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Traumatic Brain Injury A Case Study

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Traumatic Brain Injury A Case Study Lisa Randall, RN, MSN, ACNS-BC RNSG 2432 Coup and Contrecoup Injuries Coup: direct skull impact Contrecoup: opposite side of ... – PowerPoint PPT presentation

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Title: Traumatic Brain Injury A Case Study


1
Traumatic Brain Injury A Case Study
  • Lisa Randall, RN, MSN, ACNS-BC
  • RNSG 2432

2
Demographics/CC
  • 23 y.o. AAM
  • Auto vs. ped
  • 8/10/08

3
HPI
  • Dancing on I-35 under the influence of crack
    cocaine and ETOH.
  • Hit by 2 cars gt 50mph
  • GCS 12 on arrival, but declined to 4
  • Eyes 4gt1
  • Verbal 3gt1
  • Motor 5gt2

4
History
  • PMH
  • Denies, but GSW (metallic pellets CXR)
  • PSH
  • Denies
  • Social Hx
  • Single, no children, unemployed, unfunded
  • ETOH, amphetamines, cannibis
  • Recently released from jail for drug possession
  • Meds
  • Denies

5
Diagnostics Normal CT
6
Subdural Hematoma
7
Diagnostics
8
Diagnostics
9
Focused A/P
  • R frontotemporoparietal SDH
  • Craniectomy
  • EVD
  • Monitor/treat ICP
  • Paraplegia/paresis
  • L2 burst fracture c subluxation L2-L3
  • T11 lamina/TP fracture
  • T10-L3 posterior fusion when stable
  • PT/OT/STrehab

10
A/P cont
  • 10th 11th rib fractures
  • R femur fracture
  • Acetabular fracture
  • Mediastinal hematoma

11
Post-Op
12
Post-Op
13
Nursing Concerns
  • Neuro checks/VS q1h
  • ICP monitoring
  • Mannitol
  • CSF drainage
  • CPP monitoring
  • IVF
  • Vasopressors
  • MAP monitoring
  • Sedation/analgesia
  • Seizure prophylaxis
  • Infection prophylaxis
  • Skin care

14
Interdisciplinary Collaboration
  • Trauma
  • Pulmonary/CC
  • Orthopedics
  • ID
  • SW/CM
  • Nursing
  • PT/OT/ST/RT
  • WOCN
  • Dietary

15
Evaluation
  • Rehabilitation
  • Assessment
  • Decreased short term memory
  • Paraparesis
  • DF 2/5, PF 2/5, HF 4-/5
  • Cranioplasty

16
Epidemiology of Head Trauma
  • Occurs every 15 seconds
  • 500,000 annual ED visits
  • Most common causes MVAs, falls, assaults
  • Males 15-24, elderly gt 75
  • Accounts for 40 of traumatic deaths

17
Pathophysiology of TBI
  • 1st
  • Primary Injury initial insult i.e. from bleed

18
Second
  • Secondary Injury delayed injury from hypoxia,
    ischemia, and release of neurotoxins
  • Excitatory amino acids can cause swelling and
    neuronal death
  • Endogenous opioids cause increased metabolism,
    using glucose supplies
  • Increased ICP, especially gt 40 leads to brain
    hypoxia, ischemia, hydrocephalus, herniation
  • Hydrocephalus clotted blood obstructs CSF
    outflow tracts and absorption of CSF, disrupts
    blood-brain barrier

19
Head Trauma
  • Concussion
  • Contusion
  • Epidural hematoma (EDH)
  • Subdural hematoma (SDH)
  • Basilar skull fracture
  • Diffuse axonal injury (DAI)

20
Epidural
Contusions
Basilar skull fracture
Depressed skull Fracture
21
Types of Injuries
  • Mild Traumatic Brain Injury
  • Concussion brief change in mental status with
    axonal swelling
  • Moderate to Severe Brain Injury
  • Contusion bruising
  • Fractures linear,comminuted, depressed, basalar
  • Bleeds epidural, subdural, intracerebral

22
Mild Traumatic Brain Injury
  • Period of LOC lt 30 mins with a GCS of 13-15 after
    this LOC
  • Amnesia to the event
  • Alteration in mental status at the time of the
    event (dazed and confused)

23
Types of Concussion
  • Grade I (confusion, no amnesia, no LOC)
  • Remove from activity (may return when
    asymptomatic)
  • 3 concussions in 3 months no activity that risks
    head trauma for 3 months
  • Grade II (confusion and amnesia)
  • Remove from activity for day
  • Recheck in 24 hours
  • No activity for 1 week
  • Two grade II concussions in 3 months, no activity
    for 3 months
  • Grade III (LOC)
  • To ED for CT
  • Symptom free for 2 weeks, then another 30 days
  • Two grade III concussions, no activity for 3
    months

24
Post-Concussive Syndrome
  • Somatic symptoms headache, sleep disturbance,
    dizziness, vertigo, nausea, fatigue, sensitivity
    to light or noise
  • Cognitive attention, concentration, memory
    problems
  • Affective irritability, depression, anxiety,
    emotional lability

