Neurosensory: Traumatic Brain Injury (TBI)

1
Neurosensory Traumatic Brain Injury
(TBI) Brain Tumors

• Marnie Quick, RN, MSN, CNRN

2
Normal brain protected by
3
Normal brain
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
Traumatic Brain Injury (TBI)
Etiology/Pathophysiology

• Risk factors- MVA elevated blood alcohol
  contact sports acts of violence- gun, knife
• Mechanism of craniocerebral trauma
• Acceleration (movement)-deceleration (stationary)
• Coup (impact)-contrecoup (opposite) phenomenon
• Blunt or penetrating injury
• Closed head injury
• Scalp lacerations
• Skull fractures- Linear comminuted depressed
  basilar open/closed

8
Coup-contracoup injury
9
(No Transcript)
10
Penetrating injury- Gunshot to brain
11
Penetrating injury Knife in brain
12
Basilar skull fracture- Base of skull fractured
13
Basilar skull fracture is base of skull if
posteriorgt Battle sign-
ecchymosis behind the ear
14
Basilar skull fracture is more anterior Raccoon
eyes- periorbital ecchymosis
15
Basilar Skull fractures can cause leakage of CSF
from meninges
16
Minor Brain Injury

• Concussion- sudden transient disruption of neural
  activity in the brain with change in LOC
• Post Concussion Syndrome- may occur after other
  brain injuries- severity of symptoms are not
  related to severity of brain injury. Sym may
  persist wks-months

17
Major Brain Injury- Focal injury

• Brain contusion- bruising coup-contracoup
• Brain laceration- tearing brain tissue, ICH
• DAI- diffuse axonal injruy
• Widespread disruption of axons
• Poor prognosis
• Brain bleeds- Note meninges in relation to bleeds
  on following slides

18

19
Epidural hematoma
20
Subdural hematoma (SDH)
21
Intracerebral hematoma
22
Secondary brain injury

• Cerebral edema
• Localized or diffuse
• Peaks 24-72 hrs
• Occurs with CHI open head injury anoxia
• May in itself cause death by pressuregt herniation
• Increased ICP
• Herniation Syndromes

23
Traumatic Brain Injury (TBI) Common
Manifestations/Complications

• Increased ICP symptoms general and specific
• Restlessness- R/O respiratory waking up
• Systemic effects of acute brain injury-
  hypermetabolism, brainstorming, SIADH
• Brainstorming- hypothalamic stimulation-ANS
• CSF leak- rhinorrhea/otorrhea- basal skull Fx
• Post concussion Syndrome
• Associated cervical spinal cord injury

24
Collaborative Care Traumatic Brain Injury (TBI)

• Diagnostic studies (similar to ICP)
• Emergency management assessment and
  interventions (Lewis 1442 Table 57-9)
• Treat IICP- airway fluid positioning temp reg
  meds
• Prevention of complications
• Medications IICP seizures stress
  ulcerstrainingbrainstorming
• Diet/calories hypermetabolic state ileus
  swallow/gag
• CSF leak glucose halo HOB 30 no nasal suction
• Other SIADHgt hyponatremia
• Surgery bone repair evacuation clot
  craniotomy/ectomy burr hole cranioplasty
  monitor placement

25
Burr holescraniotomy
26
Place monitors/intraventricular drain
27
Crainectomy- bone flap out to allow for brain
expansion post op
28
Post crani
29
Traumatic Brain Injury (TBI) Nursing
assessment specific to TBI

• Health history
• Description of accident past medical history
• NVS and Glasgow Coma
• http//www.trauma.org/scores/gcs.html
• Brainstem reflexes
• VS- Late sign is Cushing reflex
• Skull/face CSF leak SCI
• Consider older adult finding

30
Pertinent Nursing Problems Specific to Traumatic
Brain Injury (TBI)

• Health promotion
• Ineffective tissue perfusion, cerebral (decreased
  intracranial adaptive capacity)
• Ineffective airway clearance/breathing pattern
• Hypothermia
• Pain
• Impaired physical mobility

