Complex: Brain & Spinal Cord Injuries

What are some statistics Traumatic Brain Injuries (TBI) related to head trauma?

• Over 69,000 TBI-related deaths in the United States in 2021 ​

• Injuries to the brain are more likely to cause death or permanent disabilities when compared to other injuries​

• Direct cost of TBI direct care: > $25 billion annually​

• People < 5 years old & > 75 years old​

  • Adolescent & young adults - most severe cases​

• Vulnerable populations

What are some causes of traumatic brain injuries?

Result of an external force; is of sufficient magnitude to interfere with daily life and warrants treatment​

• Leading causes: falls (48%), MVCs (14%), being struck by objects (15%), assaults (10%)​

• Primary vs. Secondary injury​

• Monro-Kellie hypothesis

What would cause a Scalp Injury?

Trauma from abrasion, contusion, laceration, or subgaleal hematoma​

• Minor injury but can be bleed profusely due to poor blood vessel constriction​

• Large avulsion - possibly life-threatening

What could cause Skull Fractures?

Forceful trauma ⟶ break in the continuity of skull with or without damage to the brain; classified by types & location​

• Simple (linear) - break in continuity of bone​

• Comminuted - splintered or multiple fracture​

• Depressed - skull bones displaced by force downward​

• Open vs. Closed Fractures

What are some clinical manifestations of traumatic brain injuries?

• Symptoms dependent on severity and anatomic location of underlying brain injury​

• Persistent, localized pain = possible fracture​

• Amnesia before or after injury​

• Loss of consciousness​

• Swelling in region of fracture possible​

• Bleeding/hemorrhage from nose, pharynx, ears or conjunctiva​

• Ecchymosis over mastoid (Battle sign)​

  • “Raccoon eyes”​

• CSF leak from eyes, ears or nose with basal skull fractures​

  • Infection risk - pathway for organisms​

    • Meningitis​

  • Halo sign

What Assessment is needed for TBI?

• Respiratory status​

• Cranial nerve function​

• Pupillary response​

• Sensory & motor function​

• Signs of ↑ ICP

What Diagnostics are needed for TBIs?

• ABGs​

• CBC w/ diff​

• Blood glucose level​

• Electrolyte levels​

• Blood & urine osmolarity​

• Toxicology screen

• CT scan ​

  • Fracture present? ⟶ was the brain injured?​

  • Cervical spine ​

• MRI scan

What management is needed for Non-Depressed Fractures?

• close observation for signs of brain injury​

• Discharge education for family

What management is needed for Depressed Fractures?

• requires surgery with elevation of skull & debridement​

• Consequential injuries from fracture (scalp laceration, dural tears, lacerations from bony fragments, etc.)​

What pt/family education is needed to prevent TBIs?

• Always wear helmets when skateboarding, riding a bike, motorcycle, skiing, playing football, etc. ​

• Wear your seatbelt & use approved car seats/booster seats​

• Avoid dangerous activities​

• Firearm safety​

• Avoid riding in the back of pick-up truck​

• Fall prevention at home​

What are some considerations needed when caring for Veterans w/ TBIs?

• combat-related blast injury, which can cause 4 levels of injury​

• Same treatment as civilians but more complex needs​

What are some considerations needed for older adults w/ a TBI?

• Head injuries look very different in relation to the cause of injury,­­ ↑mortality rates, ↑lengths of hospital stays & worse functional outcomes​

  • Difficulties with assessments​

  • Physiologic changes of aging can affect type & severity of injury or lead to complications​

• Anticoagulants​

• Routine eye exams​

• Medication reconciliation ​

What happens with a Closed (blunt) TBI?

head accelerates, then rapidly decelerates or collides with another object ⟶ brain tissue is damaged but there’s no opening through the skull & dura​

What happens in an Open (penetrating) TBI?

object penetrates the skull, enters brain, damages adjacent soft brain tissue or blunt trauma to head so severe that it opens the scalp, skull, and dura ⟶ brain exposed​

What happens in a focal injury when you have a contusion?

brain is bruised & damaged d/t impact of brain against skull​

What s/s would you see in a focal injury that results from a contusion?

