Transcript Traumatic Brain Injury A Case Study
Traumatic Brain Injury
A Case Study
Lisa Randall, RN, MSN, ACNS-BC RNSG 2432
Demographics/CC
23 y.o. AAM Auto vs. ped 8/10/08
HPI
Dancing on I-35 under the influence of crack cocaine and ETOH.
Hit by 2 cars > 50mph GCS 12 on arrival, but declined to 4 – Eyes 4>1 – Verbal 3>1 – Motor 5>2
History
PMH – Denies, but GSW (metallic pellets CXR) PSH – Denies Social Hx – Single, no children, unemployed, unfunded – +ETOH, +amphetamines, +cannibis – Recently released from jail for drug possession Meds – Denies
Diagnostics Normal CT
Subdural Hematoma
Diagnostics
Diagnostics
Focused A/P
R frontotemporoparietal SDH – Craniectomy – EVD – Monitor/treat ICP Paraplegia/paresis L2 burst fracture c subluxation L2-L3 T11 lamina/TP fracture – T10-L3 posterior fusion when stable – PT/OT/ST…rehab
A/P con’t
10 th & 11 th rib fractures R femur fracture Acetabular fracture Mediastinal hematoma
Post-Op
Post-Op
Nursing Concerns
Neuro checks/VS q1h ICP monitoring – Mannitol – CSF drainage CPP monitoring – IVF – Vasopressors MAP monitoring Sedation/analgesia Seizure prophylaxis Infection prophylaxis Skin care
Interdisciplinary Collaboration
Trauma Pulmonary/CC Orthopedics ID Nursing PT/OT/ST/RT WOCN Dietary SW/CM
Evaluation
Rehabilitation Assessment – Decreased short term memory – Paraparesis DF 2/5, PF 2/5, HF 4-/5 Cranioplasty
Epidemiology of Head Trauma
Occurs every 15 seconds 500,000 annual ED visits Most common causes: MVAs, falls, assaults Males 15-24, elderly > 75 Accounts for 40% of traumatic deaths
Pathophysiology of TBI
1 st
– Primary Injury: initial insult … i.e. from bleed
Second
Secondary Injury
: delayed injury from hypoxia, ischemia, and release of neurotoxins Excitatory amino acids can cause swelling and neuronal death Endogenous opioids cause increased metabolism, using glucose supplies Increased ICP, especially > 40 leads to brain hypoxia, ischemia, hydrocephalus, herniation Hydrocephalus: clotted blood obstructs CSF outflow tracts and absorption of CSF, disrupts blood-brain barrier
Head Trauma
Concussion Contusion Epidural hematoma (EDH) Subdural hematoma (SDH) Basilar skull fracture Diffuse axonal injury (DAI)
Epidural Basilar skull fracture Depressed skull Fracture Contusions
Types of Injuries
Mild Traumatic Brain Injury:
– Concussion: brief change in mental status with axonal swelling Moderate to Severe Brain Injury: – Contusion:
“ bruising
depressed, basalar intracerebral
”
– Fractures: linear,comminuted, – Bleeds: epidural, subdural,
Mild Traumatic Brain Injury
1.
2.
3.
