Traumatic Brain Traumatic Brain InjuryInjuryA Case StudyA Case Study

Lisa Randall, RN, MSN, ACNS-Lisa Randall, RN, MSN, ACNS-BCBC

RNSG 2432RNSG 2432

Demographics/CCDemographics/CC

23 y.o. AAM 23 y.o. AAM Auto vs. pedAuto vs. ped 8/10/08 8/10/08

HPIHPI

Dancing on I-35 under the influence Dancing on I-35 under the influence of crack cocaine and ETOH.of crack cocaine and ETOH.

Hit by 2 cars > 50mphHit by 2 cars > 50mph GCS 12 on arrival, but declined to 4GCS 12 on arrival, but declined to 4

– Eyes 4>1Eyes 4>1– Verbal 3>1Verbal 3>1– Motor 5>2Motor 5>2

HistoryHistory

PMHPMH– Denies, but GSW (metallic pellets CXR)Denies, but GSW (metallic pellets CXR)

PSHPSH– DeniesDenies

Social HxSocial Hx– Single, no children, unemployed, unfundedSingle, no children, unemployed, unfunded– +ETOH, +amphetamines, +cannibis+ETOH, +amphetamines, +cannibis– Recently released from jail for drug Recently released from jail for drug

possessionpossession MedsMeds

– DeniesDenies

DiagnosticsDiagnosticsNormal CT Normal CT

Subdural HematomaSubdural Hematoma

DiagnosticsDiagnostics

DiagnosticsDiagnostics

Focused A/PFocused A/P

R frontotemporoparietal SDHR frontotemporoparietal SDH– CraniectomyCraniectomy– EVDEVD– Monitor/treat ICPMonitor/treat ICP

Paraplegia/paresis Paraplegia/paresis L2 burst fracture c subluxation L2-L3L2 burst fracture c subluxation L2-L3 T11 lamina/TP fractureT11 lamina/TP fracture

– T10-L3 posterior fusion when stableT10-L3 posterior fusion when stable– PT/OT/ST…rehabPT/OT/ST…rehab

A/P con’tA/P con’t

1010thth & 11 & 11thth rib fractures rib fractures R femur fractureR femur fracture Acetabular fractureAcetabular fracture Mediastinal hematomaMediastinal hematoma

Post-OpPost-Op

Post-OpPost-Op

Nursing ConcernsNursing Concerns

Neuro checks/VS q1h Neuro checks/VS q1h ICP monitoringICP monitoring

– MannitolMannitol– CSF drainageCSF drainage

CPP monitoringCPP monitoring– IVFIVF– VasopressorsVasopressors

MAP monitoringMAP monitoring Sedation/analgesiaSedation/analgesia Seizure prophylaxisSeizure prophylaxis Infection prophylaxisInfection prophylaxis Skin careSkin care

Interdisciplinary Interdisciplinary Collaboration Collaboration TraumaTrauma Pulmonary/CCPulmonary/CC OrthopedicsOrthopedics IDID

SW/CMSW/CM

NursingNursing PT/OT/ST/RTPT/OT/ST/RT WOCNWOCN DietaryDietary

EvaluationEvaluation

RehabilitationRehabilitation

AssessmentAssessment– Decreased short Decreased short

term memoryterm memory– Paraparesis Paraparesis

DF 2/5, PF 2/5, HF DF 2/5, PF 2/5, HF 4-/54-/5

CranioplastyCranioplasty

Epidemiology of Head Epidemiology of Head TraumaTrauma Occurs every 15 Occurs every 15

secondsseconds 500,000 annual ED 500,000 annual ED

visitsvisits Most common Most common

causes: MVAs, falls, causes: MVAs, falls, assaultsassaults

Males 15-24, Males 15-24, elderly > 75elderly > 75

Accounts for 40% of Accounts for 40% of traumatic deathstraumatic deaths

Pathophysiology of TBIPathophysiology of TBI

11stst

– Primary InjuryPrimary Injury: initial insult … i.e. from bleed: initial insult … i.e. from bleed

SecondSecond

Secondary InjurySecondary Injury: delayed injury from hypoxia, : delayed injury from hypoxia, ischemia, and release of neurotoxinsischemia, and release of neurotoxins

Excitatory amino acids can cause swelling and Excitatory amino acids can cause swelling and neuronal deathneuronal death

Endogenous opioids cause increased Endogenous opioids cause increased metabolism, using glucose suppliesmetabolism, using glucose supplies

Increased ICP, especially > 40 leads to brain Increased ICP, especially > 40 leads to brain hypoxia, ischemia, hydrocephalus, herniationhypoxia, ischemia, hydrocephalus, herniation

Hydrocephalus: clotted blood obstructs CSF Hydrocephalus: clotted blood obstructs CSF outflow tracts and absorption of CSF, disrupts outflow tracts and absorption of CSF, disrupts blood-brain barrierblood-brain barrier

Head TraumaHead Trauma

ConcussionConcussion ContusionContusion Epidural hematoma (EDH)Epidural hematoma (EDH) Subdural hematoma (SDH)Subdural hematoma (SDH) Basilar skull fractureBasilar skull fracture Diffuse axonal injury (DAI)Diffuse axonal injury (DAI)