31

• Anxiety
• Decreased cerebral perfusion (IICP)
• Brain death (ethical dilemmas p.1450)
• Home care
• Home evaluation/rehab/nursing home
• Teach about post concussion syndrome BB
  spasticity dysphagia nutrition seizure
  disorder personality changes family role
  changes
• 6 months typical plateau period
• Community agencies/support groups

32

• http//library.med.utah.edu/kw/animations/hyperbra
  in/oculo_reflex/oculocephalic2.html
• http//cim.ucdavis.edu/eyes/version15/eyesim.html
• http//www.softwarefornurses.com/access/index.asp

33
Primarybrain tumors

• Arise from support cells, neurogilia cells the
  meninges or blood vessels
• Do not metastasize outside cranium
• Cause unknown

34

• Grade I and II gilomas (astrocytoma) made up of
  astrocytes are benign, slow-growing tumors
• Grade III and IV gliomas (glioblastoma Multiforme
  are invasive and fast-growing
• Meningiomas arise from the meninges
  slow-growing benign, encapsulated and compress
  the brain
• Brain tumors may be lethal due to their location

35
Gioblastoma Meningioma
36
(No Transcript)
37
Metastatic (secondary) brain tumors

• Originate from outside the brain- lung and breast
  most common sites
• Single or multiple
• Becoming more common as individual with cancer in
  other parts of the body are living longer

38
Clinical Manifestations/complications of Brain
tumors

• General ICP symptoms
• Common early symptoms headache vomiting
  papilledema (visual changes)
• Seizures- partial classification in type
• Brain tumor symptoms occur due to their ability
  to compress or destroy brain tissue edema that
  forms around the tumor hemorrhage obstruction
  of CSF flow
• Specific symptoms as to the lobe affectedgt

39
(No Transcript)
40

• Frontal lobe personality changes inappropriate
  behavior inability to concentrate impaired
  judgment headache expressive aphasia if
  dominant hemisphere motor weakness or paralysis
  from motor strip
• Parietal lobe sensory deficits- paresthesia,
  visual field deficits contralateral sensory
  disturbances from sensory strip loss of
  interpretation and discrimination for sensing
  input perceptual problems

41

• Occipital lobe visual disturbances visual
  agnosia
• Temporal lobe complex partial (psychomotor)
  seizures auditory hallucinations memory
  problems Wernicke aphasia if dominant hemisphere
• Cerebellum gait distrubances balance and
  coordination problems
• Brain stem cranial nerve dysfunction vital
  signs

42
Complications of Brain Tumors

• Hydrocephalus
• Infection
• Death is usually caused by IICP/hermiation

43
Collaborative Care for Brain Tumors
Diagnostic tests

• CT/MRI
• EEG
• PET
• Angiogram
• Tissue biopsy

44
Collaborative Care for brain tumors

• Surgery
• To remove or debulk
• Supratentorial- above tentorium
• Infratentorial-below
• Stereotaxic-localized

45

• Radiation
• Used alone or with other therapies
• Gamma or Cyber-knife
• Complication- increased cerebral edema
• Medications
• Chemotherapy IV intraventricular (ommaya
  Reservoir) or by wafer implanted
• Corticosteroids to treat brain edema
• Anticonvulsants to prevent seizures
• Rehab- outpatient or in house

46

• Health history progression of symptoms other
  cancers, disease
• Physical exam
• Neuro vital signs
• Specific signs of the local functions of
  different parts of the brain
• Similar neuro deficits as the individual with a
  stroke
• Signs of increased intracranial
  pressure/herniation

47
Pertinent Nursing Problems for Brain Tumor

• Impaired tissue perfusion, cerebral
• Self-care deficits
• Anxiety
• Risk for infection-post crani
• Acute pain
• Disturbed self-esteem
• Nutrition
• Home care- rehab home eval support groups