1 HEAD INJURY 2 Head Trauma Traumatic brain injury (TBI) Head trauma has a high potential for poor outcomes Deaths from head trauma occur at 3 time points after injury Immediately after the injury Progressive worsening of the head injury Internal bleeding Within 2 hours after injury Multisystem failure Approximately 3 weeks after injury 3 Head Trauma cont. Factors that predict a poor outcome The presence of an intracranial hematoma Increasing age of the patient Impaired or absent eye movements or pupil light reflexes Abnormal motor responses Early sustained hypotension Hypoxemia or hypercapnia ICP levels higher than 20 mm Hg 4 Nursing Assessment Always considered to have the potential for developing increased ICP Goal of nursing management of the head-injured patient is to maintain cerebral perfusion and prevent secondary cerebral ischemia 5 Primary brain injury- open or closed Open head injury Linear fracture Depressed fracture Open fracture Comminuted fracture Basilar skull fracture Penetrating injury GSW 6 TBI Open Linear fracture-80% of all skull fractures. Simple, clean break wherein impacted area bends in and surrounding area bends out. Depressed fracture-bone is pressed into the brain tissue Open fracture-scalp is lacerated, creating a direct opening to brain tissue Comminuted fracture-fragmentation of bone with depression of bone into the brain tissue 1
7 Skull Fractures 8 HEAD INJURY SKULL FRACTURE Types Simple Comminuted Depressed Assessment Fracture of the base of the skull nose (cerebrospinal fluid rhinorrhea). ears (cerebrospinal fluid otorrhea) Ecchymosis or bruising seen over the mastoid (Battle's sign). Bloody spinal fluid 9 TBI Closed head injury Concussion Contusion Laceration Diffuse Axonal Injury (DAI) Secondary injuries 10 Management- for closed fracture non depressed Depressed fractures- BoneSource, a calcium phosphate bone cement used to repair and heal cranial defects 11 BRAIN INJURY Concussion- acceleration- deceleration injury Diffuse Axonal (Shearing) Injury Traumatic Brain injury Primary Brain Injury- physical force of either an open or closed trauma Open head injury- depressed fracture, open fracture- penetrating wounds- gun shot etc. Closed- blunt trauma 12 Concussion 13 Diffuse Axonal (Shearing) Injury 14 Head movement during acceleration-deceleration injury typically seen in motor vehicle accidents 15 2
Coup (site of impact) injury to frontal area of brain and countercoup injury to frontal and temporal areas of the brain 16 BRAIN INJURY CONCUSSION; Transient disorder with momentary LOC, usually followed by complete recoverygrey matter of cortex or brainstem involved Home care r/t PCS: observe for headache, dizziness, irritability, insomnia, impaired memory and concentration-if observed, return to ED 17 BRAIN INJURY Contusion; 18 Bruising without tearing of vessels, results from the brain hitting the skull. May occur on the same side as impact (coup injury) or opposite side (contracoup injury)-base of frontal and temporal lobes involved. Occur as response to initial injury Increased intracranial pressure (ICP) Hemorrhage Epidural hematoma Subdural hematoma (SDH) Intracerebral hemorrhage Loss of autoregulation Hydrocephalus Herniation 19 BRAIN INJURY Epidural Hematoma- (Extra dural) occurs between the skull and the dura (outer meninges) that if large enough separates the dura from the skull. Generally an arterial bleed. Classical picture- pt unconscious immediately after head trauma then awakens lucid - then lapses into coma Management- relieve pressure. Decrease ICP 20 BRAIN INJURY Subdural Hematoma (SDH) collection of blood between dura (outer meninges) and arachnoid (middle layer meninges)- generally venous Classified; Acute- occurs within 24 hrs of injury- Subacute- symptomatic 2-14 days later. 21 BRAIN INJURY Chronic- weeks to months later. (As blood organizes into a clot the blood cells within the clots membrane lyse forming a fluid of high osmotic pressure. Water from surrounding 3
22 BRAIN INJURY subarachnoid space is drawn into clot producing a generally increasing intracranial mass- lead to cerebral herniation and death.) Signs and Symptoms of Subdural Hematoma depends on the size of the vessel involved and amount of bleeding Management- Burr holes and craniotomy to remove clot 23 24 INTRACRANIAL BLEEDS 25 BRAIN INJURY PROCESS 26 Subarachnoid Hemorrhage (SAH) bleeding into subarachnoid space- typically results from a venous bleed most common cause rupture of aneurysm- Berry aneurysms- congenitalassociated with smoking. ¼ die before reaching the ER. More common in females Kernig s sign-nurse flexes the leg at the hip and brings the knee to a 90 degree angle and then attempts to extend the knee. Brudzinski reflex- flex the head and the hips and knees flex + for meningitis. 