Neurosensory: Traumatic Brain Injury (TBI) & Brain Tumors

1. Neurosensory: Traumatic Brain Injury (TBI) & Brain Tumors Marnie Quick, RN, MSN, CNRN

2. Normal brain protected by:

3. Normal brain

7. Traumatic Brain Injury (TBI): Etiology/Pathophysiology • Risk factors- MVA; elevated blood alcohol; contact sports; acts of violence- gun, knife • Mechanism of craniocerebral trauma • Acceleration (movement)-deceleration (stationary) • Coup (impact)-contrecoup (opposite) phenomenon • Blunt or penetrating injury • Closed head injury • Scalp lacerations • Skull fractures- Linear; comminuted; depressed; basilar; open/closed

8. Coup-contracoup injury

10. Penetrating injury- Gunshot to brain

11. Penetrating injury: Knife in brain

12. Basilar skull fracture- Base of skull fractured

13. Basilar skull fracture is base of skull if posterior> Battle sign- ecchymosis behind the ear

14. Basilar skull fracture is more anterior Raccoon eyes- periorbital ecchymosis

15. Basilar Skull fractures can cause leakage of CSF from meninges

16. Minor Brain Injury • Concussion- sudden transient disruption of neural activity in the brain with change in LOC • Post Concussion Syndrome- may occur after other brain injuries- severity of symptoms are not related to severity of brain injury. Sym may persist wks-months

17. Major Brain Injury- Focal injury • Brain contusion- bruising; coup-contracoup • Brain laceration- tearing brain tissue, ICH • DAI- diffuse axonal injruy • Widespread disruption of axons • Poor prognosis • Brain bleeds- Note meninges in relation to bleeds on following slides

19. Epidural hematoma

20. Subdural hematoma (SDH)

21. Intracerebral hematoma

22. Secondary brain injury • Cerebral edema • Localized or diffuse • Peaks 24-72 hrs • Occurs with CHI; open head injury; anoxia • May in itself cause death by pressure> herniation • Increased ICP • Herniation Syndromes

23. Traumatic Brain Injury (TBI): Common Manifestations/Complications • Increased ICP symptoms general and specific • Restlessness- R/O respiratory; waking up • Systemic effects of acute brain injury- hypermetabolism, brainstorming, SIADH • Brainstorming- hypothalamic stimulation-ANS • CSF leak- rhinorrhea/otorrhea- basal skull Fx • Post concussion Syndrome • Associated cervical spinal cord injury

24. Collaborative Care: Traumatic Brain Injury (TBI): • Diagnostic studies (similar to ICP) • Emergency management: assessment and interventions (Lewis 1442 Table 57-9) • Treat IICP- airway; fluid; positioning; temp reg; meds • Prevention of complications • Medications: IICP; seizures; stress ulcer;straining;brainstorming • Diet/calories: hypermetabolic state; ileus; swallow/gag • CSF leak: glucose; halo; HOB 30; no nasal suction • Other: SIADH> hyponatremia • Surgery: bone repair; evacuation clot; craniotomy/ectomy; burr hole; cranioplasty; monitor placement

25. Burr holescraniotomy

26. Place monitors/intraventricular drain:

27. Crainectomy- bone flap out to allow for brain expansion post op

28. Post crani

29. Traumatic Brain Injury (TBI): Nursing assessment specific to TBI • Health history • Description of accident; past medical history • NVS and Glasgow Coma http://www.trauma.org/scores/gcs.html • Brainstem reflexes • VS- Late sign is Cushing reflex • Skull/face; CSF leak; SCI • Consider older adult finding

30. Pertinent Nursing Problems Specific to Traumatic Brain Injury (TBI): • Health promotion • Ineffective tissue perfusion, cerebral (decreased intracranial adaptive capacity) • Ineffective airway clearance/breathing pattern • Hypothermia • Pain • Impaired physical mobility

31. Anxiety • Decreased cerebral perfusion (IICP) • Brain death (ethical dilemmas p.1450) • Home care • Home evaluation/rehab/nursing home • Teach about post concussion syndrome; B&B; spasticity; dysphagia; nutrition; seizure disorder; personality changes; family role changes • 6 months typical plateau period • Community agencies/support groups

32. http://library.med.utah.edu/kw/animations/hyperbrain/oculo_reflex/oculocephalic2.htmlhttp://library.med.utah.edu/kw/animations/hyperbrain/oculo_reflex/oculocephalic2.html • http://cim.ucdavis.edu/eyes/version15/eyesim.html • http://www.softwarefornurses.com/access/index.asp

33. Primarybrain tumors • Arise from support cells, neurogilia cells; the meninges; or blood vessels • Do not metastasize outside cranium • Cause unknown

34. Grade I and II gilomas (astrocytoma) made up of astrocytes; are benign, slow-growing tumors • Grade III and IV gliomas (glioblastoma Multiforme are invasive and fast-growing • Meningiomas arise from the meninges; slow-growing; benign, encapsulated and compress the brain • Brain tumors may be lethal due to their location

35. Gioblastoma Meningioma

37. Metastatic (secondary) brain tumors • Originate from outside the brain- lung and breast most common sites • Single or multiple • Becoming more common as individual with cancer in other parts of the body are living longer

38. Clinical Manifestations/complications of Brain tumors • General ICP symptoms • Common early symptoms: headache; vomiting; papilledema (visual changes) • Seizures- partial classification in type • Brain tumor symptoms occur due to their ability to compress or destroy brain tissue; edema that forms around the tumor; hemorrhage; & obstruction of CSF flow • Specific symptoms as to the lobe affected>

40. Frontal lobe: personality changes; inappropriate behavior; inability to concentrate; impaired judgment; headache; expressive aphasia if dominant hemisphere; motor weakness or paralysis from motor strip • Parietal lobe: sensory deficits- paresthesia, visual field deficits; contralateral sensory disturbances from sensory strip; loss of interpretation and discrimination for sensing input; perceptual problems

41. Occipital lobe: visual disturbances; visual agnosia • Temporal lobe: complex partial (psychomotor) seizures; auditory hallucinations; memory problems; Wernicke aphasia if dominant hemisphere • Cerebellum: gait distrubances; balance and coordination problems • Brain stem: cranial nerve dysfunction; vital signs

42. Complications of Brain Tumors • Hydrocephalus • Infection • Death is usually caused by IICP/hermiation

43. Collaborative Care for Brain Tumors Diagnostic tests • CT/MRI • EEG • PET • Angiogram • Tissue biopsy

44. Collaborative Care for brain tumors • Surgery • To remove or debulk • Supratentorial- above tentorium • Infratentorial-below • Stereotaxic-localized

45. Radiation • Used alone or with other therapies • Gamma or Cyber-knife • Complication- increased cerebral edema • Medications • Chemotherapy: IV; intraventricular (ommaya Reservoir) or by wafer implanted • Corticosteroids to treat brain edema • Anticonvulsants to prevent seizures • Rehab- outpatient or in house

46. Health history: progression of symptoms; other cancers, disease • Physical exam • Neuro vital signs • Specific signs of the local functions of different parts of the brain • Similar neuro deficits as the individual with a stroke • Signs of increased intracranial pressure/herniation

47. Pertinent Nursing Problems for Brain Tumor • Impaired tissue perfusion, cerebral • Self-care deficits • Anxiety • Risk for infection-post crani • Acute pain • Disturbed self-esteem • Nutrition • Home care- rehab; home eval; support groups