Neurologic Trauma

Head injury

• A broad classification that includes any injury to the head as a result of trauma

• 2.9 million ER visits in the United States; majority are for a mild traumatic brain injury (TBI)

• About 56,800 people die related to TBI; about 30% of all injury-related deaths

• Most common cause of TBIs is falls

• Groups at highest risk for TBI:

  • children 0 to 4 years old

  • adolescents ages 15 to 19 years

  • adults 65 years and older

  • higher in males

• Prevention is the best approach

What is the patho of traumatic head injury?

• Primary injury: consequence of direct contact to head/brain during the instant of initial injury

  • Contusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal

• Secondary injury: damage evolves over ensuing days and hours after the initial injury

  • Caused by cerebral edema, ischemia, or chemical changes associated with the trauma

Scalp Wounds and Scull Fractures (manifestations)

• Manifestations depend on the severity and location of the injury

• Scalp wounds

  • Tend to bleed heavily and are portals for infection

• Skull fractures

  • Usually have localized, persistent pain

  • Fractures of the base of the skull

• Bleeding from nose pharynx or ears

• Battle sign—ecchymosis behind the ear

• CSF leak: halo sign—ring of fluid around the blood stain from drainage

Brain Injury (Open v Closed etc.)

• Closed TBI (blunt trauma): acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue

• Open TBI (penetrating): object penetrates the brain or trauma is so severe that the scalp and skull are opened

• Concussion: a temporary loss of consciousness with no apparent structural damage

• Contusion: more severe injury with possible surface hemorrhage

  • Symptoms and recovery depend on the amount of damage and associated cerebral edema

  • Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs

• Diffuse axonal injury: widespread axon damage in the brain seen with head trauma. Patient develops immediate coma

• Intracranial bleeding

  • Epidural hematoma

  • Subdural hematoma

    • Acute and subacute

    • Chronic

  • Intracerebral hemorrhage and hematoma

Concussion

• Patient may be admitted for observation or sent home

• Observation of patients after head trauma; report immediately

  • Observe for any changes in LOC

  • Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety

  • Difficulty in speaking or movement

  • Severe headache

  • Vomiting

• Patient should be aroused and assessed frequently

Location of Epidural, Subdural, and Intracerebral Hematomas

Epidural Hematomas

• Blood collection in the space between the skull and the dura

• Patient may have a brief loss of consciousness with return of lucid state; then as hematoma expands, increased ICP will often suddenly reduce LOC (S&S)

• An emergency situation!

• Treatment includes measures to reduce ICP, remove the clot, and stop bleeding (burr holes or craniotomy)

• Patient will need monitoring and support of vital body functions; respiratory support

Subdural Hematomas

• Collection of blood between the dura and the brain

• Acute or subacute

  • Acute: symptoms develop over 24 to 48 hours

  • Subacute: symptoms develop over 48 hours to 2 weeks

  • Requires immediate craniotomy and control of ICP

• Chronic

  • Develops over weeks to months

  • Causative injury may be minor and forgotten

  • Clinical signs and symptoms may fluctuate

  • Treatment is evacuation of the clot

Intracerebral Hematomas

• Hemorrhage occurs into the substance of the brain

• May be caused by trauma or a nontraumatic cause

• Treatment

  • Supportive care

  • Control of ICP

  • Administration of fluids, electrolytes, and antihypertensive medications

  • Craniotomy or craniectomy to remove clot and control hemorrhage; this may not be possible because of the location or lack of circumscribed area of hemorrhage

Management of the Patient with a Head Injury

• Assessment and diagnosis of the extent of injury with initial physical and neurologic examinations

• CT and MRI scans are the main neuroimaging diagnostic tools

• Positron emission tomography (PET) for assessing brain function

• Assume cervical spine injury until it is ruled out

• Apply cervical collar and maintain until cleared

• Therapy to preserve brain homeostasis and prevent secondary brain injury

  • Stabilize cardiovascular and respiratory function to maintain cerebral perfusion/oxygenation

  • Control of hemorrhage and hypovolemia

  • Maintain optimal blood gas values

  • Treat increased ICP and cerebral edema

  • Surgery if indicated

  • Monitor ICP and drain CSF as needed

What are the supportive measures with Head Injury?

• Respiratory support: intubation and mechanical ventilation

• Seizure precautions and prevention

• NG tube to manage reduced gastric motility and prevent aspiration

• Fluid and electrolyte maintenance

• Pain and anxiety management

• Nutrition

How is patient with traumatic brain injury assessed?

• Health history with focus on the immediate injury, time, cause, and the direction and force of the blow

• Baseline assessment

• LOC—Glasgow Coma Scale

• Frequent and ongoing neurologic assessment

• Multisystem assessment

What is the nursing interventions for the patient with traumatic brain injury?

