Overview of Traumatic Brain Injury and Management Strategies

What is traumatic brain injury (TBI)?

A disruption in normal brain function caused by an external force, such as a blow, jolt, or penetrating injury to the head.

What are the two types of injuries caused by TBI?

Primary injury (direct damage at the moment of impact) and secondary injury (delayed damage from processes like cerebral edema and increased intracranial pressure).

What is a coup-contrecoup injury?

Brain damage occurring at the site of impact (coup) and on the opposite side (contrecoup) due to brain movement within the skull.

What is diffuse axonal injury (DAI)?

Shearing of axons due to rotational forces, commonly seen in high-speed accidents.

What are hematomas in the context of TBI?

Blood collections (epidural, subdural, intracerebral) that can increase intracranial pressure.

What is cerebral edema?

Swelling that elevates intracranial pressure, reducing cerebral perfusion.

How is TBI classified by severity?

Using the Glasgow Coma Scale (GCS): Mild (GCS 13-15), Moderate (GCS 9-12), Severe (GCS 3-8).

What characterizes mild TBI?

Concussion, brief loss of consciousness, or amnesia, with symptoms like headache, confusion, and dizziness.

What characterizes moderate TBI?

Longer unconsciousness, neurological deficits, and potential for complications.

What characterizes severe TBI?

Prolonged coma, significant neurological impairment, and high risk of mortality.

What is a closed head injury?

A non-penetrating injury caused by blunt force, such as in motor vehicle accidents.

What is a penetrating injury?

An injury where an object pierces the skull, causing focal damage, such as gunshot wounds.

What is a blast injury?

An injury common in military settings caused by pressure waves from explosions.

What is a concussion?

A temporary disruption of brain function without structural damage.

What is a contusion?

Bruising of brain tissue, often occurring at coup or contrecoup sites.

What is an epidural hematoma?

Arterial bleeding between the skull and dura, often resulting from a temporal bone fracture.

What is a subdural hematoma?

Venous bleeding between the dura and arachnoid, commonly seen in the elderly or alcoholics.

What is an intracerebral hematoma?

Bleeding within the brain parenchyma.

What is the purpose of the Glasgow Coma Scale (GCS)?

To assess eye opening, verbal response, and motor response in TBI patients.

What imaging technique is first-line for acute TBI?

Computed Tomography (CT) to detect fractures, hematomas, and edema.

What is the role of Magnetic Resonance Imaging (MRI) in TBI diagnosis?

Used for detailed assessment of diffuse axonal injury, contusions, or chronic changes, but less common in acute settings.

What is intracranial pressure monitoring used for?

To detect elevated intracranial pressure in severe TBI, using methods like intraventricular catheters.

What emerging biomarkers are used to assess TBI severity?

Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) in blood.

What is the purpose of neuropsychological testing in TBI?

To assess cognitive function post-injury, particularly in mild TBI cases.

What is the purpose of mannitol in acute TBI management?

Mannitol is an osmotic diuretic used to reduce cerebral edema and intracranial pressure (ICP).

What is the dosage range for mannitol in TBI treatment?

0.25-1 g/kg IV bolus.

What alternative treatment can be used for ICP reduction besides mannitol?

Hypertonic saline, such as 3% saline administered as a 250 mL bolus.

What should be monitored when administering hypertonic saline?

Sodium levels to avoid hypernatremia.

Which anticonvulsants are commonly used to prevent post-traumatic seizures?

Phenytoin (15-20 mg/kg IV loading dose) or levetiracetam (1000-3000 mg/day) for 7 days in high-risk patients.

What sedatives are used for ICP control in intubated TBI patients?

Propofol or midazolam.

What is the dosage range for propofol in TBI management?

1-5 mg/kg/hr.

What is the role of analgesics in TBI management?

Fentanyl or morphine are used for pain management while avoiding oversedation.

What are some potential neuroprotective agents being researched for TBI?

