1. Chapter 36: Traumatic Brain Injury

2. Statistics 80,000 have disability; 50,000 die from head injury
Head injury profiles
Age 15 to 24
Male
Causes
Motor vehicle accidents
Falls (especially in the young and older populations)
Violence

3. Mechanism of Injury
Important information to get from those at the scene
Important in determining where the injury is located and the type of neurologic deficits
Mechanism of injury
Acceleration – moving object hits nonmoving head
Deceleration – moving head hits stationary object
Coup-contrecoup – damage from rebound effect
Rotational – twisting of brain in the skull
(See Figure 36-1.)

4. Question
Which of the following predisposes an elderly patient to falls and possible head injury?
A. An enlarged cerebrum
B. Sinus arrhythmia
C. Nocturia
D. The use of steroids in the elderly

5. Answer
C. Nocturia
Rationale: Nocturia (getting up to void at night) along with decreased visual acuity leads to falls. Cerebral atrophy, not enlargement, leads to more room for the brain to move, and therefore the brain would be subject to trauma against the bony skull. Steroids are not always used in the elderly, and complications are not associated with falls. Atrial fibrillation and flutter can lead to strokes or syncope and falls.

6. Pathophysiology: Types
Primary (due to initial injury)
Types
Lacerations
Skull fracture
Basilar skull fracture
Concussion
Contusion
Hematomas
SAH (subarachnoid hemorrhage)
DAH (diffuse axonal injury)
Cerebrovascular injury
Secondary (generally due to response to injury)
Types
Cerebral edema
Ischemia
Herniation syndromes
Coma

7. Primary Injuries Scalp lacerations
Always a bit scary as they tend to bleed a lot
Skull fractures
Open/compound
Linear
Closed
Depressed
Bone fragments may enter the dura

8. Primary Injuries: Basilar Skull Fracture
Classic signs, usually due to CSF leakage from the sinuses or bleeding in unusual areas
Otorrhea
Postauricular hematoma (Battle’s sign)
Rhinorrhea
Periocular ecchymosis (“raccoon’s eyes”)

9. Question
Which of the following symptoms indicates a fracture of the middle fossa in a basilar skull fracture?
A. Otorrhea
B. Rhinorrhea
C. Raccoon’s eyes
D. Halo sign

10. Answer
A. Otorrhea
Rationale: A communicating fracture of the middle fossa in a basilar skull fracture manifests with otorrhea (CSF from the ear) or Battle’s sign (mastoid ecchymosis). A fracture of the anterior fossa or front of the skull usually produces raccoon’s eyes and rhinorrhea (CSF from the nose). The halo sign is a bloodstain surrounded by a yellowish “halo.” The halo sign can happen with any CSF drainage and is not limited to any one area of the brain.

11. Question
In a patient with a head injury, the endotracheal tube should be inserted through the nose.
A. True
B. False

12. Answer
B. False
Rationale: Nothing should be passed into the nose of a patient with head trauma, especially a basilar skull fracture. If a nasogastric or endotracheal tube is nasally inserted, the tube could pass into brain tissue because of the fracture and communication with the CSF.

13. Primary Brain Injuries
Concussion
Mild brain trauma causing an alteration in mental status
May or may not have a change in LOC
Can have memory deficits both before and after the accident
May have residual effects that need to be monitored
Contusion
Focal injury usually due to microtrauma to the vascular system
Symptoms depend on depth of injury and amount of tissue contused
Mortality can be from cerebral swelling
Usually resolves within 24 to 72 hrs

14. Primary Brain Injuries: Hematomas
Hematomas are lesions in the brain caused by traumatic bleeding. Types include:
Epidural
Subdural
Intracerebral
Traumatic subdural hemorrhage
Diffuse axonal Injury
Cerebrovascular Injury
(Refer to Figure 36-2.)

