Management of Neurological Trauma: TBI and SCI Overview

Neurological trauma

Injuries affecting the brain, spinal cord, and peripheral nerves, often resulting from trauma, falls, motor vehicle accidents (MVAs), and violence.

Traumatic Brain Injury (TBI)

Includes concussions, contusions, diffuse axonal injury, and hematomas.

Spinal Cord Injury (SCI)

Complete or incomplete loss of function below the injury site.

Increased Intracranial Pressure (ICP)

A critical secondary complication of neurological trauma.

Primary Injury (TBI)

Direct trauma to the brain, such as contusions, hematomas, and skull fractures.

Secondary Injury (TBI)

Swelling, ischemia, hypoxia, and increased ICP following the primary injury.

Primary Injury (SCI)

Damage to vertebrae, ligaments, or spinal cord tissue.

Secondary Injury (SCI)

Inflammatory response leading to edema, ischemia, and loss of function.

Normal ICP

5-15 mmHg.

Cushing's Triad

Hypertension, bradycardia, and irregular respirations, indicating late signs of herniation.

Glasgow Coma Scale (GCS)

A scale used to assess consciousness; Score 15 is normal, Score 9-12 indicates moderate TBI, and Score ≤8 indicates severe TBI (intubation required).

Signs of Increased ICP (Early)

Headache, vomiting, altered level of consciousness (LOC), sluggish pupils.

Signs of Increased ICP (Late)

Cushing's Triad, fixed pupils, posturing (decorticate/decerebrate).

Complete SCI

Total loss of function below the injury.

Incomplete SCI

Some sensory or motor function remains below the injury.

Airway & Oxygenation (TBI Management)

Prevent hypoxia with PaO₂ > 60 mmHg.

ICP Management (TBI)

Elevate HOB 30° to reduce pressure; use mannitol and hypertonic saline to reduce cerebral edema.

Neurogenic Shock Treatment (SCI)

IV fluids and vasopressors (dopamine, norepinephrine) to maintain blood pressure.

Autonomic Dysreflexia

Sudden hypertension, bradycardia, and headache due to noxious stimuli below the injury.

Traumatic Brain Injury (TBI) Complications

Includes brain herniation, seizures (post-traumatic epilepsy), and hydrocephalus.

Spinal Cord Injury (SCI) Complications

Includes neurogenic shock, autonomic dysreflexia, and respiratory failure (above C4).

TBI Rehabilitation

Involves cognitive therapy, physical therapy/occupational therapy for motor deficits, and speech therapy.

SCI Rehabilitation

Focuses on adaptive devices, mobility aids, and bowel/bladder training.

Signs of worsening ICP

Headache, vomiting, altered LOC, sluggish pupils.

Pressure ulcer prevention

Strategies to avoid skin breakdown in immobile patients.

Coping strategies

Methods to help patients and families manage stress and emotional challenges.

Glasgow Coma Scale (GCS)

15 = Normal, 9-12 = Moderate TBI, ≤8 = Severe (intubation needed).

Cushing's Triad

HTN, bradycardia, irregular breathing; signals late-stage ICP increase.

Increased Intracranial Pressure (ICP)

Normal: 5-15 mmHg. Increased ICP is a medical emergency.

Early ICP Signs

Headache, vomiting, altered LOC, sluggish pupils.

Late ICP Signs

Cushing's Triad (HTN, bradycardia, irregular breathing), fixed pupils.

ICP Management

Elevate HOB 30°, Mannitol, Hypertonic Saline, Sedation, Minimal stimulation.

Spinal Cord Injury (SCI)

Can be complete (total loss) or incomplete (partial function retained).

Neurogenic Shock (SCI)

Hypotension, bradycardia; treat with IV fluids, vasopressors, atropine.

Autonomic Dysreflexia

Sudden HTN, bradycardia; triggered by bladder distension, fecal impaction.

SCI Management

Immobilization, airway protection, neurogenic shock prevention.

Complications

Brain herniation, post-traumatic epilepsy, respiratory failure.

Rehabilitation

Physical therapy, bowel/bladder training, cognitive rehabilitation.

Nursing Priorities

Monitor for deterioration, prevent complications, educate family.

Primary Injury

Direct trauma, skull fractures, hematomas.

Secondary Injury

Swelling, ischemia, increased ICP.

Assessment

Glasgow Coma Scale (GCS), pupil response, motor function tests.

Causes of TBI

Falls (common in children & elderly), motor vehicle accidents (MVAs), assaults & violence, sports injuries.

Pathophysiology

The Monro-Kellie Hypothesis states that the brain, cerebrospinal fluid (CSF), and blood maintain a constant volume inside the skull.

Primary Injury (TBI)

Occurs at the moment of trauma (e.g., skull fractures, brain contusions).

Secondary Injury (TBI)

Occurs hours to days later due to edema, ischemia, and increased ICP.

