1

Sometimes:The Lights are on…. But nobody’s home….

Traumatic Brain Injury (TBI) 2

Adult Health IITraumatic Brain Injury—Part 1

Jerry Carley RN, MA, MSN, CNESummer 2010

Concept Map: Selected Topics in Neurological Nursing

PATHOPHYSIOLOGY

Traumatic Brain Injury (TBI)Spinal Cord Injury

Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Huntington’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease

PHARMACOLOGY

--Decrease ICP--Disease Specific Meds

ASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation

ICP Monitoring“Neuro Checks” Lab Monitoring

Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…basedOn Nursing Process: A_D_O P_I_E

Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary

Objectives4

Recall anatomy and physiology of the brain & cranial nerves

Explain pathophysiology of various brain (head) injuries

Detail signs, symptoms and prevention of Increased Intracranial Pressure (ICP)

Demonstrate effective use of Glasgow Coma Scale

Discuss medical & nursing management of brain injuries

trauma nursing is not for everyone……and traumatic brain injury is one of the trauma nurse’s greatest challenges.

5

Nasal catheters toCombat epistaxis

Endotracheal tube

Dry sterileDressing over Ears (for CSF Leak)

“N-G Tube”Inserted orally(“orogastric tube”)

RigidCervicalCollar

Is this “just blood,”Or is thereSome leakedCSF FluidIn there?

Anatomy & Physiology Review 6

OOOTTAFAGVSH

IIIIIIIVVVIVIIVIIIIXXXIXII

lfactorypticculomotorrochlearrigeminalbducensacialcousticlossopharyngealaguspinal accessoryypoglossal

Cranial Nerve Function Structures Innervated

I Olfactory Smell Olfactory Bulb

II Optic Vision Retina

III Oculomotor Eyeball movementLens AccomodationPupil Constriction

4 eyeball muscles1 eyelid muscle

IV Trochlear Eyeball Movement Superior Oblique Muscles

V Trigeminal 1. Sensation2. General Sensory From Tongue3. Proprioception

1. Face, scalp, teeth, lips, eyeballs, nose, throat lining2. Anterior 2/3 of tongue3. Muscles of mastication

VI Abducens Eyeball movement Lateral Rectus muscle

VII Facial 1. Taste2. Proprioception3. Facial Expressions4. Salivation & Lacrimation

1. Face & Scalp2. Face & Scalp3. Muscles of face4. Salivary & Lacrimal Glands

VIII Acoustic 1. Balance2. Hearing

1. Vestibular apparatus2. Cochlea

IX Glossopharyngeal

1. Taste2. Proprioception for swallowing3. Blood pressure receptors4. Swallowing & gag reflex5. Tear production6. Saliva production

1. Posterior 2/3 of tongue2. Throat muscles3. Carotid sinuses4. Throat muscles5. Lacrimal glands6. Parotid glands

X Vagus 1. Chemoreceptors2. Pain receptors3. Sensations4. Taste5. Heart Rate & Stroke Volume6. Peristalsis7. Air Flow8. Speech & Swallowing

1. Blood O2 Concentration, Aortic bodies2. Respiratory & Digestive Tracts3. External ear, larynx, pharynx4. Tongue5. Pacemaker & Ventricular Muscles6. Smooth muscles of digestive tract7. Smooth muscles of bronchioles8. Muscles of larynx & pharynx

XI Spinal Accessory

1. Head rotation, upright position2. Shrugging shoulders

1. Trapezius & sternocleidomastoid muscles

XII Hypoglossal Speech & Swallowing Tongue & Throat muscles

Brain Trauma8

Brain injury results in more trauma deaths than do injuries to any other body region!

Primary Injury

9

Mechanical trauma that occurs at the moment of impact and may lead to irreversible cell damage from physical disruption of neurons or axons

103 Top Causes

Etiology of Traumatic Brain Injury (TBI) in the U.S.

OtherSportsAssaultsFallsMVC

Other 7%

11

Motor Vehicle Crashes50 %

Falls21 %

Sports10 %

Assaults12 %

Mechanism of Closed Head Injury“Rear-Ended” – “Whiplash” Effect

12

“Coup- Contrecoup”

“Coup-Contre Coup”13

14

Boxing:

Coup-

Contre Coup

Injury :

“The second collision”

Risk Factors15

Highest in young people and the elderly

*Age 65 – 75 has highest incidence of HI of ALL age groups*

Occurs twice as often among males compared with females

Motor vehicle crashes account for the major proportion of head and brain injuries….and involve a disproportionately large number of young persons

Alcohol intoxication is a compounding factor in at least 30% to 50% of head injuries and is a contributing factor in almost ½ of all fatal motor vehicle crashes in the United States

Did you Know ?16

Laws that require helmet use have been shown to

reduce deaths

in motorcyclists

by about 30%

At the Scene: - EMS- First Responders

17

18Spinal Injury

Assumed

With

Any

Head Injury

UntilProven

Otherwise

19

1. Maintain ability to breathe

2. Prevent shock

3. Immobilization to prevent further spinal cord damage

(Backboard + C-Collar)

“ TheGoldenHour ”

EMS type C- Collar20

EMS Back Boards21

Upon Arrival to ER…22

Baseline Assessment23

Vital Signs

Glasgow Coma Score (GCS)

Prevent Further Injury!

24

The GCS is the most widely used method of defining a patient's Level of Consciousness (LOC)

25

“ Posturing ”26

Decorticate Rigidity:

*Upper arms held at the sides, with elbows, wrists , and fingers flexed. *Legs are extended & internally rotated.