15. Secondary Brain Injury
These are due to changes in the brain as a result of trauma. Types include:
Cerebral edema
Ischemia
Herniation syndromes
Coma

16. Secondary Injury: Edema and Ischemia
Cerebral edema peaks in 72 hrs
Cytotoxic
Vasogenic
Ischemia – decreased blood flow and possible infarction
Major cause of permanent injury and death

17. Secondary Injury: Herniation Syndromes
Caused by the shifting of structures under pressure. Cushing’s triad is a late sign. There are four types:
Uncal – supratentorial herniation; ipsilateral “blown pupil”; contralateral weakness
Tonsillar – through foramen magnum; respiratory arrest
Central (transtentorial)
Upward cerebellar
The first two are most commonly seen in critical care.

18. Secondary Injury: Coma
Defined as a change in the LOR
RAS is disrupted
Persistent vegetative state
Arousal but no cognitive function
Role of the GCS
Causes
Refer to Box 36-2.

19. Nursing Assessment of the Brain-Injured Patient
LOR is the most sensitive indicator
AVPU scale
Painful stimuli types
Glasgow Coma Scale
Tests for cognitive function
Alert and oriented x3
Hand grasps and letting go
Refer to Figure 36-5.

20. Eye Changes
Extraocular movements
PERRLA
Oculocephalic
Oculovestibular

21. Nursing Assessment of the Brain-Injured Patient: Brain Stem Responses
Corneal reflex
Cough/gag

22. Nursing Assessment of the Brain-Injured Patient: Motor Function
Test all of these and record responses on both sides of the body:
Localization
Withdrawal
Decorticate
Decerebrate
Babinski’s reflex

23. Nursing Assessment: Respiratory Function
Cheyne-Stokes – periods of apnea slowly building in rate/depth till a peak is met (cerebral hemisphere trauma; normal age- related change)
Central neurogenic hyperventilation – rapid, regular, sustained and deep (upper midbrain)
Apneustic – long pauses with full inspiration/expiration (brain stem)
Ataxic – irregular and unpredictable (medulla)
Refer to Figure 36-6.

24. Diagnostic Testing CT MRI Angiography
Transcranial Doppler ultrasonography
EEG
Jugular bulb catheter

25. Medical Management and Nursing Care
Airway
Always #1 priority
Keep pCO2 35 to 45 mmHg
Avoid hyperventilation in first 24 hrs
Fluid resuscitation
To keep ICP within normal range and BP stable
ICP monitoring
Positioning

26. Question
A nurse would see increased intracranial pressure during which of the following position changes?
A. Logrolling the patient
B. Extreme hip flexion
C. Keeping the head of the bed at 30 degrees
D. Placing sandbags on the side of the head to keep
it in alignment

27. Answer B. Extreme hip flexion
Rationale: Logrolling the patient, keeping the HOB at 30 degrees, and sandbagging each side of the head help lowering increased ICP. Extreme hip flexion increases intra-abdominal pressure, which can be transmitted to the cranial vault.

28. Medical Management and Nursing Care
Prevention and treatment of seizures
Medications for prophylaxis in early phase only
Dilantin (phenytoin)
General seizure precautions
Temperature maintenance
Therapeutic hypothermia doesn’t affect outcomes
Monitoring fluids and electrolytes
Diuretics
Monitoring for SIADH, diabetes insipidus, glucose and salt- wasting syndrome

29. Medical Management and Nursing Care (cont.)
Cardiovascular
Monitor for MI and rhythm disturbances
Monitor for DIC
Use of pulmonary artery catheter
Hazards of immobility (DVT, contractures)
Pulmonary
Aspiration pneumonia
ETT management, suctioning, tube feeding management
Monitor for ARDS and “flash” pulmonary edema

30. Medical Management and Nursing Care (cont.)
Nutrition
Nutrition ASAP
Protein-rich formulas
Integumentary and musculoskeletal system
Contracture prevention
Early PT
Family support
Importance of being honest and truthful
Information
Active involvement
Behavioral changes

31. Brain Death Examination
Normothermic
Coma
Negative brain stem reflexes
Apneic
Organ procurement