Management of Patients With Neurologic Trauma

Head Injury A broad classification that includes injury to the scalp, skull, or brain 1.4 million people in the U.S. receive head injuries every year (50,000 die) Head injury is the most common cause of death from trauma Most common cause of brain trauma is MVA Group at highest risk group for brain trauma are males age 15 to 24 Prevention!

Pathophysiology of Brain Damage Primary injury: due to the initial damage Contusions, lacerations, damage to blood vessels, acceleration/deceleration injury, or foreign object penetration Secondary injury: damage evolves after the initial insult Due to cerebral edema, ischemia, or chemical changes associated with the trauma Monroe-Kellie hypothesis

Pathophysiology of Traumatic Brain Injury

Manifestations Manifestations depend upon the severity and location of the injury Scalp wounds Tend to bleed heavily; scalp wounds are also portals for infection Skull fractures Usually have localized, persistent pain Classified as simple, comminuted, depressed, basilar

Manifestations Skull fractures Fractures of the base of the skull Bleeding from nose, pharynx, or ears Battle’s sign: ecchymosis behind the ear Raccoon eyes CSF may escape from the ears or nose CSF leak—halo sign—ring of fluid around the blood stain from drainage

Management of skull fractures Diagnosed via CT or MRI Nondepressed fractures do not require treatment if no underlying brain injury Depressed fractures require surgery and IV antibiotics Basilar fractures Serious d/t CSF leakage May require sugery Caution patient not to blow nose HOB elevated 30 degrees

Basilar Fractures Allow CSF to Leak From the Nose and Ears

Manifestations of Brain Injury Altered level of consciousness Pupillary abnormalities Sudden onset of neurological deficits and neurological changes; changes in sense, movement, and reflexes Changes in vital signs Headache Seizures

Initial Management of the Severe Head Injury Patient

Brain Injury Closed brain injury (blunt trauma): acceleration/ deceleration injury occurs when the head accelerates then rapidly decelerates, damaging brain tissue Open brain injury: object penetrates the brain or trauma is so severe that the scalp and skull are opened Concussion: a temporary loss of consciousness with no apparent structural damage

Brain Injury (cont.) Contusion: more severe injury with possible surface hemorrhage (“bruised”) Symptoms and recovery depend upon the amount of damage and associated cerebral edema Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs

Brain Injury (cont.) Diffuse axonal injury: widespread axon damage in the brain seen with head trauma; patient develops immediate coma Intracranial bleeding Epidural hematoma Subdural hematoma Acute and subacute Chronic Intracerebral hemorrhage and hematoma

Concussion Patient may be admitted for observation or sent home Observation of patients after head trauma; report immediately Observe for any changes in level of consciousness Difficulty in awakening, lethargy, dizziness, confusion, irritability, and anxiety Difficulty in speaking or moving Severe headache Vomiting Patient should be aroused and assessed frequently

Location of Subdural, Intracerebral, and Epidural Hemorrhages

Epidural Hematoma Blood collection in the space between the skull and the dura Patient may have a brief loss of consciousness with return of lucid state; then, as hematoma expands, increased ICP will often suddenly reduce LOC An emergency situation Treatment includes measures to reduce ICP, remove the clot, and stop bleeding Monitoring and support of vital body functions and respiratory support

Subdural Hematoma Collection of blood between the dura and the brain Most commonly caused by trauma Acute/subacute Acute: symptoms develop over 24 to 48 hours Subacute: symptoms develop over 48 hours to 2 weeks LOC and pupillary changes, hemiparesis Requires immediate craniotomy and control of ICP Chronic Develops over weeks to months, elderly are prone to this Causative injury may be minor and forgotten Clinical signs and symptoms may fluctuate; include HA, focal neuro signs, personality changes, focal seizures Treatment is evacuation of the clot

Intracerebral Hemorrhage Hemorrhage occurs into the substance of the brain May be due to trauma or a nontraumatic cause Treatment Supportive care Control of ICP Craniotomy or craniectomy to remove clot and control hemorrhage May not be possible due to the location or lack of circumscribed area of hemorrhage

Diagnostic Evaluation Physical and neurologic exam Skull and spinal x-rays CT scan MRI PET scan

Management of the Patient With a Head Injury Assume cervical spine injury until this is ruled out! Back board and cervical collar Therapy to preserve brain homeostasis and prevent secondary damage Treat cerebral edema Maintain cerebral perfusion; treat hypotension, hypovolemia, and bleeding; monitor and manage ICP Maintain oxygenation as well as cardiovascular and respiratory function Manage seizures Manage fluid and electrolyte balance

