NEUROTRAUMA: THE BRAIN AND SPINAL CORD

1. NEUROTRAUMA:THE BRAIN AND SPINAL CORD KATHY GARVIN, RN, BA, MICN Assistant Nurse Manager Department of Emergency Medicine LAC+USC Medical Center Level I Trauma Center April 2014

2. OBJECTIVES • Identify significant mechanisms of injury that put patient at high risk for brain and spinal cord injury • Identify the signs and symptoms of a significant brain or spinal cord injury and the basic pathophysiology behind the findings • Identify Nursing assessments and interventions • Identify Goals of Intervention

3. CENTRAL NERVOUS SYSTEM INJURY • BRAIN AND SPINAL CORD INJURY • ENORMOUS SUFFERING, DISABILITY AND LOSS – THE PATIENT, THE FAMILY, THE COMMUNITY • DEATH OR LONG TERM CARE, OFTEN IN THE PRIME OF LIFE

4. EPIDEMIOLOGY • World Wide: young men • Mechanism depends on area of world • Falls • Motor vehicle crash • Work/Construction • Predisposition – disease, medications

5. April 9, 2009 12:10am

9. Paramedic Notes • Jon Wilhite and 3 friends, in a small car, are hit by a drunk driver. • 0010: Fullerton emergency officials get report of a high-speed collision • 0017: 1st fire engine on scene. Passenger in the right rear seat, does not have a pulse • 0019: 1st ambulance arrives. Fire crew prepares to cut away roof to get to female driver, Jon, seated behind her, and a badly injured passenger, in the front. The driver dies moments later. • Jon is unconscious and appears to have only minor cuts. Paramedics follow protocol. C-collar, back board and lift him out of car. • 0034: Ambulance speeds to medical center at UC Irvine. Paramedic notes unequal pupils.

10. NERVE TISSUE • PRIMARY INJURY • The initial insult to the tissue resulting in neural injury • Skull fracture, epidural hematoma • Physical damage to the spinal cord or its structures • SECONDARY INJURY • Pathophysiologic changes that worsen the initial damage and reduce compensatory mechanisms • Edema, compression, cell necrosis

11. DEADLY DUO • HYPOXIA AND HYPOTENSION • Nerve tissue can’t live without: • Glucose and Oxygen • Consistent, Well-oxygenated Blood Supply • AIRWAY • BREATHING • CIRCULATION • IMOBILIZATION/POSITIONING • SPECIFIC INTERVENTIONS

12. BRAIN: EPIDEMIOLOGY • Brain injury contributing factor in 1/3 of all injury deaths - #1 cause of trauma related death • High rate of permanent disability • Contributing Factors • Alcohol, substance abuse • Anticoagulants • Incorrect use of safety restraints • Lack of protective Equipment

13. Bad for the Brain • Secondary Injury • Airway Compromise • Bleeding • Compression • Herniation • Brain Stem • Infection (Later)

14. Mechanisms of Injury • Penetrating • Energy Forces • Shearing • Tensile • Compressive • Coup-Contracoup

15. Primary Brain Injuries • Occur at the time of original insult • Direct damage done to brain parenchyma and associated with vascular injuries • Brain tissue can be lacerated, punctured or bruised by broken bones or foreign bodies • Damage is already done • Irreversible • “Treatment” is prevention of the head trauma • Focus of public health programs

16. PRIMARY BRAIN INJURIES • SCALP WOUND • Close • SIMPLE SKULL FRACTURE • DEPRESSED SKULL FRACTURE • Lacerated Dura? • Infection? • BASILAR SKULL FRACTURE • Raccoon Eyes, Battle’s Sign • CSF leakage • Infection

17. PRIMARY BRAIN INJURIES • DIFFUSE • CONCUSSION • ACCELERATION/DECELERATION • CUMMULATIVE EFFECTS • POST CONCUSSION SYNDROME • DIFFUSE AXONAL INJURY • ACCELERATION/DECELERATION, ROTATIONAL • BRAIN STEM, RETICULAR ACTIVATING SYSTEM • PROLONGED COMA, DEATH

18. INTRACRANIAL BLEEDING

19. PRIMARY BRAIN INJURIES • FOCAL • CONTUSION • Frontal/temporal, Peak is 18-36 hours • EPIDURAL • Arterial; Period of Lucidity • SUBDURAL • Bridging Veins; Elderly, Drunks • SUBARACHNOID • Blood in the CSF • INTRACEREBRAL • Deep Tissue; Increased ICP

