Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries (Nursing prospective)

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Assessment, Management and Decision Making in the
Treatment of Polytrauma Patients with Head
Injuries(Nursing prospective)

• Hayek. M
• Nursing College / Medical complex
• Najah National University

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Definition

•  Head injury is a general term used to describe
  any trauma to the head, and most specifically to
  the brain itself.
• A head injury is classified by brain injury
  types fracture, hemorrhage, or trauma.

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KEY WORDS

• traumatic brain injury (TBI), intracranial
  pressure (ICP), Glasgow Coma Scale (GCS),
  cerebral blood flow (CBF), cerebral perfusion
  pressure (CPP),

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Epidemiologic Aspects

• 80,000 survivors of head injury annually
• 125,000 children lt15yo head injured annually
• 40-60 of head injured patients have extremity
  injury
• 32,000-48,000 head injury survivors with
  orthopaedic injuries annually

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Overview

• Initial evaluation
• Prognosis
• Management of Head Injury
• Orthopaedic Issues
• Operative vs. nonoperative treatment
• Timing of surgery
• methods
• Fracture healing in head injury
• Associated injuries
• Complications

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Evaluation

• ATLSABCs
• History
• loss of consciousness
• Physical exam
• Glasgow Coma Scale
• Radiographic studies
• CT Scan

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Evaluation

• Must exclude head injury by evaluation if
• history of loss of consciousness
• significant amnesia
• confusion, combativeness
• Cannot be simply attributed to drug or alcohol
  use
• neurologic deficits on exam of cranial nerves or
  extremities

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Physical Exam

• Exam of head and cranial nerves for lateralizing
  signs
• dilated or sluggish pupil(s)
• Extremities
• unilateral weakness
• posturing
• decorticate (flexor)
• decerebrate (extensor)

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Glasgow Coma Scale

• Eye opening 1-4
• Motor response 1-6
• Verbal response 1-5

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Glasgow Coma Scale

• Eye opening
• Spontaneous 4
• To speech 3
• To pain 2
• None 1

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Glasgow Coma Scale

• Motor response
• Obeys commands 6
• Purposeful response to pain 5
• Withdrawal to pain 4
• Flexion response to pain 3
• Extension response to pain 2
• None 1

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Glasgow Coma Scale

• Verbal response
• Oriented 5
• Confused 4
• Inappropriate 3
• Incomprehensible 2
• None 1

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Glasgow Coma Scale

• Sum scores (3-15)
• lt9 considered severe
• 9-12 moderate
• 13-15 mild
• ModifiersxT if intubated (Best score possible
  11T) xTP if intubated and paralyzed (Best
  score possible is 3TP)
• Done in the field but best in trauma bay
  following initial resuscitation
  
  
  

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Treatment

• Initial
• Intubation if unresponsive or combative to give
  controlled ventilation
• pharmacologic paralysis
• after neurologic exam is completed
• Blood pressure and O2 saturation monitoring
• keep systolic gt 90 mm Hg
• 100 O2 saturation

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Management

•     Based on physical and neurological
  examination,     Xray     CT Scan     MRI    
  Treatment of increased ICP - Supportive measures
  - Ventilatory Support - Fluid and Electrolyte
  maintenance - Nutritional support - Pain and
  Anxiety management.

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Nursing Assessment

•    - History of Trauma     - Time, cause,
  direction and force of the blow     - Loss of
  consciousness, duration    Assess LOC  - Glasgow
  Coma Scale      - Response to verbal commands or
  tactile stimuli      -  Pupillary response to
  light      -  Motor Function    Vital Signs
       - Monitor for signs of increased ICP   
  Motor Function      - Move extremities, hand
  grasp, pedal push, speech

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• Nursing Mg or care with patient with HT are
  divided on the several levels including
  prevention, pre-hospital (first aid), immediate
  hospital care, acute hospital care and
  rehabilitation.
• The nurse should understand the principles behind
  medical treatment
• The nursing management of head injury aimed to
  preserve brain homeostasis, prevent secondary
  injury and to provide psychosocial support

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Nursing Management.

