Head Injury, Cranial Surgery and IICP

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Head Injury, Cranial Surgery and IICP

• NUR 2549

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Unconsciousness

• An abnormal state in which client is unaware of
  self or environment
• Can be for very short time to long term coma
• Care is designed to
• Determine the cause
• Maintain bodily functions
• Support vital functions
• Protect client from injury

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Etiology

• Arousal
• State of being awake that depends on a group of
  neurons in the brainstem
• Can maintain level of wakefulness even without
  functioning cortex

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From Human Physiology
RAS is located in brain stem
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Etiology

• Content part of consciousness
• Ability to reason, think and feel
• Also to react to stimulus with purpose and
  awareness
• Controlled by cerebral hemispheres (higher
  centers)
• Intellect and emotional function are also
  controlled in the same area.

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Major Reactions

• Two reactions affecting cerebral metabolism
  occur
• Cerebral ischemia /anoxia brain isnt getting
  enough oxygen and compensatory mechanisms take
  place
• Cerebral edema results because the brain
  compensates by dilating blood vessels trying to
  get more oxygen

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Behavior

• Document accurately what the clients behavior
  is. Example if the client opens eyes on command
  but not spontaneously, chart it as such. Be
  descriptive.

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Glascow Coma Scale

• Used to document assessment in three areas
• Eyes
• Verbal response
• Motor response
• Normal is 15 and less than 8 indicates coma

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From Rehabilitation Nursing
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From Rehabilitation Nursing
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Other Assessment

• Assess bodily function including respiratory,
  circulatory and elimination
• Pupil checks are pupils equal and how they
  react to light
• Extremity strength
• Corneal reflex test

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Intracranial Pressure

• Monro-Kellie hypothesis (applies only to children
  with a rigid skull and not neonates)
• Skull is an enclosed space with three variables
• Brain tissue
• Blood
• Cerebrospinal fluid

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Intracranial Pressure

• The skull cannot expand to allow for extra space
  occupying tissue or fluid
• If one of the three components increases the
  other two must decrease in order to compensate

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Intracranial Pressure

• Other factors that influence intracranial
  pressure
• Arterial pressure
• Venous pressure
• Intraabdominal and intrathoracic pressure
• Posture
• Temperature
• Blood gases (left off handout)

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Normal Intracranial Pressure

• Pressure exerted by total volume from
• Brain tissue
• Blood
• Cerebrospinal fluid
• Normal manometer reading 80-180
• Normal transducer reading 0-15mm Hg

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Cerebral Blood Flow

• Amount of blood going through 100g of brain
  tissue in 1 minute cerebral blood flow is
  50ml/min per 100g
• Brain uses 20 of the bodys oxygen
• Brain uses 25 of bodys glucose

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Autoregulation of Cerebral Blood Flow

• Blood vessels alter their diameter to ensure a
  constant cerebral blood flow
• Lower limit for MAP is 50mm Hg.
• Below this, cerebral flow decreases and there is
  risk of ischemia
• Upper limit is MAP of 150mmHg. Above this the
  cerebral blood vessels are maximally constricted.
  Blood vessels cannot constrict more to control
  high pressure. Blood brain barrier is disrupted
  and cerebral edema and ICP results
• MAP DBP 1/3 Pulse Pressure

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Cerebral Perfusion Pressure (CPP)

• Pressure needed to maintain blood flow to the
  brain
• MAP-ICPCPP
• Normal CPP is 60-100
• CPPgt100 is hyperperfusion and IICP
• CPPlt 60 hypoperfusion
• CPPlt30 incompatible with life

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• Elastance stiffness of the brain
• High elasticity high elastance ICP increases
  with small increases in volume
• Low elasticity brain compensates and ICP stays
  stable

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Compliance

• Low compliance is same as high elastance
• High compliance ICP remains stable
• Blood pressure
• If MAP is low, blood vessels in brain dilate to
  bring in more blood
• If MAP is high, blood vessels constrict to shunt
  away blood from brain

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Metabolic Factors affecting cerebral blood flow

• Oxygen tension When oxygen tension (PaO2) falls
  below 50, cerebral arteries dilate to increase
  cerebral blood flow. If this fails to happen,
  the brain metabolism changes to anaerobic
  metabolism and lactic acid builds up
• Carbon dioxide tension - If the blood becomes
  acidic, the blood vessels dilate to increase
  cerebral blood flow (increased CO2 and acidosis
  are potent vasodilators)

