Neurologic Trauma: Head Injuries & Spinal Cord Injuries

Head Injury: Scope & Prevention

• Broad spectrum of trauma-induced damage to scalp, skull, or brain
• U.S. annual burden:
  • $2.9\text{ million}$ emergency-department (ED) visits for traumatic brain injury (TBI)
  • $56{,}800$ deaths (≈$30\%$ of all injury-related fatalities)
• Most common etiology of TBI = falls
• High-risk cohorts:
  • Children $0\text{–}4\text{ yr}$
  • Adolescents $15\text{–}19\text{ yr}$
  • Adults $\ge 65\text{ yr}$
  • Higher incidence in males
• Primary strategy = prevention (helmets, fall precautions, seat belts, violence reduction)

Brain Damage: Primary vs. Secondary

• Primary injury – occurs at moment of impact:
  • Contusions, lacerations, skull or external hematomas, fractures, subdural hematomas, concussion, diffuse axonal injury (DAI)
• Secondary injury – evolves minutes → days post-trauma:
  • Cerebral edema, ischemia, biochemical & inflammatory cascades, ↑ intracranial pressure (ICP)
• Progressive pathophysiologic sequence:
  1. Traumatic impact
  2. Brain swelling / bleeding ↑ intracranial volume
  3. Rigid cranium prevents expansion → ICP rises
  4. Cerebral vessels compressed → ↓ cerebral blood flow (CBF)
  5. Cerebral hypoxia & ischemia; risk of herniation
  6. CBF may cease → brain death

Glossary Check: Concussion vs. Contusion

• Concussion = temporary neurologic dysfunction with no visible structural injury
• Contusion = bruise of cortical surface; may include hemorrhage & edema

Scalp Wounds & Skull Fractures

• Scalp wounds: profuse bleeding, ↑ infection risk
• Skull fracture manifestations vary by site/severity
  • Localized, persistent pain common
  • Basilar skull fracture hallmark signs:
  • CSF rhinorrhea / otorrhea (clear drainage) → positive halo sign
  • Battle sign (post-auricular ecchymosis)
  • Epistaxis or ear bleeding

Classification of Traumatic Brain Injury (TBI)

• Closed (blunt): acceleration–deceleration without skull violation
• Open (penetrating): scalp & skull breached by object/force
• Concussion: brief LOC ± retrograde amnesia; usually GCS $13\text{–}15$
• Contusion: more severe; prolonged unconsciousness, focal deficits, vitals changes
• Diffuse Axonal Injury (DAI): widespread shearing of axons → immediate coma, poor prognosis

Intracranial Bleeding Phenotypes

• Epidural Hematoma (EDH)
  • Arterial bleed between skull & dura mater
  • Classic "lucid interval" then rapid LOC decline
  • Surgical emergency: burr holes or craniotomy; ICP control; airway support
• Subdural Hematoma (SDH)
  • Venous bleed between dura & arachnoid
  • Acute: $24\text{–}48\text{ h}$ onset; Sub-acute: $48\text{ h}$–$2\text{ wk}$
  • Chronic: weeks–months; minor trauma often forgotten; fluctuating symptoms
  • Therapy: craniotomy & evacuation, ICP management
• Intracerebral Hemorrhage / Hematoma
  • Bleeding inside brain parenchyma; traumatic or spontaneous (HTN, AVM)
  • Care: supportive, ICP control, fluid & BP optimization; surgical removal if accessible

Concussion Observation Parameters (Discharge Teaching)

• Monitor and immediately report:
  • Any ↓ LOC or difficulty arousing
  • Worsening headache, dizziness, confusion, irritability, anxiety
  • Speech or motor deficits
  • Persistent nausea / vomiting
• Wake & assess frequently for first $24\text{–}48\text{ h}$

Assessment & Diagnostics for Head Injury

• Immediate physical & neurologic exam; Glasgow Coma Scale (GCS)
• Assume cervical spine injury → rigid collar until cleared
• Imaging:
  • CT scan (first-line)
  • MRI for diffuse, posterior fossa, brain-stem lesions
  • PET for cerebral metabolism/function

Acute Management Goals (Head Injury)

• Preserve cerebral homeostasis; prevent secondary damage:
  • Stabilize cardio-respiratory status → maintain cerebral perfusion pressure (CPP)
  • Control hemorrhage & hypovolemia
  • Optimize blood gases (PaO$<em>2 >60\,\text{mmHg}$; PaCO$</em>2$ targets individualized)
  • Treat ↑ ICP & edema (osmotherapy, drainage)
  • Surgical intervention when indicated (craniotomy, burr holes)
  • Continuous ICP monitoring; CSF drainage PRN

Supportive Measures (Head Injury)

• Airway & ventilation (intubation/mech vent prn)
• Seizure prophylaxis (levetiracetam, phenytoin, etc.)
• NG tube for gastric decompression & aspiration prevention
• Fluid/electrolyte balance; strict I&O
• Analgesia & anxiolysis (avoid oversedation masking neuro exam)
• Early nutrition (enteral within $24\text{–}48\text{ h}$)