• vary on size, location, and extent of cerebral edema​

  • Loss of consciousness + stupor & confusion​

  • Hemorrhage & edema (peak at 18-36 hrs) ⟶ ↑ICP & possible herniation​

• Coup & Contrecoup

What is a Coup focal injury?

damage to the brain directly under the point of impact

What is a Contrecoup focal injury?

damage to the brain on the opposite side of the head from the impact

What happens when a focal injury results in a hematoma?

collection of blood in brain may be:​

• Symptoms can be delayed until damage is significant but even small, rapidly developing hematomas can be fatal​

What is the cause of an Epidural Hematoma? (Above dura)

Can result from fracture ⟶ rupture/laceration of middle meningeal artery (between dura & skull inferior to thin portion of temporal bone)​

What are some clinical manifestations of an Epidural Hematoma?

• Symptoms progress r/t expanding hematoma​

• Brief loss of consciousness then awake & aware​

• Later restless, agitated, confused ⟶ coma​

• Herniation - dilation & fixation of pupils or paralysis of extremity​

• Significant neurological deficits & respiratory arrest within minutes​

• MEDICAL EMERGENCY

How do you manage an Epidural Hematoma?

• Burr holes - openings through skull to ↓ICP​

• Craniotomy - to remove clot & control bleeding​

• Drain placement - to prevent blood accumulation

What is an Intracerebral Hematoma (w/in brain) and what causes them?

Bleeding into parenchyma of brain; commonly from force to head over a small area (missile injuries, bullets, etc.); can also be result of non-traumatic origin​

What are the clinical manifestations of Intracerebral Hematoma (w/in brain?

• Subtle onset of symptoms​

  • Starts with new neurologic deficits then headache​

  • Nausea/vomiting

How do you manage Intracerebral Hematomas? (w/in brain)

• Supportive care​

• Control of ICP​

• Administration of fluids, electrolytes and anti-hypertensives​

• Surgery (craniotomy or craniectomy) - to remove clot & control hemorrhage but not always possible

What is a Subdural Hematoma (SDH) and what causes them? (below the dura)

Collection of blood between dura & brain, most commonly d/t trauma; typically from venous sources​

What are the clinical manifestations of an Acute Subdural Hematoma (SDH)?

• Changes in LOC​

• Pupillary signs​

• Hemiparesis​

• Coma, ↑ BP, ↓HR, ↓RR = rapidly expanding mass ⟶ immediate intervention

How do you manage Acute Subdural Hematoma (SDH)?

• Immediate craniotomy - to allow subdural clot to be removed​

• Outcome dependent on control of ICP & close monitor of respiratory function​

• High mortality rate d/t brain damage​

What are the clinical manifestations of Chronic Subdural Hematoma (SDH)?

• Time b/t injury & onset of symptoms can be lengthy (weeks to months)​

• Could be mistaken as a stroke​

• Intermittent, severe headaches, Alternating focal neurologic signs​

• Personality changes, mental deterioration, focal seizures ​

How do you manage Chronic Subdural Hematomas?

• Surgical eval for clot removal​

  • Coagulopathies & anticoagulation​

​

What is a concussion?

Temporary loss of neurologic function with no apparent structure damage to brain; known as mild TBI​

What causes a Concussion?

• Result of blunt trauma from acceleration-deceleration force, direct blow or blast injury​

• Location may affect presentation​

• Repeated concussive incidents ⟶ chronic traumatic encephalopathy

What are some things to watch out for with a concussion?

• ↓ in level of consciousness​

• Worsening headache​

• Dizziness​

• Seizures​

• Abnormal pupil response​

• Vomiting

• Irritability​

• Slurred speech​

• Numbness​

• Weakness in arms or legs

How would you medically manage a concussion?

• Physical & neurological assessments​

• Admission to inpatient floor for observation​

• CT, MRI​

• PET​

• C-Collar/C-Spine precautions​

• Goal: to preserve brain homeostasis & prevent any secondary brain injury

What causes a Diffuse Axonal Injury (DAI)?

Caused by widespread shearing and rotational forces that create damage throughout the brain & axons in cerebral hemispheres, corpus callosum & brain stemx

What can happen with a Diffuse Axonal injury (DAI)?

• Injury could be diffuse with no identifiable focal lesion​

• Prolonged traumatic coma; associated with poor prognosis than focal lesion​

  • Can also experience decorticate & decerebrate posturing, global cerebral edema in severe cases​

• Recovery dependent on severity of axonal injury

How do you medically manage Diffuse Axonal Injuries (DAI)?

• Physical & neurological assessments​

• CT, MRI​

• PET​

• C-Collar/C-Spine precautions​

• Goal: to preserve brain homeostasis & prevent any secondary brain injury​

  • Stabilization of cardiovascular & respiratory function ​

  • Control of hemorrhage & hypovolemia​

  • Maintenance of optimal blood gas values

What are some complications of Brain Injuries?