Decerebrate Rigidity:

*Jaws are clenched & neck is extended.*Arms are extended with wrists facing out.*Legs are extended.

C – Spine X-Ray“Cross-Table Lat”

Before removal of ANY immobilization devices

27

As Much as Possible In ER28

Instruct client to avoid sneezing or coughing

Provide calm environment

Maintain immobilization

Avoid meds the decrease LOC such as analgesics

Severity of Head Injury29

GCS 3 – 8 : Severe Head

InjuryGCS 9 – 12: Moderate Head

InjuryGCS 13 -15: Mild Head

Injury

GCSSCORE< 8 =COMA

30

The best guide to the severity of head

injury is the level of

consciousness(LOC)

31

History of Injury32

Loss of Consciousness?

Other victims seriously hurt?

Mechanism of injury?

Driver / passenger / seatbelt ?Fall height / what caused fall?Hit where and with what?Gunshot / impaled object ?

Open or Closed Injury ?33

Diagnostics34

Damaged areas of the brain have a reduced or no blood flow or glucose metabolism. This can be seen in the images below where there has been a blow to the head by a rock

Skull Fractures35

Present on CT scans in about two thirds of patients after head injury

Skull fractures can be linear, depressed, or diastatic and may involve the cranial vault or skull base

Depressed Skull Fractures36

A portion of the skull is extending into the intracranial space

Often results in pressure on the brain or direct injury to the brain

In addition, the bone fragment may cause a laceration of the dura mater resulting in a cerebrospinal fluid leak

Outcome is based upon the underlying brain injury. If no brain injury is present the surgery represents a cosmetic procedure and the outcome is generally quite good

37

Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving

Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli

Occipital Lobe- associated with visual processing

Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech

Basal (Basilar) Skull Fractures

38

1 frontal2 ethmoid3 sphenoid4 temporal5 parietal6 occipital

Involve the floor of the skull and include fractures of the cribriform plate, frontal bones, sphenoid bones, temporal bone and occipital bones

39

1. Frontal sinus

2. Crista galli

3. Cribriform plate

4. Lesser wing of sphenoid

5. Superior orbital fissure

6. Superior border of petrous part of temporal bone

7. Dense shadow of petrous part of temporal bone

8. Perpendicular plate of the ethmoid

9. Vomer

10. Maxillary sinus

11. Inferior concha

12. Ramus of mandible

13. Body of mandible

Basal (Basilar) Skull Fractures40

• Most basal skull fractures do not require treatment and heal themselves

• Persistent CSF leakage may warrant operative repair of the leakage, particularly CSF leaks related to frontal bone and cribiform plate fractures

Basal Skull Fractures41

Clinical Clues may include:

CSF leakage through the ear or nose (otorrhea or rhinorrhea)

Hemotympanum (blood behind the eardrum)

Bruising behind the ears (postauricular ecchymoses) “Battle Sign”

Bruising around the eyes (periorbital ecchymoses) “Raccoon Eyes” “Panda Eyes”

Injury to cranial nerves:

VII Facial nerve - weakness of the face VIII Acoustic nerve - loss of hearing I Olfactory nerve - loss of smell II Optic nerve - vision loss VI Abducens nerve - double vision

42

43

CSF Leakage44

Rhinorrhea and otorrhea are clinical signs of cerebrospinal fluid (CSF) leakage in patients with skull fracture

Presence of glucose (CSF) in otorrhea and rhinorrhea detected by Beta-2 transferrin. Nasal/ear discharge (glucostix) was traditionally used to diagnose CSF leak at the bedside, but has fallen into disuse as it has poor positive predictive value

CSF leakage opens the brain & spinal canal to infection

CSF is needed to cushion the brain, maintain pressure within the eye and cleanse the CNS (like the lymphatic system serves the same function in the rest of the body) 

45The Halo Effect

of Leaking

Serosanguinous

Cerebrospinal Fluid (CSF)

Filter Paper

Prevent Infection !46

Cover any suspected source of CSF leakage with a

Sterile Dressing STAT !

CSF Infection 47

Nuchal Rigidity

CSF has WBCs

Increased Temperature

(Sometimes) Associated with Brain Injury48

Blood on Ocular Surface : Subconjunctival Hemorrhage

Blood in the anterior chamber of the eye (hyphema) as a complication of blunt trauma. Eyes with hyphema may show other signs of damage

Another Clue….49

Avulsed eye and lacerations to the forehead

Penetrating Brain Injury50

MRI of 19 y.o Melbourne, Australia resident involved in bar fight. That’s a metal chair leg going into the left orbit. Patient survived. Not only that, the left eye was salvaged with only slight loss of visual acuity.

51

Attempted suicide with a crossbow. Patient survived, though he did lose sight in one eye, since the arrow partially severed one of his optic nerves.

Head Injury Assessment52

Obvious Skull Fractures?

Lacerations?

Deformities? (bumps / indentations)

Facial Injuries?

Blood and/or CSF drainage from nostrils? (rhinorrhea)

Blood and/or CSF drainage from ear canals? (otorrhea)

Blood and/or CSF drainage from mouth?

Blood and/or CSF drainage from eyes?

Pain?

Headache?

Collaborative Treatment Goals 53

Maintain AirwayBreathingCirculation

Maintain cerebral perfusionMaintain electrolyte balanceMaintain fluid balanceMaintain cognitive function

HOW ????

54

Prevent Secondary Injury !!!

Meaningful recovery of function after head injury is possible IF

secondary injuries are prevented or minimized

55