27 BRAIN INJURY Subarachnoid Clinical manifestations Change in LOC Sudden severe headache Photophobia Nuchal rigidity Low back pain Nausea and vomiting Fever, elevated WBC S Cranial nerve deficits Motor weakness 28 BRAIN INJURY Subarachnoid EKG changes-bradycardia, AV block, PVC s Surgery - Guglielmi detachable coil, metal clip for aneurysms. amicar (aminocaproic acid) to prevent recurrence 3 gm q 2h (36gms/d) continue for 21 days then taper dose over several days- controversial Use of antifibrinolytics, such as epsilon aminocaproic acid, is controversial. They competitively inhibit plasminogen activation and have been reported to reduce the incidence of rebleeding. Other reports warn of their detrimental vasospastic effect and increased occurrence of hydrocephalus. Consult a neurosurgeon concerning their use. 29 BRAIN INJURY Subarachnoid Cerebral vasospasm has a delayed onset; it typically starts 3-5 days after the initial SAH, achieves maximal vessel narrowing at 5-14 days, and thereafter resolves gradually To reduce the risk of vasospasm Nimotop (nimodipine)- 4
seizures Dilantin (phenytoin) 30 BRAIN INJURY Intracerebral Hemorrhage; bleeding directly into brain tissue. Causes: Symptoms- similar to sub and epidural. Although hemiplegia is more common than hemiparesis. Treatment- surgical- high mortality 31 BRAIN INJURY HEAD TRAUMA THAT COMPROMISES THE FUNCTION OF PITUITARY GLAND MAY LEAD TO DIABETES INSIPIDUS AND INAPPROPRIATE ADH RELEASE 32 CLINICAL CARE FOLLOWING HEAD INJURY Airway establish baseline data- Prevent aspiration- Cardiovascular complications- skull and scalp injuries- Infection Prevention- 33 CLINICAL CARE FOLLOWING HEAD INJURY prevention of straining- Maintenance of Normothermia- fluid and electrolyte-acid base maintenance- Monitor restlessness, pain and disorientation Restlessness- Pain- administer mild analgesics- codeine 34 CLINICAL CARE FOLLOWING HEAD INJURY seizures- positioning- to prevent stasis- stress ulcers- secondary to trauma- Rest- prevent complications of inactivity- Space activities to prevent ICP- (mouth care can raise ICP 8 mm HG or more- 35 CLINICAL CARE FOLLOWING HEAD INJURY Cerebrospinal fluid fistulas- Test tape- distinguishes CSF from mucous- positive for glucose. Halo sign- yellowish ring observation for complications 5
36 Clinical Care of Patients with CSF Fistulas A. administer antibiotics B. never attempt to clean ears or nose C. never use nasal suction D. Instruct patient not to cough, sneeze, blow his nose 37 Clinical Care of Patients with CSF Fistulas E. place sterile pad near outer opening of ear or nose. DO NOT PACK- OBSTRUCTS FREE FLOW F. replace dressings as soon as they become moist to prevent germs from passing through moisture to brain. G. note, color, consistency and approx amt of drainage H. position pt to allow free drainage if possible- 38 BRAIN TUMORS ALL INTRACRANIAL BRAIN TUMORS CAN BE FATAL; NO ROOM FOR EXPANSION. 39 BRAIN TUMORS Classification- of tumors of the Nervous system a. Intracranial tumors 1. primary intracranial tumors 2. metastatic intracranial tumors 3. Granulomas- granulation tissue production in response to chronic infection, inflammation, foreign body or to unknown cause. b. Spinal tumors c. tumors of peripheral nerves 40 BRAIN TUMORS Types of Intracranial tumors Gliomas- composed of malignant glial cells (special connective tissue of CNS) and arising from various support tissues within the Brain Neuromas or Neurofibromas- arising from nerve cells Meningiomas- arising from meninges. Various blood vessel tumors e.g. hemangiomas Developmental tumors- usually cysts, such as colloid cysts or dermoid cysts Miscellaneous- pineal tumors and pituitary tumors. 41 BRAIN TUMORS Metastatic Intracranial tumors- 10-20% of intracranial tumors Primary brain tumors only rarely metastasize out of CNS. Signs and Symptoms- Most common symptoms Localizing symptoms related to specific regions can also occur. Motor cortex tumor can lead to Jacksonian seizures- seizures on one side of the body. 42 BRAIN TUMORS Tumors of the frontal lobe can cause Localized caused by destruction, irritation or compression by the tumor of that part of the brain or near which the tumor lies. Focal weakness 6
