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TRAUMATIC BRAIN INJURY Jassin M. Jouria, MD Dr. Jas+ of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract Traumatic brain injury (TBI) is a major health issue that can lead to physical and mental disability as well as morbidity. The brain anatomy and physiology is discussed as well as the medical evaluation and diagnosis of a TBI. Additionally, the lifelong challenge of patient quality of life and implications to patients’ family members are a major focus with emphasis on current and newer medial and alternative approaches of therapy to promote improved health and wellbeing. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Continuing Nursing Education Course Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Identifying current research and guidelines related to traumatic brain injuries is needed to support health providers and nurses in order to help reduce TBI-related morbidity and improve patient care outcomes. Assessment tools and testing to assist in the diagnosis of a TBI is needed to appropriately develop a treatment plan and to select new technology that supports improved care. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Course Purpose To provide nursing professionals with knowledge of how to care for the patient with a TBI as well as for the needs of their family. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Activity Review Information Reviewed by Susan DePasquale, MSN, FPMHNP-BC Release Date: 1/29/2016 Termination Date: 1/29/2019 Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Head trauma may include an alteration in consciousness that involves any trauma to the a. scalp b. skull c. brain d. All of the above. 2. A majority of traumatic brain injury cases occur as the result of a. gunshot wounds b. transportation accidents c. sports injuries d. domestic violence 3. Mild injuries typically cause all EXCEPT: a. brief, change in mental status. b. seizure disorder. c. no long-term adverse affects. d. temporary loss of consciousness. 4. The nervous system is comprised of two regions: a. Central Nervous System and Peripheral Nervous System b. Central Nervous System and Autonomic Nervous System c. Autonomic Nervous System and Peripheral Nervous System d. Autonomic and Parasympathetic Nervous Systems. 5. The cranial bones include the a. frontal, temporal, occipital, parietal, lacrimal b. foramen magnum, frontal, temporal, occipital, parietal c. maxilla, malar, temporal, occipital, parietal d. foramen magnum, volar, frontal, temporal, occipital nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction Traumatic brain injury has many causes, including sports injuries, violence, vehicular accidents, and falls. Each instance is unique and outcomes can be difficult to predict, which is why every patient with a potential traumatic brain injury (TBI) needs to be appropriately assessed and provided with immediate, intensive care to address his or her needs. Traumatic brain injuries can present with a wide array of symptoms and every symptom needs to be treated seriously. Even cases that present as mild can become serious in a matter of seconds. Over 5 million people in the United States are survivors of traumatic brain injuries. Many of them have long-term disabilities as a result of their injury. Medical professionals who understand the unique needs of TBI patients are the key to minimizing the potential impact of these disabilities. Health care providers must be familiar with the different causes and types of head injury to adequately treat trauma patients. In many instances, head injury will accompany other trauma-induced injuries. Therefore, all trauma patients must be evaluated for head injuries, even if no signs are present. Many head injuries will not produce immediate symptoms, even if significant damage has occurred.1 A patient should be evaluated using standard guidelines and diagnostic imaging, if appropriate.2 When a head injury is detected, treatment should begin immediately to avoid further complications. Overview Of TBI Head trauma involves any trauma to the scalp, skull or brain and may include an alteration in consciousness, even if it is brief. Patients who experience head trauma will have a range of symptoms depending on the nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com type of injury, the force, the location and the severity of the injury. In some patients, the injury will be mild and resolve over a short period of time. However, in other patients, the trauma will produce severe injuries that have long-term effects. The most common causes of head trauma include:3 Motor vehicle accidents Firearm-related injuries Falls Assaults Sports-related injuries Recreational accidents Traumatic Brain Injury is one of the most common trauma related injuries, and is the most severe form of head trauma. According to the Center for Disease Control, approximately 1.7 million traumatic brain injuries occur each year.4 Many of these injuries occur along with other injuries. While traumatic brain injury is considered one type of head trauma, it is sometimes used to refer to most head injuries that a patient experiences. In fact, some providers use the term traumatic brain injury interchangeably with head trauma. Traumatic brain injury is commonly referred to as either TBI, acquired brain injury, or head injury.5 It is caused by a sudden trauma to the head that causes damage to the brain. Depending on how the trauma occurs, the resulting damage may be focal or it can be diffuse.6 Traumatic brain injury can result from either a closed head injury or from a penetrating head injury.4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Traumatic brain injury is the direct result of a blow to the head. However, not all forces to the head cause traumatic brain injury. Depending on a number of factors, such as the level of impact and the type of object, the severity of the injury may range from non-existent to severe.7 In instances where the force actually causes some level of trauma, the injury will range from mild to severe.4 Mild injuries typically cause a minor, or brief, change in mental status. Mild injuries may result in a temporary loss of consciousness, but there will be no long-term adverse affects.8 Severe injuries can result in full, extended loss of consciousness. They may also cause short or long-term amnesia.9 Throughout all levels of injury, TBI produces a range of functional and sensory changes. These changes impact the patient’s movement, thinking, sensation, language, and emotions.4 Many of the symptoms of traumatic brain injury develop over time and may not appear for a number of days or weeks. In some rare cases, the symptoms may not appear for months.10 Many patients with mild traumatic brain injury will recover within a number of weeks or months, although some symptoms may persist for longer.6 In patients who experience moderate to severe traumatic brain injury, the recovery time is greater. In fact, many moderate to severe TBI patients never fully recover.11 Many TBI symptoms are life long complications. According to the Center for Disease Control (CDC), approximately 5.3 million Americans are living with a TBI-related