1. Traumatic Brain Injury & Brain Tumors Fall 2009
John Nation, RN, MSN
Adapted from the notes of Marnie Quick, RN, MSN and Charlene Morris, RN, MSN

2. The Brain!

3. Have you read Lewis pages 1481 -1493?
Of Course.
Not yet, but I will within the next 48 hours.
Could you repeat the question?

4. The Brain

5. Brain A & P Three major components- Cerebrum
Right and left hemispheres
Four lobes- frontal, temporal, parietal, and occipital
Frontal Lobe-
Cognitive function
Memory retention
Voluntary eye and motor movements
Expressive speech via Broca’s area
Temporal Lobe-
Speech reception via Wernicke’s area
Visual and auditory integration
Parietal Lobe-
Spatial information and control
Occipital Lobe-
processing of sight

6. Brain A & P (Cont’d) Brainstem- Includes midbrain, pons, and medulla
Respiratory function
Vasomotor function
Cardiac function
Centers for sneezing, coughing, vomiting, sucking, swallowing, and hicupping

7. Brain A & P (Cont’d) Cerebellum-
Located under the occipital lobe of the cerebrum
Coordinates voluntary movement
Trunk stability
Equilibrium

8. Incidence of Traumatic Brain Injury
1.1 million people treated and released annually in the US
50,000 people die and 235,000 are hospitalized
22% of hospitalized clients die
Men twice as likely to have TBI as women

9. Incidence (Cont’d) Mortality rate after severe head injury around 35%
More than half of people who survive severe head injury have serious disability

10. Risks Motor Vehicle Accidents (MVA) - 42,642 deaths due to MVA in 2006
- 3,475 deaths in Texas alone
Elevated Blood Alcohol Levels
Sports-related Trauma
Recreational Activities- Cliff jumping, rock climbing, mountain biking, etc.
Assault- Firearms, blunt trauma

11. Brack ED Research

12. Mechanisms of Injury
Acceleration Injury- struck in head by a moving object
Deceleration Injury- head hit non-moving object
Blunt or penetrating injury to the brain
Closed head injury

13. Mechanisms of Injury (Cont’d)
Coup-countercoup injury- brain rebounds within skull, causing injuries at site of impact (coup) and directly opposite (countercoup)
Countercoup injury often more severe
Source: Patrick J. Lynch, Creative Commons License 2006

14. Types of Head Injury
Scalp Lacerations- - external - extensive bleeding secondary to lots of blood vessels with poor constrictive abilities - care focused on preventing blood loss and infection

15. Skull Fractures Linear Skull Fracture- Break in continuity of bone
No alteration of relationships of parts
Frequently associated with low- speed injuries
Dura is intact
Accounts for around 80% of all skull fractures

16. Skull Fractures (Cont’d)
Depressed Skull Fracture-
Inward indentation of skull
Frequently associated with powerful blow/ mechanism of injury

17. Skull Fractures (Cont’d)
Simple Skull Fractures-
No fragmentation or communicating lacerations
Associated with low to moderate impact
Comminuted Skull Fractures-
Multiple fractures with bone fragmentation
Associated with direct, high-momentum impact
Compound Skull Fractures-
Scalp laceration and depressed fracture with communicating pathway to intracranial cavity

18. Skull Fracture Locations

19. Basilar Skull Fractures
Fractures along the base of the skull
Can include cranial nerve deficits
*Battle’s sign* *Raccoon Eyes*

20. Battle’s Sign (Postauricular ecchymosis) Raccoon Eyes (Periorbital ecchymosis)

21. Basilar Skull Fracture (Cont’d)
Cerebrospinal Fluid (CSF)-
Rhinorrhea- leaking of CSF from the nose
Otorrhea- leaking of CSF from the ear
Client is at high risk for meningitis

22. Assessment for CSF
Test fluid for positive glucose reading- CSF gives positive glucose reading
If blood is also in CSF, testing for glucose is not reliable since blood has glucose as well
Allow fluid to leak onto 4x4, observe drainage over a few minutes, a yellowish ring around the blood indicates presence of CSF.

