U2L3: Rysa Brain Injuries

traumatic brain injury (TBI)

injury to brain relating to force of impact

types of TBIs

closed injury & penetrating injury

GCS score indicating severe brain injury

<=8 -> golden standard for determining TBI

closed TBI

no break in skull -> caused by rapid accelerations & decelerations

penetrating TBI

results in break in skull

direct closed head injury

aka focal -> force directly impacts the head

indirect closed head injury

aka diffuse -> injury caused by compression & rebounding of brain accel/decel

indirect closed head injury outcome

diffuse axonal injury (doesn't show up on initial imaging) -> loss of consciousness & coma

primary impact of closed head injury

direct hit

secondary impact of closed head injury

brain rebounding -> most common cause of morbidity/mortality

why are closed head injuries more concerning in children?

higher BF to brain -> increase chance of brain swelling & cerebral edema

who are concussions more common in?

women w smaller necks

concussion

most common traumatic brain injury

consussion MOA

jarring of the brain -> accel/decel

what type of injury is a concussion?

functional not structural -> imaging looks normal but has expected symptoms

concussion immediate signs (4)

- confusion

- vomiting

- amnesia

- loss of consciousness -> not required

what should be first step if child is suspected to have a concussion?

sit them out -> can cause second impact syndrome if hit again

concussion common symptoms (6)

- headache

- migraine

- dizziness

- n/v

- fatigue

- mood changes

what can experiencing dizziness when concussion occurs signify?

long recovery time

post concussion syndrome

3 or more symptoms lasting > 4 weeks

risk factors for getting post concussion syndrome (2)

- previous concussion or condition

- the younger the child

concussion symptoms in young children (4)

- sad mood

- unable to pay attention

- more temper tantrums

- loss of new skill

concussion clinical subtypes (6)

- cognitive/fatigue

- vestibular

- ocular

- post traumatic migraine

- cervical

- anxiety/mood

* can fall into 1 category or all

signs of cognitive/fatigue concussion

trouble concentrating, learning, retaining new info

sign of vestibular concussion

balance issues

sign of ocular concussion

difficulty w tracking

signs of post traumatic migrain concussion

headache, nausea, light sensitivity

concussion dx (5)

- physical exam

- interview

- neurocognitive tests

- vestibular ocular motor screening

- imaging

concussion management (3)

- physical & cognitive rest

- active tx

- athletes removed from play until medically cleared

how should you rest when having concussion?

if gets symptoms with activity -> stop & cut back

- includes stationary ways of working brain not just physical activity

active tx for concussion (4)

- vestibular therapy

- vision therapy

- exertion therapy

- meds

linear skull fracture

most common, asymptomatic, & heals in 3-4 months

comminuted skull fracture

multiple breaks in skull

depressed skull fracture

part of skull is pushed in -> possible emergent surgery

open skull fracture

skin is open

basilar skull fracture

break in bone at base of skull -> serious bc close proximity to brainstem

basilar skull fracture signs

battle sign, raccoon eyes, CSF leak

battle sign

bruising behind ear -> not initial

raccoon eyes

2 black eyes

how can you determine if liquid leaking is CSF?

clear, slightly yellow, halo w blood, contains glucose

where does CSF leak from?

ear or nose -> concern for things going in & causing inf

*question orders for things to go into nose or nasopharynx

hemorrhage

ongoing bleeding from damaged BV -> more serious

hematoma

bruising

epidural hemorrhage/hematoma

occurs between skull & dura so doesn't cross suture lines -> children usually handle well

epidural hemorrhage/hematoma characteristics (3)

- associated w linear skull fracture

- arterial -> requires quick tx

- frequently affects meningeal artery

signs of epidural hemorrhage/hematoma (3)

- loss of consciousness -> normal period -> lethargy/coma

- in enlarged pupil

- vomiting

subdural hemorrhage/hematoma

occurs between dura & arachnoid space so cross suture lines -> more common & children don't handle well

subdural hemorrhage/hematoma characteristics (3)

- venous (acute or chronic) -> tearing of bridging veins

- common in infants w non-accidental trauma -> abuse

- infant high mortality w diffuse injury

shaken baby syndrome (abusive head trauma) head injury outcomes (3)

- non accidental trauma (NAT)

- subdural hemorrhage/hematoma

- retinal hemorrhages

how can you detect retinal hemorrhages?

seen on ophthalmic exam

associated findings w abusive head trauma (2)

- fractures -> esp in ribs

- bruising at different stages

education for preventing shaken baby syndrome

when frustrated w child, put down in crib and walk away

clinical manifestations for minor TBI (6)

- possible loss of consciousness

- transient confusion -> fast change

- somnolence -> sleepy

- listlessness -> no energy

- irritability

- pallor

signs of progression in TBI (5)

- altered mental status

- increased agitation

- focal neuro deficits

- emesis

- changes it vitals

severe TBI outcome

increased ICP

dx tests for TBI

- CT

- MRI

- cervical spin x-ray

- EEG -> detects seizures

cerebral perfusion pressure (CPP) calculation

MAP-ICP=CPP

what should your CPP be?

>60 -> parameters may be adjusted for child's age

TBI pts ICP goal

<20

severe brain injury surgical tx (5)

- evacuation of blood/tissue craniotomy

- external ventricular drain (EVD)

- ICP monitoring

- licox monitor

- craniectomy w duraplasty & possible lobectomy

external ventricular drain (EVD)

diverts flow of CSF externally -> flow rate determined by level above midbrain

severe brain injury medical tx (4)

- NPO

- hypothermia

- hypertonic saline therapy

- PaCO2 management

severe brain injury pharm tx (6)

- mannitol

- sedation & paralytics

- pentobarbital coma

- antiepileptics

- antibiotics

- adrenocorticosteroids

how does regulating CO2 help w brain injuries?

high CO2 is a potent vasodilator -> management reduces inflammation

severe brain injury nursing care assessment (5)

- monitor LOC & ICP

- vitals

- check for CSF drainage

- serum Na

- urine output

severe brain injury nursing care interventions (5)

- HOB 30 degrees

- head in neutral position

- cervical collar until cleared

- possible swallowing issues

- possible splints & helmet

what does sequela TBI include? (4)

- post-concussion syndrome

- post-traumatic headaches

- post-traumatic seizures -> increased risk in children

- hydrocephalus

sequela TBI physical developmental implications (4)

- impaired senses

- fine/gross motor deficits

- balance/coordination problems

- language deficits

sequela TBI cognitive developmental implications (5)

- memory loss

- confusion

- inattention

- cognitive delays

- diminished abstract reasoning

sequela TBI social developmental implications (3)

- aggression/anti-social behavior

- impaired adaptive behaviors

- diminished self worth