Neurology Management of Patients With Neurologic Trauma Chapter 63.
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Transcript of Neurology Management of Patients With Neurologic Trauma Chapter 63.
General Information• Involves injury to
– Scalp– Skull– Brain
• High Risk Groups– Male vs. Female?
• Male
– Age?• < 30yrs
– #1 Variable• Alcohol
Pathophysiology• Damage • Swelling • ICP • Displacement • Blood flow • O2 • Ischemia • Infarction• Deathmosis
Skull Injuries / Fractures
• Classifications– Linear
• Line
– Comminuted• A bone is shattered into
many pieces
– Depressed• Comminuted fx in which
broken bones are displaced inward
Skull Injuries / Fractures
• Classifications– Basilar:
• Breaks in boned at the base of the skull
– Open:• The dura is torn
– Closed• The dura is intact
Skull Injuries / Fractures
• Clinical manifestations– Local injury– Pain
• Persistent
– Swelling?• Sometimes
Skull Injuries / Fractures
• Clinical Manifestations– Halo Sign
• Description– Blood stain surrounded
by a yellowish ring
• Indication– CSF leak
Skull Injuries / Fractures
• Clinical Manifestations– Basilar
• Hemorrhage from – Nose– Pharynx– Ears
• Blood under the – Conjunctiva
• Battle’s sign• CSF otorrhea• CSF rhinorrhea
Skull Injuries / Fractures
• Medical Management– Non-depressed skull
fractures• Usually do no require
– Surgical treatment
• Do require close– Observation
Skull Injuries / Fractures
• Medical Management– Depressed skull fractures
• May require surgery • Surgical debridement• Antibiotics
Quote from text
“After the skull fragments are elevated, the area is debrided. Large defects can be repaired immediately with bone or artificial grafts; if significant cerebral edema is present, repair of the defect can be delayed for 3-6 months.”
Skull Injuries / Fractures• Medical Management
– Basilar skull fractures• Usually open or closed?
– OPEN
• Keep nose and ears– Clean
• Sterile cotton pad/ball– Loosely inserted
• Instruct pt not to – Blow nose
• HOB:– Up
• I-ICP protocol
Question??????
• You notice the sheet under a patients head is red with blood, but the stain has a yellowish ring around it. What would be a priority nursing actions?– Notify MD– Infection control!!– Act first -- document last
Question????
• How do you prevent infections in a patient with a head wound?– Clean– Inject antibiotic
• A patient enters the ER following a MVA where he was thrown from the car. He has a major head wound. His vital signs show very low blood pressure. What does this indicate?– Hypovolemia– More than just head injury
Question????
• An open skull fracture means what? What nursing measures do you implement? What are the risks? – Dura mater is torn– CSF leakage possible– Increase risk of infection
Question?????
• What kind of an injury produces hemorrhaging from the nose, pharynx and ears?– Basil skull fracture
Question????
• Do you give morphine for pain to a patient with head injury? Why or why not?– NO– Interferes with accurate neuro assessment
Brain Injury
• Concussion– Pathophysiology
• Temporary loss of neurologic function with no apparent
• Structural damage
– Closed / open?• Closed
– Duration of unconsciousness?• Seconds to few minutes
Brain Injury
• Concussion– Emergency S&S
• Difficulty awakening• Dysphasia• Confusion• Severe H/A• Vomiting• Weak on one side
Brain Injury
• Concussion– Medical treatment
• Analgesics– Mild
• Observe for post-concussion syndrome
• Return to ER if you see any of the emergency S&S
Brain Injury
• Concussion– Gerontologic
Considerations• Will recover more • Slowly with • More complications
Brain Injury: Contusion• Pathophysiology– The brain is bruised,
with possible surface hemorrhage
– Duration of unconsciousness:• More than concussion
– Potential of infarction & necrosis
Brain Injury: Contusion
• Contracoup/Contralateral Phenomenon– Damage to brain occurs
opposite to impact
Brain Injury: Contusion• Symptoms: Similar to shock
– Activity• Motionless
– Pulse• Faint
– Respirations• Shallow
– Skin• Cool & pale
– Bowel & bladder • Evacuation
– BP•
– Temp•
Question????
• Is a concussion an open or closed head injury?– Closed
• Is a contusion an open or closed head injury?– Closed
Brain Injury: Intracranial Hemorrhage
• A collection of blood that develops within the cranial vault
• Small & fast vs. large & slow
• Symptoms are frequently delayed
Question????
• Which is more fatal, a small hematoma that develops rapidly or a large hematoma that develops slowly?– Fast = Fatal
Brain Injury: Intracranial Hemorrhage
• Epidural hematoma / Extradural hematoma– Blood collects
• Btw the skull & dura
– Usually due to• Fx of skull
– Type of blood vessel• Arterial bleed
– Onset of symptoms• Rapid
Brain Injury: Epidural hematoma
• Clinical manifestations– Time of injury
• Momentary loss of consciousness
– Lucid interval• Compensation
– Sudden S&S of compression
Brain Injury: Subdural Hematoma
• Collection of blood– Btw dura & brain
• Usually due to– Trauma– Venous blood
Brain Injury: Intracerebral Hemorrhage & Hematoma
• Bleeding into– Brain
• Usually due to– Aneurysm– Missile injuries
Management of Brain Injuries
• Treatment of I-ICP• Assume spinal injury• Baseline neurological
assessment• Brain Death
Question?