23. Complications of Skull Fracture
Intracranial infections
Hematoma
Meningeal and brain tissue damage

24. Urinary Retention Risk for Infection Powerlessness
A client is admitted to the ER with altered level of consciousness and bilateral periobital ecchymosis. Both rhinorrhea and otorrhea are present. The priority nursing diagnosis would be:
Urinary Retention
Risk for Infection
Powerlessness
Disturbed Body Image

25. Traumatic Brain Injury
Brain Injury Video Clip

26. Types of Skull Fractures (Cont’d)
Open Skull Fracture- extension of the fracture into the dura or air sinuses
Closed Skull Fracture- can lead to increased risk for elevated ICP

27. Minor Brain Injury Concussion-
Brief disruption in level of consciousness (LOC)
Retrograde amnesia (difficulty remembering event)
Headache
Usually of short duration
Usually not admitted to hospital if loss of consciousness < 5 minutes

28. Minor Brain Injury (Cont’d)
Concussion Precautions:
Monitor for:
worsening headache
Vomiting
Confusion/ change in level of consciousness
Weakness on one side of body
Inability to wake up

29. Minor Brain Injury (Cont’d)
Post Concussion Syndrome:
Generally 2 weeks to 2 months post injury
Headache, decreased attention span, personality/ behavioral changes, decreased short term memory, lethargy
Can significantly impact daily life

30. Major Head Trauma Contusion-
Bruising of the brain within an area of the brain
Usually connected with a closed head injury
May involve bleeding, necrosis, and infarction at the site of a fracture
Clients on anticoagulation therapy with contusion are at higher risk for severe injury and death
Seizure is a common complication

31. Major Brain Injury (Cont’d)
Laceration-
Tearing of the brain tissue
Commonly seen with penetrating injuries (ie gunshot, knife wounds), open fractures, and depressed fractures
Surgical repair not possible
The larger the area of injury, the worse the outcome

32. Major Brain Injury (Cont’d)
Diffuse Axonal Injury (DAI)-
Widespread axonal damage
Can be present with mild to severe TBI
Results in axon swelling and disconnection
Results in decreased LOC, increased ICP, and global cerebral edema
90% of clients remain in persistent vegetative state

33. Major Brain Injury (Cont’d)
Epidural Hematoma-
Bleeding between the dura and the skull
Is a true emergency
Usually seen with laceration to an artery, frequently the middle meningeal artery
Frequently initial loss of consciousness followed by a temporary improvement in condition (called a lucid interval)

34. Epidural Hematoma (Cont’d)
Signs and Symptoms-
Lucid interval following initial loss of consciousness
Decreased level of consciousness
Headache
Nausea and vomiting
Progresses rapidly
Rapid surgical intervention needed!

35. Subdural Hematoma Subdural Hematoma-
Bleed between the outer arachnoid membrane and the dura mater
Tends to be caused by a venous bleed, though can be arterial in nature
More common than epidural hematoma
Usually slower to develop than epidural hematoma

36. Subdural Hematoma Signs and Symptoms-
Similar to signs/symptoms of increased ICP
Decreasing LOC
Headache

37. Types of Subdural Hematomas
Acute
Subacute
Chronic
onset 24 to 48hrs p trauma
onset 48 hrs to 2 weeks p trauma
onset > 20 days p trauma
Immediate decline
Altered mental status
Progressive change in LOC
Tx with craniotomy, evacuation, decompression
Evacuation and decompression

38. Intracerebral Hematoma
Caused by bleeding within the parenchyma (aka the nervous tissue)
Occurs with around 16% of head injuries

39. Review Scalp lacerations Skull fractures Concussions Contusions
Diffuse Axonal Injury
Epidural Hematoma
Subdural Hematoma
Intracerebral Hematoma

40. Immediate admission to ICU
A victim of an automobile accident was found unconscious at the scene of the accident but regained consciousness during transport to the hospital. Shortly after admission, her Glasglow Coma Scale is 8, and an epidural hematoma is suspected. The nurse plans care anticipating the following treatment:
IV furosemide
Immediate craniotomy
IV corticosteriods
Immediate admission to ICU

41. Abnormal hormone production Respiratory dysfunction
Your client with an injury to the brain stem is at risk for which of the following complications?
Impaired Balance
Abnormal hormone production
Respiratory dysfunction
Impaired temperature regulation

42. In planning long-term care for the client following brain trauma, the nurse includes teaching and support for the family primarily because:
Clients will always have some residual deficits from the brain trauma
Most clients experience seizure disorders in the years following brain trauma
Families become dysfunctional and unable to cope during convalesence
Clients with head injuries with unconsciousness often have changes in personality with loss of concentration and memory processing

43. Collaborative Care for TBI
Diagnostic Studies-
CT scan - best diagnostic study to evaluate head trauma related to rapid diagnosis and treatment
Spinal x-ray, skull x-ray
MRI
PET (Positron Emission Tomography)
Transcranial Doppler (to measure CSF velocity)

44. Collaborative Care for TBI (Cont’d)
Diagnostic Tests (Cont’d)-
ABG’s
CBC
Glucose
Electrolytes

45. Assessment Findings (Pg 1484 in Lewis)
Fractures/depressions
Battle’s Sign, Raccoon eyes
Cheyne-strokes respirations
Decreased O2 saturation
Pulmonary edema

46. Assessment Findings (Cont’d)
Unequal/ dilated pupils
Confusion
Abusive/ slurred speech
Altered LOC
Seizures
Incontinence
Posturing
Glasgow coma scale <12
CSF leaking form ears or nose

