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Terms in this set (91)
What is the most common blunt mechanism of injury that causes traumatic brain injury (TBI)?
An MVC is one of the most common mechanisms of injury that results in traumatic brain injury. The injury can range from mild to severe TBI. A fall is the most common mechanism of TBI in pediatric patients younger than the age of 12 years. Most adolescent TBI results from an MVC, sports injuries, and assault (Box 1.1).
What is it called when a moving object impacts a stationary head?
Blunt trauma to the head is described based on the mechanism of injury. The term acceleration injury indicates a moving object, such as a baseball bat, impacting the head. .
is when the head is moving and strikes a stationary object, such as in MVC when the head hits the windshield
What is it called when a brain injury occurs without any impact to the head itself?
An indirect injury occurs when the brain moves in the cranial vault following an acceleration-deceleration without the head impacting an object. A direct injury is an impact to the head, either through an acceleration, deceleration, or acceleration-deceleration mechanism.
Following a gunshot to the head, the bullet is found within the cranial vault. What type of injury is this?
Penetrating injury with a gunshot wound indicates that the bullet entered the cranial vault but did not exit it. The bullet remains in the skull. Perforating injury is when the bullet enters and exits the cranium
Following an impact to the head, an injury to the brain occurs on the opposite side of the impact. What is this injury called?
A coup injury occurs at the area of impact and a contre-coup injury is brain injury that occurs on the opposite side of the impact. Coup-contre-coup injuries are commonly associated with epidural and subdural hematomas.
The mechanism of injury that most commonly causes a coup-contre-coup injury
is an impact to the lateral side of the skull.
What type of injury results in diffuse axonal injury (DAI) to the brain?
Rotational injury, such as in vehicle rollover, can result in shearing of the brain tissue. This type of injury is called diffuse axonal injury. Presence of DAI indicates a poorer functional outcome of the TBI patient.
What type of injury causes chronic traumatic encephalopathy?
Repetitive TBIs that trigger progressive degeneration of brain tissue result in chronic traumatic encephalopathy (CTE). The injuries frequently are mild traumatic brain injuries (MTBI) related to contact sports injuries.
What patient population is most likely to present with a chronic subdural hematoma (SDH)?
Elderly patients are likely to present with chronic SDH. Other patient populations include alcoholics and dementia patients. Chronic SDHs tend to hemorrhage slowly. These patients have cortical atrophy, which allows for more blood volume to accumulate before an increase in intracranial pressure (ICP) occurs (Box 1.2)
Cytotoxic edema causes intracellular swelling and is a result of hypoxia or anoxic injuries. Vasogenic cerebral edema is a swelling or extra fluid in the interstitial space and is a result of trauma to the tissue. TBI will have a combination of both cytotoxic and vasogenic edema.
Following a brain trauma, there is a loss of autoregulation in the areas of injury. Cerebral blood flow is shunted away from the uninjured areas of the brain to the areas of injury. This causes a "steal phenomenon" and results in hypoxia in uninjured areas of the brain.
is used to treat cerebral edema and pulls fluid from the interstitial space. It is most effective with managing vasogenic edema.an
What is the anatomical difference in pediatric patients that makes them more likely to experience a brain injury with a trauma?
The head of a child is larger in proportion to the rest of his or her body and the stability of the neck and ligaments is not fully developed. This makes the child susceptible to TBI in an MVC.
What is the triad of symptoms typically seen in shaken baby syndrome (SBS)?
Subdural hematoma, retinal hemorrhage, and cerebral edema.
SBS is a result of a violent shaking of the child
. This is also called abusive head trauma. The head may or may not have contacted an object but the movement of the brain contents causes a shearing effect. The result is typically bilateral SDH and DAI. The injury is often fatal and can cause lifelong severe neurological disabilities.
have a characteristic pattern for SBS and are used frequently to assist with the diagnosis of SBS
What type of fracture is a displaced comminuted fracture of the skull?
A depressed skull fracture is a comminuted fracture that is displaced into the meninges and brain tissue. This injury is commonly associated with epidural, subdural, and parenchymal hematomas. A linear skull fracture has a nondisplaced fracture line.
A patient develops cerebrospinal fluid (CSF) leak following a blow to the side of the head. What type of fracture does this patient have?
Basilar skull fractures may result in CSF leaks from ears (otorrhea) or from the nose (rhinorrhea). The base of the skull is divided into the anterior, middle, and posterior skull base or fossa. Fractures may occur anywhere throughout the skull bases, but the anterior fossa is the most common area for basilar skull fractures.
