Neurosensory: Traumatic Brain Injury (TBI) & Brain Tumors

Marnie Quick, RN, MSN, CNRN

Normal brain protected by:

Normal brain

Traumatic Brain Injury (TBI): Etiology/Pathophysiology Risk factors- MVA; elevated blood alcohol;

contact sports; acts of violence- gun, knife Mechanism of craniocerebral trauma

Acceleration (movement)-deceleration (stationary) Coup (impact)-contrecoup (opposite) phenomenon Blunt or penetrating injury Closed head injury Scalp lacerations Skull fractures- Linear; comminuted; depressed;

basilar; open/closed

Coup-contracoup injury

Penetrating injury- Gunshot to brain

Penetrating injury: Knife in brain

Basilar skull fracture- Base of skull fractured

Basilar skull fracture is base of skull if posterior> Battle sign- ecchymosis behind the ear

Basilar skull fracture is more anterior Raccoon eyes- periorbital ecchymosis

Basilar Skull fractures can cause leakage of CSF from meninges

Minor Brain Injury

Concussion- sudden transient disruption of neural activity in the brain with change in LOC

Post Concussion Syndrome- may occur after other brain injuries- severity of symptoms are not related to severity of brain injury. Sym may persist wks-months

Major Brain Injury- Focal injury

Brain contusion- bruising; coup-contracoup Brain laceration- tearing brain tissue, ICH DAI- diffuse axonal injruy

Widespread disruption of axons Poor prognosis

Brain bleeds- Note meninges in relation to bleeds on following slides

Epidural hematoma

Subdural hematoma (SDH)

Intracerebral hematoma

Secondary brain injury

Cerebral edema Localized or diffuse Peaks 24-72 hrs Occurs with CHI; open head injury; anoxia May in itself cause death by pressure> herniation

Increased ICP Herniation Syndromes

Traumatic Brain Injury (TBI): Common Manifestations/Complications

Increased ICP symptoms general and specific Restlessness- R/O respiratory; waking up Systemic effects of acute brain injury-

hypermetabolism, brainstorming, SIADH Brainstorming- hypothalamic stimulation-ANS CSF leak- rhinorrhea/otorrhea- basal skull Fx Post concussion Syndrome Associated cervical spinal cord injury

Collaborative Care: Traumatic Brain Injury (TBI):

Diagnostic studies (similar to ICP) Emergency management: assessment and interventions

(Lewis 1484 Table 57-9) Treat IICP- airway; fluid; positioning; temp reg; meds Prevention of complications

Medications: IICP; seizures; stress ulcer;straining;brainstorming Diet/calories: hypermetabolic state; ileus; swallow/gag CSF leak: glucose; halo; HOB 30; no nasal suction Other: SIADH> hyponatremia

Surgery: bone repair; evacuation clot; craniotomy/ectomy; burr hole; cranioplasty; monitor placement

Burr holescraniotomy

Place monitors/intraventricular drain:

Crainectomy- bone flap out to allow for brain expansion post op

Post crani

Traumatic Brain Injury (TBI): Nursing assessment specific to TBI

Health history Description of accident; past medical history

NVS and Glasgow Coma

http://www.trauma.org/scores/gcs.html Brainstem reflexes VS- Late sign is Cushing reflex Skull/face; CSF leak; SCI Consider older adult finding

Pertinent Nursing Problems Specific to Traumatic Brain Injury (TBI):

Health promotion Ineffective tissue perfusion, cerebral (decreased

intracranial adaptive capacity) Ineffective airway clearance/breathing pattern Hypothermia Pain Impaired physical mobility

Anxiety Decreased cerebral perfusion (IICP) Brain death (ethical dilemmas p.1485) Home care

Home evaluation/rehab/nursing home Teach about post concussion syndrome; B&B;

spasticity; dysphagia; nutrition; seizure disorder; personality changes; family role changes

6 months typical plateau period Community agencies/support groups

http://library.med.utah.edu/kw/animations/hyperbrain/oculo_reflex/oculocephalic2.html

http://cim.ucdavis.edu/eyes/version15/eyesim.html

http://www.softwarefornurses.com/access/index.asp

Primarybrain tumors Arise from support

cells, neurogilia cells; the meninges; or blood vessels

Do not metastasize outside cranium

Cause unknown

Grade I and II gilomas (astrocytoma) made up of astrocytes; are benign, slow-growing tumors

Grade II and IV gliomas (glioblastoma Multiforme are invasive and fast-growing

Meningiomas arise from the meninges; slow-growing; benign, encapsulated and compress the brain

Brain tumors may be lethal due to their location

Gioblastoma Meningioma

Metastatic (secondary) brain tumors Originate from outside

the brain- lung and breast most common sites

Single or multiple Becoming more common

as individual with cancer in other parts of the body are living longer

Clinical Manifestations/complications of Brain tumors General ICP symptoms Common early symptoms: headache; vomiting;

papilledema (visual changes) Seizures- partial classification in type Brain tumor symptoms occur due to their ability

to compress or destroy brain tissue; edema that forms around the tumor; hemorrhage; & obstruction of CSF flow

Specific symptoms as to the lobe affected>

Frontal lobe: personality changes; inappropriate behavior; inability to concentrate; impaired judgment; headache; expressive aphasia if dominant hemisphere; motor weakness or paralysis from motor strip

Parietal lobe: sensory deficits- paresthesia, visual field deficits; contralateral sensory disturbances from sensory strip; loss of interpretation and discrimination for sensing input; perceptual problems

Occipital lobe: visual disturbances; visual agnosia Temporal lobe: complex partial (psychomotor)

seizures; auditory hallucinations; memory problems; Wernicke aphasia if dominant hemisphere

Cerebellum: gait distrubances; balance and coordination problems

Brain stem: cranial nerve dysfunction; vital signs

Complications of Brain Tumors Hydrocephalus Infection Death is usually caused by IICP/hermiation

Collaborative Care for Brain Tumors Diagnostic tests CT/MRI EEG PET Angiogram Tissue biopsy

Collaborative Care for brain tumors Surgery

To remove or debulk Supratentorial- above

tentorium Infratentorial-below Stereotaxic-localized

Radiation Used alone or with other therapies Gamma or Cyber-knife Complication- increased cerebral edema

Medications Chemotherapy: IV; intraventricular (ommaya

Reservoir) or by wafer implanted Corticosteroids to treat brain edema Anticonvulsants to prevent seizures

Rehab- outpatient or in house

Health history: progression of symptoms; other cancers, disease

Physical exam Neuro vital signs Specific signs of the local functions of different parts

of the brain Similar neuro deficits as the individual with a stroke Signs of increased intracranial pressure/herniation

Pertinent Nursing Problems for Brain Tumor

Impaired tissue perfusion, cerebral Self-care deficits Anxiety Risk for infection-post crani Acute pain Disturbed self-esteem Nutrition Home care- rehab; home eval; support groups