AH III Exam 3 - TBI & ICP

What is “coup” regarding a TBI?

Primary impact (getting hit in the head) → initial damage

What is “countre-coup”? (TBI)

Secondary impact of accident → brain moves

Scalp wounds blood loss

Tend to bleed heavily; portal of infx

Early s/s of basilar fracture of skull (2)

• Bleeding from nose pharynx or ears

• CSF leak → halo sign

Late s/s of basilar fracture (2)

• Battle’s sign → ecchymosis behind the ear

• Racoon eyes

What is a concussion?

Temporary loss of consciousness w no structural damage → no bleeding, CT looks ok

What is a contusion?

More severe injury w possible bleeding

What is diffuse axonal injury?

Widespread axon damage seen w head trauma → pt develops immediate coma

S/S of diffuse axonal injury & what scan do we need? (3)

• No hemorrhage

• CT looks ok but pt isn’t waking up

• Need an ***MRI***!!!!

What is a subdural hematoma & what is it caused by?

• Blood under the dura → tearing of bridging veins

• Caused by brain damage

S/S of subdural hematoma (3)

• No s/s initially → usually within 72 hrs of event

• Chronic s/s can take up to 3 weeks-months

• Often mistaken for a stroke

What is an epidural hematoma? (2)

• Blood between dura & skull

• Arterial bleed!!! - happens fast

S/S of Epidural hematoma + tx (2)

• **Transient LOC followed by a lucid period** → pt is in a comatose state then awakes suddenly

• NEURO EMERGENCY!!! → take to OR asap for surgery

What are we concerned for w a Epidural hematoma?

• Lateral herniation!!!

• Brain shifts downward to brainstem → can quickly cause brain-death

What is intracranial hemorrhage? (2)

• Trauma over a small area within the brain tissue

• NOT surgical!!

What should we do if we notice any change at all in our pts w herniation?

CAT scan asap!!!!

What is CPP?

Amount of pressure needed to maintain blood flow to the brain

How do we calculate CPP?

MAP - ICP = CCP

ICP normal parameters

0-15 → 15 > = BAD

CPP normal parameters

≥ 60 (brain perfusion)

MAP normal parameters

≥ 65 (organ perfusion)

How would we describe the skull?

As a cranial vault that rigid

What is the Monro-Kellie doctrine?

There is limited space for expansion within skull, any increase in one, will change the vol of others

External cause of Intracranial htn (5)

• Suctioning

• Position changes

• PEEP

• Environ stimuli

• Nursing care/visitors

Whose ICP should we monitor? (2)

• Early recognition of changes in ICP

• Head injuries - GCS <8

Early s/s of increased ICP (6)

• HA

• N/V

• Change in LOC

• Lethargy

• Irritability

• Slow decision making

• Assess pt thoroughly every hr

Late s/s of increased ICP (3)

• Pupillary changes

• Seizures

• Posturing

What is cushing’s response? (2)

• Nervous system response in an attempt to rescue under-perfused brain

• ***Increase in sys BP, widening pulse pressure, bradycardia***

What is cushing’s triad + s/s? (3)

• If increased ICP not treated → rlly BAD

• ****Htn, bradycardia, bradypnea****

• Brainstem herniation is imminent ☹ rip

Management of ICP (3)

• Airway → intubation/vent

• CCP

• Negative fluid balance

How can we manage CCP w increased ICP (3)

• Keep head in neutral position, HOB 30-45 degrees

• Avoid extreme rotation & flexion of joins

• Make sure jug veins are open!!!

How does negative fluid balance help our pt w increased ICP? (3)

• Moving fluid from area of lower concentration to higher concentration

• Offload swelling from brain cells

• Hypertonic solutions!!!

Meds to manage increased ICP (2)

• Mannitol 20%

• Hypertonic Saline

• Will decrease BP

What should we monitor w increase ICP? (think abt meds) (2)

• Serum osmo → no higher than 320!!!

• K+ levels

What is ventriculostomy?

• Catheter inserted into a lateral ventricle of brain, connected by a fluid filled system to transducer → records ICP

• Gives ICP + drains CSF

Notes w managing ventriculostomy (2)

• Prevention of infx!!! → aseptic technique (mask + gloves)

• Assess the CSF fluid for cloudiness or blood

  • Cloudiness = infx

Secondary complications of ventriculostomy (2)

• Diabetes insipidus

• SIADH

What is a cranicetomy?

Removal of the bone flap to relieve pressure - surgical intervention

What is a carnitomy?

Bone flap stays on

What are burr-holes?

• Small piece of skull removed → drain blood → put back on

• Used for chronic SDH

Interventions for increased ICP (6)

• Ongoing assessment - any neuro changes: call provider & anticipate CT

• Maintenance of airway

• Monitor electrolytes & osmo

• Adequate nutrition

• Seizure precautions

• Maintain body temp → issues thermoreg; need core temp