1. Head Trauma Brain Injury M.DuBois Fennal, PHD, RN, CNS

2. Brain Injury An injury to the brain caused by impact, swelling, bleeding, infection, hypoxia or ischema An injury to the brain caused by impact, swelling, bleeding, infection, hypoxia or ischema

3. Etiology Blow to the head (blunt trauma) or increase inter-cranial pressure Blow to the head (blunt trauma) or increase inter-cranial pressure

4. Incidence A leading cause of death and disability in the US A leading cause of death and disability in the US Two million people in the US every year with two thirds being below age 30 Two million people in the US every year with two thirds being below age 30 More common in males than in females More common in males than in females 500,000 hospitalizations 500,000 hospitalizations Leading cause of death between ages 1- 44 Leading cause of death between ages 1- 44

5. Motor vehicle accidents responsible for the most of the deaths Motor vehicle accidents responsible for the most of the deaths Increase blood alcohol levels are big contributors Increase blood alcohol levels are big contributors Falls, sports injuries, occupational injuries, assaults, and gunshot wounds Falls, sports injuries, occupational injuries, assaults, and gunshot wounds

6. Mechanism of Injury Acceleration (baseball bat) Acceleration (baseball bat) Deceleration (concrete wall) Deceleration (concrete wall) Acceleration/deceleration (coup- contrecoup) Acceleration/deceleration (coup- contrecoup) Closed head injury Closed head injury Open Head injury Open Head injury

7. Types Concussion: Transient temporary neurogenic dysfunctio Concussion: Transient temporary neurogenic dysfunctio Contusion: Bruising of brain, venous hemorrhage occurs when the brain strikes the inner skull Contusion: Bruising of brain, venous hemorrhage occurs when the brain strikes the inner skull Diffuse Axonal Injury (DAI): Widespread distruption of axons in white matter. Loss of consciousness, vegetation, and/or death. Diffuse Axonal Injury (DAI): Widespread distruption of axons in white matter. Loss of consciousness, vegetation, and/or death.

8. Pathophysiology Primary: Initial damage to the brain cause by the impact (contusions, lacerations, ruptured blood vessels, bruising from coup contracoop injury, penetration injury) Primary: Initial damage to the brain cause by the impact (contusions, lacerations, ruptured blood vessels, bruising from coup contracoop injury, penetration injury) Secondary: cerebral edema, ischemia, and chemical imbalances Secondary: cerebral edema, ischemia, and chemical imbalances

9. Intercranial hematoma: subdural venous bleed, caused by trauma Intercranial hematoma: subdural venous bleed, caused by trauma Epidural: arterial bleed caused by trauma Epidural: arterial bleed caused by trauma Intracerebral bleed: Hemorrhage into the brain substance itself Intracerebral bleed: Hemorrhage into the brain substance itself

10. Clinical Manifestations Loss of consciousness Loss of consciousness Amnesia Amnesia Headache Headache Drowsiness, confusion, dizziness Drowsiness, confusion, dizziness Visual distrubances Visual distrubances Seizure Seizure Bradycardia, apnea, pallor, hypotension Bradycardia, apnea, pallor, hypotension

11. Brain Stem Injury Decebrate posturing Decebrate posturing Decorticate posturing Decorticate posturing Non reactive pupils Non reactive pupils Abnormal respiratory patterns Abnormal respiratory patterns

12. Diagnosis Neurological exam Neurological exam CT Scan CT Scan MRI MRI ABG’s ABG’s ICP ICP

13. Medical Management Depend on the injury Depend on the injury Mannitol for increased ICP Mannitol for increased ICP Ventilator and intubation Ventilator and intubation Steroids Steroids Hemodynamic monitoring Hemodynamic monitoring ICP line ICP line CBC, Lytes, Glucose, Serum Osmolarity CBC, Lytes, Glucose, Serum Osmolarity

14. Nursing Management Assessment (respirations, pain, orientation) Assessment (respirations, pain, orientation) Tissue perfusion Tissue perfusion Communication Communication Prevent Infection Prevent Infection Nutrition Nutrition Prevent Injury Prevent Injury Rest, Elimination and safety Rest, Elimination and safety

15. Increased Intercranial Pressure Definition: Pressure exerted by the cerebrospinal fluid within the ventricles of the brain. Measures between 0-15 mm Hg Definition: Pressure exerted by the cerebrospinal fluid within the ventricles of the brain. Measures between 0-15 mm Hg

16. Etiology Increased volume of the brain Increased volume of the brain Cerebral edema Cerebral edema Trauma Trauma Surgery Surgery Stroke Stroke Tumor Tumor

17. Increased volume of blood Increased volume of blood Hematomas Hematomas AV malformations AV malformations Aneurysm Aneurysm Stroke Stroke Increase in PCO2 Increase in PCO2

18. Increased volume of CSF Increased volume of CSF Decrease absorption of CSF Decrease absorption of CSF Congenital hydrocephalus Congenital hydrocephalus

