1. Management of Patients With Neurologic Trauma

2. 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!

3. 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

4. Pathophysiology of Traumatic Brain Injury

5. 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

6. 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

7. 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

8. Basilar Fractures Allow CSF to Leak From the Nose and Ears

9. 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

10. Initial Management of the Severe Head Injury Patient

11. 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

12. 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

13. 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

14. 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

15. Location of Subdural, Intracerebral, and Epidural Hemorrhages

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. Glasgow Coma Scale

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Posey Mitt Used to Prevent Self-Injury

32. 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

33. 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

34. 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

35. 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

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

38. 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

39. 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

40. 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

41. 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)

42. 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

43. 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

44. 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

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

46. 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

47. 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

48. 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

49. 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

50. 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

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

52. 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

53. 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

54. 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

55. RotoRest Bed

56. Cervical Collar

57. Halo Systems for Cervical and Thoracic Injuries

58. 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