• (1) Monitor vital signs closely.
• (a) Accurately assess and document
  neurological status.
• (b) Evaluation of alterations of
  consciousness is crucial since symptoms progress
  rapidly.
• (2) Maintain patent airway.
• (a) Intubation and hyperventilation.
• (b) If patient is not intubated, maintain
  agood sposition.
• (c) Be aware that stimulation of coughing
  when suctioning increases intracranial pressure
  and may precipitate seizure activity.

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Nursing Management.

• (3) Administer medications as ordered.
• (4) Elevate head of bed (30º).
• (5) Administer hypertonic I.V. solutions as
  ordered
• Be alert for all signs and symptoms for pts who
  have brain trauma .

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Nursing Management.

• (6) Protect patient from injury if seizures
  occur.
• (7) Maintain normal body temperature.
• Should readmission if
• (1) Fever greater than 100ºF. (2) Pulse less
  than 50 beats per minute. (3) Vomiting. (4)
  Slurred speech. (5) Dizziness. (6) Blurred or
  double vision. (7) Unequal pupil size. (8) Blood
  or fluid discharge from ears or nose. (9)
  Increased sleepiness. (10) Inability to move
  extremities. (11) Convulsions. (12)
  Unconsciousness

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ICP Monitoring (Nursing prospective)

• Indications
• severe head injury (GCS lt 9)
• abnormal head CT
• or
• normal CT and at least two of the following
• age over 40
• uni- or bilateral flexor or extensor posturing

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ICU Management Goals (nursing intervention)

• O2 saturation 100
• Mean arterial pressure 90-110 mm Hg
• ICP lt 20 mm Hg
• Cerebral Perfusion Pressure (CPPMAP-ICP) gt70 mm
  Hg

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ICU Adjuncts ___be Attentions

• HCT 30-33
• PaCO2 352 mm Hg
• CVP 8-14 mm Hg
• avoid dextrose IV
• maintain euthermia or mild hypothermia

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Factors Influencing Prognosis

• Age
• Younger pts have greatest potential for survival
  and recovery
• 61-75 mortality if over 65
• 90 mortality in elderly with ICP gt20 and coma
  for more than 3 days
• 100 mortality if GCS lt 5, uni- or bilateral
  dilated pupils, and age over 75

survival and recovery not predictable except in
old pts
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Factors Influencing Prognosis

• Hypotension--50 increase in mortality with
  single episode of hypotension
• Hypoxia
• Delay in treatment
• prolonged transport
• surgical delay when lateralizing signs present

Potentially controllable!!
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Outcome

• Glasgow Outcome Score
• 1-dead
• 2-vegetative
• 3-cannot self care
• 4-deficits but able to self care
• 5-return to preinjury level of function

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Nonoperative Management

• Treatment of choice when
• nonoperative means best treat that particular
  fracture
• operative risks outweigh potential benefits
• Modalities
• splint
• brace
• cast
• traction
• Caveat
• device must be removed periodically to inspect
  underlying skin for decubiti

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Health care team roles

• First aid may be given by emergency medical
  technicians. Physicians trained in emergency
  medicine often provide initial care in a
  hospital. Neurosurgeons and neurologists may be
  asked to assist with care. Rehabilitation
  specialists such as physicians, physical
  therapists, speech therapists, or occupational
  therapists may provide rehabilitation. Nurses
  provide supportive care throughout, including
  24-hour care, home nursing care, and patient
  education.
• Preventions
• Rehab.
• Cope..
• Advocate and help

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Summary

• Orthopaedic injuries are common in head injured
  polytrauma patients
• Head injury outcome is difficult to predict
• Management requires multidisciplinary approach
• Operative management is safe and often improves
  functional outcome if secondary brain insults are
  avoided
• Hypotension, hypoxia, increased ICP
• Holistic nursing intervention approach must be
  done to maximize chance of survival