Comprehensive Study Notes: Management of Patients with Neurologic Trauma, Tumors, and Degenerative Disorders

Overview of Head Injury and Traumatic Brain Injury (TBI)

• Definition of Head Injury: A broad classification encompassing any injury to the head resulting from trauma.

• Epidemiology and Statistics in the United States:

  • Approximately $2.9 \times 10^6$ emergency room visits annually are attributed to head injuries.

  • The vast majority of these visits are for mild Traumatic Brain Injury (TBI).

  • TBI-related deaths total about $56,800$ annually, accounting for approximately $30\%$ of all injury-related deaths.

• Etiology:

  • Falls: The most common cause of TBIs.

• High-Risk Populations:

  • Children aged $0$ to $4$ years old.

  • Adolescents aged $15$ to $19$ years.

  • Adults aged $65$ years and older.

  • Incidence is higher in males than in females.

• Prevention: Always considered the best approach to management.

Pathophysiology of Brain Damage

• Primary Injury: The immediate consequence of direct contact to the head/brain at the instant of initial injury.

  • Includes: Contusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussions, and diffuse axonal injury.

• Secondary Injury: Damage that evolves over ensuing hours and days following the initial impact.

  • Causes: Cerebral edema, ischemia, or chemical changes associated with trauma.

Sequential Pathophysiology of TBI

1. Traumatic Injury: The brain suffers a traumatic event.

2. Swelling/Bleeding: Brain swelling or bleeding increases intracranial volume.

3. Rigid Cranium: Because the cranium is rigid and allows no room for expansion, Intracranial Pressure (ICP) increases.

4. Vascular Compression: Pressure on blood vessels within the brain causes cerebral blood flow to slow down.

5. Hypoxia and Ischemia: Cerebral hypoxia and ischemia occur.

6. Herniation: ICP continues to rise; the brain may herniate.

7. Cessation of Flow: Cerebral blood flow ceases entirely.

Scalp Wounds and Skull Fractures

• Manifestations: Clinical signs depend on the severity and specific location of the injury.

• Scalp Wounds:

  • Tend to bleed heavily due to high vascularity.

  • Serve as potential portals for infection.

• Skull Fractures:

  • Characterized by localized, persistent pain.

• Basilar Skull Fractures (Fractures of the Base of the Skull):

  • Bleeding: May occur from the nose, pharynx, or ears.

  • Battle Sign: Ecchymosis appearing behind the ear (over the mastoid).

  • CSF Leak: Cerebrospinal fluid may leak from the ears or nose.

  • Halo Sign: A diagnostic sign where a ring of clear fluid (CSF) surrounds a blood stain on drainage.

Classifications of Brain Injury

• Closed TBI (Blunt Trauma): Results from acceleration/deceleration injury; the head accelerates and then rapidly decelerates, damaging brain tissue without opening the skull.

• Open TBI (Penetrating): Occurs when an object penetrates the brain or when trauma is severe enough to open the scalp and skull.

• Concussion: A temporary loss of neurologic function with no apparent structural damage to the brain.

• Contusion: A more severe injury involving bruising of the brain surface and possible surface hemorrhage.

  • Recovery and symptoms depend on the extent of damage and associated cerebral edema.

  • Involves longer periods of unconsciousness and more pronounced neurologic deficits or vital sign changes.

• Diffuse Axonal Injury (DAI): Widespread axon damage throughout the brain following head trauma. The patient typically develops an immediate coma.

Intracranial Hemorrhage and Hematoma

Epidural Hematoma

• Location: Collection of blood in the space between the skull and the dura mater.

• Clinical Presentation: Patient may experience a brief loss of consciousness followed by a "lucid state." As the hematoma expands, ICP rises suddenly, rapidly reducing the Level of Consciousness (LOC).

• Status: This is an extreme medical emergency!

• Treatment: Measures to reduce ICP, surgical removal of the clot, and stopping the bleed via burr holes or craniotomy.

• Support: Requires intensive monitoring of vital functions and respiratory support.

Subdural Hematoma

• Location: Collection of blood between the dura and the brain surface.

• Acute: Symptoms develop within $24$ to $48$ hours; requires immediate craniotomy and ICP control.

• Subacute: Symptoms develop over $48$ hours to $2$ weeks.

• Chronic:

  • Develops over weeks to months.

  • The initial causative injury may be minor or forgotten.

  • Clinical signs and symptoms may fluctuate.

  • Treatment: Evacuation of the clot.

Intracerebral Hemorrhage

• Location: Hemorrhage occurring directly into the substance of the brain.

