Neurologic Trauma 8-10 Questions

1. Neurologic Trauma8-10 Questions Monti Smith, MSN, RN

2. Increased Intracranial Pressure • The cranial vault contains: • Brain tissue • Blood • Cerebrospinal fluid • These three things give your brain a state of equilibrium • Monro-Kellie Hypothesis - ↑ in any of the cranial vault components causes a change in the volume of the others by displacing or shifting CSF, ↑ CSF absorption or ↓ blood volume

3. Pathophysiology of ICP • Normal ICP is 10 – 15 mm Hg • Most commonly associated with head injury • Secondary effect in conditions such as: • Brain tumor • Subarachnoid hemorrhage • Encephalopathies • ↑ ICP affects cerebral perfusion, produces distortion, and shifts brain tissue

4. Pathophysiology cont. • Reduced cerebral blood flow results in ischemia • Complete ischemia for > 3-5 mins. results in irreversible damage • Early stages of ischemia - vasomotor centers are stimulated resulting in a slow bounding pulse & respiratory irregularities

5. Pathophysiology cont. • CO2 concentration regulates cerebral blood flow – rise causes dilation whereas a fall vasoconstricts • Cerebral edema occurs when there is ↑ in water content of the brain tissue

6. Pathophysiology – Cerebral Response to ↑ ICP • Autoregulation – the brain’s ability to change the diameter of its blood vessels automatically for maintenance of constant cerebral blood flow • Cushing’s response – the brain’s attempt to restore blood flow by increasing arterial pressure to overcome increased intracranial pressure

7. Decompensation Phase • Exhibit changes in mental status & V/S – Cushing’s triad: • Bradycardia • Widening pulse pressure/hypertension • Respiratory changes • Herniation of brain stem + occlusion of cerebral blood flow = cerebral ischemia & infarction = leading to brain death

9. If there is a Q on the test: • What you would look for in the question, do they have these three things: • Far apart BP • Pulse in the 50’s • Temp would be high

10. Clinical Manifestations of ↑ICP • Change in level of responsiveness-consciousness • The most important indicator of the pt’s condition • Any sudden change in condition has neurologic significance: • Restlessness without cause • Confusion • ↑ drowsiness

11. Complications of ↑ICP • Brain stem herniation • Not much you can do for this • Diabetes insipidus • Treat with fluid, check on lyte’s • Syndrome of inappropriate antidiuretic hormone • Restrict fluids

12. Management of ↑ICP • ↑ICP is a true emergency a treat promptly • Goal – ↓ cerebral edema, lowering volume of CSF, or ↓ blood volume while maintaining cerebral perfusion • Administer osmotic diuretics to dehydrate brain & reduce cerebral edema • Mannitol • Glycerol

13. Nursing Diagnoses • Ineffective airway clearance • Diminished cough and gag reflexes • Ineffective breathing patterns • Ineffective cerebral tissue perfusion • Deficient fluid volume • Risk for infection • b/c of hole they put in head to monitor pressure

14. What Can The Nurse Do? • Maintain airway & monitor breathing • Maintain proper positioning • Maintain proper fluid balance • Monitor for s/s of infection • Monitor for potential complications • Stool softeners to prevent straining during a poo • Keep an emotional/stress free environment

15. Management of ↑ICP • Foley catheter to monitor urinary output • Serum osmolality levels to assess hydration • Corticosteriods to help reduce edema • Maintain cerebral perfusion by using fluid volume & inotropic agents • Reduce CSF & blood volume by draining CSF • Control fever to ↓ rate at which cerebral edema forms

16. Head Injuries • Trauma to scalp, skull, or brain • Primary: initial damage to the brain (like you get hit in the head with a hammer) • Secondary: evolves over hours & days after the injury (like Liam Neeson’s wife) • An injured brain is different than other injured body parts because of its location! • There is no where for the swelling and all that to go, so the pressure just increases and is super bad news • Scalp injuries – causes lots of bleeding, but usually minor

17. Types of Force • Acceleration injury • Head in motion • Like in a car wreck • Deceleration injury • Head suddenly stopped • Like if you’re sitting stopped in your car and someone hits you

