Traumatic Brain Injury
A Case Study
Lisa Randall, RN, MSN, ACNS-BC
RNSG 2432
Demographics/CC
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23 y.o. AAM
Auto vs. ped
8/10/08
HPI
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Dancing on I-35 under the influence of
crack cocaine and ETOH.
Hit by 2 cars > 50mph
GCS 12 on arrival, but declined to 4
– Eyes 4>1
– Verbal 3>1
– Motor 5>2
History
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PMH
– Denies, but GSW (metallic pellets CXR)
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PSH
– Denies
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Social Hx
– Single, no children, unemployed, unfunded
– +ETOH, +amphetamines, +cannibis
– Recently released from jail for drug possession
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Meds
– Denies
Diagnostics
Normal CT
Subdural Hematoma
Diagnostics
Diagnostics
Focused A/P
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R frontotemporoparietal SDH
– Craniectomy
– EVD
– Monitor/treat ICP
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Paraplegia/paresis
L2 burst fracture c subluxation L2-L3
T11 lamina/TP fracture
– T10-L3 posterior fusion when stable
– PT/OT/ST…rehab
A/P con’t
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10th & 11th rib fractures
R femur fracture
Acetabular fracture
Mediastinal hematoma
Post-Op
Post-Op
Nursing Concerns
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Neuro checks/VS q1h
ICP monitoring
– Mannitol
– CSF drainage
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CPP monitoring
– IVF
– Vasopressors
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MAP monitoring
Sedation/analgesia
Seizure prophylaxis
Infection prophylaxis
Skin care
Interdisciplinary
Collaboration
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Trauma
Pulmonary/CC
Orthopedics
ID
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SW/CM
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Nursing
PT/OT/ST/RT
WOCN
Dietary
Evaluation
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Rehabilitation
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Assessment
– Decreased short
term memory
– Paraparesis
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DF 2/5, PF 2/5, HF
4-/5
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Cranioplasty
Epidemiology of Head
Trauma
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Occurs every 15
seconds
500,000 annual ED
visits
Most common causes:
MVAs, falls, assaults
Males 15-24, elderly
> 75
Accounts for 40% of
traumatic deaths
Pathophysiology of TBI
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1st
– Primary Injury: initial insult … i.e. from bleed
Second
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Secondary Injury: delayed injury from hypoxia,
ischemia, and release of neurotoxins
Excitatory amino acids can cause swelling and
neuronal death
Endogenous opioids cause increased metabolism,
using glucose supplies
Increased ICP, especially > 40 leads to brain
hypoxia, ischemia, hydrocephalus, herniation
Hydrocephalus: clotted blood obstructs CSF outflow
tracts and absorption of CSF, disrupts blood-brain
barrier
Head Trauma
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Concussion
Contusion
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Basilar skull fracture
Diffuse axonal injury (DAI)
Epidural
Contusions
Basilar skull
fracture
Depressed skull
Fracture
Types of Injuries
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Mild Traumatic Brain Injury:
– Concussion: brief change in mental
status with axonal swelling
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Moderate to Severe Brain Injury:
– Contusion: “bruising”
– Fractures: linear,comminuted,
depressed, basalar
– Bleeds: epidural, subdural,
intracerebral
Mild Traumatic Brain
Injury
Period of LOC < 30 mins with a GCS
of 13-15 after this LOC
2. Amnesia to the event
3. Alteration in mental status at the
time of the event (dazed and
confused)
1.