Epidural

Basilar skull fracture

Depressed skull Fracture

Contusions

Types of InjuriesTypes of Injuries

Mild Traumatic Brain Injury:Mild Traumatic Brain Injury:– ConcussionConcussion: brief change in mental : brief change in mental

status with axonal swellingstatus with axonal swelling Moderate to Severe Brain Injury:Moderate to Severe Brain Injury:

– Contusion: Contusion: ““bruisingbruising””– FracturesFractures: linear,comminuted, : linear,comminuted,

depressed, basalardepressed, basalar– BleedsBleeds: epidural, subdural, : epidural, subdural,

intracerebralintracerebral

Mild Traumatic Brain Mild Traumatic Brain InjuryInjury1.1. Period of LOC < 30 mins with a Period of LOC < 30 mins with a

GCS of 13-15 after this LOCGCS of 13-15 after this LOC2.2. Amnesia to the eventAmnesia to the event3.3. Alteration in mental status at the Alteration in mental status at the

time of the event (dazed and time of the event (dazed and confused)confused)

Types of ConcussionTypes of Concussion

Grade I (confusion, no amnesia, no LOC)Grade I (confusion, no amnesia, no LOC)– Remove from activity (may return when asymptomatic)Remove from activity (may return when asymptomatic)– 3 concussions in 3 months: no activity that risks head 3 concussions in 3 months: no activity that risks head

trauma for 3 monthstrauma for 3 months Grade II (confusion and amnesia)Grade II (confusion and amnesia)

– Remove from activity for dayRemove from activity for day– Recheck in 24 hoursRecheck in 24 hours– No activity for 1 weekNo activity for 1 week– Two grade II concussions in 3 months, no activity for 3 Two grade II concussions in 3 months, no activity for 3

monthsmonths Grade III (LOC)Grade III (LOC)

– To ED for CTTo ED for CT– Symptom free for 2 weeks, then another 30 daysSymptom free for 2 weeks, then another 30 days– Two grade III concussions, no activity for 3 monthsTwo grade III concussions, no activity for 3 months

Post-Concussive Post-Concussive SyndromeSyndrome Somatic symptomsSomatic symptoms: headache, : headache,

sleep disturbance, dizziness, sleep disturbance, dizziness, vertigo, nausea, fatigue, vertigo, nausea, fatigue, sensitivity to light or noisesensitivity to light or noise

CognitiveCognitive: attention, : attention, concentration, memory problemsconcentration, memory problems

AffectiveAffective: irritability, depression, : irritability, depression, anxiety, emotional labilityanxiety, emotional lability

Moderate and Moderate and Severe Brain InjurySevere Brain Injury

ContusionContusion

Small bleedsSmall bleeds Cerebral EdemaCerebral Edema Deficits are Deficits are

based on lobe based on lobe involvedinvolved

FracturesFractures

LinearLinear ComminutedComminuted

Depressed Skull Depressed Skull FractureFracture

95% go to 95% go to surgerysurgery

Antibitoics for Antibitoics for infectioninfection

Brain tissue is Brain tissue is involvedinvolved

Treatment for CSF leak

Epidural HematomaEpidural Hematoma

Laceration of dural Laceration of dural arteries or veinsarteries or veins

Classically laceration of Classically laceration of middle meningeal middle meningeal arteryartery

Temporal bone Temporal bone fracturesfractures

““Lucid intervalLucid interval”” followed followed by rapid deteriorationby rapid deterioration

Acute bleedAcute bleed

Subdural HematomaSubdural Hematoma

60-80% mortality60-80% mortality Tearing of bridging Tearing of bridging

veins, pial artery, veins, pial artery, or cortical veinsor cortical veins

Acute vs chronicAcute vs chronic

Traumatic Subarachnoid Traumatic Subarachnoid HemorrhageHemorrhage Lacerations of Lacerations of

vessels in vessels in subarachnoid subarachnoid spacespace

TSAH SAH

Intraventricular and Intraventricular and Intraparenchymal Intraparenchymal HemorrhageHemorrhage

Intraventricular Intraventricular hemorrhagehemorrhage– Very severe TBIVery severe TBI– Poor prognosisPoor prognosis

Intracerebral Intracerebral hemorrhagehemorrhage– Parenchymal injuries Parenchymal injuries

from lacerations or from lacerations or contusionscontusions

– Large deep cerebral Large deep cerebral vessel injuryvessel injury

Coup and Contrecoup Coup and Contrecoup InjuriesInjuries

Coup: direct skull Coup: direct skull impactimpact

Contrecoup: Contrecoup: opposite side of opposite side of impactimpact

Due to negative Due to negative pressure forces pressure forces causing both causing both vascular and vascular and tissue damagetissue damage

DAIDAIDiffuse AxonalDiffuse Axonal Injury Injury

Neurologic ExamNeurologic Exam

Decreased Decreased neurologic neurologic function is best function is best predictor of brain predictor of brain injuryinjury

