Traumatic Brain Injury A Case Study Lisa Randall, RN, MSN, ACNS-BC RNSG 2432

Demographics/CC 23 y.o. AAM Auto vs. ped 8/10/08

HPI Dancing on I-35 under the influence of crack cocaine and ETOH. Hit by 2 cars > 50mph GCS 12 on arrival, but declined to 4 Eyes 4>1 Verbal 3>1 Motor 5>2

History PMH PSH Social Hx Meds Denies, but GSW (metallic pellets CXR) Single, no children, unemployed, unfunded +ETOH, +amphetamines, +cannibis Recently released from jail for drug possession Meds

Diagnostics Normal CT

Subdural Hematoma

Diagnostics

Diagnostics

Focused A/P R frontotemporoparietal SDH Paraplegia/paresis Craniectomy EVD Monitor/treat ICP Paraplegia/paresis L2 burst fracture c subluxation L2-L3 T11 lamina/TP fracture T10-L3 posterior fusion when stable PT/OT/ST…rehab

A/P con’t 10th & 11th rib fractures R femur fracture Acetabular fracture Mediastinal hematoma

Post-Op

Post-Op

Nursing Concerns Neuro checks/VS q1h ICP monitoring CPP monitoring Mannitol CSF drainage CPP monitoring IVF Vasopressors MAP monitoring Sedation/analgesia Seizure prophylaxis Infection prophylaxis Skin care

Interdisciplinary Collaboration Trauma Pulmonary/CC Orthopedics ID SW/CM Nursing PT/OT/ST/RT WOCN Dietary

Evaluation Rehabilitation Assessment Cranioplasty Decreased short term memory Paraparesis DF 2/5, PF 2/5, HF 4-/5 Cranioplasty

Epidemiology of Head Trauma Occurs every 15 seconds 500,000 annual ED visits Most common causes: MVAs, falls, assaults Males 15-24, elderly > 75 Accounts for 40% of traumatic deaths

Pathophysiology of TBI 1st Primary Injury: initial insult … i.e. from bleed

Second Secondary Injury: delayed injury from hypoxia, ischemia, and release of neurotoxins Excitatory amino acids can cause swelling and neuronal death Endogenous opioids cause increased metabolism, using glucose supplies Increased ICP, especially > 40 leads to brain hypoxia, ischemia, hydrocephalus, herniation Hydrocephalus: clotted blood obstructs CSF outflow tracts and absorption of CSF, disrupts blood-brain barrier

Head Trauma Concussion Contusion Epidural hematoma (EDH) Subdural hematoma (SDH) Basilar skull fracture Diffuse axonal injury (DAI)

Epidural Contusions Basilar skull fracture Depressed skull Fracture

Types of Injuries Mild Traumatic Brain Injury: Concussion: brief change in mental status with axonal swelling Moderate to Severe Brain Injury: Contusion: “bruising” Fractures: linear,comminuted, depressed, basalar Bleeds: epidural, subdural, intracerebral

Mild Traumatic Brain Injury Period of LOC < 30 mins with a GCS of 13-15 after this LOC Amnesia to the event Alteration in mental status at the time of the event (dazed and confused)

Types of Concussion Grade I (confusion, no amnesia, no LOC) Remove from activity (may return when asymptomatic) 3 concussions in 3 months: no activity that risks head trauma for 3 months Grade II (confusion and amnesia) Remove from activity for day Recheck in 24 hours No activity for 1 week Two grade II concussions in 3 months, no activity for 3 months Grade III (LOC) To ED for CT Symptom free for 2 weeks, then another 30 days Two grade III concussions, no activity for 3 months

Post-Concussive Syndrome Somatic symptoms: headache, sleep disturbance, dizziness, vertigo, nausea, fatigue, sensitivity to light or noise Cognitive: attention, concentration, memory problems Affective: irritability, depression, anxiety, emotional lability

Moderate and Severe Brain Injury

Contusion Small bleeds Cerebral Edema Deficits are based on lobe involved

Fractures Linear Comminuted

Depressed Skull Fracture 95% go to surgery Antibitoics for infection Brain tissue is involved

Treatment for CSF leak

Epidural Hematoma Laceration of dural arteries or veins Classically laceration of middle meningeal artery Temporal bone fractures “Lucid interval” followed by rapid deterioration Acute bleed