disability.4 A majority of traumatic brain injury cases (approximately half) occur as the result of transportation accidents, which includes automobiles, motorcycles, bicycles, and pedestrian accidents. These accidents are the major cause of TBI in people under age 75.5 For those 75 and older, falls cause the majority nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com of TBIs.12 Approximately 20% of TBIs are due to violence, such as firearm assaults and child abuse, and about 3% are due to sports injuries.10 The cause of the TBI plays a role in determining the patient’s outcome. For example, approximately 91% of firearm TBIs (two-thirds of which may be suicidal in intent) result in death, while only 11% of TBIs from falls result in death.10 Civilians and military personnel in combat zones are also at increased risk for TBIs. The leading causes of such TBI are bullets, fragments, blasts, falls, motor vehicle-traffic crashes, and assaults. Blasts are a leading cause of TBI for active-duty military personnel in war zones.13 Anatomy and Physiology of the Brain The head is a complex region comprised of various components, all of which can be injured during head trauma situations. The components of the head and brain are outlined below. Nervous System The brain is part of the nervous system and operates in conjunction with other parts of the body to provide operative functions.14 The nervous system is comprised of two regions: Central Nervous System (CNS) Peripheral Nervous System (PNS) The central nervous system houses the brain and spinal cord, while the peripheral nervous system is comprised of spinal nerves and cranial nerves.15 The spinal nerves branch from the spinal cord outward and the cranial nerves branch from the brain outward. The peripheral nervous system also houses the autonomic nervous system.14 The autonomic nervous system controls various functions including:16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Breathing Digestion Heart rate Secretion of hormones Scalp15 The scalp is the soft tissue that covers the entire area of the skull. It is comprised of five layers: Skin Connective tissue Epicranial aponeurosis Loose areolar tissue Pericranium The first three layers of the scalp are joined together to form one unit, but the unit is able to move freely along the loose areolar tissue that covers the pericranium. The pericranium adheres to the calvaria (skullcap).14 Skull16 The skull provides protection for the brain. It consists of two distinct regions: Cranial Bones: Foramen Magnum Frontal Temporal Occipital Parietal nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Facial Bones: Lacrimel bone Inferior nasal conchae Vomer Nasal bone Malar Maxilla bone Mandible bone A dense white fibrous membrane called the periosteum, which is very vascular, covers the skull bone. The periosteum provides nutrition to the bone cells through branches that it sends into the bone. These nutrients are necessary for brain growth and repair. At the base of the skull is the foramen magnum, which is an opening in the occipital bone through which the spinal cord passes.17 Meninges15 The region between the brain and the skull is called the meninges. This area is comprised of three layers of tissue. The tissue covers the brain and the spinal cord and provides protection to both areas. The three layers of the meninges are: Dura mater Arachnoid Pia mater The dura mater is the outermost layer of the meninges, and the pia mater is the innermost layer. The dura mater contains two layers of membrane. The outer layer is called the periosteum and the inner layer is the dura. The dura lines the inside of the entire skull. It helps protect and secure the brain by nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com creating small folds and compartments. The folds of the dura are called the falx and the tentorium. The right and left side of the brain is separated by the falx. The upper and lower parts of the brain are separated by the tentorium.16 The arachnoid layer of the meninges is thin and delicate and contains a number of blood vessels. It covers the entire surface of the brain. The space between the dura and arachnoid membranes is referred to as the subdural space.18 The pia mater is the layer of the meninges that is located closest to the surface of the brain. The pia mater is comprised of a number of blood vessels that branch far into the brain. The pia covers the entire surface of the brain and follows the folds of the brain. Major arteries supply blood. The area between the arachnoid and the pia is referred to as the subarachnoid space, which contains cerebrospinal fluid.19 Cranial Vault (brain) The cranial vault is the region of the head that houses the cerebrum, cerebellum, and brainstem.14 The cranial vault is comprised of the following components:20 Brain tissue (80%) Cerebral Spinal Fluid (CSF) (10%) Blood (within blood vessels) (10%) The following table provides descriptions of each area of the cranial vault.15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Region Description The cerebrum is the largest part of the brain and is composed of right and left hemispheres. It performs higher functions like interpreting touch, vision and hearing, as well as speech, reasoning, emotions, learning, and fine control of movement. The surface of the cerebrum has a folded appearance called the cortex. The cortex contains about 70% of the 100 billion nerve cells. The nerve cell bodies color the cortex grey-brown giving it the Cerebrum name – gray matter. Beneath the cortex is long connecting fibers between neurons, called axons, which make up the white matter. The folding of the cortex increases the brain’s surface area allowing more neurons to fit inside the skull and enabling higher functions. Each fold is called a gyrus, and each groove between folds is called a sulcus. There are names for the folds and grooves that help define specific brain regions. The cerebellum is located under the cerebrum. Its function is to Cerebellum coordinate muscle movements, maintain posture, and balance. The brainstem includes the midbrain, pons, and medulla. It acts as a relay center connecting the cerebrum and cerebellum to the spinal cord. It performs many automatic functions such as Brainstem breathing, heart rate, body temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and swallowing. Ten of the twelve cranial nerves originate in the brainstem. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Right and Left Hemispheres The brain is divided into two hemispheres, the right hemisphere and the left hemisphere, which are joined by the corpus callosum fibers. These fibers are responsible for delivering messages to each hemisphere. The right hemisphere controls the left side of the body and the left hemisphere controls the right side of the body.16,21 The left hemisphere controls the following functions: Speech Comprehension Arithmetic Writing The right hemisphere controls the following functions: Creativity Spatial ability Artistic skills Musical skills Injury to the cranial vault commonly produces an increase in intracranial pressure. Ultimately, according to the Monroe-Kellie Doctrine, when the nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com volume of any of the three cranial components increases, the volume of one or both of the others must decrease or the intracranial pressure will rise.22 Intracranial volume typically increases when the patient experiences cerebral edema, intracranial mass, or an increase in blood or cerebral spinal fluid.23 Lobes: The right and left hemisphere is further divided into lobes by fissures. Each hemisphere contains four lobes:24 Frontal Temporal Parietal Occipital Each of the lobes is divided into areas that control specific functions. However, while the lobes are divided, they do not function independently. The complexity of the cranial cavity requires consistent relationships between the various lobes as well as between the left and right hemispheres.14 The following table provides information on the different functions of each lobe.16 Lobe Frontal Lobes Function The frontal lobes are the largest of the four lobes responsible for many different functions. These include motor skills such as voluntary movement, speech, intellectual and behavioral functions. The areas that produce movement in parts of the body are found in the primary motor cortex or precentral gyrus. The prefrontal cortex plays an important part in memory, intelligence, concentration, temper and personality. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The premotor cortex is a region found beside the primary motor cortex. It guides eye and head movements and a person’s sense of orientation. Broca's area, important in language production, is found in the frontal lobe, usually on the left side. Occipital Lobes These lobes are located at the back of the brain and enable humans to receive and process visual information. They influence how humans process colors and shapes. The occipital lobe on the right interprets visual signals from the left visual space, while the left occipital lobe performs the same function for the right visual space. Parietal Lobes These lobes interpret simultaneously, signals received from other areas of the brain such as vision, hearing, motor, sensory and memory. A person’s memory and the new sensory information received, give meaning to objects. Temporal Lobes These lobes are located on each side of the brain at about ear level, and can be divided into two parts. One part is on the bottom (ventral) of each hemisphere, and the other part is on the side (lateral) of each hemisphere. An area on the right side is involved in visual memory and helps humans recognize objects and peoples' faces. An area on the left side is involved in verbal memory and helps humans remember and understand language. The rear of the temporal lobe enables humans to interpret other people’s emotions and reactions. Vascular System Regular and consistent blood flow is crucial to the maintenance of brain activity. Approximately 20% of the cardiac output of blood is used for arterial blood flow.14 The brain is responsible for the regulation of blood flow nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com over various blood pressure ranges using vasodilation or vasoconstriction of the arteries.23 Blood is supplied to the brain by two primary arteries:25 Carotid: These arteries are responsible for providing circulation to the anterior region of the brain. The anterior region of the brain includes the frontal, temporal, partial, and occipital lobes. The carotid arteries supply the brain with approximately 80% of the blood flow. Vertebral Arteries: The vertebral arteries are responsible for the posterior circulation of the brain. These arteries join together and form the basilar artery. The vertebral arteries provide approximately 20% of the blood flow to the brain. While the anterior and posterior circulation function independent of each other, they often communicate with each other using communicating arteries that come together to form the Circle of Willis.18 The Circle of Willis responds to decreased arterial flow by establishing a protective mechanism. It shunts blood from the anterior to posterior regions of the brain, or vice versa. This protective measure helps delay the deteriorating neurological signs and symptoms that are often present in patients.15 The following table provides an overview of the different arterial regions and functions.14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Anterior Circulation Anterior Cerebral Supplies most medial portions of frontal lobe and superior medial Artery (ACA) parietal lobes. Anterior Connects the anterior cerebral arteries at their closest juncture. Communicating Artery (AcomA) Internal Carotid Ascends through the base of the skull to give rise to the anterior Artery (ICA) and middle cerebral arteries, and connects with the posterior half of the circle of Willis via the posterior communicating artery. Middle Cerebral Trifurcates off the ICA and supplies the lateral aspects of the Artery (MCA) temporal, frontal and parietal lobes. Posterior Circulation Posterior Connects to the anterior circle of Willis with the posterior cerebral Communicating artery of vertebral-basilar circulation posteriorly. Artery (PcomA) Posterior Cerebral Supplies the occipital lobe and the inferior portion of the temporal Artery (PCA) lobe. A branch supplies the choroid plexus. Basilar Artery Formed by the junction of the two vertebral arteries, it terminates (BA) as a bifurcation into the posterior and cerebral arteries supplying the brainstem. Vertebral Artery The vertebrals emerge from the posterior base of the skull (VA) (Foramen Magnum) and merge to form the basilar artery supplying the brainstem. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Cranial Nerves The brain includes twelve cranial nerves that control specific bodily functions.26 The following is a list of the cranial nerves and the functions that they control:27 Olfactory: Smell Optic: Visual fields and ability to see Oculomotor: Eye movements and eyelid opening Trochlear: Eye movements Trigeminal: Facial sensation Abducens: Eye movements Facial: Eyelid closing, facial expression, and taste sensation Auditory/vestibular: Hearing and sense of balance Glossopharyngeal: Taste sensation and swallowing Vagus: Swallowing and taste sensation Accessory: Control of neck and shoulder muscles Hypoglossal: Tongue movement Hypothalamus The hypothalamus is directly responsible for sending messages to the pituitary gland.15 The structure itself is very small, but it contains a number of nerve connections that make communication between the hypothalamus and the pituitary gland possible.28 The hypothalamus receives information from the autonomic nervous system and is responsible for the following functions:14 Eating Sexual behavior Sleeping Body temperature regulation nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Emotions Hormone secretion Movement Brain Stem The brainstem is the part of the brain that connects the brain to the spinal cord. It is located in front of the cerebellum.23 The brainstem is comprised of three components:16 Midbrain – responsible for ocular motion Pons – responsible for coordinating eye and facial movements, facial sensations, hearing, and balance Medulla Oblongata – controls breathing, blood pressure, heart rhythms, and