Head injuries, surgeries, ICP, seizures, spinal cord injury

falls

most common cause of traumatic brain injury

epidural hemorrhage

• hemorrhage above dura, under skull

• medical emergency!!!

• usually a rupture of the middle meningeal artery

  • faster bleeding from an artery—> more dangerous

• herniation

  • pressure builds up and pushes brain tissue somewhere else.

  • LOC

  • pupil dilation, paralysis of extremity

subdural hemorrhage

• hemorrhage below the dura, between the dura and the brain

• usually venous

• may be acute, subacute, or chronic

• common in elderly people taking anticoagulants

intracerebral hemorrhage

• hemorrhage within the brain tissue

• result of focused injury or system issues

• hypertension—> CVA

concussion

• global, microscopic

• widespread, homogenous impairment of brain cells

  • cells under-perform

• no visible bleeding

• no structural damage

• confusion, irritability, disorientation, headache.

contusion

• localized, macroscopic

• structural damage to cells- cells die

• effects peak 18-36 hours after injury

• coup-contrecoup

  • brain moves back and forth on brain stem, leading to multiple locations of brain injury.

• can cause increased ICP d/t bleeding

• blurred vision, disorientation, unsteady gait, vomiting, slurred speech, coma.

craniectomy

removal of part of skull to allow room for swelling

cranioplasty

repair of skull using metal/plastic plate

approaches for brain surgery

• supratentorial on top

• infratentorial on bottom

• separated by tentorium

Assessment tools

• Glasgow Coma Scale (GCS)

  • most widely used method for evaluation of coma

  • shortcomings: limited utility in intubated pts that can’t speak, inability to assess brainstem reflexes

• Full Outline of Unresponsiveness (FOUR)

  • provides further neurological details

  • useful for intubated patients

• higher score is better for both

Intracranial pressure

• balance of brain tissue, blood, and CSF

• normal range: 7-15 mmHg

• increase d/t injury, tumor, hemorrhage, encephalopathies

• Monroe Kellie

  • increase in one component leads to a compensatory decrease in others.

• Cushing’s Triad

  • HTN- widened pulse pressure

  • bradycardia

  • bradypnea

• can lead to seizures, Diabetes insipidus, SIADH

decorticate posturing

• signs of severe damage to the brain at the corticospinal tract

• arms adducted and flexed- towards core

• hands clenched

• uni or bilateral

• may progress or alternate to the other posturing

• better out of the 2 (still not good)

decerebrate posturing

• severe damage to the brain at brainstem level

• arms adducted, extended, and pronated

• wrists flexed

• head and neck arched backwards

• muscles are tightened, held rigidly

• worse than the other posturing

seizures

• uncontrolled, abnormal, recurring electrical discharges in brain

• either idiopathic or acquired

• can be general- whole brain, or

• can be focal/partial

  • simple- consciousness intact

  • complex- impairment but no LOC.

• manifestations:

  • LOC, excessive movement, loss of muscle tone, disturbances in mood, behavior, etc.

Status Epilepticus

• seizure lasting longer than 5 minutes

• emergency!!

• without waking between

Seizure medications

anticonvulsants- valium/diazepam, ativan/lorazepam, dilantin/phenytoin.

increased ICP medications

mannitol- osmotic diuretic

corticosteroids- reduce cerebral edema

dilantin- prophylaxis seizure activity

antibiotics

anti-anxiety

Diabetes Insipidus

• deficiency in anti-diuretic hormone secretion

• results in polydipsia and polyuria- fluid drains out

• low urine specific gravity

• dehydration

• caused by increased ICP, surgical irradiation of pituitary, or CNS infection

• might cause unintentional weight loss

• replace fluids and ADH with vasopressin

• sodium above 140= dehydration

Syndrome of Inappropriate ADH (SIADH)

• excess in ADH secretion

• leads to fluid retention (no edema)- fluid stays in

• dilution hyponatremia

• caused by increased ICP, bronchiogenic carcinoma, pneumonia, hemothorax

• replace sodium with hypertonic solution

• sodium below 135=confusion

Spinal Cord Injuries - primary vs. secondary

• primary- permanent

• secondary- reversible if treated in 4 hrs

Tetraplegia

C5-C7

deltoids, biceps, wrist, extender, triceps, hand, chest muscles, abdominal muscles, leg muscles, bowel, bladder, sexual function

Paraplegia

T12-L1

leg muscles, bowel, bladder, sexual function

Spinal cord injury medications

• methylpredinosolone

  • decreases inflammation near injury which appears to reduce damage to nerve cells

• glucocorticoids

  • suppress immune response

• vasopressors/dopamine

  • for hypotension

• atropine

  • bradycardia

Autonomic Dysreflexia

• reaction of the autonomic nervous system to overstimulate

• occurs with injuries above T6

• sudden onset!

  • HTN, throbbing headache, diaphoresis, nasal stiffness, blurred vision, nausea, bradycardia

halo traction

• immobilizes cervical fractures

• form of skeletal traction

• ring affixed to skull with pins, ring attached to a jacket by rods

• allows early mobilization and rehab

• fall risk!!

• never grasp the rods to assist the patient to reposition

• skin assessment