MEDICAL SURGICAL NURSING 2

Dr. Anthony Toledo

BRAIN BRAIN INJURIESINJURIES

BRAIN INJURYan injury to the skull or brain

that is severe enough to interfere with

normal functioning.

Closed/Blunt Brain Injury: occurs when head accelerates and then rapidly or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura.Open Brain Injury: occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path, or when blaunt trauma is so severe that it opens the scalp, skull and dura to expose the brain.

PATHOPHYSIOLOGY

Brain suffers traumatic injury

Brain swelling or bleeding increases intracranial volume

Rigid cranium allows no room for expansion of contents so intracranial pressure increases

Pressure on blood vessels within the brain causes blood flow to the brain to slow

Cerebral hypoxia and ischemia occur

Intracranial pressure continues to rise. Brain may herniate

Cerebral blood flow ceases

- Signs and symptoms of increased intracranial pressure- Cerebrospinal fluid leakage from ears and nose- Battle’s Sign:

▪ altered level of conciousness▪ confusion▪ papillary abnormalities▪ altered or absent gag reflex▪ absent corneal reflex▪ sudden onset of neurologic deficits▪ changes in vital signs ( altered respiratory

pattern, widened pulse pressure, bradychardia, tachycardia, hypothermia or hyperthermia)

▪ vision and hearing impairement▪ sensory dysfunction▪ headache and seizures

ASSESSMENT OF BRAIN INJURIES

Clinical Manifestations:

Types of Brain Injury

A. Concussion- a temporary loss of neurological function with no

apparent structural damage often a head injury.

- also referred as MILD TRAUMATIC BRAIN INJURY.

- no known exact recovery time.- involves a period of unconsciousness lasting from

a few seconds to few minutes.- if frontal lobe is affected, patient may exhibit

bizarre irrational behavior- if temporal lobe, it can produce amnesia or

disorientation.

B. Contusion- brain is bruised w/ severe sub-dural hemorrhage- patient is unconscious for morethan several seconds- signs and symptoms depend on the size of contusion and amount of associated cerebral edema.- patient may lie motionless, with a faint pulse, shallow respirations- BP and temperature are sub-normal.- vertigo and residual headache are common.-seizures may occur.- Patients are conscious and easily disturbed from any form of stimulation, may become hyperactive at times.- pulse, respirations, temperature and other body functions return to normal but full recovery maybe delayed for months.

c. Intracranial Hemorrhagehematomas that develop w/in

the cranial vault.

Types Of

Intracranial

Hematomas

Epidural Hematoma (extradural hematoma or hemorrhage)

After a head injury, blood may collect in the epidural space between the skull and the dura. This can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery (the artery that runs between the dura and the skull inferior to a thin portion of temporal bone),

and hemorrhage from this artery causes rapid pressure on the brain.

• There is a momentary loss of conciousness occurring at the time of injury, followed by a lucid interval. During the lucid interval, compensation for expanding hematomas take place by rapid absorption of CSF and decreased intravascular volume. When these mechanisms cannot compensate, it produces a marked elevation of ICP., and the patient’s condition deteriorates rapidly.

Subdural Hematoma A collection of blood between the dura and brain, a space

normally occupied by a thin cushion of fluid. - Most common cause is: trauma or result of coagulopathies

or rupture of an aneurysm.

- Frequently venous in origin and caused by ruptures of small vessels that bridge the subdural space.

- It can be:a. Acute Subdural Hematoma: associated with major head injury involving contusion or laceration, symptoms develop over 24 to 48 hours.b. Subacute Subdural Hematoma: result of less severe contusions and head trauma. Clinical manifestations usually appear between 48 hours and 2 weeks after injury.c. Chronic Subdural HematomaDevelop from seemingly minor head injury and are frequently seen in elderly.Time between injury and onset of symptoms are lengthy.

Intracerebral Hemorrhage and Hematoma

Bleeding into the substance of the brain. It is commonly seen in head injuries when force is exerted to the head over small area.

May result from:- systemic hypertension- rupture of saccular aneurysm- vascular anomalies- intracranial tumors- bleeding disorders- complications of anticoagulant theraphy- may have insidious onset, beginning with the

development of neurologic deficits followed by headache.

MANAGEMENTOf

B r a I n I n j u r y

▪ patient is presumed to have a cervical spine injury until proven otherwise.

▪ patient is transported from scene of injury on a board with the head and neck maintained in alignment with axis of the body.

▪ cervical collar should be applied and maintained until cervical spine x-rays have been obtained and absence of cervical spinal cord injury is documented.

Treatment of Intracranial Pressure

- prevent secondary injury and

maintain adequate cerebral oxygenation.

- surgery is required for evacuation of blood clots, debridement and elevation of depressed fractures of the skull, and suture of severe scalp lacerations.

- monitor ICP, if increased, maintain adequate oxygenation, elevate head of bed and maintain normal blood volume.

▪Supportive MeasuresTreatment also includes:

– Ventilatory support– Seizure prevention– Fluid and electrolyte maintenance– Nutritional support– Management of pain and anxiety– Comatose patients are intubated and mechanically

ventilated– Administer anti-seizure agents to prevent secondary

brain damage– Benzodiazepines maybe prescribed to calm patient

without decreasing LOC.– Insertion of nasogastric tube to reduce gastric motility

and reverse peristalsis.