Period of LOC < 30 mins with a GCS of 13-15 after this LOC Amnesia to the event Alteration in mental status at the time of the event (dazed and confused)
Types of Concussion
Grade I (confusion, no amnesia, no LOC) – Remove from activity (may return when asymptomatic) – 3 concussions in 3 months: no activity that risks head trauma for 3 months Grade II (confusion and amnesia) – Remove from activity for day – Recheck in 24 hours – No activity for 1 week – Two grade II concussions in 3 months, no activity for 3 months Grade III (LOC) – To ED for CT – Symptom free for 2 weeks, then another 30 days – Two grade III concussions, no activity for 3 months
Post-Concussive Syndrome
Somatic symptoms: headache, sleep disturbance, dizziness, vertigo, nausea, fatigue, sensitivity to light or noise Cognitive: attention, concentration, memory problems Affective: irritability, depression, anxiety, emotional lability
Moderate and Severe Brain Injury
Contusion
Small bleeds Cerebral Edema Deficits are based on lobe involved
Fractures
Linear Comminuted
Depressed Skull Fracture
95% go to surgery Antibitoics for infection Brain tissue is involved
Treatment for CSF leak
Epidural Hematoma
Laceration of dural arteries or veins Classically laceration of middle meningeal artery Temporal bone fractures “ Lucid interval ” followed by rapid deterioration Acute bleed
Subdural Hematoma
60-80% mortality Tearing of bridging veins, pial artery, or cortical veins Acute vs chronic
Traumatic Subarachnoid Hemorrhage
Lacerations of vessels in subarachnoid space TSAH SAH
Intraventricular and Intraparenchymal Hemorrhage
Intraventricular hemorrhage – Very severe TBI – Poor prognosis Intracerebral hemorrhage – Parenchymal injuries from lacerations or contusions – Large deep cerebral vessel injury
Coup and Contrecoup Injuries
Coup: direct skull impact Contrecoup: opposite side of impact Due to negative pressure forces causing both vascular and tissue damage
DAI
Diffuse Axonal Injury
Neurologic Exam
Decreased neurologic function is best predictor of brain injury Pay attention to cranial nerves
Management of Acute Brain Trauma
Labs: CBC, electrolytes, type and screen, tox and ETOH screen CT Brain CT angiography or cerebral angiography (penetrating) MRI contraindicated if metallic fragments
Management Continued. . .
Intubate GCS 8 or less or airway protection issue (Cricothyroidotomy if necessary) Maintain BP 90 mmHg systolic C-spine precautions Tetanus prophylaxis Sterile dressing to wounds Antibiotics in penetrating injury
ICP Management is the Key
ICP monitor in patients with GCS < 8 Hyperventilation not routinely recommended Elevate head of bed to 30 degrees Sedation Propofol Barbiturate Induced Coma Contraindicated in hypotension Mannitol Reduces ICP by reducing blood viscosity, improves cerebral blood flow Serum osmolality should not be > 320 Bolus dosing
To Image or Not to Image?
GCS < 15 Intoxicated Age > 55 or < 2 Amnesia to events Witnessed LOC (> 15 minutes) Repeated vomiting Evidence of basilar skull fracture Inability to recall 3 of 5 objects Coagulopathy Penetrating head injury
Ventriculostomy
Evidenced Based Medical Guidelines for TBI Management
BP and oxygenation Hyperosmolar therapy ICP monitoring CPP Infection prophylaxis DVT prophylaxis http://youtu.be/YQ609Tk-qQI PbtO2 Analgesic/sedatives Nutrition Antiseizure prophylaxis Hyperventilation Steroids Hypothermia
New Therapy
Stem Cell Therapy – Neural/Glial differentiation – Neurogenesis – Neuroplasticity – Improve motor function – Improve cognitive function
References
AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4 th Ed. 2004. Saunders. St. Davis, F.A. (2001). Taber’s Cyclopedic Medical Dictionary. F.A. Davis, Philadelphia.
Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida.
Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L. (2007). Medical-Surgical Nursign. Assessment of Management of Medical Problems. Mosby Elsevier, St. Louis, Missouri Silvestri, Linda. (2008). Comprehensive review for the NCLEX-RN Examination. Saunders Elsevier, St. Louis, Missouri.
Introduction
YouTube - Brain Plasticity
Neuroplasticity
Organizational changes caused by experience
Neurogenesis
Formation of new nerve cells
Nature vs. Nurture
Genetics – 2500 connections “major highways” Environment – 15000 “avenues & side roads”
Future
“Directed Neuroplasticity”
Brain Fitness Program
YouTube - The Brain Fitness Program (1/8)