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Metabolic Factors

• Globally
• extreme cardiovascular changes (asystole)
• Pathophysiologic states (diabetic coma)
• Focally
• Trauma and tumors

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Stages of Increased ICP

• Stage 1 High compliance and low elastance.
  Autoregulation is functioning
• Stage 2 Compliance is lower and elastance is
  increased. An increase in volume places client
  at risk for IICP
• Stage 3 High elastance and low compliance.
  Small changes in volume will cause large increase
  in ICP

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Stages of Increased ICP

• Stage 4 ICP rises to terminal levels with
  little increase in volume. Brain herniates
  leading to
• REST IN PEACE

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Increased Intracranial Pressure

• From an increase in cranial volume that results
  from increase in one or more of the following
• Brain tissue
• Blood
• Cerebrospinal fluid

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Increased Intracranial Pressure

• Cerebral edema regardless of cause, increases
  tissue volume, can lead to IICP
• Types
• Vasogenic-most common (tumors, abscesses,
  ingested toxins)
• Cytotoxic-local disruption of cell membranes
  (lesions or trauma)
• Interstitial-uncontrolled hydrocephalus,
  hyponatremia

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Complications of IICP

• Inadequate cerebral perfusion
• Cerebral herniation
• Brain shift Lateral, downward, or both
• Irreversible
• Edema and ischemia further increased
• Compression of brainstem and cranial nerves may
  be fatal
• Cerebellum and brainstem forced through foramen
  magnum

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Clinical Manifestations

• Change in level of consciousness is the most
  sensitive and important indicator of neuro status
  
• May be pronounced or subtle
• Early signs may be nonspecific restlessness,
  irritability, generalized lethargy

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Clinical Manifestations

• Changes in vital signs-this is ominous sign
• This is a late sign Cushings triad
• Increasing systolic blood pressure
• Pulse slowing and is bounding
• Irregular respiratory pattern
• May also have a change in temperature

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Clinical Manifestations

• Ocular signs
• Pupil changes are from pressure on third cranial
  nerve
• Pupils become sluggish, unequal. This is because
  of brain shift. May also be pressure on other
  cranial nerves

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Clinical Manifestations

• Decrease in motor function
• May have hemiparesis or hemiplegia
• May see posturing either decorticate or
  decerebrate
• Decerebrate more serious from damage in
  midbrain and brainstem
• Decorticate from interruption of voluntary
  motor tracts

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Clinical Manifestations

• Headache
• From compression on the walls of cranial nerves,
  arteries and veins
• Worse in the morning
• Straining and movement makes worse

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Clinical Manifestations

• Vomiting
• NOT preceded by nausea- unexpected
• May be projectile

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Diagnostic Tests

• CT
• MRI
• Cerebral angiography
• EEG
• PET
• No lumbar puncture if there is ICP because sudden
  release of pressure can cause brain to herniate
• ABGs keep O2 at 100 (Lewis 1615) and PCO2 as
  related to ICP (25-35)

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Drug Therapy

• Mannitol Rapid short acting diuretic that
  decreases ICP. Decreases total brain water
  content
• Watch fluids and electrolytes closely (I and O
  and labs)
• Dont give in cases of renal failure or if serum
  osmolality increased

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Drug Therapy

• Loop diuretics reduce blood volume and tissue
  volume
• Corticosteroids Decadron most common steroid
  used. Watch for side effects. Should be on
  antacids or H2 receptor blockers to prevent
  ulcers.

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Drug Therapy

• Barbiturates causes decrease in metabolism and
  ICP. Causes reduction in cerebral edema and
  blood flow to brain.
• Watch for hangover effects and drowsiness. Side
  effects make it harder to check LOC. Watch for
  constipation do not want client straining.
• Skeletal muscle paralyzers may be used (Pavulon)
• Antiseizure drugs - Dilantin

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Nutrition

• Clients need higher amounts of glucose to
  survive.
• Will need nutritional support quickly.
• Watch sodium if on Mannitol may need to give
  additional salt.
• Also may need additional free water if dehydrated
  watch I and O closely.
• Give low CHO diet to help with CO2

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Nutrition

• Fluid balance is controversial
• Do not want too dry
• Keep normavolemic
• Give saline either .45 or normal saline not
  glucose to help prevent additional cerebral edema

