Brain Injury

1. Brain Injury

2. Concept Map: Selected Topics in Neurological Nursing PATHOPHYSIOLOGY Traumatic Brain Injury Spinal Cord Injury Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Huntington’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation ICP Monitoring “Neuro Checks” Lab Monitoring PHARMACOLOGY --Decrease ICP --Disease Specific Meds Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more…based On Nursing Process: A_D_P_I_E Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary

3. Objectives • Recall anatomy and physiology of the brain & cranial nerves • Explain pathophysiology of various brain (head) injuries • Detail signs, symptoms and prevention of Increased Intracranial Pressure (ICP) • Demonstrate effective use of Glasgow Coma Scale • Discuss medical & nursing management of brain injuries

4. Sometimes: The Lights are on…. But nobody’s home….

5. Anatomy & Physiology Review I II III IV V VI Vii VIII IX X XI XII O O O T T A F A G V S H lfactory ptic culomotor rochlear rigeminal bducens acial coustic lossopharyngeal agus pinal accessory ypoglossal

7. Brain Trauma Brain injury results in more trauma deaths than do injuries to any other body region!

8. Primary Injury Mechanical trauma that occurs at the moment of impact and may lead to irreversible cell damage from physical disruption of neurons or axons

9. 3 Top Causes

11. Risk Factors • Highest in young people and the elderly *Age 65 – 75 has highest incidence of HI of ALL age groups* • Occurs twice as often among malescompared with females • Motor vehicle crashes account for the major proportion of head and brain injuries….and involve a disproportionately large number of young persons • Alcohol intoxication is a compounding factor in at least 30% to 50% of head injuries and is a contributing factor in almost ½ of all fatal motor vehicle crashes in the United States

12. Did you Know ? Laws that require helmet use have been shown to reduce deaths in motorcyclists by about 30%

13. Boxing: Coup- Contre Coup Injury : “The second collision”

14. “Rear-Ended” – “Whiplash” Effect

15. At the Scene: - EMS- First Responders

16. 1. Maintain ability to breathe 2.Prevent shock 3. Immobilization to prevent further spinal cord damage (Backboard + C-Collar)

17. EMS type C- Collar

18. Spinal Injury Assumed With Any Head Injury

19. EMS Back Boards

20. Upon Arrival to ER…

21. Baseline Assessment • Vital Signs • Glasgow Coma Score (GCS)

22. The GCS is the most widely used method of defining a patient's Level of Consciousness (LOC)

23. Everybody Check Hand Grasps for Motor Strength by CROSSING

26. Oculocephalic Reflex (Doll’s Eye)

27. OCR

28. C – Spine X-Ray“Cross-Table Lat”Before removal of ANY immobilization devices

29. As Much as Possible In ER • Instruct client to avoid sneezing or coughing • Provide calm environment • Maintain immobilization • Avoid meds the decrease LOC such as analgesics

30. Severity of Head Injury GCS 3 – 8 : Severe Head Injury GCS 9 – 12: Moderate Head Injury GCS 13 -15: Mild Head Injury GCSSCORE < 8 = COMA

31. The best guide to the severity of head injury is the level of consciousness

33. History of Injury • Loss of Consciousness? • Other victims seriously hurt? • Mechanism of injury? • Driver / passenger / seatbelt ? • Fall height / what caused fall? • Hit where and with what? • Gunshot / impaled object ?

34. Open orClosed Injury ?

35. Diagnostics Damaged areas of the brain have a reduced or no blood flow or glucose metabolism. This can be seen in the images below where there has been a blow to the head by a rock

36. Skull Fractures • Present on CT scans in about two thirds of patients after head injury • Skull fractures can be linear, depressed, or diastatic and may involve the cranial vault or skull base

37. Depressed Skull Fractures • A portion of the skull is extending into the intracranial space • Often results in pressure on the brain or direct injury to the brain • In addition, the bone fragment may cause a laceration of the dura mater resulting in a cerebrospinal fluid leak • Outcome is based upon the underlying brain injury. If no brain injury is present the surgery represents a cosmetic procedure and the outcome is generally quite good

38. Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli Occipital Lobe- associated with visual processing Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech

39. Basal Skull Fractures Clinical Clues may include: • CSF leakage through the ear or nose (otorrhea or rhinorrhea) • Hemotympanum (blood behind the eardrum) • Bruising behind the ears (postauricularecchymoses) • “Battle Sign” • Bruising around the eyes (periorbitalecchymoses) • “Raccoon Eyes” “Panda Eyes” Injury to cranial nerves: • VII Facial nerve - weakness of the face • VIII Acoustic nerve - loss of hearing • I Olfactory nerve - loss of smell • II Optic nerve - vision loss • VI Abducens nerve - double vision

41. Basal Skull Fractures Involve the floor of the skull and include fractures of the cribriform plate, frontal bones, sphenoid bones, temporal bone and occipital bones 1 frontal2 ethmoid3 sphenoid4 temporal5 parietal6 occipital

42. 1. Frontal sinus 2. Crista galli 3. Cribriform plate 4. Lesser wing of sphenoid 5. Superior orbital fissure 6. Superior border of petrous part of temporal bone 7. Dense shadow of petrous part of temporal bone 8. Perpendicular plate of the ethmoid 9. Vomer 10. Maxillary sinus 11. Inferior concha 12. Ramus of mandible 13. Body of mandible

43. CSF Leakage • Rhinorrhea and otorrhea are clinical signs of cerebrospinal fluid (CSF) leakage in patients with skull fracture • Presence ofglucose(CSF) in otorrhea and rhinorrhea detected by Beta-2 transferrin. Nasal/ear discharge (glucostix) was traditionally used to diagnose CSF leak at the bedside, but has fallen into disuse as it has poor positive predictive value • CSF leakage opens the brain & spinal canal to infection • CSF is needed to cushion the brain, maintain pressure within the eye and cleanse the CNS (like the lymphatic system serves the same function in the rest of the body) 

44. Halo Effect of CSF

45. Prevent Infection ! Cover any suspected source of CSF leakage with a Sterile Dressing STAT !

46. CSF Infection Nuchal Rigidity CSF has WBCs Increased Temperature

47. Basal Skull Fractures • Most basal skull fractures do not require treatment and heal themselves • Persistent CSF leakage may warrant operative repair of the leakage, particularly CSF leaks related to frontal bone and cribiform plate fractures

48. Associated with Brain Injury • Blood in the anterior chamber of the eye (hyphaema) as a complication of blunt trauma. Eyes with hyphaema may show other signs of damage Blood on Ocular Surface

49. Another Clue…. Avulsed eye and lacerations to the forehead

50. Penetrating Brain Injury