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Traumatic Brain Injury A Case Study

Traumatic Brain Injury A Case Study. Lisa Randall, RN, MSN, ACNS-BC RNSG 2432. Demographics/CC. 23 y.o. AAM Auto vs. ped 8/10/08 . HPI. Dancing on I-35 under the influence of crack cocaine and ETOH. Hit by 2 cars > 50mph GCS 12 on arrival, but declined to 4 Eyes 4>1 Verbal 3>1

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Traumatic Brain Injury A Case Study

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  1. Traumatic Brain InjuryA 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 > 50mph • GCS 12 on arrival, but declined to 4 • Eyes 4>1 • Verbal 3>1 • Motor 5>2

  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. DiagnosticsNormal 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/ST…rehab

  10. A/P con’t • 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. Trauma Pulmonary/CC Orthopedics ID SW/CM Nursing PT/OT/ST/RT WOCN Dietary Interdisciplinary Collaboration

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

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

  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 > 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 < 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. Small bleeds Cerebral Edema Deficits are based on lobe involved Contusion

  27. Linear Comminuted Fractures

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

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

  35. DAIDiffuse Axonal Injury

  36. Decreased neurologic function is best predictor of brain injury Pay attention to cranial nerves Neurologic Exam

  37. 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

  38. 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

  39. ICP Management is the Key • ICP monitor in patients with GCS < 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 > 320 • Bolus dosing

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

  41. Ventriculostomy

  42. 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 Evidenced Based Medical Guidelines for TBI Management

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

  44. References • AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St. • Davis, F.A. (2001). Taber’s Cyclopedic Medical Dictionary. F.A. Davis, Philadelphia. • Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida. • Lewis, S., Heitkemper, M., O’Brien, 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.

  45. Introduction YouTube - Brain Plasticity

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