Week 4: Intracranial Problems and Spinal Cord Injury

Monro-Kellie Principle

• the rigid skull contains brain, blood, and CSF

• and increase in one requires compensation of another

• exhausted compensation raises intracranial presure (ICP)

Normal Adult ICP

• 5-15 mm HG

Cerebral Perfusion Pressure Equation

CPP = MAP - ICP

What is Cerebral Perfusion Pressure?

• calculates the net pressure gradient driving blood flow to the brain

Severe TBI Guidance Targets

• 60-70 mm Hg

Optimal CPP for Acutely Ill Adult?

• 70-100 mmHg

Critical CPP

• <50 mmHg

• results in permanent, irreversible neurological damage

Early Manifestation of ↑ ICP

• altered LOC

• restlessness

• confusion

• pupil changes

Late Manifestations of ↑ ICP

• Cushing’s Triad

1. bradycardia

2. HTN with widened pulse pressure

3. irregular respirations

TBI: Primary Head Injury

• occurs at the moment of impact

• direct result of trauma

  • irreversible damage

TBI: Secondary Head Injury

• occurs AFTER the initial trauma

• complications

• nursing care aims to limit this

TBI: Glasgow Coma Scale (GCS) Scores

• Mild: 13-15

• Moderate 9-12

• Severe: 3-8

Glasgow Coma Scale (GCS): Considerations

• GCS ≤8 requires urgent airway assessment + likely airway support

• Older adults taking anticoagulants: may deteriorate despite an initially normal examination

ICP Management: Nursing Actions to Protect Cerebral Perfusion

• prevent hypoxemia & hypotension

• elevate HOB 30

• keep the neck neutral

• avoid excessive hip flexion or straining

• maintain spinal precautions when needed

ICP: Reducing Stimulation Actions

• provide ordered analgesia/sedation + fever control

• space activities if ICP rises

• suction only when needed

  • monitor response

• monitor GCS, pupils, motor findings, V/S

ICP: Osmotic Therapy

• mannitol or hypertonic saline may reduce edema

• monitor sodium, renal function, fluid balance, serum osmolality, and pulmonary edema

ICP: External Ventricular Drain

• level to the tragus

• maintain ordered drainage height and asepsis

• monitor ICP and CSF output/appearance

Refractory ICP: Intervention & Contraindication

1. refractory ICP may require:

• CSF drainage

• advanced sedtion

• surgery

2. corticosteroids are NOT recommended

• increased mortality

Concussion

• sudden transient mechanical head injury

• disruption of neural activity

• possible LOC

• no apparent structural damage

Contusion

• bruising of the brain issue

• within a focal area (one specific area)

• possible hemorrhage

Diffuse Axonal Injury

• shearing/tearing of the brain’s nerve fibers (axons)

• may cause coma

• often appears normal on CT

• requires MRI to see “micro-hemorrhages”

Epidural Bleeding (Hematoma)

• often artial

• may include lucid interval before rapid decline

  • temporary period of apparent recovery

• between the skull and the outer protective membrane (dura mater)

Subdural Bleeding (Hematoma)

• involves bridging veins

• blood collects between the surface of the brain and its outer covering

• chronic cases may mimic dementia or stroke

Intracerebral

• within brain tissue

Subarachnoid

• between arachnoid and pia

Intracerebral & Subarachnoid Hemorrhage: Red-Flag Manifestations

• falling GCS

• new pupil asymmetry

• weakness

• posturing required urgent escalation and imaging

  • decorticate posturing

Decorticate Posturing

• closed hands

• against chest

• rigid, extended leg

• feet point inward

  

Basilar Skull Fracture: Manifestations

• raccoon eyes

• battle sign

• CSF rhinorrhea

• CSF otorrhea (ears)

• halo sign

Basilar Skull Fracture: Considerations

• avoid nasal tubes/suctioning

• avoid nose blowing

• use a loose collection dressing

Basilar Skull Fracture: Halo Sign Diagnosis

• halo/glucose findings alone do not confirm

• beta-2 transferrin detects CSF

Halo Sign

• CSF may leak from the ears and nose following a basilar skull fracture

• creates a double ring pattern

Wired Jaw: Considerations

• airway obstruction + aspiration are priorities

• keep suction and appropriate emergency release tools at bedside

Wired Jaw: Emergency Management

• position safely

• call urgent help

• cut fixation, if airway compromise requires it

  • cutting the wire

Spinal Cord Injury (SCI)

• a neurologic condition resulting from damage to the spinal cord → disrupting motor, sensory, and autonomic pathways

Causes:

• motor vechile collisions

• falls

• degenerative disorders

Spinal Cord Injury: Immediate Priorities

• ABCs

• spinal motion restriction

• neutral alignment

• use coordinated turns per protocol

• anticipate airway support

  • high cervical injury can impair ventilation

Spinal Cord Injury (SCI): Essential Priority Assessments

Monitor:

