Download Head Injury Snap Pt I

Brain Injury
1
Concept Map: Selected Topics in Neurological Nursing
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
ICP Monitoring
“Neuro Checks”
Lab Monitoring
PATHOPHYSIOLOGY
PHARMACOLOGY
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
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, more…based
On Nursing Process:
A_D_P_I_E
--Decrease ICP
--Disease Specific
Meds
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary
Objectives
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 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
Sometimes:
The Lights are on….
But nobody’s home….
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Anatomy & Physiology Review
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I
II
III
IV
V
VI
Vii
VIII
IX
X
XI
XII
O lfactory
O ptic
O culomotor
T rochlear
T rigeminal
A bducens
F acial
A coustic
G lossopharyngeal
V agus
S pinal accessory
H ypoglossal
Cranial Nerve
Function
Structures Innervated
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Olfactory
Smell
Olfactory Bulb
II
Optic
Vision
Retina
III
Oculomotor
Eyeball movement
Lens Accomodation
Pupil Constriction
4 eyeball muscles
1 eyelid muscle
IV
Trochlear
Eyeball Movement
Superior Oblique Muscles
V
Trigeminal
1.
2.
3.
1.
2.
3.
VI
Abducens
Eyeball movement
Lateral Rectus muscle
VII
Facial
1.
2.
3.
4.
Taste
Proprioception
Facial Expressions
Salivation & Lacrimation
1.
2.
3.
4.
Face & Scalp
Face & Scalp
Muscles of face
Salivary & Lacrimal Glands
VIII
Acoustic
1.
2.
Balance
Hearing
1.
2.
Vestibular apparatus
Cochlea
IX
Glossopharyngeal
1.
2.
3.
4.
5.
6.
Taste
Proprioception for swallowing
Blood pressure receptors
Swallowing & gag reflex
Tear production
Saliva production
1.
2.
3.
4.
5.
6.
Posterior 2/3 of tongue
Throat muscles
Carotid sinuses
Throat muscles
Lacrimal glands
Parotid glands
X
Vagus
1.
2.
3.
4.
5.
6.
7.
8.
Chemoreceptors
Pain receptors
Sensations
Taste
Heart Rate & Stroke Volume
Peristalsis
Air Flow
Speech & Swallowing
1.
2.
3.
4.
5.
6.
7.
8.
Blood O2 Concentration, Aortic bodies
Respiratory & Digestive Tracts
External ear, larynx, pharynx
Tongue
Pacemaker & Ventricular Muscles
Smooth muscles of digestive tract
Smooth muscles of bronchioles
Muscles of larynx & pharynx
XI
Spinal Accessory
1.
2.
Head rotation, upright position
Shrugging shoulders
1. Trapezius & sternocleidomastoid muscles
XII
Hypoglossal
Speech & Swallowing
Sensation
General Sensory From Tongue
Proprioception
Face, scalp, teeth, lips, eyeballs, nose, throat lining
Anterior 2/3 of tongue
Muscles of mastication
Tongue & Throat muscles
Brain Trauma
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Brain injury results in more
trauma deaths than do injuries
to any other body region!
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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
3 Top Causes
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Risk Factors
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 Highest in young people and the elderly
*Age 65 – 75 has highest incidence of HI of ALL age groups*
 Occurs twice as often among males compared 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
Did you Know ?
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Laws that require helmet use have been shown to
reduce deaths
in motorcyclists
by about 30%
Boxing:
CoupContre Coup
Injury :
“The second
collision”
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“Rear-Ended” – “Whiplash” Effect
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At the Scene:
- EMS
- First Responders
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1. Maintain ability to breathe
2. Prevent shock
3. Immobilization to prevent further spinal cord
damage
(Backboard + C-Collar)
EMS type C- Collar
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Spinal Injury
Assumed
With
Any
Head Injury
EMS Back Boards
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Upon Arrival to ER…
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Baseline Assessment
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Vital Signs
Glasgow Coma Score (GCS)
The GCS is the most widely used method of defining a
patient's Level of Consciousness (LOC)
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23
Everybody
Check
Hand Grasps for Motor Strength
by
CROSSING
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Oculocephalic Reflex (Doll’s Eye)
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OCR
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C – Spine X-Ray
“Cross-Table Lat”
Before removal of ANY immobilization
devices
As Much as Possible In ER
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 Instruct client to avoid sneezing or coughing
 Provide calm environment
 Maintain immobilization
 Avoid meds the decrease LOC such as analgesics
Severity of Head Injury
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GCS
SCORE
<8=
COMA
GCS 3 – 8 : Severe Head Injury
GCS 9 – 12: Moderate Head Injury
GCS 13 -15: Mild Head Injury
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The best guide to
the severity of head
injury
is the level of
consciousness
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History of Injury
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 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 ?
Open or Closed Injury ?
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Diagnostics
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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
Skull Fractures
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 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
Depressed Skull Fractures
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 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
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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
Basal Skull Fractures
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Clinical Clues may include:
CSF leakage through the ear or nose (otorrhea or rhinorrhea)
Hemotympanum (blood behind the eardrum)
Bruising behind the ears (postauricular ecchymoses)

“Battle Sign”
Bruising around the eyes (periorbital ecchymoses)

“Raccoon Eyes” “Panda Eyes”
Injury to cranial nerves:
VII
VIII
I
II
VI
Facial nerve - weakness of the face
Acoustic nerve - loss of hearing
Olfactory nerve - loss of smell
Optic nerve - vision loss
Abducens nerve - double vision
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Basal Skull Fractures
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Involve the floor of the skull and include fractures of the cribriform plate, frontal bones,
sphenoid bones, temporal bone and occipital bones
1 frontal
2 ethmoid
3 sphenoid
4 temporal
5 parietal
6 occipital
1. Frontal sinus
2. Crista galli
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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
CSF Leakage
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 Rhinorrhea and otorrhea are clinical signs of cerebrospinal fluid
(CSF) leakage in patients with skull fracture
 Presence of glucose (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)
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Halo
Effect of
CSF
Prevent Infection !
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Cover any suspected source of
CSF leakage with a
Sterile Dressing STAT !
CSF Infection
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Nuchal Rigidity
CSF has WBCs
Increased Temperature
Basal Skull Fractures
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•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
Associated with Brain Injury
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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
Another Clue….
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Avulsed eye and lacerations to the forehead
Penetrating Brain Injury
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Head Injury Assessment
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
Obvious Skull Fractures?

Lacerations?

Deformities? (bumps / indentations)

Facial Injuries?

Blood and/or CSF drainage from nostrils? (rhinorrhea)

Blood and/or CSF drainage from ear canals? (otorrhea)

Blood and/or CSF drainage from mouth?

Blood and/or CSF drainage from eyes?

Pain?

Headache?
Collaborative Treatment Goals
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 Maintain
Airway
Breathing
Circulation
 Maintain cerebral perfusion
 Maintain electrolyte balance
 Maintain fluid balance
 Maintain cognitive function
HOW ????
Prevent Secondary Injury !!!
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Meaningful recovery of function after
head injury is possible IF secondary
injuries are prevented or minimized