47. Initial Interventions
Ensure patent airway
Stabilize cervical spine
O2 via non-rebreather
Large bore IV access (2)
Control external bleeding
Ongoing assessment

48. Ongoing Monitoring (Lewis Pg. 1484)
Maintain client warmth
Frequent vital signs, level of consiousnes, SpO2, heart rhythm, Glasgow Coma Scale, pupil size/reactivity
Assess need for intubation if unable to protect own airway (absent gag reflex)
Use caution with IV fluids to avoid overload/ increasing ICP

49. Treatment of TBI Prevent secondary injury by managing increased ICP
Primary treatment is quick diagnosis and surgery if necessary
In concussion and contusion, usually treated only with observation and management of increased ICP

50. Managing Increased ICP (At a glance from Module 10)
Airway management
Elevating head of bed 30 degrees
Temperature regulation
Osmotic diuretics (Mannitol)
Lasix
Invasive monitoring
Surgery

51. Prevention of Complications
Medications to prevent increased ICP
Prevent/ treat seizures
Stool softeners to prevent straining
Antipyretics, cooling
TPN, tube feedings, supplements
If CSF leak, do not pack nose/ears, no suctioning of nose, no blowing/ sniffing of nose. Lightly cover, change PRN,

52. Surgery for TBI
In depressed and comminuted fractures, frequently a craniotomy to remove fragments
Crainiotomy- opening into the cranium with removal of a bone flap and opening the dura
If large amount of bone is destroyed, may need:
craniectomy- removal of bone to allow brain to expand
Cranioplasty- repair of a cranial defect using articifial material

53. Surgery for TBI (Cont’d)
Acute Subdural and Epidural Hematomas-
Burr-hole openings for rapid decompression
Craniotomy
Drain generally left in place post surgery to prevent reaccumulation of blood
Evacuation of Subdural Hematoma Video

54. Nursing Assessment- Review
Frequent Nuero assessments
Frequent vital signs
Glasgow Coma Scale
Brainstem reflexes (pupils, cough, gag, Doll’s eyes)
Watch for increased BP, decreased HR, and altered respirations - Cushing’s Triad- late sign with increased ICP- very bad!
Watch for CSF leak

55. Nursing Diagnosis Ineffective airway clearance
Ineffective breathing pattern
Ineffective tissue perfusion
Acute pain
Anxiety
Hyperthermia
Decreased cerebral perfusion

56. Home Care Homecare evaluation Rehabilitation Nursing home placement
Teaching concerning post-concussion syndrome, bowel/bladder management, spasticity, dysphagia, nutrition, seizure disorder, personality changs
Family teaching
Support groups
TBI and Veterans

57. Ethical Dilemmas Brain Death- Coma
Absence of doll’s eyes ocular movements
Absence of pupillary response to light
Gag reflex absent
Complete unresponsiveness
Positive apnea test

58. Break!
song
Song
Tumor Resection

59. Brain Tumors
Benign
A growth of cells that is generally slow growing and non-invasive
Malignant
A growth of undifferentiated cells that forms an abnormal mass which performs no function and grows at the expense of healthy tissue

60. Primary Brain Tumors- a group/mass of cells that starts in the brain
Secondary (Metastatic) Tumors-
a group/ mass of cells that originates outside the brain

61. Incidence 18,500 new diagnosis in US each year
12,760 deaths each year related to brain tumors
5 year survival rate around 33%
Slightly more prevalent in males than females

62. Primary Brain Tumors Primary Brain Tumors-
Rarily metastasize outside the central nervous system
Unknown cause
Most primary brain tumors (around 66%) start in astrocytes (these tumors are called gliomas)
Greater than 50% of primary brain tumors are malignant
Can occur at any age, but more common in middle age
Must be treated or will lead to death secondary to increased ICP

63. A & P Review Neurons Supporting cells (Glial cells): Types:
Used to communicate motor and sensory information
Supporting cells (Glial cells):
Surround neurons, and keep them in place
Supply nutrients and oxygen to neurons
Insulate one neuron from another
Remove dead neurons
Types:
Astrocytes
Oligodendrocytes
Microglia

64. Types of Primary Brain Tumors (Lewis, pg. 1488)
Gliomas-
Astrocytoma- from supportive, glial cells, and astrocytes. Low grade to moderate grade malignancy.
Glioblastoma- from primitive stem cell. Highly malignant.
Oligodendroglioma- from oligodendrocytes. Benign
Medulloblastoma- from primitive neuroectodermal cell. Highly malignant and metastasizes to spinal cord and other parts of the brain.

