TBI (may change on review day)

Base on study guide, lecture, and quizlet (everything included)

What is a linear fracture?

• a line superficial 

  • Most common

  • Generally no significant complications

What is a depressed fracture?

• pushed in

  • blunt force trauma

  • focal neurilgical deficit

  • watch for seizures

What is a comminuted fracture?

• multiple linear fractures with depression of the skull

• eggshell appearance

What is a basilar skull fracture? (MUST KNOW)

Type of linear fracture at the base of the skull

What is the clinical presentation of a basilar skull fracture?

a.       Battle sign – bruising behind the ears

b.      Racoon eyes

c.        Rhinorrhea – CSF drainage from the nose

d.       Otorrhea – CSF drainage from the ear

Check for CSF “halo”-yellow ring!

Battle sign

bruising behind the ears

Racoon eyes

bruising around the eyes

Rhinorrhea

CSF drainage from the NOSE

Otorrhea

CSF drainage from the EARS

What is a subarachnoid bleed?

A brain bleed in the subarachnoid space where the CSF circulates

Uncal herniation

MOST COMMON.

pushes on the midbrain

s/s of cerebellar Tonsillar herniation

alterations in resp. and cardiac functions

rapidly progressing to cardiac arrest,

Headache and neck stiffness, reduced muscle tone

What are dolls eyes and what does it tell us?

eyes that move in the opposite direction when the head is turned-this means the brainstem is intact

if the eyes follow with the head-BADDDD

What are the most concerning signs and symptoms of a closed head injury?

changes in LOC, posturing changes, cushing's triad (bradycardia, widened pulse pressure, irregular respirations)

acute subdural hematoma

Within 48 hours and almost always seen with cortical or brainstem injury.

Risk of death is high from injury to brain tissue and expanding hematoma.

Surgical intervention probable.

chronic subdural hematoma

2 weeks to several months after. Seen in the elderly, chronic alcohol abusers, and on anticoagulants/antiplatelets

From low velocity impact

What should be monitored while giving mannitol?

hourly neuro assessments, ICP, CPP, serum osmolarity Q6H, electrolytes (K+, Na, chlor), ABGs, I/Os, VS, renal function

What is the priority intervention for a severe TBI?

Reduce ICP, maintain airway, maintain CPP, prevent secondary brain injury, normothermia, surgical interventions (craniotomy or canioectomy, burr holes), HOB 30 degrees

What interventions should you avoid with TBIs?

"Torn Scrotum Piercings Violently Send Cowards Screaming"

• T — Trendelenburg

• S — Suctioning

• P — Pressure on abdomen

• V — Valsalva maneuver

• S — Straining

• C — Coughing

• S — Sneezing

monitor V/S, avoid narcotics, maintain nutrition.

What causes a subarachnoid hemorrhage?

ruptured aneurysm caused by a traumatic injury.

this increases the risk of vasospasm.

Brain herniation

Increasing ICP related to the presence of a pocket of blood (hematoma)

-CAUSES THE BRAIN TO MOVE

signs that the brainstem is affected

-negative for dolls eyes (eyes don't move when the head is turned)

-pupils are fixed and dilated

-babinski reflex: we will see toes that fan out when stimulated (we want the toes to curl in)

-vomiting

-widening pulse pressure

-seizures

increased brain volume

Edema

-hypoxemia or hyposmolarity

-brain injuries

-tumors

-meningitis

increased blood volume

Loss of auto-regulation (HTN or head injury)

-increase CO2 or decrease o2

-fever/pain/seizures

increased CSF volume

flow or absorption blocked

-subarachnoid hemorrhage or meningitis

concussion

violent shaking up or jarring of the brain

-temporary loss of consciousness

mild reversible

contusion

-coup/countercoup

-bruising and bleeding of the brain

-neuro deficits are based on the area that is affected

coup

area under direct impact is injured

countercoup

injury distal from the site of impact

With a Basilar skull fracture client what order would the nurse question?

Insert an NG tube

Nothing should be inserted in the nose, in order to let the CSF fluid drain naturally- place the nasal drip pad under the nose. An OG can be inserted if necessary.

uncal herniation early s/s

Decreased LOC, increased muscle tone, positive Babinski reflex, Cheyne-Stokes respiration, progressing to central neurogenic hyperventilation, ipsilateral dilated pupil, and weakness.

uncal herniation late s/s

Pupils dilated and fixed, paralyzed eye movements, contralateral hemiplegia, abnormal flexor posturing, progressing to abnormal extensor posturing, and unstable vital signs progressing to cardiopulmonary arrest

Neurological Diagnostic Tests 

• CT Scans

• MRI

• Transcutaneous Doppler Study

• EEG

• Arteriogram

• Labs:  ABG, CBC, INR, PTT, BMP, BUN, Cr

• Brain Flow

Train of Four (TOF)

is a peripheral nerve stimulator that allows assessment of nerve function when neuromuscular blocking agents (paralytics) are being administered. 

Bispectral Index (BIS)

 provides a quantitative measurement of the brain during the use of sedatives.

What to get before doing TOF electrode

Get a baseline before giving paralytics or intubation. 

Count 4 then you can paralyze, asses 1-2hr

TITRATE 

Bispectral Index (BIS) monitors

monitors sedation

Normal-80-100

70- moderate sedation like a colonoscopy

Which type of herniation would you see rigid muscle, ipsilateral dilated pupil, and Cheyne Stokes respirations?

Uncal

In order to decrease metabolic demands of the brain the nurse knows to provide the following care measures execpt

Increase the PEEP on the vent settings

Traumatic Subarachnoid Hemorrhagic (TSAH)

Brain bleed in the subarachnoid space

Caused by a traumatic injury

High risk of developing VASOSPASM

Treat like a hemorrhagic stroke

Secondary Brain injury.

Consequence of initial trauma

Inflammatory response

Release of cytokines

Vasogenic edema

Hypoxia

Infection

Fluid and electrolyte imbalance

Release of cytokines causes

increased vascular permeability -> vaspogenic cerebral edema