swallowing The pons and the brainstem transmit messages from the cortex to the spinal cord and are responsible for maintaining the basic life functions.29 If this area of the brainstem is damaged or destroyed, it can cause brain death in the patient.30 Humans require these basic functions to survive and if transmission is interrupted, survival is not possible.20 The midbrain, pons, medulla and part of the thalamus contain the reticular activating system. This system is responsible for controlling wakefulness as well as attentiveness and the regulation of sleep patterns.14 The brainstem contains ten of the twelve cranial nerves that control the following:16 Hearing Eye movement nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Facial sensations Taste Swallowing Movements of the face, neck, shoulder and tongue muscles Brain Cells The two types of cells contained within the brain are the neurons and glial cells. They are sometimes referred to as the neuroglia and glia. There are approximately 50% more glial cells than neurons.31 The primary job of the neuron is to send and receive nerve impulses and signals.32 The glial cells are responsible for the following:14 Provide nutrition Provide support Maintain homeostasis Form myelin Facilitate signal transmission in the nervous system Cerebrospinal Fluid (CSF) Cerebrospinal fluid is a clear, watery substance that surrounds the brain and the spinal cord. It provides a cushion that helps protect the brain and spinal cord from injury.27 The fluid constantly circulates throughout the various channels around and within the spinal cord and brain. It is absorbed and replenished on a continuous basis.16 The fluid is produced within the ventricles, which are hollow channels within the brain.33 The chorois plexus is the ventricle structure that is responsible for the majority of cerebrospinal fluid. Typically, the amount of CSF that is produced is balanced with the amount that is absorbed.15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Ventricles There are four cavities that comprise the ventricular system. The four cavities are referred to as ventricles.34 They are connected by a series of holes that are referred to as foramen, as well as tubes.15 The cerebral hemisphere contains two ventricles referred to as the lateral ventricles. Their job is to communicate with the third ventricle using a separate opening that is called the Foramen of Munro.35 The third ventricle serves as the center of the brain, with walls comprised of the thalamus and the hypothalamus.14 The Aqueduct of Sylvius is a long tube that connects the third ventricle to the fourth ventricle.28 Other Parts of the Brain Limbic System: The limbic system includes the hypothalamus, the thalamus, the amygdala, and the hippocampus. All of these components are involved in hormone and emotional regulation.20 Pineal Gland: The pineal gland is attached to the posterior region of the third ventricle. There is no concrete understanding of the exact role of the pineal gland. However, there is some indication that it plays a role in sexual maturation.16 Pituitary Gland: The pituitary gland is located at the base of the brain within the region known as the pituitary fossa or sella turcica. This area is located behind the nose.14 The pituitary gland controls the secretion of hormones and is responsible for the control and coordination of the following activities:32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Growth and development The function of various body organs (i.e., kidneys, breasts and uterus) The function of other glands (i.e., thyroid, gonads, and adrenal glands) Due to the fact that the pituitary gland is responsible for controlling hormone secretion, it is often referred to as the “Master Gland.”20 Thalamus:23 The thalamus is comprised of the basal ganglia as well as four components: Hypothalamus Epythalamus Ventral thalamus Dorsal thalamus The thalamus is responsible for transmitting all information to and from the cortex. The primary information that is transmitted by the thalamus includes:16 Pain sensation Attention Alertness Types Of TBI The injuries sustained during head trauma are complex as they are impacted by a number of factors, including the type of trauma, the amount of force, the region, and the region injured. Since the head and brain involve a number of different structures that operate both independent of and with each other, injuries can range from mild to severe. Injuries can affect more than one area of the brain, which can cause complex injuries. Head injuries nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com are caused when an object strikes the head and transfers force to the brain tissue. The type of trauma is either blunt or penetrating. Blunt trauma produces a closed head injury, while penetrating trauma produces an open injury.10 When a patient experiences blunt trauma, one of the following types of force will occur:36 Deceleration Acceleration Acceleration-deceleration Rotational Deformation The following is an explanation of the different injuries that can occur as a result of the forces listed above:37 Deceleration forces occur when the head hits an immovable object such as the forehead hitting the windshield. This causes the skull to decelerate rapidly. The brain moves slower than the skull causing the brain tissue to collide with skull. As the brain moves over the bony prominences, it can stretch, shear or tear the tissue. Acceleration injuries can occur when an object hits the head and the skull and the brain are set in motion. Acceleration-deceleration forces occur due to the rapid changes in velocity of the brain within the cranial vault. Rotational forces occur from the twisting of the head usually after impact. The degree of injury depends upon the speed and direction the brain is rotated. Rotational forces affect white matter tissue of the brain. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The most common areas affected include the corpus collosum and the brain stem. Deformation forces occur when the velocity of the impact changes the shape of the skull and compresses the brain tissue. The brain tissue is cushioned within the cranial vault by cerebrospinal fluid, one of the protective mechanisms of the brain. Direct injury to the brain tissue can occur as contusions, lacerations, necrosis and hematomas with coup and contrecoup injuries. Coup injuries occur at the site of impact and the contrecoup injury occurs at the opposite side or at the rebound site of impact. Bi-polar injuries may occur from front to back or side to side. Quadra-polar injuries involve all sides of the brain — front, back, and each side. The most common area of impact of a coup injury is the occipital lobe and the contrecoup injury is the frontal lobe. When a patient experiences a penetrating injury, the object causing the injury breaks through the scalp and skull and penetrates the brain. Typically, the penetrating object will cause tissue lacerations, contusions and hemorrhages, along with a range of secondary injuries.38 The injury will range in severity depending on a number of factors including size, shape, speed and location of entry. Gunshot wounds and stab wounds are especially