A blow to the side of the head causes
basilar skull to buckle, resulting in fracture lines along the basilar skull.
What is an area of the brain parenchyma with hemorrhage following TBI called?
Contusions are areas of parenchymal hemorrhage that result from acceleration/deceleration and blunt impact. Contusions may initially appear as several areas of small hemorrhages, but these can increase and combine into a larger hematoma. Approximately one third of the contusions will expand in 24 hours.
Initial CT scan following TBI may not show the contusion
. Frequently, follow-up CT scans in 24 hours are obtained to identify the contusion or determine the increase in size of the contusion.
Is an epidural hematoma (EDH) most commonly caused by laceration of an artery or of bridging veins?
Laceration of an artery is the most common cause of EDH. The most common artery involved in EDH is the middle meningeal artery. Laceration of veins may also result in bleeding in the epidural space but is less common than arterial involvement. Tearing of bridging veins will hemorrhage into the subdural space (venous sinuses are located in subdural space) causing subdural hematoma.
Tearing of pial veins will cause bleeding following a trauma. Where is the hemorrhage located?
Tearing of small pial veins cause bleeding into the subarachnoid space and is called subarachnoid hemorrhage (SAH). SAH may also involve blood in the ventricles but isolated ventricular hemorrhage following trauma is unusual.
SAH following trauma does not usually result in vasospasms as does SAH following aneurysm rupture.
What are the two secondary injuries that have the greatest effect on neurological outcomes following TBI?
Hypotension and hypoxia
Secondary injuries are those neurological injuries that occur to the brain after the initial trauma. It has been found that hypotension and hypoxia are the two most important determinants of neurological outcomes
A patient develops bilateral periorbital ecchymosis following traumatic injury to the head. What is the cause of the ecchymosis?
Basilar skull fracture
Patients with basilar skull fracture may develop periorbital ecchymosis (raccoon eyes) and bruising on the mastoid process called Battle's sign.
HINT: Raccoon eyes and Battle's sign may not appear immediately following a trauma and typically develop later following injury
What is the best method to test drainage from the nose for the presence of CSF?
The halo test is used to determine the presence of CSF in drainage from the nose (rhinorrhea) or from the ears (otorrhea). To perform a halo test, dab the drainage onto gauze and look for a yellow ring surrounding the drainage. This is a positive halo and indicates presence of CSF.
The halo test is more reliable than
testing the drainage for glucose because drainage may contain blood, which also has glucose. A glucose test for CSF has more false positives.
What lab test may be used to improve the accuracy of the diagnosis for CSF in drainage?
A halo ring test can cause false positives so the gold standard (most diagnostic) is the lab testing of the drainage for CSF. Beta-2 transferrin is a variant of transferrin and is used as an endogenous marker for CSF in other bodily fluids.
has been called CSF-specific transferrin because it is highly specific for CSF.
What diagnostic study is considered the gold standard for identifying skull-base fractures?
Diagnostic CT scan of the brain found air present in the cranium and basilar skull fracture. What is the air in the cranium called?
Pneumocephalus is a complication of basilar skull fracture and may be identified on brain CT scan. Air enters through the fracture into the cranium. Management of pneumocephlaus may be with oxygen administration.
Pneumocephalus can become
a tension pneumocephalus with a resulting elevation of ICP.
An MTBI may be defined by the Glasgow Coma Scale (GSC). What GCS would indicate minor brain injury?
MTBI (used to be called a concussion) is often classified as a GCS between 13 and 15 (Box 1.5). The patient does not have to experience a loss of consciousness to have a traumatic brain injury. MTBI can be graded on severity (Box 1.6).
What is the most sensitive indicator of an increased ICP?
A change in LOC is a sensitive indicator for neurological deterioration and an increase in ICP. When performing neurological assessments, it is very important to assess for LOC
Increased systolic pressure.
Widened pulse pressure, and
Bradycardia) are signs of impending herniation but are late signs of an increased ICP.
What is the most commonly used diagnosis of DAI?
Clinical diagnosis reveals a poor neurological status and a decreased level of consciousness that are out of proportion with the injury observed on CT scan. DAI involves microscopic injuries, therefore is not seen as large changes on diagnostic studies such as a CT scan. CT imaging may demonstrate small punctate foci of hemorrhage but this is not found in all cases of DAI.
A patient presents to the emergency room following a fall off a ladder. The family reports some altered loss of consciousness after the fall. What should be included in the nurse's admission history?
Duration and severity of altered LOC.