Nursing Surveillance (Head Injury)

• Serial neurologic checks: GCS, pupils, motor, vitals
• Monitor labs: serum/urine osmolality, Na$^+$, glucose
• Skin integrity, DVT prophylaxis, stimulus control, sleep hygiene
• Family education & coping support

Traumatic Brain Injury: Potential Complications

• ↓ Cerebral perfusion, cerebral edema, herniation
• Hypoxia/ventilatory failure
• Fluid, electrolyte, nutrition imbalance
• Post-traumatic seizures

Spinal Cord Injury (SCI): Epidemiology & Etiology

• 294{,}000$Americans live with SCI-related disability</li> <li>Common mechanisms: motor-vehicle accidents (MVA), falls, violence (GSW), sports</li> <li>Demographics:$78\%$male; average age at injury$43\text{ yr}
• Risk factors: youth, male, alcohol/drug use
• Leading mortality causes: pneumonia, pulmonary embolism (PE), sepsis

SCI Pathophysiology

• Primary injury: contusion, laceration, compression at impact → often permanent
• Secondary injury: edema, ischemia, hemorrhage escalate neurologic loss
• Prompt interventions attempt to limit secondary spread

Spinal & Neurogenic Shock

• Spinal Shock
  • Immediate areflexia below lesion; flaccid paralysis & sensory loss
  • Usually resolves within \approx 4\text{ wk}$(variable)</li></ul></li> <li>Neurogenic Shock (above T$6 lesions)
    • Loss of sympathetic tone → ↓↓ BP, HR, CO; peripheral vasodilation & venous pooling
    • Anhidrosis below level of lesion

  Autonomic Dysreflexia (Hyperreflexia)

  • Acute life-threatening emergency once spinal shock resolves; lesions above T6
  • Triggers: bladder distention (most common), bowel impaction, skin stimuli
  • Presentation: pounding headache, sudden HTN, profuse diaphoresis, nausea, nasal congestion, bradycardia
  • Immediate nursing actions:
    1. Sit patient upright (↓ BP)
    2. Rapidly search & alleviate cause:
    • Drain bladder (catheter check/insert/irrigate)
    • Rectal exam for fecal mass (use anesthetic gel 10\text{–}15\text{ min} prior to removal)
    • Inspect skin, clothing, lines
    1. If BP remains ↑, give ganglionic blocker (e.g., hydralazine IV)
    2. Flag chart: "Risk for autonomic dysreflexia"
    3. Teach patient prevention strategies

  Respiratory & Airway Care in SCI

  • Continuous monitoring: pulse oximetry, ABG, lung sounds
  • Aggressive pulmonary toilet: humidification, hydration, assisted cough, incentive spirometry, cautious suctioning

  Mobility & Musculoskeletal Management (SCI)

  • Maintain spinal alignment; log-roll only per order or with stable spine
  • Specialized rotating bed if available; otherwise turn with precautions
  • Passive ROM (PROM) ≥4$$×/day; gradual elevation to sitting
  • Cervical collar / halo as prescribed
  • Monitor orthostatic BP with position changes

  Skin, Bowel & Bladder Programs (SCI)

  • Frequent inspection & pressure off-loading; high-protein, high-calorie diet
  • Indwelling or intermittent catheterization schedule; never massage calves/thighs (DVT risk)
  • High-fiber diet, stool softeners, scheduled bowel regimen

  Traction & Pin Care

  • Cleanse pin sites per protocol; monitor for infection
  • Maintain hygiene around traction devices

  SCI Complications

  • Deep-vein thrombosis (DVT)
  • Orthostatic hypotension
  • Autonomic dysreflexia
  • Spasticity, infection, sepsis in long-term paraplegia/tetraplegia

  Planning & Goals: Traumatic Brain Injury vs. SCI

  • Head Injury Goals
    • Patent airway & optimal CPP
    • Fluid/electrolyte & nutritional balance
    • Normothermia; skin integrity; prevention of secondary injury & sleep disturbance
    • Education & coping support; absence of complications
  • SCI Goals
    • Effective ventilation; airway clearance
    • Improved mobility; prevention of injury from sensory loss
    • Intact skin; urinary & bowel control; pain reduction
    • Recognition & prevention of autonomic dysreflexia; absence of complications
    • Achievement of functional mobility, sexual expression, long-term self-management knowledge

  Quick-Fire True/False & MCQ Review

  • Contusion equals temporary loss of neuro function? → False (that’s concussion)
  • Clear nasal CSF leak indicates basilar fracture? → True
  • Never massage immobile patient’s calves/thighs? → True (risk of thromboembolus)
  • Autonomic dysreflexia: which action is NOT appropriate? → Lowering to flat side-lying position is contraindicated; always sit up first.