problematic and both have a high incidence of mortality.19 There are two classifications of brain injury:10 Primary – This type of injury occurs as a direct result of the trauma. Secondary – These injuries often develop over a period of time (typically between several hours and five days). nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Initial treatment will focus on repairing any primary injuries, while later treatment will transition to minimizing potential secondary injuries.6 When a patient experiences a head trauma, he or she will often incur both primary and secondary injuries.32 The following table provides information on both types of injury.37 Injury Description Type Primary Primary injuries are a result of acceleration-deceleration and rotational Injuries forces occurring at the time of impact. These cause coup (initial impact site) and contrecoup (rebound site of impact) injuries. The forces exerted on the brain tissue may result in shearing, tensile or compressive stresses. They can lead to ruptured blood vessels causing hemorrhage, hematomas, and/or contusions. Injuries include lacerations, bone fractures, contusions, hematomas and diffuse axonal injuries. Secondary Injuries Secondary injuries occur after the initial traumatic injury and are a consequence of the primary injury. A pathological cascade occurs due to the biochemical changes in cellular structure. These changes lead to cell death and further secondary injuries such as hypoxia, hypotension, hypercarbia, hyperexcitation, cerebral edema, pathologic changes associated with increased intracranial pressure, late bleeding and expanding intracranial lesions. Open versus Closed Injuries Head injuries can be either open or closed. With a closed injury, the patient experiences trauma in the absence of skull penetration.3 With an open injury, the patient’s skull is penetrated.28 Open and closed head injuries nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com cause different symptoms and must be treated differently. The following information provides the distinctions between the two types of injuries. Signs and Symptoms of Closed Injury:39 Altered or decreasing mental status — the best indicator of a brain injury Irregular breathing pattern Obvious signs of a mechanism of injury — contusions, lacerations, or hematomas to the scalp or deformity to the skull Blood or cerebrospinal fluid leaking from the ears or nose Bruising around the eyes (raccoon eyes) Bruising behind the ears, or mastoid process (Battle’s sign) Loss of movement or sensation Nausea and/or vomiting (vomiting may be forceful or repeated) Unequal pupil size (dilated) that does not react to light (fixed) with altered mental status Possible seizures Unresponsiveness Signs and Symptoms of Open Injury:40 Obvious results of the mechanism of injury — contusions, lacerations, or hematomas to the scalp Deformity to the skull or obvious penetrating injury A soft area or depression detected during palpation Brain tissue exposed through an open wound Bleeding from an open bone injury nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Diffuse versus Focal Injuries Brain injuries are either diffuse or focal. In focal injuries, the damage occurs throughout various areas of the brain. The damage is microscopic and widespread and it often occurs as the result of force that is exerted on the brain tissues.41 The force causes damage to the axons, which are the parts of the brain that communicate with each other and initiate nerve cell responses.42 Focal brain injuries are confined to one specific region of the brain. They cause localized damage and are easily identifiable.43 Types of Diffuse Injuries:10 concussion brain edema diffuse axonal injury Types of Focal Injuries:5 contusion intracranial hematoma extradural hematoma subdural hematoma intracerebral hematoma (ICH ) subarachnoid hemorrhage (SAH ) intraventricular hemorrhage (IVH ) The following table provides a thorough overview of the different types of injuries that contribute to traumatic brain injury.44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Primary brain Cerebral Contusion injury mechanisms – Contusions are hemorrhagic lesions resulting when Focal acceleration/deceleration forces cause differential movements between the brain and the skull or at grey–white matter interfaces. They may occur at the site of impact, referred to as a “coup” injury, if local deformation has been sufficiently severe. Contre-coup contusions may be found on the opposite side to that of the impact, but are usually found on the crests of the gyri of the cerebral hemispheres, especially in those areas most likely to have contact with bony skull protuberances: the orbital plate of the frontal bone, the sphenoidal ridge, the petrous portion of the temporal bone and the sharp edges of the falces. As a result, the basal and polar portions of the frontal and temporal lobes are most susceptible to contusions. However, contusions may also be found on the medial surfaces of the cerebral hemispheres and along the upper surface of the corpus callosum (Graham, 1999). They contribute to local neuronal destruction and ischemia, or reduced blood supply, depriving neurons of oxygen and glucose. Mechanisms of cell death occurring in contusional and pericontusional areas are termed necrosis and apoptosis. Necrosis occurs more quickly, as a result of membrane failure and ionic disruption, which degrade the neuronal cytoskeleton and cytoplasm and cause swelling and dilation of the mitochondria. Apoptosis occurs slowly over a longer period, without disruption of the cell membrane. It may be caused by neural excitation, radical-mediated injury or a disruption of calcium homeostasis. Intracranial Hematoma Vascular injury may be seen as multiple tiny “petechial” hemorrhages throughout the cerebral hemispheres. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Tearing of larger blood vessels at the time of impact results in bleeding inside the skull and the formation of a clot, which can eventually cause compression of the brain and ischemia. This may lead to the development of coma after a delay or to deterioration in conscious state, necessitating prompt surgical intervention to stop the bleeding and evacuate the hematoma. Intracranial hematomas are classified according to their anatomical location. An extradural hematoma results from bleeding between the skull and outer covering of the brain, known as the dura mater. This is most commonly a complication of a temporal skull fracture, where meningeal vessels have been torn. A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater. The elderly are at increased risk of chronic subdural hematoma because of their increased risk of falls and the greater intracranial space caused by cerebral atrophy. A subdural hygroma is a collection of cerebrospinal fluid in the subdural space through a tear in the arachnoid mater. It develops days or weeks after injury, and may form after the evacuation of an acute subdural hematoma. A subarachnoid hemorrhage refers to bleeding between the arachnoid and pia mater. This may cause arterial spasm, leading to ischaemic brain damage. It can also lead to obstruction of the flow of cerebrospinal fluid, resulting in communicating high-pressure hydrocephalus. An intracerebral hematoma is a hemorrhage within the brain caused by a deep contusion or tear in the blood vessels. As with other pathological consequences of TBI, intracerebral hematomata occur most commonly in the frontal and temporal lobes. