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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


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.)


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


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.


Pathophysiology: Types

• Primary (due to initial injury)

– Types

• Secondary (generally due to response to injury)

• Lacerations

– Types

• Skull fracture

• Cerebral edema

• Basilar skull fracture • Ischemia

• Concussion • Herniation syndromes

• Contusion

• Hematomas

• SAH (subarachnoid hemorrhage)

• DAH (diffuse axonal injury)

• Cerebrovascular injury

• Coma


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


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”)


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


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.


Question

In a patient with a head injury, the endotracheal tube should be inserted through the nose.

A. True

B. False


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.


Primary Brain Injuries

• Concussion

– Mild brain trauma causing an alteration in mental status

– May or may not have a change in LOC

– Can have memory deficits both before and after the accident

– May have residual effects that need to be monitored

• Contusion

– Focal injury usually due to microtrauma to the vascular system

– Symptoms depend on depth of injury and amount of tissue contused

– Mortality can be from cerebral swelling

– Usually resolves within 24 to 72 hrs


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.)


Secondary Brain Injury

These are due to changes in the brain as a result of trauma. Types include:

Cerebral edema

Ischemia

Herniation syndromes

Coma


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


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.


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.


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.


Eye Changes

– Extraocular movements

– PERRLA

– Oculocephalic

– Oculovestibular



Patient: Brain Stem Responses

• Corneal reflex

• Cough/gag



Patient: Motor Function

Test all of these and record responses on both sides of the body:

• Localization

• Withdrawal

• Decorticate

• Decerebrate

• Babinski’s reflex


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.


Diagnostic Testing

• CT

• MRI

• Angiography

• Transcranial Doppler ultrasonography

• EEG

• Jugular bulb catheter


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


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


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.



• 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



(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



(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


Brain Death Examination

• Normothermic

• Coma

• Negative brain stem reflexes

• Apneic

• Organ procurement


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