25
Moderate and Severe Brain Injury
26
Contusion
  • Small bleeds
  • Cerebral Edema
  • Deficits are based on lobe involved

27
Fractures
  • Linear
  • Comminuted

28
Depressed Skull Fracture
  • 95 go to surgery
  • Antibitoics for infection
  • Brain tissue is involved

29
Treatment for CSF leak
30
Epidural Hematoma
  • Laceration of dural arteries or veins
  • Classically laceration of middle meningeal artery
  • Temporal bone fractures
  • Lucid interval followed by rapid deterioration
  • Acute bleed

31
Subdural Hematoma
  • 60-80 mortality
  • Tearing of bridging veins, pial artery, or
    cortical veins
  • Acute vs chronic

32
Traumatic Subarachnoid Hemorrhage
  • Lacerations of vessels in subarachnoid space

SAH
TSAH
33
Intraventricular and Intraparenchymal Hemorrhage
  • Intraventricular hemorrhage
  • Very severe TBI
  • Poor prognosis
  • Intracerebral hemorrhage
  • Parenchymal injuries from lacerations or
    contusions
  • Large deep cerebral vessel injury

34
Coup and Contrecoup Injuries
  • Coup direct skull impact
  • Contrecoup opposite side of impact
  • Due to negative pressure forces causing both
    vascular and tissue damage

35
DAI Diffuse Axonal Injury
36
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37
Neurologic Exam
  • Decreased neurologic function is best predictor
    of brain injury
  • Pay attention to cranial nerves

38
Management of Acute Brain Trauma
  • Labs CBC, electrolytes, type and screen, tox and
    ETOH screen
  • CT Brain
  • CT angiography or cerebral angiography
    (penetrating)
  • MRI contraindicated if metallic fragments

39
Management Continued. . .
  • Intubate GCS 8 or less or airway protection issue
    (Cricothyroidotomy if necessary)
  • Maintain BP 90 mmHg systolic
  • C-spine precautions
  • Tetanus prophylaxis
  • Sterile dressing to wounds
  • Antibiotics in penetrating injury

40
ICP Management is the Key
  • ICP monitor in patients with GCS lt 8
  • Hyperventilation not routinely recommended
  • Elevate head of bed to 30 degrees
  • Sedation
  • Propofol
  • Barbiturate Induced Coma
  • Contraindicated in hypotension
  • Mannitol
  • Reduces ICP by reducing blood viscosity, improves
    cerebral blood flow
  • Serum osmolality should not be gt 320
  • Bolus dosing

41
To Image or Not to Image?
  • GCS lt 15
  • Intoxicated
  • Age gt 55 or lt 2
  • Amnesia to events
  • Witnessed LOC (gt 15 minutes)
  • Repeated vomiting
  • Evidence of basilar skull fracture
  • Inability to recall 3 of 5 objects
  • Coagulopathy
  • Penetrating head injury

42
Ventriculostomy
43
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44
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45
Evidenced Based Medical Guidelines for TBI
Management
  • BP and oxygenation
  • Hyperosmolar therapy
  • ICP monitoring
  • CPP
  • Infection prophylaxis
  • DVT prophylaxis
  • http//youtu.be/YQ609Tk-qQI
  • PbtO2
  • Analgesic/sedatives
  • Nutrition
  • Antiseizure prophylaxis
  • Hyperventilation
  • Steroids
  • Hypothermia


46
New Therapy
  • Stem Cell Therapy
  • Neural/Glial differentiation
  • Neurogenesis
  • Neuroplasticity
  • Improve motor function
  • Improve cognitive function

47
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48
References
  • AANN Core Curriculum for Neuroscience Louis, MO.
    Nursing, 4th Ed. 2004. Saunders. St.
  • Davis, F.A. (2001). Tabers Cyclopedic Medical
    Dictionary. F.A. Davis, Philadelphia.
  • Greenberg, Mark. (2006). Handbook of
    Neurosurgery. Greenberg Graphics, Tampa,
    Florida.
  • Lewis, S., Heitkemper, M., OBrien, P., Bucher,
    L. (2007). Medical-Surgical Nursign. Assessment
    of Management of Medical Problems. Mosby
    Elsevier, St. Louis, Missouri
  • Silvestri, Linda. (2008). Comprehensive review
    for the NCLEX-RN Examination. Saunders Elsevier,
    St. Louis, Missouri.

49
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50
Introduction
  • YouTube - Brain Plasticity

51
Neuroplasticity
  • Organizational changes caused by experience

52
Neurogenesis
  • Formation of new nerve cells

53
Nature vs. Nurture
  • Genetics
  • 2500 connections
  • major highways
  • Environment
  • 15000
  • avenues side roads

54
Future
  • Directed Neuroplasticity

55
Brain Fitness Program
  • YouTube - The Brain Fitness Program (1/8)
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