From the notes of Charlene Morris MSN, RN John Nation MSN, RN & Marnie Quick MSN, RN, CNRN

1. Altered Cerebral Function and Increased intracranial pressure (ICP)Ashley Valentino MSN, BSN, RNupdated Spring 2013 From the notes of Charlene Morris MSN, RN John Nation MSN, RN & Marnie Quick MSN, RN, CNRN

2. Head Injury • Head injury – a broad classification that includes any injury or trauma to _____, ______, or _______. • TBI is a serious form of head injury • 5.3 million live with disabilities resulting from TBI • MVC, falls most common cause • Other causes? • Males twice likely to sustain TBI than females • Head trauma= high potential for poor outcome** Deaths from trauma occur at what points? **Factors that predict poor outcome = ICP levels > than 20 mmHg, presence of intracranial hematoma, abnormal motor responses, GCS on arrival**

3. Glasgow Coma Scale A score of 13 to 14 indicates mild deficit. A score between 9 and 12 points to moderate deficit, and a score of 8 or less indicates severe coma.

4. Head Injury: TBI • GCS on arrival strong predictor of survival!! • GCS below ____ indicates only 30%-70% chance of survival • Majority of deaths occur immediately after injury - massive hemorrhage - shock ** Monitor neurological status; prompt surgical intervention critical in prevention of death**

5. Head Injury: Scalp Lacerations • External head trauma • Associated with profuse bleeding • Major complications: • Bleeding • Infection

6. Head Injury: Skull Fractures • Frequently occur with head trauma • Major complications = intracranial infections, hematoma, brain tissue damage • Characteristics: • linear vs. depressed • simple, comminuted, compound • open vs. closed Severity of skull fracture depends on? • TX – possible craniotomy if loose bone fragments • craniectomy if large amounts of bone destroyed

8. Head Injuries: Manifestations • Depends on location of fracture (Box 57-7) • Symptoms can evolve over course of several hours - Battle’s sign- what is this? - Rhinorrhea – patient teaching? - Otorrhea • If these occur, raise HOB & notify physician immediately!! ** Risk of _________ is high with a CSF leak ** - what will be administered? - Dextrostix, Tes-tape, halo - NG tube??

9. Head Trauma: Concussion • Minor diffuse injury • GCS 13-15 • change in LOC • may or may not lose total conciousness • Postconcussion syndrome - 2 wks – 2 months after injury - What s/s will you see? - What will we teach?

10. Diffuse Axonal Injury (DAI) • Results after mild, moderate, or severe TBI • Damage to cerebral hemispheres, basal ganglia, thalamus, and brainstem • axon swelling and disconnection • 12-24 hours to develop • Symptoms: - decreased LOC - increased ICP, global cerebral edema - what else will you see? *90% patients with DAI remain in vegetative state*

11. Focal Injury: Laceration • actual tearing of brain tissue • Can occur with depressed or open fractures with penetrating injuries • ** Tissue damage severe ** • surgical intervention impossible • Medical management – like what? • Intracerebral hemorrhage associated with cerebral laceration – poor prognosis! - Leads to increased ICP, expansion of hematoma

12. Focal Injury: Contusion • bruising of brain tissue; localized • minor to severe- GCS scale? • most associated with closed head injury • may contain areas of - hemorrhage, infarction, necrosis, and edema • occurs at fracture site • seizures common complication • Coup- countercoup injury (often noted) • brain moves inside skull • related to high impact injury • multiple contused areas

13. Focal Injury: Contusion • Prognosis depends on what? • May continue to rebleed • appear to “blossom” on CT scan - * worse neurological outcome ** • seizures common complication • anticoagulant use associated with ________, __________, and ___________. What should we assess for?

14. Focal Injury: Epidural Hematoma • results from bleeding between the _____ and inner surface of the skull • ** Neurological emergency!! ** • rapid surgical intervention • what S/S will you see? • associated with linear fracture • crosses major artery in dura • causes tear • can be venous or arterial in origin • Venous tear = develop slowly • arterial tear = rapidly developing, high pressure - often includes meningeal artery

15. Focal Injury: Subdural Hematoma • occurs from bleeding between the ______ and the _______ _____ of the ________. • usually results from injury to brain tissue and blood vessels • more common in older adults – why? • can be confused with dementia • usually venous in origin – develops? • sagittal sinus = source of most subdural hematomas • can be acute, subacute, and chronic