20. Signs and Symptoms • ALWAYS THE SAME • Altered Level of Consciousness • Loss of Consciousness • Agitated, Restless, Drowsy, Irritable • Headache • Nausea and Vomiting • Dizzy • Altered Motor, Speech • Signs of Increased Intracranial Pressure

21. Secondary Brain Injury • Damage that occurs after the initial insult (ongoing injury processes) • Result of intracranial and systemic insults • Emergency Department Treatment • Focused on limiting the extent of secondary brain injury

22. Secondary Injury • Bleeding • Cerebral Edema • Increased Intracranial Pressure • Hypoxia/Hypotension • Also: • Hypo/Hypercarbia • Seizures • Electrolyte Abnormalities • Coagulopathies • Hyperthermia • Infection

23. INTRACRANIAL PRESSURE • Closed Vault Containing: • BRAIN • CEREBRSPINAL FLUID • BLOOD • Constant balance in volume between the 3 • Cerebral Autoregulation • Compensatory Mechanism Fail • Rapid increase in intracranial pressure

24. INTRACRANIAL PRESSURE Early signs of increased intracranial Pressure • Headache • Nausea and vomiting • Amnesia • Altered level of consciousness • Restlessness • Drowsiness Changes in speech • Loss of judgment

25. INTRACRANIAL PRESSURE Late signs of increased intracranial Pressure • Dilated, non-reactive pupils • Unresponsiveness to verbal or painful stimuli • Abnormal motor posturing • Changes in respiratory rate and pattern • Cushing’s triad

26. INTRACRANIAL PRESSURE Cushing’s Triad Late signs of severe increased ICP Hypothalamic Response to Ischemia • Increased Blood Pressure with Widening pulse pressure (>50) • Bradycardia • Irregular breathing: • Cheyne-Stokes

27. BRAIN HERNIATION • Supratentorial • Uncal (1) • Central transtentorial (2) • Cingulate (3) • Trans-calvarian (4) • Infratentorial • Upward transtentorial (5) • Tonscillar (Cerebellar) (6)

28. EXPECT • HEAD OF BED AT 30 DEGREES • HEAD MIDLINE • MANNITOL OR HYPERTONIC SALINE • ANTI-SEIZURE MEDICATION • EMERGENCY VENTRICULOSTOMY • CRANIOTOMY, MONITORING BOLT OR CLOT EVACUATION • SEDATION • NORMOTHERMIA • Pain Medication

29. CEREBRAL PERFUSION Adequate delivery of oxygen and nutrients to the brain is dependent on: • Cerebral Blood Flow • Cerebral Perfusion Pressure (CPP) • Intracranial Pressure (ICP) • Cerebral autoregulation • Pressure autoregulation • Chemical autoregulation CPP = MAP – ICP MAP= (SYS. + 2X DIA.)/3 GOAL: CPP > 70mmHg

30. Cerebral Perfusion • Maintain CPP between 60 and 70mm Hg • Even a single episode of hypotension can have serious consequences for damaged neural tissue • The brain needs constant supply of glucose and oxygen • Fluids, Blood, Vasopressors • Mannitol, Hypertonic Saline

31. HYPERVENTILATION • Consider Hyperventilation only if signs of emergent increased ICP resistant to all other treatment • OXYGEN - Vasoconstricts • CARBON DIOXIDE – Vasodilates • NORMAL RANGE OF ETCO2 • 35-45MM Hg • Hyperventilation – Vasoconstriction and decreased ICP. May lead to CerebralIschemia

32. SPINAL CORD INJURY (SCI) • An insult to the spinal cord resulting in changed neurological function • Motor • Sensory • Autonomic • May be temporary or permanent

33. CLASSIFICATION • Tetraplegia: (quadriplegia) • Cervical region injury • Loss of muscle strength to all four extremities • Most critical: support respiratory function • Paraplegia • Injury to the spinal cord in the • Thoracic • Lumbar • Sacral segments • T12 and L1 are the most common level

34. SECONDARY INJURY • Hemorrhage into cord compartments • Inflammatory response to initial insult (Biochemical cascade, progressive edema and cell necrosis) • Hypoxia due to local and systemic hypoperfusion • Systemic hypotension from other injuries (bleeding) or neurogenic shock • Collectively damage intact neighboring tissue