19. Lesions Lesions Tumors Tumors Abscesses Abscesses

20. Incidence None known None known 90 percent of fatal head injuries 90 percent of fatal head injuries

21. Monro-Kellie Hypothesis Brain Matter = 80% Brain Matter = 80% Intravascular blood = 10% Intravascular blood = 10% Cerebrospinal fluid = 10% Cerebrospinal fluid = 10%

22. Pathophysiology Cranial insult> Tissue edema> Increase Intercranial Pressure> Compression of arteries> Decrease cerebral blood flow> decrease oxygen with death of brain cells>Edema around necrotic cells> Increase intercranial pressure with compression of brain stem and respiratory center> accumulation of CO2 and vasodilation>Increase ICP and blood volume=death Cranial insult> Tissue edema> Increase Intercranial Pressure> Compression of arteries> Decrease cerebral blood flow> decrease oxygen with death of brain cells>Edema around necrotic cells> Increase intercranial pressure with compression of brain stem and respiratory center> accumulation of CO2 and vasodilation>Increase ICP and blood volume=death

23. Diagnosis Assessment Assessment CT Scan CT Scan CT Monitoring CT Monitoring

24. Medical Management Insertion of ICP line Insertion of ICP line Steroids Steroids Anti-hypertensive therapy Anti-hypertensive therapy Hemodynamic monitoring Hemodynamic monitoring

25. Mannitol Mannitol Hyperventilation Hyperventilation Hypothermia Hypothermia Sedation (propolol) Sedation (propolol) Analgesics (fentanyl) Analgesics (fentanyl) Neuromuscular blockades Neuromuscular blockades Barbiturate coma (nembutal, pentobarbital,) Barbiturate coma (nembutal, pentobarbital,)

26. Nursing Management Assessment Assessment Maintenance of ICP Maintenance of ICP Administration of fluids and medication Administration of fluids and medication Elevate the head of the bed (15-30 degrees) Elevate the head of the bed (15-30 degrees) Hemodynamic monitoring Hemodynamic monitoring

27. Knowledge of ventilation mangement Knowledge of ventilation mangement Safety Safety Prevent infection Prevent infection Management of hypothermic states Management of hypothermic states

28. Seizures Definition: Central nervous system stimulation produced by excessive abnormal neuronal discharge. Definition: Central nervous system stimulation produced by excessive abnormal neuronal discharge.

29. Etiology Given the right circumstances created by any stressor, anyone can become subject to seizures (Hickey, 2003) Given the right circumstances created by any stressor, anyone can become subject to seizures (Hickey, 2003) Genetic Tendency Genetic Tendency Pathological processes Pathological processes Injury Injury

30. Incidence 2-4 million Americans suffer from ‘epilepsy 2-4 million Americans suffer from ‘epilepsy Onset, 0-2 years, 5-7 years, early puberty especially in girls Onset, 0-2 years, 5-7 years, early puberty especially in girls 90% of patients with seizures disorders experience first seizure before age 20 90% of patients with seizures disorders experience first seizure before age 20

31. Pathophysiology Seizures arise from abnormal hyperactive, hypersensitive neurons. Epileptogenic cells are different from so called normal cells/neurons Seizures arise from abnormal hyperactive, hypersensitive neurons. Epileptogenic cells are different from so called normal cells/neurons Autonomous Autonomous Emits excessively large numbers of paroxysmal discharges Emits excessively large numbers of paroxysmal discharges Exact mechanism is not known Exact mechanism is not known

32. Classification Partial seizures (simple) Partial seizures (simple) Partial seizures (complex) Partial seizures (complex) Generalized seizures (tonic/clonic, petit mal) Generalized seizures (tonic/clonic, petit mal) Unclassified epilepctic seizures Unclassified epilepctic seizures

33. Diagnosis Search for the underlying cause Search for the underlying cause History History Blood work, urinalysis, electrolytes, glucose, Ca, BUN, Blood work, urinalysis, electrolytes, glucose, Ca, BUN, EEG EEG

34. Clinical Manifestations Depends on the type of seizure Depends on the type of seizure Depends on the area of the brain Depends on the area of the brain

35. Medical Management Diet (Ketogenic, high fat, not acceptable) Diet (Ketogenic, high fat, not acceptable) Medication (anticonvulsants such as dilantin and phenobarbital) Medication (anticonvulsants such as dilantin and phenobarbital) Surgical mgt. for causes such as tumors, lesions etc. Surgical mgt. for causes such as tumors, lesions etc.

36. Nursing Management Safety Safety Seizure precautions Seizure precautions Prevent injury Prevent injury Tongue Tongue Airway, suction, O2, Airway, suction, O2, Limbs Limbs Head Head

37. Assessment Aura Aura Behavior Behavior Starting point Starting point During the seizure During the seizure Posticital (after the seizure) Posticital (after the seizure)

38. Documentation Very Important Very Important Requires highly develop observation skills Requires highly develop observation skills Knowing what to look for Knowing what to look for