• DI & SIADH​

• Herniation​

• ↑ ICP​

• Hematoma/hemorrhage

• Traumatic Brain Injury → Increased Intracranial Pressure → Coma → Herniation → Brain Death

What are some clinical manifestations of Brain Injuries?

• Severe headache​

• Nausea/vomiting​

• ↓ LOC, restlessness, irritability​

• Dilated or pinpoint nonreactive pupils​

• Cranial nerve dysfunction​

• Altered breathing pattern - Cheyne-Stokes respirations, central neurogenic hyperventilation, apnea​

• Deterioration in motor function​

• Cushing’s triad​

• Seizures

What interventions are needed for Brain Injuries?

• Ongoing assessment of secondary injuries​

• Immobility​

  • C-spine precautions, splints, specialty beds​

• Monitor fluid and electrolytes​

• Seizure precautions​

• Nasogastric tube insertion​

• Craniotomy​

• Burr holes​

• External ventricular drain (EVD)​

• Family support​

  • Brain death & organ donation

What medications are needed to treat Brain Injuries?

• Mannitol​

• Dexamethasone​

• Barbiturates, Propofol ​

• Phenytoin, diazepam​

• Opioids

What are spinal cord injuries?

Injury to spinal cord, vertebral column, supporting soft tissue or intervertebral discs caused by trauma​

What are the most common causes of Spinal Cord Injuries?

• MVCs​

• Falls​

• Violence (mostly GSWs)​

• Sports-related injuries​

• 2019 indirect patient cost for care: over $77k/year

What are some risk factors for Spinal Cord Injuries?

younger age, males, alcohol & illicit drug abuse​

What are some major causes of death for a pt w/ a spinal cord injury?

pneumonia, pulmonary embolism (PE), sepsis​

What happens in a spinal cord injury?

• Wide range of damage​

  • Transient concussion ⟶ Contusion, laceration, compression of spinal cord ⟶ Complete transection

What does paraplegia mean?

paralysis of lower body

What does tetraplegia mean?

paralysis of all 4 extremities (formerly quadriplegia)​

What are the different types of Incomplete Spinal Cord Syndromes?

• Central Cord injury

• Lateral Cord (Brown-Sequard) injury

• Anterior Cord Injury

• Injury to the Conus Medullaris or Cauda Equina

What is the typical cause of a Central Cord Syndrome Injury?

Injury or edema of central cord, typically cervical area

What deficits are seen with a Central Cord spinal injury?

• Motor deficits (upper vs. lower extremities)​

• Sensory loss (usually more pronounced in upper extremities)​

  • Loss of motor power and sensation in upper extremeties

  • Incomplete Loss in thoracic core region

• Bowel/bladder dysfunction

What are the causes of an Anterior Cord Syndrome Injury?

• Acute disc herniation or hyperflexion injuries r/t fractures/dislocation of vertebra​

• Result of injury to anterior spinal artery (supplies ⅔ of spinal cord)

What deficits are seen in an Anterior Cord Spinal Injury?

• Loss of pain, temperature, motor function below level of lesion​

• Light touch, position, & vibration sensation = intact

What are some causes of a Lateral Cord (Brown Sequard Syndrome) Spinal Injury?

Transverse hemisection of cord (north to south), usually from ​

• a knife or missile injury​

• fracture/dislocation of a unilateral articular process, or​

• possibly an acute ruptured disc​

​

What deficits are seen w/ a Lateral Cord Spinal Injury?

• Ipsilateral paralysis or paresis + loss of touch, pressure, & vibration​

  • Loss of voluntary motor control on the same side as the cord damage

• Contralateral loss of pain & temperature

  • Loss of pain & temperature sensation on opposite side

What are some clinical manifestations are seen with Spinal Cord injuries

• Dependent on type & level of injury​

  • Lowest level with intact sensory or motor function​

    • Total or partial​

  • Loss of bladder & bowel control ​

  • Loss of sweating & vasomotor tone​

  • Marked reduction of blood pressure (from loss of peripheral vascular resistance)​

  • Acute pain​

  • Respiratory dysfunction​

    • Injuries at or above C4 ⟶ paralysis of diaphragm​

      • Ventilator support​

    • Injuries of T12 and above

What Assessment is needed for a suspected Spinal cord injury?

• Detailed neurological assessment​

  • Secondary injuries

What diagnostics is needed for a suspected Spinal cord injury?