Supportive Measures Respiratory support; intubation and mechanical ventilation Seizure precautions and prevention NG to manage reduced gastric motility and prevent aspiration Fluid and electrolyte maintenance Pain and anxiety management Nutrition

Brain Death Potential organ donor Brain death declared when patient is considered to have irreversible loss of all brain function Cardinal signs Coma Absence of brain stem reflexes Apnea

Nursing Process—Assessment of the Patient With Brain Injury Health history with focus upon the immediate injury, time, cause, and the direction and force of the blow; loss of consciousness, amnesia Baseline assessment LOC: Use Glasgow Coma Scale Frequent and ongoing neurologic assessment

Glasgow Coma Scale

Nursing Process—Diagnosis Ineffective airway clearance and impaired gas exchange r/t brain injury Ineffective tissue perfusion r/t decreased CPP Deficient fluid volume Imbalanced nutrition Risk for injury r/t seizures and disorientation

Nursing Process—Diagnosis Risk for impaired skin integrity r/t hemiparesis or immobility Disturbed thought processes r/t brain injury Disturbed sleep pattern r/t frequent neuro checks Interrupted family process

Collaborative Problems/Potential Complications Decreased cerebral perfusion Cerebral edema and herniation Impaired oxygenation and ventilation Impaired fluid, electrolyte, and nutritional balance Risk of post-traumatic seizures

Nursing Process—Planning Major goals include maintenance of patent airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, maintenance of normal temperature, maintenance of skin integrity, improvement of cognitive function, prevention of sleep deprivation, effective family coping, increased knowledge about rehabilitation process, and absence of complications

Interventions Provide ongoing neuro assessment and monitoring is vital Maintain airway Positioning to facilitate drainage of oral secretions with HOB usually elevated 30° to decrease venous pressure Suctioning with caution Prevention of aspiration and respiratory insufficiency Monitor ABGs, ventilation, and mechanical ventilation Monitor for pulmonary complications, potential ARDS

Interventions (cont.) Monitor I&O and daily weights Monitor blood and urine electrolytes, osmolality and blood glucose (watch for SIADH, DI) Management of hyperglycemia Implement measures to promote adequate nutrition Implement strategies to prevent injury Assess oxygenation Assess for constriction due to dressings and casts Pad side rails to prevent self-injury Use mittens to prevent self-injury; avoid restraints

Posey Mitt Used to Prevent Self-Injury

Interventions Strategies to prevent injury Maintain body temperature Reduce environmental stimuli Use adequate lighting to reduce visual hallucinations Implement measures to minimize disruption of sleep–wake cycles Provide skin care Maintain body temperature Maintain appropriate environmental temperature Use coverings: sheets, blankets as per patient needs Administer acetaminophen for fever Use cooling blankets or cool baths; prevent shivering

Interventions (cont.) Support cognitive function Support family Provide and reinforce information Implement measures to promote effective coping Set realistic, well-defined, short-term goals Refer patient for counseling Refer patient to support groups Patient and family teaching: table 57-11

Spinal Cord Injury (SCI) 222,000 persons in the U.S. live with disability from SCI Causes include MVAs (50% violence (11%), falls (24%), and sports injuries (9%) Males account for 78% of SCIs Young people ages 16 to 30 account for more than half of all new SCIs Risk factors include alcohol and drug use Most commonly C5-C7

Spinal Cord Injury (SCI) (cont.) The result of cord compression by bone, interruption in blood supply, traction the results in pulling of the spinal cord, or transection from trauma Primary injury is the result of the initial trauma Secondary injury is usually the result of ischemia, hypoxia, and hemorrhage which destroys the nerve tissues Secondary injuries are thought to be reversible/ preventable during the first 4 to 6 hours after injury Extent of injury best determined 72 hours or later after injury

Spinal Cord Injury (SCI) (cont.) Classifications Mechanism of injury Level of Injury Skeletal Neurologic level Degree of injury

Manifestations Respiratory Cardiovascular Urinary Gastrointestinal Cervical and thoracic injuries Cardiovascular Bradycardia Hypovolemia Urinary Retention Gastrointestinal Hypomotility Neurogenic bowel Integumentary Thermoregulation Decreased ability to sweat or shiver below lesion