35. BAD FOR THE CORD • Hypoxia • Compression • Manipulation (25% of Injuries) • Hypotension • Bleeding

36. NEUROGENIC VS SPINAL SHOCK • Spinal Shock • Short term loss of spinal cord function • Injury at any cord level • Starts 30-60 minutes following a spinal cord injury • Results in flaccid paralysis, areflexia and anesthesia below the level of injury • Resolves in days to weeks

37. NEUROGENIC VS. SPINAL SHOCK • Neurogenic Shock • A form of distributive shock • Injury at T6 and above • Impairment of Sympathetic Pathway • Loss of vasomotor tone causing hypotension and venous pooling • Loss of sympathetic innervation to heart: bradycardia • Loss of thermoregulation: poikilothermia • Loss of ability to sweat: anhydrosis

38. VENTILATION AND SPINAL CORD INJURY • Injury of C3 And above • Loss of phrenic nerve • Likely to cause death from respiratory arrest • Injury between C3 and C5 • Loss of diaphragmatic innervation • Likely to cause respiratory insufficiency • Injury between C6 and T8 • Involves loss of intercostal and abdominal muscle function • Causing increase work of breathing

39. SPINAL CORD INJURY UNTIL PROVEN OTHERWISE IF: • Significant mechanism of injury • high speed motor vehicle collision • Fall from a height • Diving accident • Electrocution • Direct neck trauma • Head or Neck pain associated with trauma • Motor or sensory deficits • Altered Level of Consciousness • Distracting Injury

40. NURSING ROLE • Early identification of potential Brain/Spinal Cord Injury • Recognize significant mechanism of injury • Identify signs and symptoms • Good Assessment Skills • Interventions that protect patient from secondary harm

41. Primary and Secondary Surveys • Primary Survey – Assess for life threatening injuries, if identified, stop immediately and address before moving on • Airway with Spinal Cord Precautions • Breathing and Ventilation • Circulation • Disability – mental status • Exposure

42. Primary and Secondary Surveys • Secondary Survey • Complete head to toe and focused assessment • History • Everything else

43. Primary Survey

44. Hospital Notes • 0042: Ambulance arrives to hospital’s ER. Paramedic gives report and trauma team takes over. “They all had a job. They were all doing it at once.” • 0044: 2nd ambulance leaves the crash scene with 2nd patient on the backboard. • 0050: Ultrasound (FAST) and X-ray no bleeding in lungs or abdomen • Blood pressure stable. • Hypothermic • 0101: CT – atlanto-occipital dislocation (internal decapitation), broken ribs, shoulder blade and collapsed lungs. Fracture at the base of the skull, bleeding into his brain.

45. AIRWAY AND SPINAL PROTECTION • Airway with simultaneous spinal protection • Manually hold head/neck in line • Patient alert enough to maintain airway? • Inspect the airway using jaw thrust (if able) • Tongue, secretions, blood, vomit, edema, foreign body, retropharyngeal hematoma • Gentle, frequent suction (avoid vagal stimulation and hypoxia) • Quick check of head and neck for life threatening injury/bleeding

46. AIRWAY WITH SPINAL STABILIZATION • Oxygen • Oral-tracheal intubation with in-line stabilization is the preferred method • Any episode of hypoxia can lead to cord/brain ischemia and further injury • Plan for: rigid C-collar (if able), head supports, long board, log roll patient • Minimal movement/manipulation of spine!

47. BREATHING/VENTILATION • Assess patient’s respiratory status • Spontaneous? Need for assistance? • Rate and rhythm • Equal chest rise and fall • Use of accessory muscles • Vocalizations • Skin signs • Is the patient tiring? Assist • Trauma patient, look for: chest wall stability and penetrating injuries • The higher the injury, the higher the risk for respiratory failure

48. CIRCULATION • Bleeding? Control it • Skin signs • Hypovolemia: pale, cool, diaphoretic • Neurogenic shock: warm, dry • Palpate central pulses • Hypovolemia: tachycardia • Neurogenic shock: bradycardia • May be taking medication that affects heart rate, especially the elderly • Compare pulses • Intravenous access x 2 • Bradycardia may require atropine or pacing

49. DISABILITY • What is the patient’s mental status? • Altered? • Intoxicated? • Distracting Injury? • Significant Head or Neck Trauma? • Check pupils

50. DISABILITY/MENTAL STATUS