• Ongoing assessment and monitoring are vital

• Maintain adequate airway

• Monitor neurologic function

  • LOC with GCS

  • Vital signs

  • Motor function

  • Other neurologic signs

• I&O and daily weights

• Monitor blood/urine electrolytes, osmolality and blood glucose

• Early initiation of nutritional therapy

• Improve coping and support of cognitive function

• Preventing sleep pattern disturbance

• Support of family

  • Provide and reinforce information

  • Measures to promote effective coping

  • Setting of realistic, well-defined short-term goals

  • Referral for counseling

  • Support groups

• Strategies to prevent injury

  • Assessment of oxygenation

  • Assessment of bladder and urinary output

  • Assessment for constriction caused by dressings and casts

  • Padded side rails

  • Mittens to prevent self-injury; avoid restraints

  • Reduce environmental stimuli

  • Adequate lighting to reduce visual hallucinations

  • Measures to minimize disruption of sleep–wake cycles

  • Skin care

  • Measures to prevent infection

• Maintaining body temperature

  • Maintain appropriate environmental temperature

  • Use of coverings: sheets, blankets to patient needs

  • Administration of acetaminophen for fever

  • Cooling blankets or cool baths; avoid shivering

Spinal Cord Injury

• 294,000 persons in the United States live with disability from SCI

• Causes include MVAs, falls, violence (gunshot wounds), and sports-related injuries

• Males account for 78% of SCIs

• Average age of injury is 43

• Risk factors include young age, male gender, alcohol and drug use

• Major causes of death are pneumonia, pulmonary embolism (PE), and sepsis

Pathophysiology of Spinal Cord Injury

• The result of concussion, contusion, laceration, or compression of spinal cord

• Primary injury: result of the initial trauma and usually permanent

• Secondary injury: SCI includes edema and hemorrhage

• Major concern for critical care nurses

• Treatment is needed to prevent partial injury from developing into more extensive, permanent damage

How is patient with spinal cord injury assessed?

• Monitor respirations and breathing pattern

• Lung sounds and cough

• Monitor for changes in motor or sensory function; report immediately

• Assess for spinal shock

• Monitor for bladder retention or distention, gastric dilation, and ileus

• Temperature; potential hyperthermia

• With neurogenic shock: cold or hot, hypotension, bradycardia, warm dry skin bc of vasodilation

What is the nursing interventions for the patient woth spinal cord injury?

• Promoting effective breathing and airway clearance

  • Monitor carefully to detect potential respiratory failure

• Pulse oximetry and ABGs

• Lung sounds

  • Early and vigorous pulmonary care to remove secretions

  • Suctioning with caution

  • Breathing exercises

  • Assisted coughing

  • Humidification and hydration

• Improving mobility

  • Maintain proper body alignment

  • If not on a specialized rotating bed, turn only if spine is stable and as indicated by physician

  • Monitor blood pressure with position changes

  • PROM at least four times a day

  • Use neck brace or collar when patient is mobilized

  • Move gradually to erect position

• Strategies to compensate for sensory and perceptual alterations

• Measures to maintain skin integrity

• Temporary indwelling catheterization or intermittent catheterization

• NG tube to alleviate gastric distention

• High-calorie, high-protein, high-fiber diet

• Bowel program and use of stool softeners

• Traction pin care

• Hygiene and skin care related to traction devices

Spinal shock v Neurogenic shock

• Spinal shock

  • A sudden depression of reflex activity below the level of spinal injury

  • Muscular flaccidity, lack of sensation and reflexes

• Neurogenic shock

  • Caused by the loss of function of the autonomic nervous system

  • Blood pressure, heart rate, and cardiac output decrease

  • Venous pooling occurs because of peripheral vasodilation

  • Paralyzed portions of the body do not perspire

What is autonomic dysreflexia?

• Acute emergency!

• Occurs after spinal shock has resolved and may occur years after the injury

• Occurs in persons with SC lesions above T6

• Autonomic nervous system responses are exaggerated

• Symptoms: severe pounding headache, sudden increase in blood pressure, profuse diaphoresis, nausea, nasal congestion, and bradycardia

• Triggering stimuli: distended bladder (most common cause), distention or contraction of visceral organs (e.g., constipation), or stimulation of the skin

• Anthing even wrinckle in sheet, somthing pressing on skin, constipation etc. → place in siting position

What is the nursing interventions for autonomic dysreflexia?

• Place patient in seated position to lower BP

• Rapid assessment to identify and eliminate cause

  • Empty the bladder using a urinary catheter or irrigate or change indwelling catheter

  • Examine rectum for fecal mass

  • Examine skin

  • Examine for any other stimulus

• Administer ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) IV

• Label chart or medical record that patient is at risk for autonomic dysreflexia

• Instruct patient in prevention and management