43 BRAIN TUMORS General Symptoms of intracranial tumors caused by generalized disturbances of cerebral function Headache, (frontal and occipital more severe in early morning. Nausea and vomiting no relation to meals. Papilledema seizures,- especially in adults without history of head trauma. Dizziness and vertigo from intracranial circulatory impairment. Changes in mental status- 44 Management of Brain Tumors Surgical excision of tumor. Brain Mapping steriotatic approach- allows for precise location of the tumor- steriotatic frame. Brachytherapy- insertion of isotopes into the area 131I. Gamma knife for radiosurgery high doses of radiation into the precise area. No surgical incision disadvantage -lag time between treatment and desired result 45 Management of Brain Tumors Radiation Radiation is delivered from within the surgical cavity created at the time of dissection. Being a site-specific, internal radiation treatment, it delivers a high dose directly to the surrounding tissue of the original cancer site, thereby radiating the area of greatest recurrence.. 46 A GAMMA KNIFE TREATMENT 47 Management of Brain Tumors As part of the multimodality approach, chemotherapy may be given before, during, or after other therapies Obstacles to success include blood brain barrier Chemotherapy not usually effective Nitrosureas-carmustine (BCNU) and lomustine (CCNU) most frequently used PCV- topotecan (Hycamtin- promising results). Chemo given IV, PO,intraarterial,intrathecal, intraventricular via an Ommaya reservoir 48 Ommaya reservoir 49 Management of Brain Tumors Thalidomide to decrease vascular supply Polymer wafer implants carmustine BCNU Gliadel wafer, which is the first new treatment to be approved for brain cancer in more than two decades. Its manufacturer describes it as the first technology capable of delivering chemotherapy directly to the site of a tumor. up to eight dime-sized wafers are placed directly into the tumor cavity after resection. The drug slowly dissolves over a period of weeks and thereby provides a high drug concentration to the residual cells. (2003) 50 51 Management of Brain Tumors Medical decrease intracranial pressure, seizures 7
Nursing- Observe for increasing ICP Early signs of motor function impairment 52 Intracranial Aneurysms Intracranial aneurysm BERRY Aneurysm is most common congenital aneurysm. Aneurysms result from a congenital defect in the middle layer of the vessel wall degenerative changes in the vessel wall at the same site constant stress caused by the force of the flow of blood particularly at the bifurcation. 53 Symptoms of Intracranial Aneurysm caused by compression of surrounding brain tissue or cranial nerves. Ex: aneurysm of anterior cerebral artery- may compress optic nerve causing unilateral impairment of vision. In general does not produce symptoms Premonitory signs- Usually onset of symptoms sudden 54 Symptoms of Intracranial Aneurysm Severe headache (occipital) and usually accompanied by vomiting. May loose consciousness immediately or initially present with confusion and lethargy. Generalized seizures. meningeal irritation, stiff neck and back and leg pain, motor weakness, monoparesis and hemiparesis 55 Management Surgical- evacuation of hemorrhage if life is threatened by increased pressure Medical- use of antihypertensives Antifibrinolytic agents to prevent lysis of clot and reduce risk of rebleeding- Epsilon-( aminocaproic acid), EACA, AMICAR. Decrease Intracranial Pressure- Prophylactic anticonvulsants-dilantin, Nimotop to prevent vessel spasm and recurrence of bleeding 56 Intracranial Aneurysm AFTER AN ANEURYSM RUPTURES, A CLOT FORMS AT THE SITE OF THE HEMORRHAGE AND FOR A FEW DAYS REBLEEDING IS PREVENTED. AS THE CLOT BEGINS TO DISSOLVE THE CHANCE OF REBLEEDING INCREASES, WITH THE GREATEST RISK OF REBLEEDING OCCURRING AT ABOUT THE SEVENTH DAY 57 Case Study A 16 year old- unrestrained driver, suffered a compound fracture of the skull and facial fractures in a motor vehicle accident. On admission to the hospital he was immediately taken to surgery for evacuation of a right subdural hematoma in the temporal region and repair of facial fractures. 58 Case Study On the fourth post operative day, the nurse discovers the following: Subjective data: Increasingly difficult to arouse 8
Objective Data: Glasgow coma scale decreased from 10 to 5 Nucal rigidity, ICP between 20-30 mm hg despite CSF drainage and mannitol Temp 102.2 0 F, BP 110/60, HR 114 59 Critical Thinking Questions 1. What is the probable cause of the patient s change in neurologic status? 2. What are the contributing factors that put the patient at risk for complications after the head injury and surgery? 3. Discuss the pathophysiologic basis for the symptoms exhibited by the patient. 60 Critical Thinking Questions 4. On the basis of the nursing assessment, what are the priority interventions? 5. Discuss the possible areas for organisms to gain access to the meninges in this case. 6. Based on the assessment data presented, write 3 or more nursing diagnoses. Are there any collaborative problems? 9