Download - Neurology Management of Patients With Neurologic Trauma Chapter 63.

Neurology

Management of Patients With Neurologic Trauma

Chapter 63

Head Injuries

• TBI– Traumatic Brain Injury

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

Scalp Injuries

• Clinical manifestation– Bleeding

• Profusely!

Scalp Injuries

• Abrasion:– Wound caused by • Rubbing or • Scrapping the skin

Scalp Injuries

• Contusion:– Injury to the tissue

without…• Breaking the skin

Scalp Injuries

• Laceration– The act of…• Tearing

Scalp Injuries

• Avulsion– The…– Tearing away of a

structure or part

Scalp Injuries

• Complication– Infection– Clean– Use procaine/Lidocaine– Suture

Skull Injuries / Fractures

• Classifications– Linear

• Line

– Comminuted• A bone is shattered into

many pieces

– Depressed• Comminuted fx in which

broken bones are displaced inward


• Classifications– Basilar:

• Breaks in boned at the base of the skull

– Open:• The dura is torn

– Closed• The dura is intact


• Clinical manifestations– Local injury– Pain

• Persistent

– Swelling?• Sometimes


• Clinical Manifestations– Halo Sign

• Description– Blood stain surrounded

by a yellowish ring

• Indication– CSF leak


• Clinical Manifestations– Basilar

• Hemorrhage from – Nose– Pharynx– Ears

• Blood under the – Conjunctiva

• Battle’s sign• CSF otorrhea• CSF rhinorrhea


• Diagnostic Tests– X-ray– CT– MRI– Angiography

• Hematoma


• Medical Management– Non-depressed skull

fractures• Usually do no require

– Surgical treatment

• Do require close– Observation


• 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– S&S

• LOC• Memory loss• Headache

Brain Injury

• Concussion– Emergency S&S

• Difficulty awakening• Dysphasia• Confusion• Severe H/A• Vomiting• Weak on one side

Brain Injury

• Concussion– Diagnostic tests

• CT• MRI• X-ray• Neuro checks

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: Epidural hematoma

• Management– Extreme emergency– Burr Holes

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

Question?????

• How will you know when a patient is no longer in spinal shock?– Reflexes return

SCI: Complications & InterventionsDeep Vein Thrombosis / DVT

• S&S

• Treatment

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 & InterventionsThermal Regulation

• Not perspire• Fever?

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


S&S• Above injury– Vasodilation– Pounding H/A– Profuse diaphoresis– Nasal congestion

• Bradycardia• Hypertension– > 300 mmHg systolic


Treatment• Monitor BP• How BP fast?– HOB

• Find & remove noxious stimuli

• If med with apresoline – crash

Question?????

• What can lead to autonomic hypereflexia?– Bowel impaction– Hang nail

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

SCI: Complications & InterventionsDepression

SCI: Complications & InterventionsInfections

• Respiratory• UTI• Wound

The Quadriplegic Patient

• See homework and reading

• Ch 63