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Laboratory Work

• ABGs regularly
• Electrolytes daily

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Nursing Interventions

• Airway and respiratory suction only as needed
  and for 10 seconds at a time, only 2 passes.
  Give 100 O2 prior to suctioning.
• Avoid abdominal distention may need NG tube to
  decompress stomach
• Sedate with care if not on a vent, use sedation
  that will not interfere with respiration or mask
  any neuro changes

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Nursing Interventions

• Keep HOB elevated 30 degrees if BP is normal
• If BP is low will need to put HOB flat
• Keep head in alignment to prevent cutting off
  venous flow from the head
• Dont elevate knees this will increase
  intrathoracic pressure
• Turn gently from side to side if turning raises
  ICP, client will need to stay on back

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Nursing Interventions

• If client is posturing frequently during care,
  will need to sedate first and then do only one
  thing at a time. Minimize stimulation
• These clients can become agitated and combative
  avoid over stimulating them
• Restraining them will make them MORE AGITATED and
  RAISE THEIR ICP!

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Nursing Interventions

• Use minimal stimulation perhaps one family
  member that is particularly calming not the
  entire neighborhood can stay with client
• Use a calm voice when talking to the client
• Calmly tell the client what you are going to do
  when providing care
• NO TV IN ROOM
• Keep room darkened if needed

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Nursing Interventions

• Keep body temperature within normal limits
• Give ordered PRN antipyretics (probably Tylenol)
• May need to use cooling blanket
• Do not use ice on client

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Nursing Interventions

• Hygiene keep skin clean and dry. Watch for
  skin breakdown
• May need to be on a special bed
• Keep mouth clean and moist
• May need eye drops to moisten eyes
• Families need a lot of support even after client
  leaves ICU
• Client may benefit from rehab to help him adapt
  and progress

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Nursing Interventions

• Prevent infection
• Protect from injury
• Avoid factors that increase ICP
• Psychological support

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Pediatric Considerations

• Open fontanels allow expansion of skull
• Neuro changes may be harder to detect because
  child cannot communicate as well
• Cushings triad rarely seen in children
• Compare childs behavior with their developmental
  level

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Pediatric Considerations

• Assess for developmental differences and physical
  anomalies
• Is child appropriate for age?
• Look for physical injuries such as bites, bruises
• Use special Glascow coma scale for child

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Pediatric Considerations

• Allow parent to stay with child as much as
  possible
• Avoid unnecessary stimulation
• Crying will increase ICP

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Head Trauma

• Usually signifies craniocerebral trauma
• Includes alteration in consciousness
• High potential for poor outcome
• Death at injury
• Death within 2 hours after injury
• Death 3 weeks after injury

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Head Trauma statistics

• 3 million/year in the U.S.
• Mortality rate is 19 per 100,000
• MVAs and falls have decreased as causes
• Firearm-related head injury deaths have increased

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Head Trauma

• Scalp lacerations scalp has many blood vessels
  and will bleed profusely. Watch for infection
• Skull fracture types
• Linear
• Depressed
• Simple
• Comminuted
• Compound

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Skull Fracture Locations

• Frontal
• Orbital fracture
• Temporal fracture
• Parietal fracture
• Posterior fossa fracture
• Basilar skull fracture
• Occurs at base of the skull
• Watch for rhinorrhea and otorrhea
• Test fluid leaking from nose or ear for glucose
  and watch for halo
• If the drainage is CSF then the fracture has
  crossed the dura

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Head Trauma

• Check head injury client for bruising around eyes
  called raccoon eyes
• Also look at hairline at nape of neck behind ear
  for bruising called Battles sign
• Major complications of basilar skull fracture are
  infection and hematoma

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Battles sign
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Minor Head Trauma

• Concussion client may not lose consciousness
• Will be a brief change in LOC, client may not
  remember the event and will have headache
• Post-concussion syndrome is 2 weeks to 2 months
  after injury

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Post Concussion Syndrome

• Persistent headache
• Lethargy
• Personality changes
• Short attention span
• Decreased short-term memory
• When client is discharged after concussion nurse
  should instruct family on what to watch for and
  when to call Dr.

