Traumatic Brain and Spinal Cord Injury

OBJECTIVES

  • Explain pathophysiology, incidence/prevalence, etiology, risk factors, and mechanisms of injury associated with spinal cord injuries (SCI) and traumatic brain injury (TBI).
  • Discuss health promotion and prevention of SCI and TBI.
  • Describe focused history and assessment for patients with SCI and TBI.
  • Describe laboratory tests and diagnostic procedures used in diagnosis and treatment of patients with SCI and TBI.
  • Discuss and prioritize nursing care of patients with SCI and TBI.
  • Describe common treatments for patients with SCI and TBI including rationales and nursing implications.
  • Compare and contrast stabilization techniques and devices for SCI care.
  • Describe potential complications and prevention for SCI and TBI.
  • Evaluate patient care based on identified priority problems.
  • Describe care transitions to rehabilitation or home; identify healthcare resources for SCI and TBI patients.

ANATOMY OF THE BRAIN AND SPINE

  • Skull and Brain:

    • Components include sphenoid, nasal, ethmoid, zygomatic bones, maxilla, frontal bone, parietal bone, occipital bone, and various sutures.
    • Major brain areas:
    • Frontal Lobe: Involved in thinking, memory, behavior, movement
    • Temporal Lobe: Involved in hearing, learning, feelings
    • Parietal Lobe: Responsible for language and touch
    • Occipital Lobe: Responsible for sight
    • Cerebellum: Balance and coordination
    • Brainstem: Controls breathing, heart rate, and temperature

  • Spine Anatomy:

    • Composed of 5 sections:
    • Cervical: 7 vertebrae (C1-C7)
    • Thoracic: 12 vertebrae (T1-T12)
    • Lumbar: 5 vertebrae (L1-L5)
    • Sacral: 5 fused vertebrae
    • Coccygeal: 3-5 vertebrae
    • Protects the spinal cord, which communicates signals between the brain and body via 31 pairs of spinal nerves.
    • Functions: motor function, sensory function, and autonomic function (reflexes).

TRAUMATIC BRAIN INJURY (TBI)

  • Pathophysiology:

    • Damage to neuronal tissues from external forces varying from mild to severe.
    • Injury levels:
    • Mild: Glasgow Coma Scale (GCS) score of 13-15
    • Moderate: GCS score 9-12
    • Severe: GCS score 3-8

  • Risk Factors:

    • Age, falls, motor vehicle crashes (MVCs), drug/alcohol use, occupation, sports, assaults.

  • Mechanisms of Injury:

    • Blunt: Object strikes head, or head strikes an object.
    • Penetrating: High-velocity projectiles, low-velocity objects.
    • Blast Injuries: Caused by pressure wave from explosions.

  • Primary vs Secondary Injuries:

    • Primary: Occurs at the moment of trauma (e.g., skull fractures, concussions).
    • Secondary: Develops as a result of initial trauma, leading to issues like vascular dysfunction and inflammation.

SKULL FRACTURES

  • Types:

    • Closed: Simple fracture with no skin penetration.
    • Compound (Open): Skin laceration present, high risk of infection.
    • Depressed: Bone pressed inward into brain tissue, may cause serious injury.
    • Basilar: Fracture at base of skull, includes signs like raccoon eyes and CSF leaks.

  • Management:

    • Medical: Pain management, possible antibiotics for infection risk.
    • Surgical: Required for compound fractures, severe leaks, or persistent fractures.

CONCUSSION AND CONTUSION

  • Concussion:
    • Damage without skull break; can cause headaches, dizziness, and confusion; symptoms typically resolve within 72 hours but may last longer in some cases.
  • Contusion:
    • Bruising of brain tissue; may result in severe symptoms like prolonged unconsciousness and focal neurological signs.

INTRACRANIAL HEMATOMAS/HEMORRHAGE

  • Types include:
    • Epidural Hematoma: Arterial bleeding leading to loss of consciousness and lucid periods.
    • Subdural Hematoma: Venous bleed that often causes delayed symptoms.
    • Subarachnoid Hemorrhage: Typically presents as a sudden severe headache.

SPINAL CORD INJURY (SCI)

  • Definition:

    • Damage to spinal cord leading to loss of movement and/or sensation.

  • Etiology:

    • Most often caused by MVCs, falls, violence, sports, and medical/surgical factors.

  • Incidence: Approximately 17,000 new cases annually in the U.S. with a high prevalence in young males.

  • Pathophysiology:

    • Primary SCI: Direct damage to the spinal cord from injury.
    • Secondary SCI: Due to complications like ischemia and inflammation following the primary injury.

COMPLICATIONS OF SCI

  • Neurogenic Shock:
    • Occurs with SCI above T6, resulting in hypotension and bradycardia.
  • Autonomic Dysreflexia:
    • Characterized by severe hypertension and bradycardia due to strong stimuli below the injury level.

NURSING MANAGEMENT

  • Monitor respiratory function, vital signs, bowel, and bladder management, and skin integrity.
  • Interventions for Complications:
    • Prevent DVT/PE, manage anxiety/depression, and monitor for signs of infection.
  • Educate on health promotion and prevention strategies tailored for SCI/TBI patients.

EMERGENT CARE FOR TBI AND SCI

  • Conduct a primary and secondary survey, including respiratory support, IV fluids, and thorough neurological assessments.
  • Use of diagnostic tools: CT and MRI as indicated for both TBI and SCI assessments.