Head Trauma and Subdural Hematoma inda Alexander, MSN, CCRN, CNRN, CNOR, CRNFA\ Nae Joyce, a 27-year-old right-handed patient, was involved in a motor vehicle accident, Joyce was an unrestrained passenger in a car that swerved off the road and struck a tree. She was Gjected from the car and was found unconscious by the emergency medical service personnel, After being placed on a spinal board and in a Philadelphia collar, Joyce was trans- ported by helicopter to the nearest emergency department trauma center. Joyce was Somewhat combative and unresponsive to commands at arrival. Her pupils were reactive bilaterally (left > right). Her respiratory rate was 40 breaths/min and labored. Subsequently, an endotracheal tube was placed, and mechanical ventilation was started. Additional treat- ment included placement of a subclavian intravenous (IV) line, arterial catheter, and Foley catheter, Initial evaluation of her cervical spine revealed no abnormal findings, and the long spine board and Philadelphia collar were removed. Joyce's diagnostic data were as follows! BP 90/40 mm Hg HR 100 bpm Respirations 40 breaths/min ‘Temperature 36.7°C (08°) Pupils Reactive left > right Glasgow Coma Scale score 9 Joyce's initial computed tomography (CT) scan of the head revealed a left temporal cerebral contusion with a midline shift of brain structures. The CT scan also revealed a left temporal parietal subdural hematoma (SDH). After surgical removal of the hematoma, Joyce was transferred to the critical care unit, Intubation and mechanical ventilation were continued. An intracranial pressure (ICP) monitoring device was placed. The following were her diagnostic data after surgery: 1cP 25 mm Hg BP 130/88 mm Hg HR 100 bpm Respirations 12 breaths/min Temperature 37.8° C (100° F) pH 7.48Chapter 14 Mead Trauma snd Subsdural Hematoma ws Peo, 40. mm Hg Po, 434mm Hg HCOy 20.4 mmol/L Ventilator settings were as follows: ve 700 mb Rate 12/min Flo, 100% As Joyce recovered from the general anesthesia, she opened her eyes to speech Nerbalized incomprehensible sounds, and exhibited abnormal general flexion to obmain 3 Glasgow Coma Scale score of #. Over the next 2 hour, Joyce's body temperature increas to 38:3" C (1O1* F). Despite hyperventilation, Joyce's ICP remained elevated. Her —— osmolality was 282 mOsm/1, K° level was 1.9 mmol/L, and Na” level was 139 mmol/L P operative orders inchised the following Fluid restriction to mamntain patient armotiity between 30% and 313 mOvnt Furosemide (Lasix) 20 mg gh, Mannitol (Oxntrot) 25 to $0 g periodic bok Prenytoin (Ditartin) 100 may gah Jovee’s ICP remained elevated for more than 72 how, then gradually her pressure Stabilized. After 2 weeks in the intensive care unit, joyer was transier 2 neurobogic step-down unit and then to 4 head injury rehahelitstion unit“UNIT HE NEUROLOGIC ALTERATIONS _ HEAD TRAUMA AND SUBDURAL HEMATOMA QUESTIONS 1. Where does head trauma rank as a ca use of death in the United States? What are the statistics associated with head trauma? Include morbidity and mortality information, 2. Identify the leading causes of head injury. 3. What is the rationale for Joyce being placed on a long spine board with a Philadelphia collar? |. What is the Glasgow Goma Scale? How is this scale helpful? i - clinical presenta- ifferentiate the types of skull fractures associated with head trauma. What = Tian ana| patioptnstlony ate pertnertin these ype of aura? ement of an endotracheal or nasogastric tube. sg special considerations that are necessary for patients with basilar skull fractures forccrapter 14 10. nu. 12. 3}. 14. 15. 197 List ibe the dif and describe the diffuse injuries associated with traumatic head injury. Discuss the significance of a midline shift Identify the types of SDHs. Include the pathology and clinical presentation of SDH. ‘What surgical intervention is indicated for patients with SDH? Define ICP. What methods are available for monitoring ICP? Describe the potential complications of ICP monitoring. What factors determine when an ICP monitoring device is placed? List and deseribe possible secondary injuries with head injury. ased on Joyce's arterial blood ges results, what ventilator changes should be anticipated? What is the desirable arterial carbon dioxide pressure (Paco;) range in the presence of increased ICP?18. What is autoregulation and how does it affect cerebral blood flow and ICP? 19. aioe a 2 |e blovl pressure of 120/72 aig eal Tee avers cerebral Be fildenypressre|(G?): 1s he CPP an acceptable valve? Dscussthe drawbacks of using CPP Jes. _ 20. Discuss the medical management that should be anticipated for patients with head injuries. _ {nclude the rationale and identify at least one potential complication associated with each. uy 21. Define and discuss the clinical significance of posturing such as abnormal flexion and abnormal extension. ntroling hyperthermia in the management of patients with head the relevance of corChapter 14 tHead Trauma and 5 199 23, What nursing management actions are cf secondary Injury in patients with ential to prevent or minimize the effects ad injuries? 24, What are the potential extracranial effects of increased ICP? Which cranial nerves must be intact before the patient eats or drinks?