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Major Head Trauma

• Contusion bruising of brain tissue
• Has area of necrosis infarction and hemorrhage
• Often from coup - contrecoup injury
• Seizures are common after contusion

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Major Head Trauma

• Lacerations
• Tearing of brain tissue
• Occurs with depressed skull fracture and
  penetrating injuries
• May have bleeding into the brain
  structures-intracerebral hemorrhage
• Very difficult to remove blood

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Major Head Trauma

• Epidural hematoma
• Comes from bleeding between dura and inner
  surface of the skull
• Will be unconscious, then awake, and then
  deteriorate
• Headache, nausea and vomiting
• Needs surgical intervention to prevent brain
  herniation and death

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Subdural Hematoma

• Usually bleeding is from veins, so bleeding is
  GENERALLY slower than epidurals
• CAN be from arteries and these require IMMEDIATE
  removal
• Administration of anticoagulants is one of the
  causes of CHRONIC TYPES esp. in the elderly.

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Diagnostic Studies

• Skull xrays routine to r/o or identify fracture
• CT/MRI are best to determine trauma rapidly

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Emergency Management-Initial

• Airway
• Stabilize cervical spine
• Oxygen administration
• IV access (2 large bore catheters), LR or NS
• Control external bleeding with pressure
• Assess for rhinorrhea, otorrhea, scalp wounds
• Remove clothing

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Emergency Management-Ongoing

• Maintain patient warmth
• Monitor VS, LOC, O2 sats, cardiac rhythm, GCS,
  pupil size and reactivity
• Anticipate intubation if absent gag reflex
• Assume neck injury with head injury
• Administer fluids cautiously to prevent IICP

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Rehab

• Most head trauma requires rehab
• Some rehab units do coma management
• Client may have trouble swallowing and need
  speech therapy
• Client may agitate easily and act out sexually
• May be a flight risk and have to be in a locked
  ward until passes through the agitation phase

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From Rehabilitation Nursing
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From Rehabilitation Nursing
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Pediatric Client

• Child is vulnerable to acceleration deceleration
  injuries because their neck is supple and moves
  around easily and the head is larger in
  proportion to their bodies
• In a very young child the cranium may be able to
  expand enough to allow for some edema

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Pediatric Client

• Epidural hemorrhage is rare in children
• Subdural hemorrhage from shaken baby syndrome,
  falls
• Can result in quadriplegia, hyperthermia, bulging
  fontanels
• Retinal hemorrhages
• Dizziness
• Unsteady gait

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Elderly

• At risk for head trauma from falls
• Be alert if client has fallen and is taking
  anticoagulants

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Cranial Surgery

• Brain tumor (benign or malignant)
• CNS infection
• Hydrocephalus
• Vascular abnormalities
• Intracranial bleeding
• Aneurysm repair
• Arteriovenous malformation
• Craniocerebral trauma
• Skull fractures
• Epilepsy
• Intractable pain

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Types of Cranial Surgery Stereotactic

• Stereotactic neurosurgery
• Often computer assisted to precisely target area
• CT and MRI used to image targeted tissue
• Burr hole or bone flap for entry
• Can remove small tumors and abscesses, drain
  hematomas, perform ablative procedures, repair AV
  malformation
• Reduces damage to surrounding tissue

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Types of Cranial Surgery Craniotomy

• Location varies
• Frontal
• Parietal
• Occipital
• Temporal
• Combination
• Burr holes drilled, saw to remove bone flap
• Bone flap wired or sutured after surgery
• Drain may be placed to remove blood or fluid

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Nursing Care Pre-op

• Compassion
• Uncertainty and fear about prognosis/complications
  
• Teaching
• What can be expected
• Hair will be shaved
• Client will be in ICU after surgery

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Nursing Care Post-op

• Prevent increased ICP!!!
• Maximum swelling occurs within 24-48 hours
• Frequent assessment of neuro status x 48 hrs.
• Monitor fluids, electrolytes, osmolality closely
• Detects changes in sodium regulation, onset of
  diabetes insipidus, severe hypovolemia
• Positioning varies depending on procedure
• Assess dressing, drainage, incision
• Care to prevent wound infection

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Nursing Care ambulatory and home

• Rehab potential depends on reason for surgery,
  post-op course of recovery, and clients general
  health
• Nursing considerations
• Foster independence for as long as possible to
  highest degree possible
• Positioning, skin and mouth care, ROM exercises,
  bowel and bladder care, adequate nutrition
• Potential recovery cannot be determined until
  cerebral edema and IICP subside