65. Type of Brain Tumors (Cont’d)
Meningioma- from meninges. Mostly benign but can be malignant
Acoustic Neuroma- from cells that for myelin sheath around nerves. Usually benign or low-grade malignancy
Pituitary adenonma- originates in pituitary gland. Usually benign.
Hemangioblastoma- from blood vessels of brain. Rare and benign.
Primary CNS lymphoma- forms in lyphocytes. Seen in transplant recipients and AIDS patients

66. Secondary Brain Tumors
More common than primary brain tumors
Originate outside the brain, frequently from lung and breast
Single or multiple brain tumors
Increasing frequency as individuals with cancer live longer

67. Clinical Manifestations of Brain Tumors
Depend on the location and size of tumor
General symptoms of increased intracranial pressure- headache, nausea, vomiting, papilledema- increased optic disc swelling
Seizures

68. Local Symptoms of Brain Tumors
Frontal Lobe- personality changes, visual disturbances, memory problems, hemiplegia
Parietal Lobe- speech problems, unilateral neglect, spatial disorders, inability to write
Occipital Lobe- visual disturbances and seizures
Temporal Lobe- fewer specific symptoms. When present, seizures, dysphagia.

69. Local Symptoms of Brain Tumors (Cont’d)
Cerebellum- gait disturbance, cooridination problems
Brainstem- headache on awakening, visual changes, drowsiness, hearing loss, hemiparesis, dysphagia, dysarthria

70. Complications Ventricular enlargement (hydrocephalus)
surgical treatment can be needed to relieve pressure.
Ventriculoatrial shunt- placement of a shunt with one way valve from from right lateral ventricle to the right atrium
Ventriculoperitoneal- placement of a shunt with one way valve from from right lateral ventricle to the peritoneum

71. Ventriculoperitoneal shunt
Shunt Placement Video

72. Complications (Cont’d)
Infection- S&S include fever, headache, stiff neck, weakness, seizures
Death- usually caused by increased intracranial pressure or herniation

73. Collaborative Care Diagnostic Tests- CT Head MRI
EEG- diagnostic test that measures the electrical activity of the brain
PET
Angiogram of the head
Tissue Biopsy (usually done in surgery)

74. Surgery Used both to remove tumor or for symptom relief
Complete surgical removal not always an option secondary to tumor location or involvement of vital parts of the brain
Deep central areas of dominant hemisphere, posterior corpus callosum, or the upper brainstem are typically considered inoperable

75. Awake Craniotomy Video

76. Surgery (Cont’d)
Supratentorial- cranial surgery above the tenoritum (double fold of dura between the cerebrum and the cerebellum). Post-op HOB up degrees
Infratentorial- surgery below the tentortium- cerebellum and brainstem
HOB angle per MD order

77. Surgery (Cont’d) Stereotaxic surgery-
Presision localization of area of brain using 3-dimensional coordinates
Used for biopsy and dissection
Resection of Brain Tumor Video

78. Radiation Therapy Used alone or with other therapies
Stereotactic radiosurgery
Closed skull destruction of tumor using intracranial guiding device
Gamma knife- high dose radiation precisely on tumor
Surgical lasers also used- create thermal energy to destroy tumor
Major advantage is decreases damage to surronding tissue

79. Gamma Knife vs Cyberknife
Fixed head frame used
Used only on the head
Uses multiple beams
Isocenter(s) chosen based on CT findings
Usually 1 doses only
Hospitalized during treatment
Cyber Knife
Used on brain and body lesions
Uses only one beam
No head frame
Hospitalization not needed
X-Rays during treatment used to guide beam

80. Medications Chemotherapy-
Limited effectiveness due to blood-brain barrier, tumor-cell drug resistance, and large variances between types of tumor cells
Nitrosoureas (CNU, CCNU)
Temozolomide (Temodar)- first agent found to cross blood-brain barrier
Intrathecal administration delivers to the CNS via Ommaya Reservoir
Wafer implantion- chemotherapy-laden biodegradeable wafer placed at tumor site during surgery
Ommaya reservoir

81. Medications (Cont’d) Corticosteroids used to treat edema
Prednisone, Solu-medrol, Decadron
Anticonvulsants used to prevent seizures
Tegretol, Depakote, Keppra, Neurontin, Lamictal, Dilantin

82. Rehabilition Coping Adapting Assistance as needed
Resources in community

83. Nursing Assessment Health History- Physical Exam-
Course of symptoms, other cancers
Physical Exam-
Neuro vital signs
Assess for signs of tumor in specific part of brain (as discussed previously)
Watch for aphasia, visual field loss, motor and sensory loss
Observe for signs of increased ICP

84. Nursing Diagnosis Impaired tissue perfusion, cerebral
Self-care deficits
Anxiety
Risk for infection
Risk for injury
Acute pain
Disturbed self-esteem
Nutrition
Home care

85. The End!