Traumatic Brain Injury Injury that is the result of an external force and is of sufficient magnitude to interfere with daily life and prompts the seeking of treatment Traumatic Brain Injury Common causes o Falls o Motor vehicle crashes o Struck by objects o Assaults Traumatic Brain Injury Higher risk populations o Children 0-4 years old o Adolescents 15-19 years old o >65 years old Preventing Head Injuries Obey traffic laws and do not drive under the influence Seat belts and shoulder harness Do not ride in the back of pickup trucks Advise motorcyclists and bicycle riders to wear helmets Water safety instruction Fall prevention education Protective devices for athletes Firearms in locked in secure area Pathophysiology Primary injury o Consequence of direct contact to the head/brain during the instant of initial injury Causing extracranial focal injuries as well as possible focal brain injuries from sudden movement of the brain within the cranial vault Secondary injury o Evolves over the ensuing hours and days after the initial injury and results from inadequate delivery of nutrients and oxygen to the cells Pathophysiology Monro-Kellie hypothesis o Cranial vault contains three main components: brain, blood, and cerebrospinal fluid (CSF) o Cranial vault is a closed system o If one of the three components increases in volume, at least one of the other two must decrease in volume or the pressure will increase Pathophysiology https://youtu.be/o4DyoQLyWt4 Cerebral perfusion pressure (CPP) is the pressure needed to ensure blood flow to the brain o CPP = MAP - ICP Intracranial Pressure Hydrostatic force measured in the brain CSF compartment Balance among the three components (brain tissue, blood, CSF) maintains the ICP Factors that influence ICP o Arterial pressure, venous pressure, intraabdominal and intrathoracic pressure, posture, temperature, blood gases Normal ICP 5-15 mm Hg Methods of Measuring Intracranial Pressure Ventriculostomy (gold standard) o Specialized catheter is inserted into the lateral ventricle and coupled to an external transducer o Measures the pressure within the ventricles, facilitates removal and/or sampling of CSF, and allows for intraventricular drug administration Brain Injury Traumatic Brain Injury, closed (blunt) o Occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged but there is no opening through the skull and dura Brain Injury Traumatic Brain Injury, open (penetrating) o Occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain Skull Fractures Break in the continuity of the skull caused by forceful trauma Can occur with or without damage to the brain Classified by type and location (Depressed is bad) o May have CSF leakage from nose or ear o Battle sign (bruising behind mastoid) o Worry of meningitis (Increased risk. Watch for signs) Types of Brain Injury Contusion o Brain is bruised and damaged in a specific area because of severe acceleration– deceleration force or blunt trauma o Can be characterized by loss of consciousness associated with stupor and confusion o Prevention of additional insults Edema that can peak after (Relisten here) Types of Brain Injury Intracranial Hemorrhage o Hematomas are collections of blood in the brain that may be epidural, subdural, or intracerebral o Symptoms delayed until hematoma is large enough to cause distortion of the brain and increased ICP Types of Brain Injuries Concussion o Temporary loss of neurologic function with no apparent structural damage to the brain o Referred to as “mild TBI” o Blunt trauma from an acceleration–deceleration force, a direct blow, or a blast injury Types of Brain Injuries Concussion (continued) o Observe the patient for a decrease in LOC, worsening headache, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, and numbness or weakness in the arms or legs o Chronic traumatic encephalopathy Diffuse Axonal Injury Results from widespread shearing and rotational forces that produce damage throughout the brain No lucid interval, immediate coma, decorticate and decerebrate posturing, and global cerebral edema Head Injury – Medical Management Diagnosis o CT & MRI Presume cervical spine injury Preserve brain hemostasis and prevent secondary brain injury o Cerebral edema, hypotension, respiratory depression o Maintain adequate cerebral perfusion, control hemorrhage and hypovolemia, maintenance of optimal ABGs Treatment of Increased Intracranial Pressure If the ICP remains elevated, it can decrease the CPP Increased ICP interventions o Maintain adequate oxygenation o Elevate the head of bed o Maintain normal blood volume Supportive Measures Ventilatory support Seizure prevention (May give anticonvulsants) Fluid and electrolyte maintenance Nutritional