Neurosensory: Traumatic Brain Injury (TBI) & Brain Tumors Marnie Quick, RN, MSN, CNRN

Normal brain protected by:

Normal brain

Traumatic Brain Injury (TBI): Etiology/Pathophysiology Risk factors- MVA; elevated blood alcohol; contact sports; acts of violence- gun, knife Mechanism of craniocerebral trauma Acceleration (movement)-deceleration (stationary) Coup (impact)-contrecoup (opposite) phenomenon Blunt or penetrating injury Closed head injury Scalp lacerations Skull fractures- Linear; comminuted; depressed; basilar; open/closed

Coup-contracoup injury

Penetrating injury- Gunshot to brain

Penetrating injury: Knife in brain

Basilar skull fracture- Base of skull fractured

Basilar skull fracture is base of skull if posterior> Battle sign- ecchymosis behind the ear

Basilar skull fracture is more anterior Raccoon eyes- periorbital ecchymosis

Basilar Skull fractures can cause leakage of CSF from meninges

Minor Brain Injury Concussion- sudden transient disruption of neural activity in the brain with change in LOC Post Concussion Syndrome- may occur after other brain injuries- severity of symptoms are not related to severity of brain injury. Sym may persist wks-months

Major Brain Injury- Focal injury Brain contusion- bruising; coup-contracoup Brain laceration- tearing brain tissue, ICH DAI- diffuse axonal injruy Widespread disruption of axons Poor prognosis Brain bleeds- Note meninges in relation to bleeds on following slides

Epidural hematoma

Subdural hematoma (SDH)

Intracerebral hematoma

Secondary brain injury Cerebral edema Localized or diffuse Peaks 24-72 hrs Occurs with CHI; open head injury; anoxia May in itself cause death by pressure> herniation Increased ICP Herniation Syndromes

Traumatic Brain Injury (TBI): Common Manifestations/Complications Increased ICP symptoms general and specific Restlessness- R/O respiratory; waking up Systemic effects of acute brain injury- hypermetabolism, brainstorming, SIADH Brainstorming- hypothalamic stimulation-ANS CSF leak- rhinorrhea/otorrhea- basal skull Fx Post concussion Syndrome Associated cervical spinal cord injury

Collaborative Care: Traumatic Brain Injury (TBI): Diagnostic studies (similar to ICP) Emergency management: assessment and interventions (Lewis 1484 Table 57-9) Treat IICP- airway; fluid; positioning; temp reg; meds Prevention of complications Medications: IICP; seizures; stress ulcer;straining;brainstorming Diet/calories: hypermetabolic state; ileus; swallow/gag CSF leak: glucose; halo; HOB 30; no nasal suction Other: SIADH> hyponatremia Surgery: bone repair; evacuation clot; craniotomy/ectomy; burr hole; cranioplasty; monitor placement

Burr holes craniotomy

Place monitors/intraventricular drain:

Crainectomy- bone flap out to allow for brain expansion post op

Post crani

Traumatic Brain Injury (TBI): Nursing assessment specific to TBI Health history Description of accident; past medical history NVS and Glasgow Coma http://www.trauma.org/scores/gcs.html Brainstem reflexes VS- Late sign is Cushing reflex Skull/face; CSF leak; SCI Consider older adult finding

Pertinent Nursing Problems Specific to Traumatic Brain Injury (TBI): Health promotion Ineffective tissue perfusion, cerebral (decreased intracranial adaptive capacity) Ineffective airway clearance/breathing pattern Hypothermia Pain Impaired physical mobility

Decreased cerebral perfusion (IICP) Anxiety Decreased cerebral perfusion (IICP) Brain death (ethical dilemmas p.1485) Home care Home evaluation/rehab/nursing home Teach about post concussion syndrome; B&B; spasticity; dysphagia; nutrition; seizure disorder; personality changes; family role changes 6 months typical plateau period Community agencies/support groups

http://library. med. utah http://library.med.utah.edu/kw/animations/hyperbrain/oculo_reflex/oculocephalic2.html http://cim.ucdavis.edu/eyes/version15/eyesim.html http://www.softwarefornurses.com/access/index.asp

Primary brain tumors Arise from support cells, neurogilia cells; the meninges; or blood vessels Do not metastasize outside cranium Cause unknown

Grade I and II gilomas (astrocytoma) made up of astrocytes; are benign, slow-growing tumors Grade III and IV gliomas (glioblastoma Multiforme are invasive and fast-growing Meningiomas arise from the meninges; slow-growing; benign, encapsulated and compress the brain Brain tumors may be lethal due to their location

Gioblastoma Meningioma

Metastatic (secondary) brain tumors Originate from outside the brain- lung and breast most common sites Single or multiple Becoming more common as individual with cancer in other parts of the body are living longer

Clinical Manifestations/complications of Brain tumors General ICP symptoms Common early symptoms: headache; vomiting; papilledema (visual changes) Seizures- partial classification in type Brain tumor symptoms occur due to their ability to compress or destroy brain tissue; edema that forms around the tumor; hemorrhage; & obstruction of CSF flow Specific symptoms as to the lobe affected>

Frontal lobe: personality changes; inappropriate behavior; inability to concentrate; impaired judgment; headache; expressive aphasia if dominant hemisphere; motor weakness or paralysis from motor strip Parietal lobe: sensory deficits- paresthesia, visual field deficits; contralateral sensory disturbances from sensory strip; loss of interpretation and discrimination for sensing input; perceptual problems

Occipital lobe: visual disturbances; visual agnosia Temporal lobe: complex partial (psychomotor) seizures; auditory hallucinations; memory problems; Wernicke aphasia if dominant hemisphere Cerebellum: gait distrubances; balance and coordination problems Brain stem: cranial nerve dysfunction; vital signs

Complications of Brain Tumors Hydrocephalus Infection Death is usually caused by IICP/hermiation

Collaborative Care for Brain Tumors Diagnostic tests CT/MRI EEG PET Angiogram Tissue biopsy

Collaborative Care for brain tumors Surgery To remove or debulk Supratentorial- above tentorium Infratentorial-below Stereotaxic-localized

Rehab- outpatient or in house Radiation Used alone or with other therapies Gamma or Cyber-knife Complication- increased cerebral edema Medications Chemotherapy: IV; intraventricular (ommaya Reservoir) or by wafer implanted Corticosteroids to treat brain edema Anticonvulsants to prevent seizures Rehab- outpatient or in house

Health history: progression of symptoms; other cancers, disease Physical exam Neuro vital signs Specific signs of the local functions of different parts of the brain Similar neuro deficits as the individual with a stroke Signs of increased intracranial pressure/herniation

Pertinent Nursing Problems for Brain Tumor Impaired tissue perfusion, cerebral Self-care deficits Anxiety Risk for infection-post crani Acute pain Disturbed self-esteem Nutrition Home care- rehab; home eval; support groups