Pay attention to Pay attention to cranial nervescranial nerves

Management of Acute Management of Acute Brain TraumaBrain Trauma

Labs: CBC, electrolytes, type and Labs: CBC, electrolytes, type and screen, tox and ETOH screenscreen, tox and ETOH screen

CT BrainCT Brain CT angiography or cerebral CT angiography or cerebral

angiography (penetrating)angiography (penetrating) MRI contraindicated if metallic MRI contraindicated if metallic

fragmentsfragments

Management Management Continued. . .Continued. . . Intubate GCS 8 or less or airway Intubate GCS 8 or less or airway

protection issue protection issue (Cricothyroidotomy if necessary)(Cricothyroidotomy if necessary)

Maintain BP 90 mmHg systolicMaintain BP 90 mmHg systolic C-spine precautionsC-spine precautions Tetanus prophylaxisTetanus prophylaxis Sterile dressing to woundsSterile dressing to wounds Antibiotics in penetrating injuryAntibiotics in penetrating injury

ICP Management is the ICP Management is the KeyKey

ICP monitor in patients with GCS < 8ICP monitor in patients with GCS < 8 Hyperventilation not routinely recommendedHyperventilation not routinely recommended Elevate head of bed to 30 degreesElevate head of bed to 30 degrees SedationSedation

PropofolPropofol Barbiturate Induced ComaBarbiturate Induced Coma

Contraindicated in hypotensionContraindicated in hypotension MannitolMannitol

Reduces ICP by reducing blood viscosity, improves Reduces ICP by reducing blood viscosity, improves cerebral blood flowcerebral blood flow

Serum osmolality should not be > 320Serum osmolality should not be > 320 Bolus dosing Bolus dosing

To Image or Not to To Image or Not to Image?Image? GCS < 15GCS < 15 IntoxicatedIntoxicated Age > 55 or < 2Age > 55 or < 2 Amnesia to eventsAmnesia to events Witnessed LOC (> 15 minutes)Witnessed LOC (> 15 minutes) Repeated vomitingRepeated vomiting Evidence of basilar skull fractureEvidence of basilar skull fracture Inability to recall 3 of 5 objectsInability to recall 3 of 5 objects CoagulopathyCoagulopathy Penetrating head injuryPenetrating head injury

VentriculostomyVentriculostomy

Evidenced Based Medical Evidenced Based Medical Guidelines for TBI Guidelines for TBI ManagementManagement BP and oxygenationBP and oxygenation Hyperosmolar Hyperosmolar

therapytherapy ICP monitoringICP monitoring CPPCPP Infection Infection

prophylaxisprophylaxis DVT prophylaxisDVT prophylaxis http://youtu.be/YQ609Tk-qQI

PbtO2PbtO2 Analgesic/Analgesic/

sedativessedatives NutritionNutrition Antiseizure Antiseizure

prophylaxisprophylaxis HyperventilationHyperventilation Steroids Steroids HypothermiaHypothermia

New TherapyNew Therapy

Stem Cell TherapyStem Cell Therapy– Neural/Glial differentiationNeural/Glial differentiation– NeurogenesisNeurogenesis– NeuroplasticityNeuroplasticity– Improve motor functionImprove motor function– Improve cognitive functionImprove cognitive function

AANN Core Curriculum for Neuroscience Louis, AANN Core Curriculum for Neuroscience Louis, MO. MO. Nursing, 4Nursing, 4thth Ed. 2004. Saunders. St. Ed. 2004. Saunders. St.

Davis, F.A. (2001). Taber’s Cyclopedic Medical Davis, F.A. (2001). Taber’s Cyclopedic Medical Dictionary. Dictionary. F.A. Davis, Philadelphia.F.A. Davis, Philadelphia.

Greenberg, Mark. (2006). Handbook of Greenberg, Mark. (2006). Handbook of Neurosurgery. Neurosurgery. Greenberg Graphics, Tampa, Greenberg Graphics, Tampa, Florida.Florida.

Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L. Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L. (2007). (2007). Medical-Surgical Nursign. Medical-Surgical Nursign. Assessment of Assessment of Management of Medical Management of Medical Problems. Mosby Problems. Mosby Elsevier, St. Louis, Elsevier, St. Louis, MissouriMissouri

Silvestri, Linda. (2008). Comprehensive review Silvestri, Linda. (2008). Comprehensive review for the for the NCLEX-RN Examination. Saunders NCLEX-RN Examination. Saunders Elsevier, St. Elsevier, St. Louis, Louis, Missouri.Missouri.

ReferencesReferences

IntroductionIntroduction

YouTube - Brain Plasticity

NeuroplasticityNeuroplasticity

Organizational changes caused by Organizational changes caused by experience experience

NeurogenesisNeurogenesis

Formation of new nerve cellsFormation of new nerve cells

Nature vs. NurtureNature vs. Nurture

GeneticsGenetics– 2500 connections2500 connections

““major highways”major highways”

EnvironmentEnvironment– 1500015000

““avenues & side roads”avenues & side roads”

FutureFuture

“ “Directed Neuroplasticity”Directed Neuroplasticity”

Brain Fitness ProgramBrain Fitness Program

YouTube - The Brain Fitness Program (1/8)