18. Skull Fractures • Break in the continuity of the skull caused by a forceful trauma • Fracture may be open or closed • Open is if you have any tear in the dura • Closed is when the dura is still intact • Types of Fractures • Simple – a clean break, straight little line • Comminuted – a splintered break or there are multiple fracture lines • Depressed – bone fragments that are depressed or imbedded into the brain tissue • Basilar – fracture at the base of the skull

19. Clinical Manifestations • Dependent on severity and distribution of brain injury • Persistent, localized pain suggest fracture • X-ray needed for diagnosis • Basilar skull fracture frequently produces hemorrhage and CSF leakage • Bloody CSF suggests brain laceration or contusion

20. Assessment & Diagnostics • Physical Exam & Neuro status • CT scan • MRI • Cerebral angiography

21. Medical Management • Close observation if nonsurgical • HOB is usually 30 degrees • Surgery for depressed fractures • IV antibiotics for these guys • Monitor for CSF leakage • Might leak out ears (otorrhea) and nose (rhinorrhea) • Get some sterile gauze and place it with some tape under their nose. Tell the pt not to be blowing their nose

22. Traumatic Brain Injury • Occurs as a result of an external physical force that may produce a diminished or altered state of consciousness • The brain responds to forces by forward movement within the cranial vault • Motor vehicle crashes are the most common cause • The cognitive impairment that they suffer from that is usually irreversible

23. Battle Sign • Like a bruise or whatever behind their ear. This is a good indicator that they hada basilar skull fracture. This is a good assessment.

24. Primary Brain Injury • Results from physical stress within the brain tissue caused by open or closed trauma • Open head injury – occurs with skull fracture or penetration of the skull • The brain has been exposed to the outside/environmental contaminants. Not too good… Damage that occurs to the vessels, sinuses, cranial nerves, anything like that • Closed head injury – result of blunt trauma and is more serious • You’re hit really hard and your brain gets squished. You can’t really go in and repair anything.

25. Types of Brain Injuries • Concussion – minor, client may or may not lose consciousness, causes no structural damage • These guys should go to the hospital to make sure it’s not something more serious, but generally these people will be sent home and be given instructions to stay awake or woken often if they do sleep. Make sure they’re not confused, vomiting, c/o weakness or HA, etc. This is important b/c these are signs of internal damage. Usually take a few days to get over • Contusion – major, client loses consciousness, brain is bruised • This pt may lose consciousness for a few mins, usually have a decrease in BP, respirations, can lose control of their bowel/bladder. Usually when they go unconscious you can usually easily rouse them, but they’re very hyperactive when they get up (like all jumpy and what-not). Usually take several months to get over. Client may be left with HA, vertigo, seizures after the contusion.

26. Epidural Hematoma • Results from arterial bleeding into the space between the dura and inner surface of the skull. • Often these are caused by fractures of the temporal bones. The break can cause a tear to the artery right there and it will form quickly

27. Epidural Hematomas • Initial s/s: • They go unconscious then they have a brief period of lucidity followed by a decreased LOC • This is a medical emergency! This person can have respiratory arrest w/I minutes! • For this person they go in and drill holes to decrease the ICP. If there’s a clot they go in and remove it. If there is a bleed they’ll go and try to stop it. Might put in a drain to prevent reacumulation of the blood

28. Medical Management • MEDICAL EMERGENCY!!!!! • Burr holes through skull • Possible craniotomy • Drain

29. Subdural Hematoma • Results from venous bleeding into the space beneath the dura and above the arachnoid • Most common cause is trauma. Can be caused by bleeding disorderes or ruptured aneurysms. Most are venous (caused by ruptures of small vessels). Arterial ones are more rapid.

30. Types of Subdurals • Acute – occur with major head trauma, s/s develop over 24-48 hours. • S/S changes in LOC • Subacute – occur with less severe contusions, s/s develop 48 hours-2 weeks • S/S changes in LOC • Chronic – occur with minor head injuries, s/s develop 3 weeks-3 months, most frequently seen in the elderly (we get older and our brain shrinks in our skull that stays the same size). Harder to diagnose. Symptoms can mimic dementia or Alzheimer's

31. Intracerebral Hemorrhage • Accumulation of blood within the brain tissue caused by tearing of small arteries and veins in the white matter • Direct trauma (fractures and things, bullet wounds, stab injuries). You’ll see it a lot if someone has a tumor that bleeds all around it. High BP can cause this, anti-coagulation therapy people who fall and hit their heads, bleeding disorders