• Causes: Trauma or non-traumatic causes.

• Treatment:

  • Supportive care and ICP control.

  • Administration of fluids, electrolytes, and antihypertensive medications.

  • Craniotomy or craniectomy for clot removal (though this may be impossible if the hemorrhage is deep or not circumscribed).

Nursing Management and Supportive Measures for TBI

• Concussion Observation: Patients may be sent home or admitted. Immediate reporting is required for:

  • Changes in LOC.

  • Difficulty awakening, lethargy, dizziness, confusion, irritability, or anxiety.

  • Difficulty speaking or moving.

  • Severe headache or vomiting.

  • Note: Patients should be aroused and assessed frequently.

• General Supportive Measures:

  • Respiratory support; intubation and mechanical ventilation.

  • Seizure precautions and prevention.

  • NG tube to manage reduced gastric motility and prevent aspiration.

  • Fluid and electrolyte maintenance.

  • Pain and anxiety management; nutrition.

• Interventions:

  • Maintain patent airway and adequate Cerebral Perfusion Pressure (CPP).

  • Monitor neurologic function via Glasgow Coma Scale (GCS).

  • I&O, daily weights, and monitoring of blood/urine electrolytes/osmolality and blood glucose.

  • Injury prevention: Padded side rails, mittens (avoid restraints), reduced environmental stimuli (lighting to prevent hallucinations).

  • Thermoregulation: Maintain appropriate room temp, acetaminophen for fever, or cooling blankets (avoid shivering).

Spinal Cord Injury (SCI)

• Epidemiology:

  • Approximately $294,000$ people in the U.S. live with disabilities from SCI.

  • Causes: Motor Vehicle Accidents (MVAs), falls, violence (gunshots), and sports.

  • $78\%$ of patients are male; the average age of injury is $43$.

  • Risk Factors: Young age, male gender, alcohol, and drug use.

• Mortality: Major causes of death are pneumonia, pulmonary embolism (PE), and sepsis.

• Pathophysiology:

  • Primary Injury: The result of initial trauma; usually permanent.

  • Secondary Injury: Edema and hemorrhage following the SCI.

Spinal vs. Neurogenic Shock

• Spinal Shock:

  • Sudden depression of reflex activity below the level of the spinal injury.

  • Manifests as muscular flaccidity and lack of sensation/reflexes.

• Neurogenic Shock:

  • Caused by the loss of autonomic nervous system function.

  • Manifests as decreased BP, HR, and cardiac output.

  • Venous pooling occurs due to peripheral vasodilation.

  • Distinction: Paralyzed portions of the body do not perspire.

Autonomic Dysreflexia

• Status: Acute emergency occurring after spinal shock has resolved.

• Eligibility: Occurs in persons with spinal cord lesions above $T6$.

• Symptoms: Severe pounding headache, sudden increase in BP, profuse diaphoresis, nausea, nasal congestion, and bradycardia.

• Triggers: Distended bladder (most common), constipation (visceral organ contraction), or skin stimulation.

• Interventions:

  1. Place patient in extreme seated position to lower BP.

  2. Rapid assessment to identify/eliminate cause (catheterize bladder, check rectum for fecal mass, check skin).

  3. Administer ganglionic blocking agents like hydralazine hydrochloride (Apresoline) IV.

Management of Brain and Spinal Cord Tumors

• Brain Tumor Classification: Based on location and histologic characteristics.

• Primary Brain Tumor Types:

  • Gliomas: (e.g., Astrocytoma, Glioblastoma multiforme).

  • Meningiomas: Arising from the meninges.

  • Acoustic Neuromas: Tumor of the acoustic nerve; causes hearing loss, tinnitus, and vertigo.

  • Pituitary Adenomas: Causes hormonal effects.

  • Angiomas: Abnormal masses of blood vessels.

• Primary Sites:

  • Brainstem: common site for Astrocytoma.

  • Pineal Area: Pineocytoma, Pineoblastoma.

• Diagnosis: CT, MRI, PET scan, EEG, and biopsy.

• Management:

  • Surgery: Goal is removal or decompression via craniotomy or transsphenoidal surgery.

  • Radiation: Cornerstone of treatment; often involves stereotactic procedures.

• Spinal Cord Tumors:

  • Intramedullary: Within the cord.

  • Extramedullary: Under the dura (intradural).

  • Extradural: Outside the dural membrane.

  • Treatment: Surgical removal or dexamethasone with radiation to relieve compression.

