- Brain and spinal cord - Meninges (protective covering for brain and spinal cord) o Dura matter (outside layer), arachnoid matter (middle layer), pia
... [Show More] matter (inner layer), epidural space (between skull and duramatter) Brain - 3 main areas - Brainstem (basics, life sustaining) - Cerebellum ( coordination) - Forebrain (includes relay station, memory, intelligence, creativity, emotions) Cerebral Cortex - Frontal lobe (front of head, controls voluntary movement, broca’s area for expressive, voluntary eye movement, judgment, reasoning, concentration) - Parietal lobe (understanding sensation, spatial relationships, perception of body parts, taste) - Temporal lobe (wernicke’s area for receptive, auditory center for sound interpretation, complicated memory patterns) - Occipital lobe (primary visual center) Cerebellum - Receives continuous information regarding the condition of muscles, joints, and tendons - Control is ipsilateral (controls same side) Head injuries - Injury to the scalp, skull, or brain. Most common cause of death from trauma. Blunt or penetrating. - Highest at risk are male’s age 15-24 r/t playing sports, being more active/impulsive and elderly r/t falls. Pathophysiology of TBI - Brain suffers traumatic injury brain swelling or bleeding increases intracranial volume rigid cranium allows no room for expansion of contents so intracranial pressure increases pressure on blood vessels within the brain causes blood flow to the brain to slow cerebral hypoxia and ischemia occur intracranial pressure continues to rise, brain may herniate cerebral blood flow ceases o If ICP goes up pt is at risk for brain herniation and pt will die Anatomy of Head Injuries - Scalp o Significant bleeding; portal of infections (direct route to brain) - Skull o Protective, rigid, fixed space. o Fractures at the base of the skull Leaking CSF from nose, pharynx, or ears • CSF if it tests + for glucose, will cause yellow halo on sheets Battle signs: ecchymosis behind the ear - Dura (protective covering) - Brain (direct, primary; indirect, secondary) Direct (Primary) Brain Injuries - Primary injury: due to initial damage (contusions, lacerations, damage to blood vessels, or foreign object penetration - Direct damage done to brain (being stabbed in the head), irreversible Indirect (Secondary) Brain Injury (Prevent, stop, slow down, or reverse) - Secondary injury is damage that evolves after the initial injury (Expanding mass, lesions, swelling, hydrocephalus (abnormal increase of CSF fluid) or bleeding. - Increased ICP and/or herniation - Diagnosis and treatments target minimizing the effects of the indirect injuries Brain Injury - Closed brain injury (blunt trauma): Acceleration/deceleration injury occurs when the head accelerates then rapidly decelerates, damaging brain tissue. (Car accident) - Open brain injury: Object penetrates brain or scalp and skull are opened from a traumatic injury. - Concussion (brain shakes): A temp loss of consciousness with no apparent structure damage. Manifestations of Brain Injury - Altered LOC (Earliest indicator) - Pupil abnormalities (Check pupils of TBI pts for size and reaction to light. Report any changes to provider immediately because they could indicate an increased ICP) - Sudden onset of neurological deficits and neurological changes; change in sense, movement, and reflexes o Flaccid limbs, drooping of face, cushing’s triad (severe HTN with widening pulse pressure, the difference between diastolic and systolic 40 or greater is widening pulse pressure. Look at trends can be moving towards cushing’s triad) - Changes in vital signs (cushing’s triad, bradycardia) - Headache, seizures (check nail bed pressure for pain) - Posturing (stimulate pain to see if they posture, pinch chest/sternal rub, if pt postures they are getting worse) o Decorticate (in towards core), decerebrate (out) Management of the Pt with a Head Injury - Always assume cervical spine injury until ruled out o Don’t move them, C-Spine collar o Log roll off slide board, log roll until Dr. clears pt with CT Scan - Preserve brain homeostasis and prevent secondary damage o Treat cerebral edema with mannitol o Maintain cerebral perfusion (keep HOB 30 degrees, neutral alignment) o Maintain oxygenation, cardiovascular, and respiratory function o Manage fluid and electrolyte balance. o Prevent seizures Prophylactic Dilantin (Phenytoin) first 7 days o Monitor for SIADH and diabetes insipidus r/t damage to the pituitary gland Supportive Measures - Respiratory support; intubation (if they can’t maintain airway), and mechanical ventilation - Seizure precautions and prevention (pad side rails, have suction available) - NG to manage reduced gastric motility and prevent aspiration o To check placement test gastric content, air bolus, or x-ray - Fluid and electrolyte maintenance o Sodium level will be effected with brain injury - Pain and anxiety management - Nutrition o Feeding tube possible o If neurologically impaired check pts ability to swallow (sit pt up, give small amount of water) - Be careful not to over sedate to be able to check neuro function properly Intracerebral Hemorrhage (Tearing of small arteries or veins) - Bleeding into the substance of the brain edema = increased ICP - May be due to trauma or a non-traumatic cause (HTN, infection, tumors) - Treatment o Supportive care (keep them breathing and heart beating) o Control of ICP (HOB 30 degrees, neutral alignment, mannitol, no straws, no coughing, no suctioning) o Administer fluids, electrolytes, and antihypertensive medication Aneurysm – control B/P, monitor B/P o Craniotomy (burr holes), craniectomy (take out whole piece) to control bleeding Intracranial Pressure (ICP) - Decreased LOC = first sign, Cushing’s triad = late sign - 10-15 is normal ICP - Intracranial space contains brain, blood vessels, and CSF o If one increases another will compensate to decrease ICP, CSF easiest to compensate (Monroe-Kellie Hypothesis) - Severe headache, decreased LOC, restless, dilated pupils, pinpoint pupils - To decrease ICP give furosemide and mannitol - Dilantin (phenytoin) for seizures - Intraventricular catheter (IVC) o Allows accurate measurement of intracranial pressure o Allows drainage or sampling of cerebrospinal fluid Nursing management for IICP - Neuro assessment (pupils dilated, decreased LOC, strength) - Positioning (neutral position, HOB 30 degrees) - Vent support (ABG’s, watch CO2, keep CO2 @ 35-38 because CO2 is a vasodilator will raise ICP) - IVC assessments (measure hourly (drainage), check drsg for drainage/infection) o NEVER FLUSH A DRAIN!!!!!!!! - Maintain fluid restriction (r/t increased ICP) - Teach pt to avoid coughing, straining during BM, sneezing, blowing nose - Maintain quiet environment and limit stimuli (give rest periods) - Maintain normal temp (increased temp with increased ICP, put pt on cooling blanket) Cushing’s traid - Widening pulse pressure (rising systolic, declining diastolic) 40 difference, Severe HTN, Bradycardia Herniation - Damage to brain from trauma increased ICP displacement of the brain matter results in herniation of the brainstem o PT will have cheyne-stokes respirations Diffuse Brain Injuries - Concussion (“mild to severe traumatic brain injury”, no significant imaging findings) o Headaches, irritable o Try to wake up q4hrs, bring back to ER if vomiting occurs or pt won’t wake up - Axonal Injury (Severe Injury caused by sheering of axons o No strenuous activity for 7 days or until headache free but @ least 7 days o No TV, no reading Focal Brain Injuries - Epidural Hematomas *EMERGENCY SITUATION* See this Pt first! o Blood collection in the space between the skull and dura. Usually caused by a tear of the middle meningeal artery. Brief loss of consciousness with return of lucid state; then, as hematoma expands, increased ICP will often suddenly reduce LOC (Lose consciousness wake up then out again) o Treatment = measures to reduce ICP o Pt needs monitoring and support of vital body functions and respiratory support - Subdural Hematomas o Slow venous bleed can die r/t bleed going unnoticed o Blood beneath dura o Very common in elderly r/t falls o Acute/subacute Acute: symptoms develop over 24 to 48 hours Subacute: symptoms develop over 48 hours to 2 weeks Requires immediate control of ICP o Chronic Develops over weeks to months Clinical signs and symptoms may fluctuate Diagnostic Evaluation - Physical and neurological exam, skull and spinal x-rays, CT scan, MRI, PET scan Pre-hospital Care of Head Injured Patients - ABC’s, spinal immobilization (anyone who falls assume they have neck injury, c-spine collar), initial resuscitation, rapid transport Head Injury Management - GOAL: Prevent of minimize secondary injuries to the brain ED Assessment of Head Injured Patients - ABC’s, history, clues to brain injury, physical exam (treat life threats first), the “D” of the ABC’s stands for neuro exam Glasgow Coma Scale (GCS) - Measures motor 1-6, verbal 1-5, eyes 1-4, 15 = best, 1 = bad - GCS scores o 13-15 – mild head injury o 9-12 – moderate hea [Show Less]