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Primary brain The mechanical force of injury may cause more diffuse neuronal injury: Diffuse membrane disruption. Some cells appear to be able to reorganize, neuronal restore their function and thereby survive this disruption, whereas change and others show persistent membrane dysfunction, with activation of axonal injury cysteine proteases (calpain and caspase), causing rapid necrotic cell death. Similarly, mechanical forces can result in scattered and multifocal axonal change throughout the subcortical white matter, corpus callosum and brain stem, termed diffuse axonal injury (DAI). In the most severe injuries, axons may be torn and retract, expelling axoplasm and forming “retraction balls”. More commonly, mechanical strains cause focal alteration of the axolemma, or disruption of sodium channels, resulting in an influx of ions such as calcium, that disrupt the cytoskeleton. This results in progressive changes disrupting axonal transport and causing local swelling of the axon, followed by detachment from its downstream segment. Both myelinated and unmyelinated fibers appear to be vulnerable. These processes may take place over several hours or days after injury, creating a potential opportunity for intervention. Various therapies aimed at protecting the mitochondria, including the use of immunophilin ligands, cyclosporin A and FK 506 and hypothermia, are under investigation. Shearing strains are thought to decrease in magnitude from the cortical surface to the center of the brain. They are enhanced along interfaces between substances of different densities and therefore DAI occurs most commonly in the grey–white matter junctions around the basal ganglia, the periventricular zone of the hypothalamus, the superior cerebellar peduncles, the fornices, fiber tracts of the corpus callosum, and in the frontal and temporal poles. A consequence of DAI is that of downstream deafferentation or denervation. The downstream axon, disconnected from its sustaining cell body, undergoes wallerian degeneration, which may take place over several months after injury. Downstream nerve terminals undergo neurodegenerative change. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Although neoplastic responses are not well understood, there is some evidence to suggest that, in the case of mild–moderate injury, diffuse deafferentation may result in sprouting of adjacent intact nerve fibers, leading to some recovery of synaptic input to the deafferented areas. However, in the case of severe injury, there appear to be maladaptive changes, with fiber ingrowth and changes in cytoarchitecture. These processes, and potential means of influencing them, are the focus of continuing experimentation. Widespread metabolic changes also occur following TBI. Across the spectrum of injury severity, TBI is followed by a short-lived increase in glucose metabolism (a sign of metabolic stress), followed by a decreased rate of glucose metabolism which may last for days or weeks and shows some correspondence with the period of recovery and with outcome. Elevated lactate and glutamate are also evident and higher levels are associated with poorer outcome. Petechial White Matter Hemorrhage DAI is most commonly associated with injuries involving acceleration– deceleration, such as motor vehicle accidents. Findings on computed tomography or magnetic resonance imaging may include the presence of petechial white matter hemorrhage as well as non-hemorrhagic white matter lesions, diffuse edema, and small subarachnoid and intraventricular hemorrhages. Deeper lesions are indicative of more severe injury. Adams et al. (1989) refer to three grades of DAI: Grade 1 where focal hemorrhagic lesions are confined to the white matter of the cerebral hemispheres; Grade 2 where there is involvement of the corpus callosum; and Grade 3 where the dorsolateral upper brain stem is involved. However, lesser degrees of DAI may also be seen in some cases. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Secondary Both intracranial and extracranial complications may result in brain injury secondary brain injury, either as a consequence of cerebral ischemia mechanisms or distortion and/or compression of the brain/mass effect. Cerebral ischemia, as a result of inadequate blood flow and consequent tissue hypoxia, is usually the ultimate cause of secondary brain damage associated with TBI. Hypoxic damage is frequently found in the border zones of areas supplied by the major cerebral arteries, particularly in the parasagittal cortex, the hippocampus, the thalamus and basal ganglia. Intracranial complications may include the following conditions outlined below. Brain Swelling There are two mechanisms, which lead to an increase in the volume of the brain following TBI. The first is an increase in the cerebral blood volume, termed hyperemia, caused by hypoxia, hypercapnia, or obstruction of major cerebral veins as a result of cerebral edema. The second is cerebral edema, resulting from an increased volume of intraor extracellular fluid in the brain tissue. Cerebral edema may be caused by damage to the walls of cerebral blood vessels, accumulation of fluid within the cell as a result of ischemia, increased intravascular pressure, or an obstruction to the flow of cerebrospinal fluid. These mechanisms may result in brain swelling of either a localized or a diffuse nature. Damage to the brain tends to be caused by a mass effect, with brain shift and/or raised intracranial pressure, leading to hypoxia/ischaemia. Infection Infection, which may develop in the subacute phase after TBI, is a complication associated with skull fracture. It can manifest itself in two forms: meningitis and cerebral abscess, causing raised intracranial pressure and/or brain shift. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Raised Intracranial Pressure Increases in intracranial pressure (ICP) are a common consequence of the abovementioned intracranial complications, causing impairment of brain function due to reduction in cerebral perfusion pressure and consequently in cerebral blood flow, resulting in ischemia, and brain shift. Uncontrolled intracranial pressure frequently causes diffuse ischemic brain damage. Cerebral autoregulation, or the ability of the brain to maintain a constant blood flow to the brain, may be impaired or lost under conditions such as increased intracranial pressure, ischemia, and inflammation or low or high mean arterial pressure, rendering the brain more vulnerable to ischaemia. Reductions in blood flow result in metabolic changes, which ultimately result in neuronal disintegration. Intracranial pressure and associated cerebral perfusion pressure are therefore routinely monitored in severe TBI cases. Another potential consequence of raised intracranial pressure, hematoma and/or brain swelling is herniation. Subfalcine herniation occurs when one cingulate gyrus herniates across the midline. A more serious type is transtentorial herniation, where there is downward displacement of the parahippocampal gyrus and uncus of one or both temporal lobes through the tentorial hiatus into the posterior fossa. Compression of the oculo-motor nerve, as well as midbrain dysfunction, commonly results from tentorial herniation. Unchecked tentorial herniation leads to a deterioration in brain stem functioning, with consequent respiratory abnormality, hyperventilation, decerebration and, eventually, death. Tonsillar herniation occurs when the cerebellum is forced through the foramen magnum, leading to symptoms of vagus nerve compression, hypoxia, edema of the medulla and, eventually, respiratory arrest and death. Decompressive craniectomy surgery involves temporarily removing a portion of frontal skull bone to increase the volume of the cranial cavity and to decrease intracranial pressure. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The procedure carries risks, and the efficacy, optimal timing and surgical methods, and neurological function in the survivors remain uncertain. While some case series and case control studies have shown decreased intracranial pressure and improved neurological outcomes, the only randomized controlled trial in adults to date has suggested that decompressive craniectomy results in poorer functional outcomes. Apart from damage due to pressure effects, secondary brain injury following TBI is caused by hypoxia, cellular influx of calcium and other ions, release of free radicals and excitotoxic neurotransmitters, and apoptotic cell death, all of which are potentially preventable. Results of clinical trials examining the efficacy of drugs that block various ion channels, scavenge free radicals, inhibit excitatory neurotransmitters, or block the internal signals for programmed cell death have, however, been disappointing. A number of reasons for this failure have been put forward, including the differences in therapeutic time windows between animal and human trials and the heterogeneity of neuropathology, which means that treatments focused on one pathological process do not attenuate other processes and thus have little overall impact in humans. There is also debate over determination and matching of injury severity levels across sites and studies and of sensitive outcome measures. Efforts towards development of such treatments continue. Extracranial Complications Extracranial complications may occur where there are multiple traumas. Injuries to other parts of the body may cause blood loss and hypotension, pulmonary injury, aspiration of vomit, or cardiac or respiratory arrest, with consequent hypoxia, causing further brain damage. Thus, prevention of these complications in the acute management stages is of paramount importance. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Delayed complications of TBI Post-Traumatic Epilepsy TBI creates an increased risk of epilepsy. Jennett (1979) estimated the overall incidence of post-traumatic epilepsy following non-missile head injury at 5 per cent. He distinguished between early posttraumatic epilepsy, which occurs within the first week after injury (most commonly in the first 24 hours), and late post-traumatic epilepsy, which typically occurs more than three months post-injury. Protracted seizures carry a risk of further brain injury, as a result of increased metabolic requirements, disruption of spontaneous respiration, and aspiration. Focal motor seizures and partial complex “temporal lobe” seizures are seen most commonly. Children are more susceptible to early epilepsy. Late epilepsy occurs in about 20 per cent of those who experience early epilepsy. Predisposing factors for epilepsy include the presence of brain contusion with subdural hematoma, skull fracture, greater injury severity and age over 65 years. In a study by Annegers and Coan (2000), the relative risk of seizures was 1.5 following mild TBI (loss of consciousness (LOC) less than 30 minutes), 2.9 following moderate TBI (LOC 30 minutes–1 day) and 17.2 following severe injury (LOC greater than one day). The risk is greatest in the first two years after injury. Another study found that patients with a Glasgow Coma Score (GCS) 3–8 had a cumulative probability of late post-traumatic seizures by 24 months post-injury of 16.8 per cent. The probability was 24.3 per cent for those with GCS score of 9–12 and 8.0 per cent for those with GCS score of 13–15, showing that GCS alone does not predict epilepsy risk. In this study one-third of late posttraumatic seizures occurred within a month of injury and 86 per cent within one year. There is also a high risk of recurrence of late onset seizures. Although anticonvulsant therapy during the first week after injury may reduce early-onset epilepsy, there is no evidence to support prophylactic treatment with anticonvulsants for prevention of late-onset post-traumatic seizures. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com While no anticonvulsants are without adverse effects, carbamazepine and valproic acid have been found to be relatively free of adverse cognitive effects relative to phenytoin. In view of the expense and potential toxicity of anticonvulsants, most clinicians withdraw medications after one to two seizure-free years. Hydrocephalus Communicating hydrocephalus, which occurs in 1–2 per cent of cases, results from obstruction to the flow of cerebrospinal fluid by blood in the subarachnoid space. This leads to ventricular enlargement and a consequent decline in cognitive function, gait disturbance and incontinence, although in the case of serious brain injury it may be difficult to discern whether the hydrocephalus is clinically significant. Shunting to treat hydrocephalus is most likely to be effective if there has been evidence of clinical deterioration. It is important to note that ventricular enlargement can also occur without signs of communicating hydrocephalus, as a result of a general reduction in the bulk of the cerebral white matter. Levels Of Severity Of TBI Severity of TBI is generally graded from mild to moderate or severe. Severity can be classified in multiple ways, and each measure has different predictive utility, including determining morbidity, mortality, or long-term functional outcomes. Patients with more severe head injuries demonstrate lower cognitive functioning and have more gradual cognitive improvements following the initial injury. Degree of severity is often based on the acute effects of the injury, such as an individual’s level of arousal or duration of amnesia, and these are measured by the Glasgow coma scale, posttraumatic nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com amnesia, duration of loss of consciousness, and degree of altered consciousness.37 The majority of TBIs are mild, consisting of a brief change in mental status or unconsciousness. Mild TBI is also referred to as a concussion. While most people fully recover from mild TBI, individuals may experience both shortand long-term effects. Moderate-severe TBI is characterized by extended periods of unconsciousness or amnesia, among other effects. The distinction between moderate and severe injuries is