16. Focal Injury: Subdural Hematoma • Acute subdural hematoma • 24 – 48 hours after trauma • immediate deterioration – what will we see? • treatment? • Subacute subdural hematoma • 48 hr – 2 wk after trauma • alteration in mental status as hematoma develops • treatment? • Chronic subdural hematoma • > 20 days after injury • progressive alteration in LOC • TX = evacuation, membranectomy

17. Focal Injury: Inracerebral Hematoma • occurs from bleeding within brain tissue • usually in frontal and temporal lobes – why? • occurs in 16% of head injuries • the _______ and ______ of hematoma determines patients outcome

18. Diagnostic Tests • ______ is best diagnostic tool to evaluate for head trauma • Other studies: • MRI • PET • Transcranial Doppler – assess what? • Cervical Spine Xray

19. Treatments • ** Prevent secondary injury = manage elevated ICP; treat cerebral edema ** • timely diagnosis, surgery if necessary! • ** significant neurological impairment = surgical evacuation! ** • Burr holes – used in extreme emergency • followed by craniotomy • drain placed – to prevent what? • If extreme swelling expected = hemicraniectomy – why?

20. Burr Holes

21. Planning: Overall Goals • maintain adequate cerebral oxygenation & perfusion • remain normothermic • achieve pain control, reduce anxiety • free of infection • attain maximal motor, cognitive, and sensory function

22. Nursing Interventions • Health promotion – like what? • ** Monitor for changes in neurological status ** • maintain cerebral perfusion and oxygenation • hemodynamic monitoring • be aware of coexisting injuries or conditions • Frequent Neuro checks • calm approach, reduce anxiety • maintain temp of 36 to 37 degrees C – cooling blanket? • sedation as necessary – prevent what? • administer antiemetics for nausea/vomiting – why?

23. Nursing Interventions • Provide patient/family support – spiritual care? • surgery consent • provide frequent status updates, open visitation • Home care • prevention of seizures • drug of choice? • assess nutritional status • speech therapy, OT, PT • assistance with financial aid, child care, social work • no driving, no drinking, no use of firearms • assist with role change (spouse to caregiver)

24. Brain Tumors • Can occur in brain or spinal cord • rarely metastasize outside CNS • contained by meninges • White males have highest incidence of malignant brain tumors • Primary vs. secondary • Secondary most common type • primary = arising from tissues within the brain • gliomas (glioblastoma, astrocytoma) • secondary = resulting from metastasis

26. Brain Tumors: Manifestations • Depend on _______ and ______ of tumor. • Headaches (common) • worse at night, may awake from sleep • dull, constant; throbbing • Seizures • common in gliomas • Nausea, vomiting – caused by what? • memory problems, personality changes • muscle weakness, sensory loss, aphasia • Hydrocephalus – leads to what? • **brain tumor left untreated = increased ICP, death**

27. Brain Tumors: Diagnostic Studies • Extensive history; comprehensive Neuro exam • New onset of seizures? • MRI, PET -detection of what? • CT = location of lesion • EEG • Why not lumbar puncture?? • Angiography – looks at what? • Computer guided stereotacitc biopsy – preliminary

28. Brain Tumors: Treatment • Goals: • identify tumor type, location • remove or decrease tumor mass • prevent/manage ICP • Surgical therapy • surgical removal = preferred treatment • partial vs. complete removal • reduces tumor mass, reducing ICP • Ventricular Shunt – risks? • tx for hydrocephalus; gradually put patient in upright position • catheter placed in lateral ventricle; tunneled through skin • drains CSF – drains into where?

30. Brain Tumors: Treatment • Radiation Therapy • follow-up measure after surgery • stereotactic radiosurgery – radiation precisely directed at a location in brain • radiation seeds- may be implanted into brain • complications?? • tx with Decardon, Solu-Medrol - how do these work? • Chemotherapy • nitrosoureas • Gliadel wafer – implanted at time of surgery • Ommaya reservoir • Temodar – 1st oral chemotherapeutic agent

31. Brain Tumors: Nursing Intervention • Goals: • maintain normal ICP • maximize neurological functioning • achieve pain control • patient/family aware of prognosis, long term implications • Provide support – end of life, palliative care? • Protect patient from self harm – how? • Prevent seizures/ seizure precautions • Encourage self care; mobility with supervision • Establish communication system • Assess nutritional status – dietary consult? TF?

