IMS CH 63

Epidemiology & Risk Factors

• Traumatic Brain Injury (TBI)
  • Most common overall cause: Falls
  • Other major causes: Motor-vehicle accidents (MVAs), assaults/abuse, sports injuries
  • Highest-risk age groups
  • Children (high activity, playground falls)
  • Adolescents 15–19 y (driving, contact sports)
  • Adults ≥ 65 y (balance deficits, poly-pharmacy)
• Spinal Cord Injury (SCI)
  • Top 5 causes (approx. U.S. figures)
  1. MVAs (≈ 46 %)
  2. Falls (≈ 22 %)
  3. Violence ∕ gunshot/knife (≈ 16 %)
  4. Sports/recreation (≈ 12 %)
  5. Disease/tumor/degeneration
  • Risk enhancers: young age, male gender (higher risk behavior + sport participation), ETOH/drug use

Classification of Brain Injury

• Acquired, non-traumatic: tumor, infection, aneurysm, hypoxia, metabolic issues
• Traumatic
  • Open (penetrating) vs. closed (blunt)
  • Primary named lesions
  • Concussion: transient LOC ± amnesia, no structural defect
  • Contusion: bruised brain with surface hemorrhage, risk for edema → ↑ICP
  • Diffuse axonal injury (not explicitly named in transcript but implied under severe blunt)
  • Fractures
  • Scalp wounds: heavy bleeding, infection portal → meningitis risk
  • Basilar skull # → otorrhea/rhinorrhea (CSF leak) ; Battle sign, raccoon eyes

Pathophysiology Highlights

• Hemorrhage → mass effect → ↑ intracranial pressure (ICP)
• ↑ICP consequences: brain tissue shift / herniation, decreased cerebral perfusion, seizures (disrupted electrical activity)
• Classic vital-sign response (Cushing’s triad)
  • $\text{↑ Systolic BP (widened PP)}$
  • $\text{↓ HR (bradycardia)}$
  • $\text{↓ RR (bradypnea / irregular)}$

Intracranial Hematomas

Diagnostics

• CT (fast, open, gold standard for bleed)
• MRI (better for diffuse / soft tissue; claustrophobia issues → benzodiazepine pre-med e.g. lorazepam, diazepam)
• PET / SPECT for metabolism, not acute bleed
• Continuous neuro checks: Glasgow Coma Scale $3\;\text{(deep coma)} \rightarrow 15\;\text{(normal)}$

Nursing Assessment & Monitoring (TBI)

• Frequent LOC, pupillary & motor checks; seizure watch
• Vital signs for Cushing’s changes; monitor temp (hyperthermia ↑ metabolic demand)
• Lab/lytes: Na⁺ changes (SIADH vs. DI), osmolality if on hypertonics
• Maintain cervical spine precautions until cleared (rigid collar, log roll)

Acute Management Principles

• Maintain airway & oxygenation; suction with care (can spike ICP)
• Target ICP < $20\,mmHg$, CPP > $60\,mmHg$ (if monitoring in ICU)
• Seizure prophylaxis (levetiracetam, phenytoin)
• Fluids: isotonic ; avoid hypo-osmolar
• Surveillance CT for expanding bleeds
• Nutrition: start enteral within 24–48 h if gag absent (NG before PEG/G-tube); avoid TPN unless prolonged
• Skin integrity: reposition q2h, specialty mattress

Spinal Cord Injury Basics

• Level-based nomenclature
  • Tetraplegia (Quadriplegia) = C1–C8 → all 4 limbs ± resp. muscles
  • Paraplegia = T1–L4 → lower limbs
• Functional expectations: higher level = less independence; C3–C5 "phrenic keep alive" (diaphragm)

Immediate SCI Complications

1. Spinal Shock
   • Complete flaccid paralysis & areflexia below injury, lasts <48\,h (occasionally weeks)
2. Neurogenic Shock (above T6)
   • Loss of sympathetic tone → $↓BP, ↓HR, ↓CO$, warm dry skin, venous pooling
3. Autonomic Dysreflexia / Hyperreflexia (chronic phase)
   • Stimulus below lesion (most common = bladder distention; kinked Foley) → massive sympathetic discharge below T6 with unopposed parasympathetic above
   • S&S: pounding HA, flushing & diaphoresis above lesion, pilo-erection, blurred vision, nasal congestion, severe HTN + bradycardia
   • Interventions: sit patient up → remove stimulus (straighten catheter, relieve fecal impaction, loosen clothing) → if SBP > $150\;mmHg$ give rapid-acting antihypertensive (e.g. IV hydralazine 10 mg) → close BP q2-3 min; label chart for risk

Long-Term SCI Complications

• Respiratory infections (pneumonia #1 cause of late mortality)
• DVT/PE (immobility despite kinetic bed)
• Orthostatic hypotension
• Spasticity & contractures → PROM, baclofen
• Pressure ulcers → skin checks, specialty cushion
• Neurogenic bladder & bowel → scheduled intermittent cath, digital stimulation with MD order (watch for vagal response)
• Chronic pain, depression; refer to support groups/counseling

Rehabilitation & Assistive Devices

• Halo vest traction
  • Keeps cervical spine aligned; pin-site care $50\%$ H₂O₂ : NS per order; do not tighten loose pins – call ortho/neurosurgery
  • Log-roll entire body to turn; no bending at waist
• Rotorest / kinetic therapy bed: continuous rotation but still DVT risk → SCDs, Lovenox
• Wheelchair skills: tetraplegic may retain finger movement to drive powered chair

Nutrition, Temperature & Skin Care

• High-calorie, high-protein diet (hypermetabolic state)
• Maintain normothermia: fever increases O₂ demand; antipyretics, cooling blanket, tepid sponge bath
• Turn q2h, air-flow mattress; pad bed rails for seizure protection

Ethical & Psychosocial Considerations

• Discuss prognosis early; balance hope with realism
• Involve family in care, teach signs of ↑ICP and autonomic dysreflexia
• Consider advanced directives (ventilator dependence, craniectomy bone flap decisions)

Key Numbers & Formulas (Exam Quick-Look)

• Normal ICP: $5–15\,mmHg$; treat if >20
• Cushing’s triad = $↑BP$ (widened PP) + $↓HR$ + $↓RR$
• GCS ranges $3–15$; score ≤ $8$ ⇒ intubate
• Autonomic dysreflexia threshold: SBP rise > $20–40\,mmHg$ from baseline or SBP ≥ $150$

Practical Mnemonics

• “FALLS cause most head calls” (Falls = #1 TBI)
• Bladder, Bowel, Backrest (B³) → top 3 triggers of autonomic dysreflexia
• SCAB to remember spinal shock complications: Shock, Clots, Autonomic issues, Breathing problems