Spinal Cord Injury Management Immobilization on backboard, head in neutral position Acute phase medical management Goal is to prevent further SCI and observe to symptoms of progressive neuro deficits High dose steroids are controversial Adequate oxygenation and airway management Skeletal fracture reduction and traction Halo vest to immobilize cervical spine while allowing early ambulation Surgical management Indicated for compression of cord, unstable vertebral body, wound penetrates cord,bony fragments in canal, neuro status deteriorates

Spinal and Neurogenic Shock Spinal shock A sudden depression of reflex activity below the level of spinal injury Muscular flaccidity and lack of sensation and reflexes (particularly bladder and bowel) Neurogenic shock Due to the loss of function of the autonomic nervous system (vasomotor tone); vital organs affected Blood pressure, heart rate decrease, and cardiac output decreases Venous pooling occurs due to peripheral vasodilation Paralyzed portions of the body do not perspire

Autonomic Dysreflexia (AD) Acute emergency Occurs after spinal shock has resolved and may occur years after the injury (table 61-7) Occurs in persons with a SC lesion above T6 Autonomic nervous system responses are exaggerated Symptoms include severe pounding headache, sudden increase in blood pressure, profuse diaphoresis, nausea, and bradycardia Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (such as constipation)

Nursing Interventions for AD Place patient in seated position to lower BP Impose rapid assessment to identify and eliminate cause Empty the bladder using a urinary catheter and irrigate/change indwelling catheter Examine rectum for fecal mass Examine skin Examine for any other stimulus Administer ganglionic blocking agent such as hydralazine or nifedipine Label chart or medical record that patient is at risk for autonomic dysreflexia

Nursing Process—Assessment of the Patient With SCI Monitor respirations and breathing pattern Assess lung sounds and cough Monitor for changes in motor or sensory function; report immediately Assess for spinal shock and neurogenic shock Monitor for bladder retention or distention, gastric dilation, and ileus Temperature; assess for potential hyperthermia

Nursing Process—Diagnosis Ineffective breathing pattern Ineffective airway clearance Impaired physical mobility Disturbed sensory perception Risk for impaired skin integrity Impaired urinary elimination Constipation Acute pain

Collaborative Problems/Potential Complications DVT Spasticity of muscles Pneumonia Infection Bowel and bladder dysfunction

Collaborative Problems/Potential Complications Orthostatic hypotension Interruption in vasoconstriction mechanism May be managed with abdominal binders or hose Autonomic dysreflexia Identify and remove stimulus Sitting position to lower BP Teach pt to identify triggers and avoid them

Nursing Process—Planning Major goals include improved breathing pattern and airway clearance, improved mobility, improved sensory and perceptual awareness, maintenance of skin integrity, promotion of comfort, and absence of complications

Implementation Promotion of respiratory function Monitor carefully to detect potential respiratory failure Pulse oximetry and ABGs Lung sounds Early and vigorous pulmonary care to prevent and remove secretions Suctioning with caution (can stimulate vagus nerve) Breathing exercises Assisted coughing

Implementation Improving mobility Maintain proper body alignment Turn only if spine is stable and as indicated by physician Monitor blood pressure with position changes PROM at least 4 times a day Use neck brace or collar, as prescribed, when patient is mobilized Move gradually to erect position

Implementation Neurogenic bladder Any type of bladder dysfunction related to abnormal bladder innervation Urinary drainage options Indwelling catheter Intermittent catherization Spastic bladder may be treated with anticholinergics or Botox Urinary diversion

Implementation Neurogenic bowel Volunary control of bowel function may be lost Prevent constipation Stimulation Bowel programs See table 61-10

Implementation Sexuality Depending on level of lesion, treatment for ED may be indicated If male is unable to obtain erection, consider specialist to discuss other options for sexuality Fertility options - males and females Open, culturally sensitive discussion

Implementation Other Maintain skin integrity DVT prevention Implement high-calorie, high-protein, high-fiber diet Implement traction pin care for halo Provide hygiene and skin care related to traction devices Allow patient to grieve

Evaluation - Expected Patient Outcomes Demonstrates improvement in gas exchange and clearing secretions Moves within limitations of dysfunction and demonstrates completion of exercises within limitations Demonstrates adaptation to sensory and perceptual alterations Demonstrates optimal skin integrity Regains urinary bladder function Regains bowel function Reports absence of pain Is free from complications

RotoRest Bed

Cervical Collar

Halo Systems for Cervical and Thoracic Injuries

Interventions Implement strategies to compensate for sensory and perceptual alterations Implement measures to maintain skin integrity Provide temporary indwelling catheterization or intermittent catheterization Use NG tube to alleviate gastric distention