A reported altered LOC requires more information from those who observed the injury. This includes the duration of the altered mentation, degree of altered LOC, other neurological symptoms experienced, and mechanism of injury.
Retrograde amnesia is the loss of memory before the traumatic event. It is commonly determined by asking the patient about the last thing he or she remembers before the traumatic event.
Posttraumatic amnesia is the loss of memory from the time of unconsciousness until the first memory after the event. Antegrade amnesia is the inability to create new memory after the event. An example of antegrade amnesia is when a person is unable to remember anything that happened the rest of the day despite being conscious.
A rapidly expanding EDH following a severe TBI can result in an uncal herniation. Which pupil will dilate following uncal herniation?
Uncal herniation is a lateral displacement and herniation of brain tissue caused by a unilateral expanding mass. The pupil affected by the herniation is the ipsilateral pupil.
It will dilate and become nonreactive. SDH may also be a rapidly expanding mass and can cause uncal herniation with dilated ipsilateral pupil.
Dilated pupil is caused by the injury or stretch of cranial nerve (CN)
III (oculomotor). CNs do not cross (except CN IV), so symptoms are ipsilateral.
Which of the hematomas following TBI has the classic presentation of a lucid period?
EDH has a classic presentation of a period of lucidity. The patient may have been unconscious initially, experiences a period of being awake, then loses consciousness again.
What complication of abdominal trauma can increase ICP and worsen neurological outcomes?
Abdominal compartment syndrome (ACS)
ACS is a complication of abdominal trauma. It causes an increase in abdominal pressure that results in a decrease in venous drainage from the brain. This elevates the intracerebral blood volume and ICP.
Increased pressure in the thoracic cavity can have the same effect as ACS. Multisystem trauma patients with combination abdominal or thoracic trauma with brain injury should be assessed for the presence of ACS; treatment should be initiated to lower abdominal and thoracic pressures.
What is a commonly used assessment tool to measure the deficit in cognitive functioning following a TBI?
The Ranchos Los Amigos Scale is used to measure a deficit in cognitive function. The tool is frequently used to determine the patient's level of cognitive functioning for rehabilitation capabilities and prognosis following TBI. The scale is divided into eight stages (or 10 stages in the revised version) ranging from appropriate to coma.
What is the primary management of a depressed skull fracture?
Following a depressed skull fracture, surgical debridement is used to remove the bony pieces that cause damage to the meninges and brain tissue. This is followed later by cranioplasty to replace the portion of the debrided skull.
The use of cranioplasty to repair the skull defect also serves a cosmetic purpose.
What is the prehospital and emergency room priority of care for severe traumatic brain injured patients?
To check airway and breathing
Hypoxia and hypotension are secondary injuries that will worsen neurological outcomes. The prehospital goals are to initiate treatment to prevent secondary injuries.
This includes obtaining and maintaining airway and breathing to prevent hypoxia and initiating fluid resuscitation to prevent hypotension and hypoperfusion. Care should also be taken to secure the cervical spine as cervical spine injuries are commonly associated with head trauma.
Intubation is considered in patients with GCS of less
than or equal to 8.
What are the mean arterial pressure (MAP) and the PaO2 goals for TBI?
MAP and PaO2 greater than 80 mmHg
Systemic hypoxia is an independent predictor of increased morbidity and mortality. A single episode of hypotension (blood pressure less than 90 mmHg) is associated with worsening outcomes.
Maintaining an MAP greater than 80 mmHg in severe traumatic brain-injured patients (GCS less than 8) will improve brain perfusion. If GCS is more than 8, then MAP is maintained greater than 70 mmHg. Oxygenation goal is to maintain PaO2 between 80 and 120 mmHg and arterial saturation greater than 92% to prevent secondary hypoxic injuries.
An ICP monitor was placed in the trauma intensive care unit (ICU) to monitor a patient with severe traumatic brain injury. What should be the goal for the cerebral perfusion pressure (CPP)?
Maintain pressure greater than 60 mmHg
CPP is a measurement used at the bedside to estimate cerebral blood flow (CBF). The CPP is calculated when the patient has an ICP monitor and the goal is to maintain greater than 60 mmHg to improve CBF.
The ICP should be maintained at less than 20 mmHg. If CPP is less than 60 mmHg following adequate fluid resuscitation, a vasoconstrictor may be administered to increase MAP. CPP more than 70 mmHg is not recommended because of the risk of volume overload and acute respiratory distress syndrome (ARDS).
Infants and young children may tolerate increased pressure better because of open sutures and fontanelles
, but they can still experience increased ICP and may require ICP monitoring similar to adults.