Degenerative Neurologic Disorders

Parkinson’s Disease

• Pathophysiology: Progressive movement disorder associated with decreased levels of dopamine due to destruction of dopaminergic neuronal cells in the substantia nigra of the basal ganglia.

• Cardinal Signs: Tremor, rigidity, bradykinesia/akinesia, and postural instability.

• Autonomic Symptoms: Sweating, drooling, flushing, gastric/urinary retention, and orthostatic hypotension.

• Pharmacology: Levadopa is the primary treatment. Anticholinergics like benztropine mesylate control tremor. Antihistamines (diphenhydramine hydrochloride) may also reduce tremors.

Huntington Disease

• Definition: Chronic, progressive, hereditary disease resulting in choreiform movement and dementia.

• Genetics: Transmitted as an autosomal dominant trait.

• Pathology: Premature death of cells in the striatum (basal ganglia) and cortex.

Amyotrophic Lateral Sclerosis (ALS)

• Also known as: "Lou Gehrig disease."

• Pathology: Loss of motor neurons in the anterior horn of the spinal cord and motor nuclei of the lower brainstem.

• Manifestations: Progressive muscle weakness, atrophy, spasticity, and brisk deep tendon reflexes.

Terminology for Movement Disorders

• Akathisia: Restlessness, urgent need to move, and agitation.

• Bradykinesia: Very slow voluntary movements and speech.

• Dyskinesia: Impaired ability to execute voluntary movements.

• Paresthesia: Sensation of numbness, tingling, or "pins and needles."

Questions & Discussion

• Question: Is a contusion a temporary loss of neurologic function with no structural damage?

  • Answer: False. That describes a concussion. A contusion is bruising of the brain surface.

• Question: Is clear rhinorrhea a sign of a basilar fracture?

  • Answer: True. It indicates a CSF leak.

• Question: Should you massage the calves of an immobile patient?

  • Answer: False. Never massage them, as it may dislodge an undetected thromboembolus.

• Question: For a patient with SCI at $T5$ displaying autonomic dysreflexia symptoms, which intervention is inappropriate?

  • Answer: Lowering the patient to a flat, side-lying position. The patient must be seated upright to help lower blood pressure.

• Question: What is a common tumor of the brainstem?

  • Answer: Astrocytoma.

• Question: Which anticholinergic is used for Parkinson's?

  • Answer: Benztropine mesylate.

Signs and Symptoms of Head Injury and TBI

• Signs of Head Injury: These can vary greatly depending on the severity of the injury and can include:

  • Loss of consciousness (even briefly)

  • Confusion or disorientation

  • Difficulty concentrating

  • Memory issues (amnesia or forgetfulness)

  • Dizziness or balance problems

  • Nausea and vomiting

  • Headache that worsens over time

  • Blurred vision, double vision, or other vision changes

  • Sensitivity to light or noise

  • Difficulty speaking or slurred speech

  • Unusual behavior or mood changes     

Interventions for TBI

• Concussion Observation: After a concussion, patients may be sent home or admitted based on the severity; immediate reporting of the following is crucial:

  • Changes in Level of Consciousness (LOC)

  • Difficulty awakening, lethargy, dizziness, confusion, irritability, or anxiety

  • Difficulty speaking or moving

  • Severe headache or vomiting

  • Note: Patients should be aroused and assessed frequently to monitor for deterioration of condition.

• General Supportive Measures:

  • Respiratory Support: May require intubation and mechanical ventilation depending on the severity of injury and LOC.

  • Seizure Precautions: Since TBI patients are at an increased risk for seizures, take precautions to prevent injury during seizures.

  • Nutritional Support: Patients may need an NG tube to manage reduced gastric motility and prevent aspiration due to decreased consciousness and neurological function.

  • Fluid and Electrolyte Maintenance: Ensure that the patient receives adequate hydration and electrolyte balance.

  • Pain and Anxiety Management: Administer medications as needed based on vital signs and patient reports.     

• Neurologic Interventions:

  • Monitoring neurologic function using the Glasgow Coma Scale (GCS) to continually assess the patient’s responsiveness and function.

  • Conducting Intake and Output (I&O) assessments as well as daily weights to monitor hydration and nutrition.

  • Regularly checking blood and urine electrolytes, osmolality, and blood glucose to manage physiological status effectively.

  • Injury Prevention: Employ safety measures to prevent further injury, such as padded side rails, mittens (to avoid restraints), and reducing environmental stimuli to prevent agitation or hallucinations.

  • Thermoregulation: Maintain appropriate room temperature and manage fever with acetaminophen while using cooling blankets to avoid shivering.