1-24-08 Cynthia Casey

Traumatic Brain Injury

Head Injuries

• Primary-initial damage resulting from the event

• Secondary-damage occurring later from pressure, bleeding, edema, etc.

• Scalp Injury

o Minor

o Infection

• Skull fractures

• Medical Management

o Non-depressed skull fractures require close observation

 Dura intact

o Depressed skull fractures are treated surgically

 To remove pieces from the brain

Concussion

• Temporary loss of neurological function with no structural damage

• Period of unconsciousness lasting a few seconds to a few minutes

• May experience dizziness or seeing “spots”

• May have complete loss of consciousness

• Could affect behavior if frontal lobe involved

• Treatment

o May be hospitalized overnight

o Observe for headache, dizziness, lethargy, irritability, or anxiety

• Instruct family to observe for

o Difficulty in awakening

o Difficulty in speaking
 o Confusion

o Severe headache

o Weakness on one side of the body

o Vomiting

Contusion

• Bruising of the brain

• More severe

• Possible surface hemorrhage

• May be unconscious for more than a minute

• S/S depends on size of contusion and amount of cerebral edema and location
of contusion

• May be aroused but slip back into unconsciousness

• May look like shock

o Blood pressure and temperature are below normal

o Shallow respirations

o Faint pulse

o Cool, pale skin

• If there is severe brain damage they will have

o Abnormal motor function

o Abnormal eye movement

o Increased ICP

o Cerebral irritability

 Light, sound, etc. is very bothersome to patient (similar to

migraine)

o Residual Headache

o Vertigo
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Diffuse Axonal Injury

• Axon is at the tail of the neuron (where the impulses travel)

• Widespread damage to axons

• Seen in mild, moderate, or severe head trauma

• In severe, there’s immediate coma with decorticate and decerebrate

posturing

• Recovery dependent on severity of brain damage

Intracranial Hemorrhage

• Epidural hematoma

o Symptoms are r/t expanding hematoma

o May have momentary loss of consciousness

o Compensation

 Rapid absorption of CSF and decreased intravascular volume

 Maintains normal ICP

o Decompensation

 Increased ICP

 Altered consciousness

 Focal neuro deficit

• Deficits associated with injured area

 Patient deteriorates rapidly

 Extreme emergency

• Burr hole

• Craniotomy

• May put in drain to prevent accumulation of the blood

• Subdural hematoma

o Between the dura and the brain

 o Usually venous

o Can be acute, subacute, or chronic

 Acute

• Major head injury

• Develops over 24-48 hours

• Changes in LOC, pupil signs, hemiparesis

• Changes indicate expanding mass

 Sub-acute

• Less severe

• 48-72 hours up to 2weeks before onset of s/s

• S/S similar to acute

 Chronic

• Most often in elderly

• Time of injury and manifestation can be weeks to months

• May be mistaken as a stroke

• Brain adapts

• S/S fluctuate

o Headache

o Personality changes

o Focal seizures

o Mental deterioration

• Intracerebral hemorrhage

o Bleeding into the substance of the brain

o Onset insidious

 Neurological deficits
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 Headache

o Management

 Control of ICP

 Careful administration of fluids, electrolytes, and hypertensive

medications

 Craniotomy

 Burr hole

 Craniectomy

Management of brain injury

• Patent airway

• Neuro assessment

• Head and neck maintained and in alignment

• CT, MRI, PET scan

• Monitor ICP

• May need ventilation

• Seizure precautions

• May need nutritional support

• Care for pain and anxiety

Assessment

• When did the injury occur

• What caused the injury

• What was the direction or force of blow

• LOC

• Can they respond to commands

• Response to tactile stimulation if unconscious

 • Pupils response to light

• Corneal and gag reflex

• Motor function

• Glascow Coma scale

Complications

• Decreased cerebral perfusion

• Cerebral edema and herniation

• Impaired oxygenation or ventilation

• Impaired fluid, electrolyte and nutritional balance

• Risk for post traumatic seizure

Management

• Monitoring LOC

o Glascow coma scale

• Vital signs

• Motor function

• Maintain airway

• Monitor fluid and electrolyte imbalance

o Intake and output

• Promote nutrition

• Prevent injury

• Maintain body temperature

• Maintain skin integrity

• Improve cognitive function

• Prevent sleep disturbance

• Family coping
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Legal/ethical issues

• Advanced directive

• Child abuse

• Organ donation

Basilar Skull Fracture

• Can’t be diagnosed by CT scan

• CSF leakage from ears and nose

o Raise HOB

• Bruising over the mastoid

• Blood under the conjunctiva

Spinal Cord Injuries

Acute Phase

• Maintain physiological stability

• Prevent any further injury to the spinal cord

• Immobilize the spinal cord

• Need to be in extended position

• Manage spinal shock

o Sudden depression of reflex activity in the spinal cord which is below

the level of the lesion

o Muscles below the lesion become paralysized and flaccid

o Heart rate and blood pressure drops

o May have decrease in cardiac output

o Venous pooling

o Peripheral dilation

o If the injury is high, worry about airway, due to intercostals muscles

 and diaphragm

o Pooling of secretions

o Increased CO2 decrease in O2

o Respiratory failure and pulmonary edema

• Assessment

o Motor function

o Sensation

o Urinary retention, bladder distention

o Intake and output

o Constipation

o Pain and discomfort

• Medical management

o Corticosteroids

o Surgical management

o Cervical traction (Halo)-teach pt. to call you before they get up, until
they adjust to the Halo

• Complications

o Spasticity

 Treat with anti-spasmotic

o Disuse syndrome

 Do ROM exercises

o Pressure ulcers

o Autonomic dysreflexia

o Thrombophlebitis

 TED/ SCD

 Lovenox
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 ROM exercises

o Orthostatic hypotension

o Infection and sepsis

 UTI

 Pressure ulcers

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