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What is the major risk factor for traumatic brain injury (TBI)
Mechanism of Injury
- Acceleration: when immobile head struck
- Deceleration: head is moving and object it hit is still
- Rotation injury when head twists as it hits
- Acceleration-deceleration injury: Moving object hits immobile head which then hits second object
Types of TBI
- Blunt Trauma
- --Brain actually moves inside skull as struck, as it's only tethered at the base
- --Disruption to small blood vessels occurs as it scrapes the inside of the skull
- Penetrating Trauma
- --Velocity of object and fracture of bone creates the damage
- --High velocity (bullets) produce shock waves
- Coup-Contrecoup (Counterblow in French)
- --Injury is to side opposite of the side hit
- Scalp Injury
- --Lacerations, hematomas
- Skull Fractures
- --Depressed: adds pressure to brain
- --Basilar: at back of skull-->raccoon eyes.
- Brain Injuries
- Concussions: Short decrease in LOC, amnesia
- Contusions: May be severe, will be localized
- Diffuse Axonal Injuries: small injuries all over the brain r/t anorexia, anemia, hypoxia, post cardiac arrest. May--> posturing (flexion/extension).
- Decreased LOC is primary S&S
- May present with posturing, increased ICP
What do you need to know about epidural hematoma?
- Between skull and dura mater usually associated with skull fracture:
- --Forms large clot, usually quickly (arterial)
- --Unconscious immediately after HI
- --Awakens with lucid interval
- --LOC rapid deteriorates, needs prompt attention.
- --Quickly becomes comatose
- --Confirm with CT scan
- --Prompt intervention is essential
- Subdural Hematoma (blood collects between the dura mater and arachnoid mater)
- Acute/subacute: will cause bleeding in area of edema
- --S&S appear 24-48 hours after injury
- --Comprise ¼ of all TBI
- --Onset of S&S is slower than Epidural Bleed
- --May have variable change in LOC (fluctuates)
- --HA, irritable and confused
- Chronic: common with ETOH
- --Occurs with atrophy, so more room for bleeding
- --Appears recovered then gets hemiparesis, pupil changes
- --Surgical evacuation with drains left in
- Bleeding directly into parenchymal tissue of the brain
- Can't be resected
- From rapid reversal of ischemia
- Cell wall damage from oxygen free radicals
- Occurs after massive hypotension (like cardiac arrests or awaking from anesthesia)
Nuring care for Traumatic Brain injury
- Airway, airway, airway
- Circulatory support
- Protect cervical spine, keep ICP low
- F&E, Elimination (IV lines, foley catheter)
- Nutritional support (feeding tubes)
- Complication management
- Some are surgically managed
- Rehabilitation for nearly everyone.
Things to know about Spinal Cord Injuries
- 10,000 new injuries each year, males 16-30 most common
- Auto, motorcycle, gunshot or knife wounds
- Non-traumatic injuries
- Vascular diseases
Mechanisms of injury for spinal cord injury
- Flexion rotation
- Hyperextension (diver's fracture)
- Compression fractures
- C1 (odontoid process) fractures
- C2 (hangman's fracture)
- Most common are C1-C2, C4-C5, T11-T12
- Early cord edema can make exact location difficult to recognize (even reflexes are distorted)
Pathyphys of spinal cord injury
- Rarely torn or transected by direct trauma
- Due to cord compression by bone displacement, interruption of blood supply to cord, traction from pulling on cord
- GSW and Stab wounds can cause tearing and transection
- Primary injury- initial disruption of axons as a result of stretch or laceration
- Rectal tone is a good diagnositc for spinal cord injury
Pathophys of secondary injury r/t spinal cord injury
- Damage from ischemia, hypoxia, microhemorrhage and edema
- Molecular level- cell death occurs, can continue for weeks or months after initial injury
- Complete cord damage in severe trauma related to autodestruction of cord initial care and management critical to limit processes
- Edema- can cause permanent damage within 24 hours, can develop secondary to inflammatory response, can compress cord and increase ischemic damage. Think about admin Decedron.
- Extent of injury and prognosis for recovery most accurately determined at least 72 hrs or more after injury
SnSs of SCI
- Reflexes altered
- Cord bladder?
- Automatic bladder
- Autonomic dysreflexia with exaggerated ANS reflexes related to full bladder/bowel distention with massive HTN (vasoconstriction) fever,dilated pupils. This is life threatening!!
- Muscle spasms
- Spinal Cord Shock: hypotension, multiorgan destruction.
SnSs of spinal cord shock
- Affects about 50% with acute SCI
- Temporary neurologic syndrome lasting days to months.
- Decreased reflexes below level of injury
- Loss of sensation below level of injury
- Flaccid paralysis below level of injury
- May mask post injury neurologic function
- Active rehab. may still begin
What is neuorgenic shock
- Due to the loss of vasomotor tone caused by injury
- Characterized by hypotension and bradycardia- important clinical clues
- Loss of sympathetic nervous system tone innervation causes peripheral vasodilation, venous pooling, decreased cardiac output
- Usually with cervical or high thoracic injury
Care for spinal cord injury?
- Care at accident scene
- Care in ED and radiology
- Early hospital care
- --Halo Traction
- --Respiratory support
- --Cardiovascular support (hypotension)
- --Aspiration risk
- --Depression management
- --Nutritional support
- --Neuro assessments
Possible nursing diagnosis?
- Pretty much all of them
- Management of constipation becomes important. Intervention is typically digital stimulation.
Nursing management for SCI pt.
- Maintain airway, oxygenation, suction, ventilation
- Immobilize spine- skeletal traction via tongs (Crutchfield or Gardner-Wells), halo traction
- Monitor VS, fluid balance, neuro assessment
- Prevent complications of immobility- rehab starts on admission- specialty beds
- Medications- Methylprednisolone considered within 8 hours of injury possible neuro risks and potential risks
- relieve edema- corticosteroids, anti-inflammatories
- prevent discomfort- analgesics, sedatives, muscle relaxants
- Prepare for surgery- possible decompressive laminectomy, spinal fusion
- If SCI is suspected, DO NOT MOVE PT. WAIT FOR DR./ROTATION TEAM TO DO IT.