Subdural Hematoma 60-80% mortality Tearing of bridging veins, pial artery, or cortical veins Acute vs chronic

Traumatic Subarachnoid Hemorrhage Lacerations of vessels in subarachnoid space TSAH SAH

Intraventricular and Intraparenchymal Hemorrhage Intraventricular hemorrhage Very severe TBI Poor prognosis Intracerebral hemorrhage Parenchymal injuries from lacerations or contusions Large deep cerebral vessel injury

Coup and Contrecoup Injuries Coup: direct skull impact Contrecoup: opposite side of impact Due to negative pressure forces causing both vascular and tissue damage

DAI Diffuse Axonal Injury

Neurologic Exam Decreased neurologic function is best predictor of brain injury Pay attention to cranial nerves

Management of Acute Brain Trauma Labs: CBC, electrolytes, type and screen, tox and ETOH screen CT Brain CT angiography or cerebral angiography (penetrating) MRI contraindicated if metallic fragments

Management Continued. . . Intubate GCS 8 or less or airway protection issue (Cricothyroidotomy if necessary) Maintain BP 90 mmHg systolic C-spine precautions Tetanus prophylaxis Sterile dressing to wounds Antibiotics in penetrating injury

ICP Management is the Key ICP monitor in patients with GCS < 8 Hyperventilation not routinely recommended Elevate head of bed to 30 degrees Sedation Propofol Barbiturate Induced Coma Contraindicated in hypotension Mannitol Reduces ICP by reducing blood viscosity, improves cerebral blood flow Serum osmolality should not be > 320 Bolus dosing

To Image or Not to Image? GCS < 15 Intoxicated Amnesia to events Witnessed LOC (> 15 minutes) Repeated vomiting Evidence of basilar skull fracture Inability to recall 3 of 5 objects Coagulopathy Penetrating head injury

Ventriculostomy

Evidenced Based Medical Guidelines for TBI Management BP and oxygenation Hyperosmolar therapy ICP monitoring CPP Infection prophylaxis DVT prophylaxis http://youtu.be/YQ609Tk-qQI PbtO2 Analgesic/sedatives Nutrition Antiseizure prophylaxis Hyperventilation Steroids Hypothermia

New Therapy Stem Cell Therapy Neural/Glial differentiation Neurogenesis Neuroplasticity Improve motor function Improve cognitive function

References AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St. Davis, F.A. (2001). Taber’s Cyclopedic Medical Dictionary. F.A. Davis, Philadelphia. Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida. Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L. (2007). Medical-Surgical Nursign. Assessment of Management of Medical Problems. Mosby Elsevier, St. Louis, Missouri Silvestri, Linda. (2008). Comprehensive review for the NCLEX-RN Examination. Saunders Elsevier, St. Louis, Missouri.

Introduction YouTube - Brain Plasticity

Neuroplasticity Organizational changes caused by experience Neurons constantly lay down new pathways for neural communication and to rearrange existing ones throughout life—hence learning, memory, etc. Example—eyelids of a cat sutured—they perform better with sound localization tasks—neurons expand into cortical areas normally used for visual processing. There was also an increase in the cortical area devoted to whiskers.

Neurogenesis Formation of new nerve cells 1980’s—song birds—increased neurons during seasons when engaged in singing. During other times when not singing, the number of neurons decreased—no neurogenesis. However, not thought to occur in primates—neurogenesis was thought to be restricted throughout evolution as brain becomes more complex.

Nature vs. Nurture Genetics Environment 2500 connections 15000 “major highways” Environment 15000 “avenues & side roads” The avenues and side roads form a dense, complex network that is always under construction.

Future “Directed Neuroplasticity” Stem cells stimulated to migrate to areas and differentiate into specific types of neurons—replace cells lost to stroke, etc. New tx for brain damage/injury and/or cog. Disabilities (ADHD, dyslexia, down syndrome). With directed neuroplasticity, scientists and clinicians can deliver calculated sequences of input, and/or specific repititive patterns of stimulation, to cause desirable and specific changes in the brain. Skills lost can be relearned, the decline of abilities can be staved off or reversed and entirely new fxns can be gained.

Brain Fitness Program YouTube - The Brain Fitness Program (1/8)