Progesterone, erythropoietin, and statins.

What type of antidepressants are recommended for post-TBI depression?

SSRIs, such as sertraline (50-200 mg/day).

What cognitive enhancers are used for cognitive deficits after TBI?

Methylphenidate (5-20 mg twice daily) or amantadine (100-200 mg/day).

What is the purpose of baclofen in chronic TBI management?

To treat spasticity.

How often should GCS assessments be performed during the acute phase of TBI?

Every 1-2 hours.

What signs indicate increased ICP during neurological monitoring?

Unilateral pupil dilation and Cushing's triad (hypertension, bradycardia, irregular respirations).

What is the recommended head position to optimize cerebral perfusion in TBI patients?

Maintain the head of bed at 30 degrees.

What should be avoided to ensure venous drainage in TBI patients?

Neck constriction, such as tight tracheostomy ties.

What is the significance of monitoring for diabetes insipidus in TBI patients?

It can present with polyuria and low urine specific gravity.

What are the acute complications of TBI?

Increased ICP, seizures, infections, hydrocephalus, and cranial nerve injuries.

What chronic complications can arise from TBI?

Post-concussion syndrome, chronic traumatic encephalopathy (CTE), cognitive and behavioral changes, motor impairments, and endocrine dysfunction.

What is the prognosis for patients with mild TBI?

Most recover within weeks to months, but 10-20% may experience post-concussion syndrome.

What is the mortality rate for severe TBI cases?

30-50% mortality.

How does early intervention affect TBI outcomes?

Early intervention improves outcomes.

What are some prevention strategies for traumatic brain injury (TBI)?

Use of helmets in sports and motor vehicle activities, fall prevention strategies in the elderly, and public education on TBI risks and safety measures.

What clinical findings are consistent with a mild traumatic brain injury (TBI)?

Brief loss of consciousness, GCS score of 14, normal CT scan, headache, and nausea.

What is the Glasgow Coma Scale (GCS) score range for mild TBI?

13-15.

What should a patient with mild TBI avoid for at least 48 hours after injury?

Physical exertion.

What instructions should a nurse give to a patient being discharged after a mild TBI?

Rest and avoid physical exertion, return to the ED for worsening symptoms, avoid screens and bright lights, and wake the patient every 2-3 hours to assess alertness.

Why is ibuprofen contraindicated for patients with TBI?

Ibuprofen increases the risk of bleeding, which is a concern in TBI due to potential for hematomas.

What are the vital signs of a patient with mild TBI?

BP 130/80 mmHg, HR 88 bpm, RR 16 breaths/min, SpO2 98% on room air.

What are the vital signs of a patient with severe TBI in the ICU?

BP 160/90 mmHg, HR 60 bpm, RR 12 breaths/min (ventilator-controlled), SpO2 96%.

What GCS score indicates severe TBI?

A GCS score of 6.

What findings indicate increased intracranial pressure (ICP)?

ICP reading >20 mmHg, bradycardia (HR 60 bpm), hypertension (BP 160/90 mmHg), and pupil dilation.

What is Cushing's triad?

A clinical syndrome characterized by hypertension, bradycardia, and irregular respirations, often indicating increased ICP.

What is the role of mannitol in treating increased ICP?

Mannitol is administered to reduce intracranial pressure.

What should the nurse monitor during the administration of mannitol?

Vital signs, urine output, and signs of dehydration or fluid overload.

What is a common symptom of mild TBI?

Headache and nausea.

What does unilateral pupil dilation suggest in a TBI patient?

Increased intracranial pressure (ICP).

What is the significance of a normal CT scan in mild TBI?

It often indicates no acute abnormalities despite the presence of symptoms.

What is a common characteristic of seizures in TBI?

Seizures are more associated with moderate to severe TBI, not mild TBI.

What should a patient with mild TBI do if they experience worsening headache or vomiting?

Return to the emergency department.