What is the osmotic diuretic used to treat cerebral edema and lower ICP?
Hold administration of mannitol if serum osmolality is greater than 320 mOsm/L.
Mannitol is an osmotic diuretic that is used to increase serum osmolality, creating a pull of fluid from the extravascular to intravascular space. This lowers cerebral edema and ICP.
While administering mannitol, care should be taken to avoid hypovolemia (because of the diuresis) and hypotension. Fluid resuscitation may be required to prevent hypovolemia. Serum osmolality and sodium levels need to be obtained at least every 6 hours with hyperosmolar therapy.
What is the potential adverse effect of administering hypertonic saline to lower cerebral edema?
Central pontine myelinolysis (CPM).
Avoid administering hypertonic saline in patients who are hyponatremic. Mannitol would be the better answer in that situation.
Acute renal failure.
Central pontine myelinolysis.
Worsening pulmonary edema.
Sustained hyperventilation with hypocarbia and respiratory alkalosis can cause what harmful effects in a traumatic brain-injured patient?
PaCO2 is a potent cerebral vasodilator. If the PaCO2 is decreased because hyperventilation and hypocarbia occur, this causes cerebral vasoconstriction, reduced CBF, and a decrease in ICP.
Sustained or aggressive hyperventilation is not recommended because of its effect on CBF, even though it can lower ICP. The PaCO2 goal is 35 to 45 mmHg (maintaining on the lower side of normal if ICP is elevated).
When a patient suddenly loses consciousness because
of a rapidly elevating ICP, the trauma nurse may hyperventilate for a short period to lower the ICP until definitive management of the patient can occur.
A patient is admitted to the ICU after craniotomy to remove acute SDH. The bone is left out and will be replaced at a later date. What is this called?
A bone flap is removed during the craniotomy and not replaced to allow for more room for the brain to swell. This is called decompressive surgery. Patients still can herniate through the bone flap, causing strangulation of brain tissue, and will still need to be treated for an increase in ICP. A hemicraniectomy may also be performed to allow a greater amount of decompression.
What is the temperature goal when caring for a severe TBI patient?
Between 36°C and 37°C
Elevated body temperatures have adverse effects on TBI patients and normothermia should be maintained. Even though non-brain-injured patients' fever is allowed to increase body temperatures to the range of 38.3°C to 38.5°C, the brain may begin to experience injury at a temperature greater than 37°C.
Fever increases brain metabolism, elevates levels of proinflammatory cytokines, and may increase ICP. Hypothermia has also been found to worsen outcomes in traumatic brain-injured patients and should be avoided unless there is refractory elevated ICP.
Which type of IV fluid is most commonly used to maintain fluid volume in a TBI patient?
NS is an isotonic crystalloid commonly used to resuscitate and maintain fluid volume in a TBI patient. NS may also be used initially to correct hyponatremia (Na+ less than 140 mEq/L).
HINT: Avoid dextrose in the intravenous (IV) fluids because hyperglycemia is considered a secondary injury and can worsen neurological outcomes.
Sedation and analgesia may be provided to control agitation and pain following TBI. What adverse effect should be monitored closely to prevent secondary brain injuries?
Sedation also involves the potential loss of an accurate neurological assessment.
Analgesia and sedation can lower the ICP and facilitate mechanical ventilation but may cause vasodilation with hypotension and decreased CBF. Hypotension is a secondary injury that may worsen neurological outcomes.
Close monitoring of blood pressure (BP) is required when administering analgesics and sedatives. Analgesia and sedation may also affect respiratory functions and should be used cautiously to prevent respiratory depression and hypoxia, unless mechanically ventilated.
How long should the seizure prophylaxis be continued following a severe TBI?
For 7 days.
Continuous electroencephalogram (EEG) monitoring may be used to identify nonconvulsive seizures in TBI patients not waking up following the trauma.
Seizure prophylaxis is recommended for 7 days following a severe TBI
. If the patient has not had a seizure within 7 days following the trauma, the antiepileptic drug may be discontinued. Seizure prophylaxis is not recommended in mild to moderate traumatic brain-injured patients.
are not recommended in managing cerebral edema or increased ICP in TBI patients.
A gastric tube is required in a patient with TBI. What type of gastric tube should be placed?
An OGT is the preferred gastric tube in patients with TBI with a potential risk of having basilar skull fracture. Nasogastric tube placement can result in the tube entering the brain through the cribriform fracture in basilar skull fractures. The cribriform plate is located in the anterior fossa or skull base.
Where is the gauze placed in patients with rhinorrhea?
Taped under the nose.
