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

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: secondary injury involving white matter, progressing over days

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

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.