Types of Concussion
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Grade I (confusion, no amnesia, no LOC)
– Remove from activity (may return when asymptomatic)
– 3 concussions in 3 months: no activity that risks head
trauma for 3 months
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Grade II (confusion and amnesia)
–
–
–
–
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Remove from activity for day
Recheck in 24 hours
No activity for 1 week
Two grade II concussions in 3 months, no activity for 3
months
Grade III (LOC)
– To ED for CT
– Symptom free for 2 weeks, then another 30 days
– Two grade III concussions, no activity for 3 months
Post-Concussive
Syndrome
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Somatic symptoms: headache, sleep
disturbance, dizziness, vertigo,
nausea, fatigue, sensitivity to light or
noise
Cognitive: attention, concentration,
memory problems
Affective: irritability, depression,
anxiety, emotional lability
Moderate and
Severe Brain Injury
Contusion
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Small bleeds
Cerebral Edema
Deficits are based
on lobe involved
Fractures
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Linear
Comminuted
Depressed Skull Fracture
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95% go to surgery
Antibitoics for
infection
Brain tissue is
involved
Treatment for CSF leak
Epidural Hematoma
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Laceration of dural
arteries or veins
Classically laceration of
middle meningeal artery
Temporal bone fractures
“Lucid interval” followed
by rapid deterioration
Acute bleed
Subdural Hematoma
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60-80% mortality
Tearing of bridging
veins, pial artery, or
cortical veins
Acute vs chronic
Traumatic Subarachnoid
Hemorrhage
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Lacerations of vessels
in subarachnoid space
TSAH
SAH
Intraventricular and
Intraparenchymal Hemorrhage
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Intraventricular
hemorrhage
– Very severe TBI
– Poor prognosis
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Intracerebral hemorrhage
– Parenchymal injuries from
lacerations or contusions
– Large deep cerebral vessel
injury
Coup and Contrecoup
Injuries
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Coup: direct skull
impact
Contrecoup:
opposite side of
impact
Due to negative
pressure forces
causing both
vascular and tissue
damage
DAI
Diffuse Axonal
Injury
Neurologic Exam
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Decreased
neurologic function
is best predictor of
brain injury
Pay attention to
cranial nerves
Management of Acute Brain
Trauma
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Labs: CBC, electrolytes, type and
screen, tox and ETOH screen
CT Brain
CT angiography or cerebral
angiography (penetrating)
MRI contraindicated if metallic
fragments
Management Continued.
..
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Intubate GCS 8 or less or airway
protection issue (Cricothyroidotomy if
necessary)
Maintain BP 90 mmHg systolic
C-spine precautions
Tetanus prophylaxis
Sterile dressing to wounds
Antibiotics in penetrating injury
ICP Management is the
Key
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ICP monitor in patients with GCS < 8
Hyperventilation not routinely recommended
Elevate head of bed to 30 degrees
Sedation
 Propofol
 Barbiturate Induced Coma
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Contraindicated in hypotension
Mannitol
 Reduces ICP by reducing blood viscosity, improves cerebral blood
flow
 Serum osmolality should not be > 320
 Bolus dosing
To Image or Not to
Image?
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GCS < 15
Intoxicated
Age > 55 or < 2
Amnesia to events
Witnessed LOC (> 15 minutes)
Repeated vomiting
Evidence of basilar skull fracture
Inability to recall 3 of 5 objects
Coagulopathy
Penetrating head injury
Ventriculostomy
Evidenced Based Medical
Guidelines for TBI Management
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BP and oxygenation
Hyperosmolar
therapy
ICP monitoring
CPP
Infection
prophylaxis
DVT prophylaxis
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http://youtu.be/YQ609Tk-qQI
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PbtO2
Analgesic/sedatives
Nutrition
Antiseizure
prophylaxis
Hyperventilation
Steroids
Hypothermia
New Therapy
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Stem Cell Therapy
– Neural/Glial differentiation
– Neurogenesis
– Neuroplasticity
– Improve motor function
– Improve cognitive function
References
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AANN Core Curriculum for Neuroscience Louis, MO.
Nursing, 4th Ed. 2004. Saunders. St.
Davis, F.A. (2001). Taber’s Cyclopedic Medical
Dictionary.
F.A. Davis, Philadelphia.
Greenberg, Mark. (2006). Handbook of Neurosurgery.
Greenberg Graphics, Tampa, Florida.
Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L.
(2007).
Medical-Surgical Nursign. Assessment of
Management of Medical Problems. Mosby
Elsevier, St. Louis,
Missouri
Silvestri, Linda. (2008). Comprehensive review for the
NCLEX-RN Examination. Saunders Elsevier, St.
Louis, Missouri.
Introduction
YouTube - Brain Plasticity
Neuroplasticity
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Organizational changes caused by experience
Neurogenesis
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Formation of new nerve cells
Nature vs. Nurture
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Genetics
– 2500 connections
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“major highways”
Environment
– 15000
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“avenues & side roads”
Future
“Directed Neuroplasticity”
Brain Fitness Program
YouTube - The Brain Fitness Program
(1/8)