carotid bruit (bell)
• Private Room
• If HOB up 30 degrees
• If conscious soft diet s caffeine
• mannitol, requires inline filter

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Nursing cont.

• ABGs hypercapnia (CO2 gt45mm Hg) will dilate
  cerebral blood vessels and constrict with levels
  lt21
• Serum O2 lt50mm Hg dilation
• gt80mm decrease CBF

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Brain Attacks

• Third cause death US and Canada
• Higher incidence in SE
• Higher risk with African Americans,
  Japanese,Chinese
• Risk factors HTN ,AGE - see complet list in
  textbook
• Decline since 80s
• 1/3 survivors, 2nd stroke in 5 yrs!
• Precursor TIAs STAT RX!!
• TIA reversible, 2-15minutes
• gt 6hrs can lead to infarcts
• Sx severe headache, speechlessness,
• partial vision loss 1 eye,
  weakness,numbness,
• unexplained dizziness