Concussion

Temporary brain dysfunction with no structural damage

Contusion

Brain bruising, often causing edema

Epidural Hematoma

Bleeding between skull & dura

Subdural Hematoma

Bleeding between dura & brain

Intracerebral Hemorrhage

Bleeding within brain tissue

Diffuse Axonal Injury (DAI)

Widespread axonal damage from trauma

Signs of Increased ICP - Early signs

Headache, nausea, vomiting, confusion, sluggish pupils.

Signs of Increased ICP - Late signs

Cushing's Triad (HTN, bradycardia, irregular breathing), decerebrate posturing, fixed pupils.

Spinal Cord Injury (SCI)

Injury to the spinal cord that can result in loss of function.

Risk Factors for SCI

Young males (highest risk), alcohol & drug use, MVAs, falls, diving injuries, violence (gunshot wounds, stab wounds)

Mechanism of Injury - Hyperflexion

Head-on collisions, falls

Mechanism of Injury - Hyperextension

Rear-end collisions, falls onto the chin

Mechanism of Injury - Penetrating Trauma

Gunshot wounds, stab wounds

Mechanism of Injury - Compression Injuries

Diving, falling objects

SCI Levels & Effects - C1-C4

Complete paralysis below neck, requires ventilation

SCI Levels & Effects - C5-C8

Varying arm/hand dysfunction, some shoulder/elbow function

SCI Levels & Effects - T1-T6

Paraplegia, loss of trunk control

SCI Levels & Effects - L1-L5

Some leg movement, bowel/bladder issues

Central Cord Syndrome

Hyperextension injury, often in older adults

Anterior Cord Syndrome

Injury to anterior 2/3 of spinal cord

Brown-Séquard Syndrome

Hemisection of spinal cord (penetrating injury)

Neurogenic Shock (SCI)

Caused by loss of sympathetic tone → severe hypotension, bradycardia, hypothermia.

Autonomic Dysreflexia (SCI at T6 or above)

Life-threatening hypertensive crisis triggered by bladder distension, constipation, skin stimulation.

Spinal Shock

Loss of reflexes, flaccid paralysis, loss of sensation below injury level.

Respiratory Failure (C1-C4 Injuries)

High cervical injuries impair diaphragm function → mechanical ventilation needed.

TBI Nursing Priorities

Monitor for worsening neuro signs, Prevent secondary brain injury (O₂, BP control, ICP management), Seizure precautions (antiepileptics if needed), Educate on post-concussion symptoms

SCI Nursing Priorities

Prevent pressure ulcers (turn Q2H, skin checks), DVT prophylaxis (Heparin, SCDs, ROM exercises), Bowel/bladder training (scheduled voiding, stool softeners), Monitor for autonomic dysreflexia (BP spikes, bradycardia)

Long-Term Rehab for TBI

Cognitive therapy, PT/OT, speech therapy

Long-Term Rehab for SCI

Wheelchair mobility, adaptive devices, emotional support

GCS ≤8

Intubate

Cushing's Triad

Signals ICP crisis

Mannitol & hypertonic saline

Reduce ICP

SCI above C4

Requires ventilatory support

Primary brain injury

Occurs at the moment of trauma

Epidural hematoma

Often has a lucid interval before rapid deterioration due to arterial bleeding

Bradycardia and hypertension

Part of Cushing's Triad, a late sign of herniation

Airway protection

The priority due to the risk of respiratory failure, especially in cervical spine injuries

Autonomic dysreflexia

A hypertensive emergency that occurs with SCI at or above T6

Increased ICP assessment finding

Bradycardia and hypertension suggest worsening ICP

Essential intervention for increased ICP

Minimize stimulation and elevate HOB to 30°

Sudden, pounding headache and flushed skin in SCI

Check the patient's bladder for distension

Late sign of increased ICP

Cushing's triad

Medication to reduce cerebral edema in TBI

Mannitol

Neurogenic shock

Neurogenic shock results from loss of sympathetic tone, causing hypotension, bradycardia, and vasodilation.

Increased ICP management

Minimize stimulation and elevate HOB to 30°.

Autonomic dysreflexia trigger

Autonomic dysreflexia is triggered by noxious stimuli, most commonly a full bladder or fecal impaction.

Cushing's triad

Hypertension, bradycardia, and irregular breathing (Cushing's Triad) indicate brain herniation.

Mannitol

Mannitol is an osmotic diuretic that decreases ICP by drawing fluid out of the brain.

Traumatic Brain Injury (TBI)

TBI can result from falls, motor vehicle accidents, assaults, and sports injuries.

Monro-Kellie Hypothesis

The Monro-Kellie Hypothesis states that the brain, cerebrospinal fluid (CSF), and blood maintain a constant volume inside the skull.

Concussion

Temporary brain dysfunction with no structural damage, symptoms include headache, dizziness, confusion, memory loss, nausea, and irritability.

Contusion

Brain bruising, often causing edema, symptoms include LOC changes, confusion, stupor, and risk of ICP increase.

Epidural Hematoma

Bleeding between the skull & dura, characterized by a lucid interval followed by rapid deterioration.

Subdural Hematoma

Bleeding between dura & brain, symptoms include LOC changes, pupil abnormalities, and seizures.