Surgical procedures:

Ventriculostomy- a procedure that drains cerebrospinal fluid from the ventricles to bring the pressure down by way of an external ventricular drain.Decrompressive Craniectomy- is a last resort surgical procedure in which part of the skull is removed in an attempt to reduce severely high ICP.

HEAD INJURIES

CAUSES

• motor vehicular accidents

• violence

• falls

PATHOPHYSIOLOGY

• Brain suffer trauma injurybrain swelling or bleeding increasing intracranial volumerigid cranium allows no room to expansion

• Of contents so intracranial pressures increasespressure on blood vessels w/in the brain causes blood flow to the brain to slow

cerebral hypoxia & ischemia occurintracranial pressure continues to rise. Brain may herniated.

SCALP INJURIES

• The scalp is rich with blood vessels, so even a minor cut there can bleed profusely. The "goose egg" or swelling that may appear after a head blow is the result of the scalp's veins leaking fluid or blood into (and under) the scalp. It may take days or even weeks to disappear

• Trauma may in an abrasion, contusion, laceration, or hematoma beneath the layer of the tissue of the scalp.

• Scalp wounds are potential portals of entry of microorganism that causes intracranial infections.

SKULL FRUCTURE

• Ah skull fractures is a break in the continuity of the skull caused by forceful trauma.

• Skull fractures are classified as linear, comminuted, depressed , or basilar.

Clinical Manifestation

• Hemorrhage from nose, pharynx, or ears blood may appear under the conjunctiva.

• Battle’s sign- bluish discoloration under the mastoid area.

• CSF ortorrhea

• CSFRhinorrhea

• Halo sign

Assessment & diagnostic findings

– CT scan

– MRI

– cerebral angiography

Nsg. Management:

• Motor for declining LOC- use of Glasgow• Maintain patient airway• Elevate bed, sunction, monitor AVG• Monitor fluid and electrolytes balnce• daily weights • IVF therapy• prevent injury• minimize environmental stimuli

Preventing Head Injuries

• It's impossible to prevent kids from ever being injured, but there are ways to help prevent head blows.

SPINAL CORD INJURY

WHAT IS A SPINAL CORD INJURY?   • Spinal Cord Injury (SCI) is damage to the spinal

cord that results in a loss of function such as mobility or feeling. Frequent causes of damage are trauma (car accident, gunshot, falls, etc.) or disease (polio, spina bifida, Friedreich's Ataxia, etc.). The spinal cord does not have to be severed in order for a loss of functioning to occur. In fact, in most people with SCI, the spinal cord is intact, but the damage to it results in loss of functioning. SCI is very different from back injuries such as ruptured disks, spinal stenosis or pinched nerves.

2 categories of spinal cord injury

• COMPLETE - an injury that does not allow any function below the level of the injury

• INCOMPLETE - there is some functioning below the primary level of the injury. With the advancement in acute treatment of spinal cord injuries, incomplete injuries are becoming more common.

EMERGENCY MANAGEMENT

• Emergency management. The first objective of emergency management of spinal cord injury is to establish ABC (airway, breathing, and circulation). The spine must be immobilized to prevent further injury. The patient must be transported rapidly to the nearest medical center, preferably a Level 1 Trauma Center. If blood pressure is low, fluid and drug therapies must be given to maintain blood flow in the spinal cord. In cervical spinal cord injuries that affect breathing, ventilatory support may be necessary. A foley catheter is usually placed in the bladder to drain urine.

DIAGNOSTIC FINDINGS AND CLINICAL MANAGEMENT

• Early surgery also allows earlier movement and earlier physical therapy, which are important for preventing complications and regaining as much function as possible. Use of imaging methods such as computed tomography (CT) scans to visualize fractures and magnetic resonance imaging (MRI) to image contusions, disc herniation, and other damage can help define the appropriate treatment for a particular patient. Several types of metal plates, screws, and other devices also are now available for surgically stabilizing the spine.

EFFECTS OF SPINAL CORD INJURY

• Quadriplegia - Cervical (neck) injuries, Injuries above the C-4 level may require a ventilator for the person to breathe. C-5 injuries often result in shoulder (deltoid) and biceps control, but no control at the wrist or hand. C-6 injuries generally yield wrist control (wrist extensors), but no finger hand function. Individuals with C-7 and T-1 injuries can straighten their arms (tricepts) but still may have dexterity problems with the hand and fingers

• Paraplegia - Injuries at the thoracic level and below. with the hands not affected. At T-1 to T-8 there is most often control of the hands, but poor trunk control as the result of lack of abdominal muscle control. Lower T-injuries (T-9 to T-12) allow good truck control and good abdominal muscle control. Sitting balance is very good. Lumbar and Sacral injuries yield decreasing control of the hip flexors and legs.

• High spinal injuries (C-1, C-2) can result in a loss of many involuntary bodily functions, including the ability to breathe. Breathing aids such as mechanical ventilators or diaphragmatic pacemakers may be needed to regulate a persons breathing in these cases. Other effects of SCI may include low postural blood pressure (Postural Hypotension), inability to regulate blood pressure effectively , reduced control of body temperature (poikilothermic), inability to sweat below the level of injury, and chronic pain.

THE END