Frequently, gauze is taped under the nose to absorb the drainage. This allows for the estimation of the amount of drainage or CSF leak that is occurring.
Never pack the nose with gauze in patients with rhinorrhea. This can increase the risk of meningitis.
Following a basilar skull fracture with a known CSF leak, at what level should the head of the bed (HOB) be placed?
The HOB should be elevated greater than 30 degrees in patients with a known CSF leak. Conservative treatment is usually recommended for basilar fractures and CSF leaks, which include strict bed rest; elevated HOB; no coughing, sneezing, and straining. Antibiotic prophylaxis is not recommended following a basilar skull fracture and CSF leak.
A patient is being discharged home from the emergency department following an MTBI while playing football. What is the most appropriate recommendation on when the patient can return to playing football?
Once the patient is symptom-free.
Second-impact syndrome can occur with a second impact within hours to weeks of the initial TBI.
Current guidelines recommend a graduated increase in the level of activity for the athlete progressing from the initial stage of "light exercise" toward "full contact" activity,
once the athlete is completely symptom-free at rest. This is to prevent a secondary impact syndrome, which can result in death and repetitive injuries.
A patient with a TBI should be placed in what position to lower the ICP?
Elevating the HOB by 30 degrees facilitates venous drainage, lowers blood volume in the cranium, thereby lowering the ICP. Laying the HOB flat will increase an ICP. Also maintain the neck in a neutral position to avoid jugular vein constriction.
Elevated body temperatures should be managed quickly in brain-injured patients to prevent secondary brain injury. Applying a cooling blanket to lower the body temperature is a nursing intervention that may be used.
Other methods to lower the body temperature may include administering antipyretic medications, controlling of room temperature, and intravascular cooling (Box 1.14). The goal is to maintain a normothermic body temperature.
Management of posttraumatic headache is similar to
benign headaches and includes abortive treatments with triptans.
can also increase metabolism and should be treated if it occurs during cooling of the patient.
The brain is most susceptible to
plasticity early after a trauma, so rehabilitation begins on admission.
Following a depressed skull fracture, the patient develops fever and elevated white blood cell (WBC) counts. What would be the potential complication of the depressed skull fracture?
CNS infections, such as meningitis, are potential complications following a depressed and basilar skull fracture.
: Signs of an infection are elevated fever and WBC count; meningitis is the infection associated with depressed skull fracture
How many months following the TBI does the neurological improvement begin to slow down?
At about 6 months
The greatest improvements following TBI occur within the first 6 months then begin to slow down with minimal improvement after 1 year.
Which CN may be injured by a basilar skull fracture if patient presents with asymmetrical facial expressions?
acial (CN VII)
CN injuries can be associated with basilar skull fractures. CN I (olfactory or sense of smell) can be affected if the cribriform plate is fractured. CN II (optic) injury can result in unilateral blindness and dilated pupil. The facial nerve (CN VII) is more commonly damaged with middle fossa and temporal bone injury
A head CT scan of a trauma patient finds intracerebral hemorrhage. What medication therapy would the trauma nurse suspect the patient to be taking?
Anticoagulation or antiplatelet therapy
Anticoagulation and antiplatelet therapy are the common therapies that result in intracerebral hemorrhage and may occur following any trauma. Reversal of the bleeding complications is considered a priority and may include administering a reversal agent if there is an antidote for the medication.
Correct the coagulopathy with prothrombin complex concentrates (PCC) in life-threatening bleeds. Other blood products may include fresh frozen plasma (FFP) and cryoprecipitate..
HINT: If the patient was on antiplatelet therapy, administer platelets.
Repetitive MTBIs in contact sports can result in what complication?
Chronic traumatic encephalopathy (CTE).
HINT: The pathophysiology of CTE is similar to Alzheimer's disorder and Parkinson's disease, but this is a preventable dementia.
A patient presents to the clinic with frequent headaches and states he had a concussion about 2 months ago. What is the cause of the headaches?
Posttraumatic headaches develop in about 30% to 40% of patients following MTBI. The headaches may increase during periods of stress, tension, or activity (Box 1.16).
What is the brain's ability to reorganize neural pathways called?
Plasticity is the ability of the brain's neural pathways to reorganize based on stimulation, new experiences, and new learning. Pediatric brains have greatest plasticity but adult brains can reorganize neural pathways to learn and improve one's recovery. Engaging in activities helps the brain develop new pathways.
Inform the family that it may take up to 1 year after the injury to have
an understanding of the degree of physical recovery achieved; however, psychological recovery may take even longer.
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