• motor/sensory function

• respiratory effort

• BP, HR

• bladder function

Spinal Cord Injury: Completeness

• complete: total loss of sensory & motor function below injury

• incomplete: partial preservation of motor, sensory, or autonomic function below injury

Spinal Cord Injury: Perfusion + BP Goals

• avoid HoTN

  • causes secondary ischemic injury to already compromised nervous tissue

• administer ordered fluids/vasopressors

  • keeps BP ↑

• MAP of 75-80

  • avoids forced augmentation (artificial BP management)

• no active augmentation above 90-95 mmHg for 3-7 days

Spinal Shock

• neurologic/reflex problem

• temporary loss of reflexes below injury

• flaccid paralysis

  • sudden muscle weakness, limpness, and a complete loss of muscle tone

• provide supportive care and reassessment

Neurogenic Shock

• circulatory problem

• loss of sympathetic vascular tone

  • often with injury at T6 or above

• watch for: HoTN, bradycardia

• support perfusion (fluids, vasopressors)

Autonomic Dysreflexia

• life-threatening, sudden overreaction of the involuntary nervous system that causes a dangerous spike in blood pressure

• occurs after spinal shock

• often occurs after spinal reflexes return and can recur

Autonomic Dysreflexia: Recognize these Signs

• usually SCI at/above T6

• sudden hypertension

  • often >20 mmHg above baseline

• pounding headache

• flushing/sweating above injury

• possible bradycardia

Autonomic Dysreflexia: Priority Actions

• sit upright and lower legs if feasible

• summon help

• loosen restrictive clothing

• check BP/pulse every 1-2 mins until stable

Autonomic Dysreflexia: Remove The Trigger

• check bladder distention and catheter obstruction first

• assess bowel/skin triggers

  • avoid unplanned rectal manipulation that can worsen the episode

• give rapid-onset, short-duration antihypertensive

Spinal Cord Injury: Prevention Secondary Complication

• support cough and lung expansion

• prevent VTE

• prevent pressure injuries

• prevent orthostatic HoTN

• follow individualized: repositioning, bowel, and bladder programs

Spinal Cord Injury: Long-Term Support

• rehabilitation

• adaptive equipment

• skin checks

• caregiver training (autonomic dysreflexia)

• psychosocial support

Seizure

• transient, uncontrolled electrical disscharge in the brain

• causes: motor. sensory, autnomic, or cognitive changes

Epilepsy

• ≥ 2 unprovoked seizures

• 1 with high recurrence risk

• metabolic causes ≠ epilepsy

Focal Onset Seizure

• begin in one hemisphere

• person is conscious and will remember the seizuzre

• altered LOC

Generalized Onset (Bilateral) Seizure

• involves bilateral networks

• happens without warning

• loss of consciousness

Tonic-Clonic Seizure

• tonic = stiffening

• clonic = rhythmic jerking

• classic type

Atonic Seizure

• sudden loss of muscle tone → fall

• common in children

• high risk for head injury

Myoclonic Seizure

• brief, shock-life muscle jerks

Absenece Seizures

• brief impaired awareness

• staring, unresponsive

During a Seizure

• Stay with the patient

  • time the event, protect the head

  • clear hazards

  • support airway/breathing

• Turn side-lying when safe

  • maintain spine precautions if trauma is suspected

  • do not restrain or place anything in the mouth.

Convulsive Status Epilepticus

• seizure ≥ 5 minutes OR repeated seizures without recovery

• medical emergency → treat immediately

Convulsive Status Epilepticus: Response+Treatment

• activate emergency response

• support ABCs

• check glucose

• give prescribed rescue benzodiazepine promptly

• prepare further antiseizure therapy and airway support if seizures persist

After Seizure

• reassess breathing

• GCS

• pupils

• injuries

• return to baseline; reorient calmly

After Seizure Documentation

• duration

• first body part involved

• movements

• awareness

• recovery

ICP Management: Tier I (Foundational Care)

• HOB 30-45

• Suctioning: limit to 2 passes, <10 seconds

• do NOT cluster care

• sedation

ICP Management: Tier II (Osmotic Therapy)

• Hypertonic Saline (3%)

  • pulls excess fluid out of the brain cells

  • elderly: pulmonary edema (crackles in lungs)

ICP Management: Tier III (Advanced Interventions)

• Barbiturate Coma

  • ↓ the brain's metabolic and oxygen demands

• Induced Hypothermia

  • slows down cellular metabolism and oxygen demand

• Decompressive Craniectomy

  • removal of a portion of the skull

  • allows brain to swell outward

  • do NOT position the patient on the operative side.