32. Cranial Surgery: Types • Craniotomy • removal of bone flap; opening into dura to remove lesion • can be used to drain blood; relieve ICP • may have drain • after surgery, bone flap wired or sutured • Stereotactic Radiosurgery • often computer guided • precise location of specific area • used for biopsy, removal of small brain tumors, drainage of hematomas • * What is the advantage here? *

33. Post- Craniotomy

34. Cranial Surgery: Nursing Interventions • Goals: • return to normal consciousness • pain control, nausea • maximize neuromuscular functioning • rehabilitated to maximum ability • Acute Intervention • pre-operative teaching; provide support • post-operative teaching- what to expect ** Primary nursing goal post-op? ** • frequent neuro assessments x first 48 hours • monitor fluid & electrolytes – which one? • control pain and nausea – Phenergan?

35. Cranial Surgery: Nursing Interventions • Acute Intervention Continued • keep HOB 30-45 degrees – expect when? • assess dressing: drainage, color, odor? • * Notify surgeon immediately for increase in bleeding or if clear drainage is present!!! ** • If bone flap removed, do not place patient on operative side! • skin, mouth care • scalp care, assess for infection of incision • antiseptic soap or hospital policy

36. Cranial Surgery: Discharge • Encourage independence, maximize functioning • rehabilitation referral – case management • ST, OT, PT – will they need these at discharge? • Assess nutritional status • Patient/family support

37. Intro to Intracranial Pressure: • Skull is a closed box; 3 essential volume components • brain tissue – 78% • blood – 12% • cerebrospinal fluid (CSF) – 10% • What is Intracranial Pressure (ICP) ? • hydrostatic force measured in brain CSF compartment • a balance among 3 essential components maintains ICP

38. What factors influence ICP? • Changes in: • arterial pressure • venous pressure • intrabdominal or intrathoracic pressure • posture • temperature • blood gases – specifically which one? • * An increase or decrease in ICP depends on the ability of the brain to accommodate to changes *

39. Monro-Kellie doctrine: • Alexander Monro & George Kellie (18th century) • * Only applies to closed skull* • “ The three components must remain relatively constant within the closed skull structure” • “ If the volume of any 3 components increases, volume from another component will decrease; the total intracranial volume will not change” • compensatory adaptations? • What if compensatory adaptations fail?

40. How is ICP measured? • Measured in ventricles, subarachnoid space, subdural space, or brain tissue – using what? • ** Normal ICP = 5 – 15 mmHg ** • A sustained pressure above the upper limit is considered abnormal

41. ICP Pressure Transducer

42. Cerebral Blood Flow: • Cerebral blood flow (CBF) = amount of blood in ml passing through 100 g of brain tissue in __________ • universal CBF = 50ml/min per 100g brain tissue • ** Difference in blood flow between white matter and gray matter of the brain ** • gray matter faster blood flow (75ml/min) • white matter slower blood flow (25ml/min) • Maintenance CBF critical – what does the brain need?

43. How is CBF Regulated? • Brain regulates own CBF in response to metabolic needs • ____________ is the automatic adjustment in size of cerebral blood vessels to maintain constant blood flow • What is the purpose? • **Only effective in a person with MAP of 50mmHG – 150 mmHg ** • < 50 mmHg = CBF decreases; cerebral ischemia • What symptoms would you see? • > 150 mmHg = vessels maximally constricted

44. Regulating CBF • ___________ is the pressure needed to ensure adequate blood flow to brain • CPP = MAP- ICP • does not consider effect of cerebral vascular resistance • CPP = Flow x Resistance • increase in cerebral vascular resistance= impaired blood flow to brain • Normal CPP 60 – 100 mmHg

45. Transcranial Doppler • Used to measure what?

46. Regulating CBF • AS CPP decreases, autoregulation fails • leads to decrease in CBF • ** CPP < than 50 mmHg = ischemia, neuronal death ** • CPP < 30 mmHg = not compatible with life • ** Critical to maintain MAP when ICP elevated** • Which patient’s may need a higher CPP?

47. What affects CBF? • Cardiac, respiratory arrest • diabetic coma • systemic hemorrhage * When autoregulation lost, CBF influenced by BP, hypoxia, catecholamines *

48. What affects CBF? • C02, 02 hydrogen ions affect vessel tone • PaCO2 vasoactive agent - Increase in PaCO2= dilation - Decrease in PaCO2 = constriction • decrease in 02 tension = accumulation of lactic acid, increasing acidic environment • increased dilation occurs; autoregulation may be lost

49. Changes in Pressure • _________ is the expandability of the brain • Compliance = Volume/Resistance • Low compliance – small change in volume causes increase in pressure • Intracranial Pressure-volume curve • Stage 1 = total compensation • Stage 2 = at risk for increase in ICP • Stage 3 = great increase in ICP - Stage 4 = ICP rises to lethal levels

50. Pressure -Volume Curve