support Management of pain and anxiety NG tube Brain Death Cardinal signs of brain death o Coma o Absence of brainstem reflexes o Apnea Nursing Process – Traumatic Brain Injury - Assessment When did the injury occur? What caused the injury? A high-velocity missile? An object striking the head? A fall? What was the direction and force of the blow? Nursing Process – Traumatic Brain Injury - Assessment The nurse should determine if there was a loss of consciousness, the duration of the unconscious period, and if the patient could be aroused Nursing Process – Traumatic Brain Injury - Assessment Physical assessment o Glasgow Coma Scale Response to tactile stimuli Pupillary response to light Corneal and gag reflexes Motor function Collaborative Problems/Complications Decreased cerebral perfusion Cerebral edema and herniation Impaired oxygenation and ventilation Impaired fluid, electrolyte, and nutritional balance Risk of posttraumatic seizures Planning/Goals Maintenance of a patent airway Adequate CPP Fluid and electrolyte balance Adequate nutritional status Prevention of secondary injury Effective family coping Maintenance of body temperature within normal limits Maintenance of skin integrity Improvement of coping Prevention of sleep deprivation Increased knowledge about the rehabilitation process Absence of complication Nursing Interventions Maintaining the airway o HOB 30 degrees o Suctioning (Not excessively) o Prevent aspiration o ABGs o Monitor for respiratory complications Nursing Interventions Monitoring neurologic function o Level of Consciousness (GCS) [LOC is best indicator of neuro dysfunction o Vital signs Bradycardia, increasing systolic BP, widening pulse pressure (Cushing Reflex) Cushings Triad Nursing Interventions Motor Function o Observe for spontaneous movements o Patient raise and lower extremities o Painful stimuli Nursing Interventions Other neurologic signs w/ TBI o Size and equality of pupils and reaction to light o Anosmia (Loss of smell) o Eye movement abnormalities o Aphasia o Memory deficits o Seizures o Psychological defects Nursing Interventions Monitoring fluid and electrolyte balance o Osmotic diuretics, inappropriate antidiuretic hormone secretion, posttraumatic diabetes insipidus o Sodium imbalances o Daily weight o I&O o Nursing Interventions Promoting adequate nutrition o Increased need for protein o Parenteral or enteral feedings (enteral preferred) Until swallowing reflux returns and the patient can meet caloric requirement orally Nursing Interventions Preventing injury o Agitation May also be the result of discomfort from catheters, IV lines, restraints, and repeated neurologic checks o Restlessness May be caused by hypoxia, fever, pain, or a full bladder Nursing Interventions Preventing Injury (continued) o Ensure oxygenation is adequate o Bladder not distended o Padded side rails o Mitts o Avoid opioids o Reduce environmental stimuli o Minimize disruption of sleep-wake cycles Nursing Interventions Maintaining body temperature o Fever Check temp q 2-4 hrs Identify cause Acetaminophen Cooling devices Nursing Interventions Improving coping o Memory deficits o Decreased ability to focus and sustain attention to a task (distractibility) o Impulsivity o Egocentricity o Slowness in thinking, perceiving, communicating, reading, and writing Nursing Interventions Supporting Family Coping o Provide family members with accurate and honest information o Encourage families to set well-defined short-term goals o Family counseling o Support groups Monitoring and Managing Potential Complications Decreased central perfusion pressure o Adequate CPP is > 50 mm Hg o Decrease cerebral edema and increase venous outflow from the brain Elevation of HOB, IV fluids, CSF drainage o Prevent hypotension IV fluids, vasopressors Monitoring and Managing Potential Complications Cerebral edema and herniation o At risk for increased ICP and brainstem herniation o Cerebral edema most common cause of increased ICP Herniation results in irreversible brain anoxia and brain death Controlling ICP in Patients with Severe Brain Injury Elevate the head of the bed as prescribed. Maintain the patient’s head and neck in neutral alignment (no twisting or flexing the neck). Initiate measures to prevent the Valsalva maneuver (e.g., stool softeners). Maintain body temperature within normal limits. Administer oxygen (O2) to maintain partial pressure of arterial oxygen (PaO2) >90 mm Hg. Controlling ICP in Patients with Severe Brain Injury Maintain fluid balance with normal saline solution. Avoid noxious stimuli (e.g., excessive suctioning, painful procedures). Administer sedation to reduce agitation. Maintain cerebral perfusion pressure of 50–70 mm Hg.