• X-ray of suspected injury​

• Lateral cervical spinal x-rays & CT/CAT​

  • Cervical neck collar (C-collar)​

  • Immobilization​

• MRI, if ligamentous injury is suspected​

  • Myelogram (if contraindicated)​

• Continuous EKG monitoring​

  • Bradycardia & asystole​

• Respiratory support​

• Urinalysis​

• ABGs, CBC​

  • Hemoglobin

What is some emergency management for SCI?

• Oxygenation & Ventilation​

• Assume that there is a SCI until it is ruled out​

• Rapid assessment, immobilization, extrication, & stabilization​

• Spinal (back) board + head & neck in neutral position​

  • Head blocks​

• Transfer & movement​

• Admission to intensive care unit

What pharmacologic therapy is needed to manage the Acute phase of a SCI?

• Norepinephrine, dopamine ​

• Atropine ​

• Dextran​

• Baclofen, dantrolene​

• Bethanechol ​

• Opioids, non-opioids, NSAIDs​

• Heparin​

• Docusate sodium, polycarbophil​

• Hydralazine, nitroglycerin​

• Spinal surgery​

• Immobilization Devices & Traction​

  • Halo Devices

How would you manage Respiratory, bowel & bladder function during the Acute phase of a SCI?

• Mechanical ventilation

• NPO​

• Neurogenic bladder

How would you manage the neurological system in a pt in the Acute phase of a SCI?

Ongoing neurological assessment

How would you manage Muscle strength and tone w/ a pt in the Acute phase of a SCI?

• Range of motion exercises​

• Mobility

What complications should you monitor for during the Acute phase of a SCI?

• Pneumonia & sepsis​

• Orthostatic hypotension

What happens when the pt goes into Neurogenic shock as an Acute complication of a SCI?

Loss of muscle tone in blood vessel wells below the level of injury due to loss of communication within sympathetic nervous system

What are the clinical manifestations of Neurogenic shock as an Acute complication of a SCI?

• Hypotension​

• Bradycardia​

• ↓ cardiac output ⟶ dependent edema, peripheral vasodilation, venous pooling​

• Loss of temperature regulation​

• Greater risk of developing venous thromboembolism (VTE)​

How do you treat neurogenic shock as an Acute complication of a SCI?

Vasopressors or atropine, IV fluids

What happens in Spinal shock as an Acute complication of a SCI?

Sudden depression of reflex activity in spinal cord that happens below the level of injury d/t inflammation

What are the clinical manifestations of spinal shock as an Acute complication of a SCI?

• Flaccid paralysis​

• Absent reflexes​

• Autonomic responses​

  • Hypotension, bradycardia ⟶ more damage to spinal cord​

  • MAP > 85 mmHg​

• Paralytic ileus

What happens when a pt develops Venous Thromboembolism (VTE) as an Acute complication of a SCI?

• Blood clot that develops in the venous vasculature that could develop into a DVT or PE​

• Greater risk d/t immobility, flaccidity, ↓ vasomotor tone

What clinical manifestations are seen when the pt has a Venous Thromboembolism (VTE) as an Acute complication of a SCI?

• Presents as pleuritic chest pain, anxiety, shortness of breath,↑PaCO2,↓PaO2​

  • Unilateral swelling, low-grade fever, temp change in affected limb​

How would you prevent a Venous Thromboembolism (VTE) as an Acute complication of a SCI?

• low-dose anticoagulation therapy​

• Use of sequential pneumatic compressions (SCDs)​

• Permanent indwelling filters ​

• Range-of-motion exercises

What is Autonomic Dysreflexia?

Life-threatening emergency in patients with SCI where exaggerated autonomic responses to stimuli that causes hypertensive emergency

Triggered by sustained stimuli at T-6 or below from:

• Restricted clothing

• Full bladder

• Pressure areas

• Fecal impaction

What are the clinical manifestations of Autonomic Dysreflexia as an Acute complication of a SCI?

• Severe, pounding headache with paroxysmal hypertension​

• Profuse sweating above spinal level of injury​

• Nausea​

• Nasal congestion​

• Bradycardia

What should you do if your pt exhibits Autonomic Dysreflexia as an Acute complication of a SCI?

• Remove the stimuli & place patient immediately in sitting position to lower blood pressure​

• Loosen tight clothing

What continuous management is needed for SCIs?

• Adjusting to life with a disability​

• Ongoing follow-up care​

• Complications indirectly related to SCI

What are some complications indirectly related to SCI?

• Disuse syndrome​

• Bladder & kidney infections​

• Spasticity​

• Depression​

• Pressure Injuries