• What type of hematoma’s are usually associated with arterial bleeds?– Epidural
• What type of hematoma’s are usually associated with venous bleeds?– Subdural
Spinal Cord Injury• Etiology– Male vs Female
• Male – Variable
• MVA– Age
• < 30 yrs– Most frequently involved
area• C-5,6,7• T12-L1
Spinal Cord Injury
• Pathophysiology– Transient concussion– Contusion– Laceration– Compression– Complete transection
Spinal Cord Injury
• Clinical manifestations– Incomplete spinal cord
lesions– Neurologic Level
• Lowest level where sensory & motor function are normal
Question?????
• Is it possible to break your back (vertebrae) without damaging your spinal cord?– Yes
Spinal Cord Injury
• Below neurologic level– Loss of sensory and
motor function– Loss of B&B control– Loss of sweating– in BP
Spinal Cord Injury• Clinical Manifestations
– Pain– Fear– Paraplegia
• Paralysis of the lower body
– Quadriplegia• Paralysis of all four
extremities
– C7-T1• Para• Quad
Question??????• If a person has a complete spinal cord injury at the
following level will they be a para or a quadriplegic?• C7?– Quad
• T4?– Para
• C4– Quad
• L3– Para
Spinal Cord InjuryEmergency Management• Rapid assessment• Immobilization
– Back board– Cervical collar– Positioning
• Head & Neck neutral– Handling
• Assign Head• 4 person
– Traction• Extrications• Stabilize
Spinal Cord Injury
Management of Acute SCI• Rx– Corticosteroids– Mannitol– IM?
• Not below level of injury
• Respiratory therapy– O2– Intubate carefully
Question????• Which of the following are appropriate site to give
a paraplegic an IM injection?– Abdomen
• ?– Deltoid
• Yes– Dorsogluteal
• No– Vastus lateralis
• No– Ventrogluteal
• No
Spinal Cord InjuryManagement of Acute SCI• Skeletal reduction &
traction– Immobilization– Reduction– Gardner-Well tongs
• No predrilled holes
– Crutchfield & Vinke tongs• Holes into the skull
– Halo vest
• Surgical interventions
SCI: Complications & Interventions
Spinal Shock• A sudden depression of reflex activity in the
spinal cord below the level of injury due to the loss of autonomic nervous system function
SCI: Complications & Interventions Spinal Shock
S&S• Areflexia• Vasodilitations – ______tension
• Hypotension
– ______ cardia• Bradycardia
• in cardiac output• Venous pooling
SCI: Complications & Interventions Spinal Shock
S&S• Muscle completely– Flaccid– Loss of temp regulating
mech• Below level of injury
• Duration– Days – weeks
SCI: Complications & InterventionsOrthostatic Hypotension
• venous return + vasoconstriction
• Pooling of blood in the legs
• HOB faint• Gradually HOB• Reclining W/C
SCI: Complications & InterventionsRespiratory Weakness
• Vital capacity–
• Secretions– Retention
• PaCO2–
• Diaphragm controls – C3-C5
• Complications– Resp Failure– Pulm edema
• If a patient developed a Pulmonary embolism due to immobility and what would their ABG’s look like?– PaCO2 • increased
– PaO2 • Decreased
– pH • Decreased
Question?????
• The cord segments involved with maintaining respiratory function are?– Cervical level 3 - 5
SCI: Complications & InterventionsBowel & Bladder
• Neurogenic bladder– Incontinent
• Bowel distention• Treatment– bulk– fluid– Stool softener– Disimpaction
SCI: Complications & InterventionsAutonomic Hyperflexia /dysreflexia
• Injury impairs normal equilibrium between the sympathetic and parasympathetic system– Vasoconstriction below the level of injury– Vasodilation above the level of injury
• Common cause– Noxious Stimuli– Below level of injury
SCI: Complications & InterventionsAutonomic Hyperflexia /dysreflexia
S&S• Above injury– Vasodilation– Pounding H/A– Profuse diaphoresis– Nasal congestion
• Bradycardia• Hypertension– > 300 mmHg systolic
SCI: Complications & InterventionsAutonomic Hyperflexia /dysreflexia
Treatment• Monitor BP• How BP fast?– HOB
• Find & remove noxious stimuli
• If med with apresoline – crash
Question?????
• What is the major danger of a patient suffering form autonomic dysreflexia?– Hypertension
SCI: Complications & InterventionsPressure Sores
• Turn • Diet– protein– cal
• Low pressure cushions