What is the purpose of monitoring a patient overnight after a mild TBI?

To assess alertness and detect any deterioration in condition.

What is the typical recovery recommendation for resuming high-risk activities after a mild TBI?

Full recovery and medical clearance are typically required before resuming activities like skateboarding.

What is the importance of public education on TBI risks?

It helps to raise awareness and promote safety measures to prevent injuries.

What are fall prevention strategies for the elderly?

Removing trip hazards and ensuring safe living environments.

Why is ibuprofen contraindicated in traumatic brain injury (TBI)?

It increases the risk of bleeding, which is a concern due to potential hematomas.

What is the GCS score of the patient admitted to the ICU after a motor vehicle accident?

6 (eyes: 1, verbal: 1, motor: 4)

What CT scan finding was revealed in the patient with severe TBI?

A right-sided epidural hematoma and cerebral edema.

What is the current intracranial pressure (ICP) reading for the patient?

25 mmHg.

What vital sign indicates hypertension in the patient?

Blood pressure of 160/90 mmHg.

Which findings indicate increased intracranial pressure (ICP)?

ICP reading of 25 mmHg, heart rate of 60 bpm (bradycardia), blood pressure of 160/90 mmHg, and pupil dilation on the right side.

What is the primary nursing action when administering mannitol for ICP reduction?

Monitor urine output for effectiveness.

What should be monitored to assess for hypernatremia during mannitol administration?

Serum sodium levels.

What is a critical vital sign to monitor for hypotension during mannitol administration?

Blood pressure.

What nursing intervention should be performed first to manage increased ICP?

Assess neurological status using GCS.

What is the correct order of nursing interventions for managing increased ICP?

Assess neurological status, notify healthcare provider, elevate head of bed, administer mannitol, minimize stimuli.

What is the priority nursing action after administering lorazepam for a seizure?

Monitor for respiratory depression.

What medication is the patient taking for depression?

Sertraline 50 mg daily.

What medication is the patient taking for attention difficulties?

Methylphenidate 10 mg twice daily.

What cognitive deficits does the patient exhibit after TBI?

Memory impairment and difficulty with attention.

What is the significance of a low GCS score in the context of TBI?

It indicates severe traumatic brain injury.

What does pupil dilation on the right side indicate in a TBI patient?

It may indicate herniation.

What is Cushing's triad in relation to TBI?

It includes hypertension, bradycardia, and irregular respirations, indicating increased ICP.

What is the purpose of elevating the head of the bed to 30 degrees in TBI patients?

To promote venous drainage and reduce ICP.

What is the role of mannitol in TBI management?

It is an osmotic diuretic used to reduce intracranial pressure.

What is the normal respiratory rate for a ventilated patient?

12 breaths/min.

What are the signs of increased ICP that nurses should monitor?

Changes in GCS, bradycardia, hypertension, and pupil changes.

What is the typical nursing response if a patient develops a seizure after TBI?

Administer lorazepam and monitor for respiratory depression.

What is the importance of minimizing environmental stimuli in TBI patients?

To prevent further spikes in intracranial pressure.

What is a recommended strategy to enhance memory in patients?

Provide a structured daily schedule.

How can socialization be encouraged for patients?

Encourage participation in group therapy.

What type of instructions should be used during patient interactions?

Use simple, clear instructions.

What therapy should be collaborated on for cognitive exercises?

Collaborate with occupational therapy.

What is the priority action for a patient expressing thoughts of self-harm?

Place the patient on one-to-one observation.

What is the best response regarding the prognosis of a patient with moderate TBI?

Moderate TBI may result in residual deficits, but rehabilitation can improve function.

What findings support a diagnosis of diabetes insipidus (DI) in a patient?

Polyuria with urine output >200 mL/hr, serum sodium of 150 mEq/L, and urine specific gravity of 1.002.

What is the expected outcome of administering desmopressin for diabetes insipidus?

Decreased urine output and normalized serum sodium.