32. Medical Management of Brain Injuries • Physical & neurological exam • CT & MRI scans • Ventilatory support • Seizure prevention • Fluid & electrolyte maintenance • Nutritional support • Management of pain & anxiety

33. What Is The Nurse’s Responsibilities? • Ongoing neurological assessment • LOC • VS • Motor function • Pupil size

34. Cerebrovascular Disorders(6-8 Questions) Monti Smith, MSN, RN

35. Stroke • Definition – A disruption in the normal blood supply to the brain • Medical emergency. Needs to be treated immediately, the longer it lasts the worse the symptoms are • 3rd most common cause of death in the United States • Primary cause of adult disability in the United States

36. Types of Strokes • Ischemic • Thrombotic • Embolic • Transient Ischemic Attack • Hemorrhagic

37. Thrombotic Stroke • Results from thrombosis or narrowing of a blood vessel • Most common cause of strokes • Associated with DM & HTN • Can be preceded by a TIA • Usually don’t lose consciousness in the first 24 hours

39. Embolic Stroke • Embolus dislodges & occludes a cerebral artery resulting in infarction & edema • Second most common cause of stroke • Mostly originates from the endocardial layer of the heart • Lodges wherever the vessel narrows or where it bifurcates • If we don’t treat the underlying cause of these kinds of strokes or else it is almost certainly going to happen again

41. Hemorrhagic Stroke • Caused by bleeding into the brain tissue, ventricles, or subarachnoid space • Causes can vary • HTN, aneurysms, bleeding tumors… • You don’t want these kinds of strokes. If you survive the acute phase you’re going to have major problems • Deficits are severe & recovery is long

42. Transient Ischemic Attack (TIA) • Temporary loss of neurologic function caused by ischemia • Can last from 15 minutes to 24 hours • Serve as a warning sign of further cerebrovascular disease • Complete recovery between attacks

43. Clinical Manifestations • Motor deficits • Hemiparesis • Hemiplegia • Ataxia • Communication • Dysarthria • Dysphagia • Aphasia • Expressive Aphasia – their brain is thinking correctly but the words are coming out wrong. They know what they want to say but can’t get it out • Receptive Aphasia – they get confused by what you say. On the way from the ear to the brain the msg gets messed up. It never gets

44. Clinical Manifestations cont. • Cognitive Impairment • Memory loss • ↓ attention span • Poor reasoning • Altered judgment • Psychological Effects • Loss of self-control • Depression • Emotional lability

45. Clinical Manifestations cont. • Perceptual Disturbances • Homonymous hemianopsia • Loss of half of your visual field • Loss of peripheral vision • Diplopia • Difficulty judging distances • Apraxia • Inability to perform a previously learned action

46. Assessment & Diagnostic Findings • History, assessment, neuro exam • CT without contrast • EKG • Carotid doppler • May also see • Cerebral angiogram • Transcranial doppler • Transesophageal echocardiography • Put scope down throat to look at the back of your heart. A regular echo can’t see the back of the heart. • MRI

47. Medical Management for Acute Stroke • Thrombolytic Therapy within 3 hours of s/s • Noncontrast CT of head • Looking for blood. If they have blood it means it might be a hemorrhagic stroke and you don’t want to give them things that are going to increase their risk of bleeding • Blood tests for coagulation studies • Screening for hx of GI bleeding in past 3 months or major surgery in last 14 days

48. Surgical Management • Carotid endarterectomy • Go in and clean out the carotid arteries of plaque and stuff • Carotid stenting • Don’t see this alone as much. May do the cleaning and stenting at the same time • Aneurysm clipping, coiling • Resection of arteriovenous malformation (AVM)

49. Medical Management • Prevention is the most important! • What are some modifiable risk factors? • HTN • Afib • ↑ Lipids • DM • Smoking • Carotid stenosis • Obesity • Excessive alcohol consumption

50. Medical Management • Coumadin for atrial fibrillation • Plavix, ASA, Ticlid for TIA’s and strokes from suspected embolic or thrombotic causes • Statins • For cholesterol • Antihypertensives