not always clear; as such, individuals with moderate and severe injuries are often grouped.45 These classification systems not only determine the severity of TBI, but also may be indicative of the degree of long-term disability. The more severe the injury, the more severe and persistent the cognitive deficits — though clinical measurements do not always concur. Severity measures graded during the acute phase sometimes reflect variance due to medications used during resuscitation, substance use, and communication issues.35 Each category has specific criteria and characteristics, which are outlined below. Mild TBI Loss of consciousness is very brief, usually a few seconds or minutes Loss of consciousness does not have to occur - the person may be dazed or confused nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Testing and scans of the brain may appear normal Most common: 75%-85% of all brain injuries are mild 90% of individuals recover within 6-8 weeks, often within hours or days, but 10% experience deficits, which may not be evident immediately More than one mild brain injury over time (i.e., sports injuries or domestic violence) increases the chance of deficits Moderate TBI Loss of consciousness lasts from a few minutes to a few hours Confusion lasts from days to weeks Physical, cognitive, and/or behavioral impairments last for months or are permanent EEG/CAT/MRI are positive for brain injury Severe TBI Prolonged unconscious state or coma lasts days, weeks, or months Categories include: o Coma o Vegetative State o Persistent Vegetative State o Minimally Responsive State o Locked-in Syndrome Examples of common cognitive-communicative, physical, and psychosocial or emotional consequences after mild, moderate, and severe TBI are outlined below.4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Mild TBI: Cognitive-Communicative o Decreased attention and concentration o Decreased speed of processing o Memory problems o Getting lost or confused o Decreased awareness and insight regarding difficulties Psychosocial/Emotional o Irritability o Depression and anxiety o Emotional mood swings Physical o Headache o Fatigue o Sleep disturbance o Visual disturbance o Dizziness o Nausea o Balance problems Moderate and Severe TBI: Cognitive-Communicative o Decreased attention and concentration o Distractibility o Memory problems o Decreased speed of processing o Increased confusion nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com o Perseveration o Impulsiveness o Decreased interaction skills o Decreased executive function abilities (for example, planning, organization, problem solving) o Decreased awareness of, and insight regarding, difficulties Psychosocial/Emotional o Dependent behaviors o Apathy o Decreased lack of motivation o Irritability o Acting out o Depression o Denial of difficulties Physical o Difficulty speaking and being understood o Physical paralysis/weakness/spasticity o Difficulties with sense of touch, temperature, movement, position o Chronic pain o Decreased bowel and bladder control o Sleep disorders o Loss of stamina o Appetite changes o Partial or total loss of vision o Weakness of eye muscles and/or double vision (diplopia) o Blurred vision nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com o Problems judging distance o Involuntary eye movements (nystagmus) o Intolerance of light (photophobia) o Decreased or loss of hearing o Ringing in the ears (tinnitus) o Increased sensitivity to sounds o Loss or diminished sense of smell (anosmia) o Loss or reduced sense of taste The following table provides a thorough overview of the neurobehavioral consequences of the different severity levels of traumatic brain injury.18 Mild Mild TBI is defined as those injuries where there is confusion or disorientation, loss of consciousness for 30 minutes or less, PTA for less than 24 hours and/or other transient neurological abnormalities such as focal signs, seizure, and intracranial lesion not requiring surgery; and a GCS score of 13–15 after 30 minutes post-injury or later upon presentation for healthcare. These manifestations must not be due to drugs, alcohol, or medications, or be caused by other injuries, treatment for other injuries (i.e., systemic injuries, facial injuries or intubation), other problems (i.e., psychological trauma, language barrier or coexisting medical conditions) or penetrating craniocerebral injury. Neurological deficits are rarely apparent following the acute stages of mild TBI. However, the person may experience a range of symptoms, including headache, dizziness, fatigue, blurred or double vision, sensitivity to noise and/or bright lights, tinnitus, restlessness, insomnia, reduced speed of thinking, concentration and memory problems, irritability, anxiety and depression and poor balance. The most common causes of these injuries are falls and motor vehicle accidents, but a significant proportion of mild TBIs also result from sports-related concussion, cycling accidents, assault and combat in the theatre of war. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Typically, individuals who have sustained mild TBI and have no other injuries return home within a few days, with the expectation of resuming their normal activities. In many cases these so-called post-concussional symptoms subside over a period of days or weeks. Neuro-psychological studies have confirmed the presence of impaired speed of information processing, attention and/or memory in the early days after injury. Recovery from symptoms and cognitive impairments appears to take place within two weeks following sports-related concussion. In other etiological groups the timeframe of recovery is more variable, but in the majority of cases symptoms have resolved within three months. However, in 15–25 per cent of cases these difficulties persist and sometimes result in significant ongoing disability and adjustment problems. The cause of such ongoing problems, termed the persistent post-concussive syndrome, remains a subject of much debate. Injury severity measures, i.e., GCS and posttraumatic amnesia (PTA) do not show a significant association with outcome following mild TBI. Ponsford and colleagues (2000) found that the factors most strongly associated with continuing symptoms following mild TBI were the presence of pre-existing neurological or psychiatric problems, being a student and the presence of other concurrent life stressors. A number of other authors have drawn attention to the overlap of post-concussional symptoms with symptoms associated with pain resulting from other injuries, medication effects, post-traumatic stress, anxiety, depression, pre-accident psychological adjustment issues, individual coping styles, the presence of other stressors and/or litigation/compensation. It would appear that these other issues interact with the effects of mild TBI to exacerbate symptoms and distress and may, in some cases, be the primary factors underpinning persistent post-concussive symptoms. However, with the use of increasingly sophisticated imaging techniques, such as DTI, MR spectroscopy, MRI-volumetry, gradient echo, diffusion weighted and susceptibility weighted MR scanning sequences, it has become possible to identify cerebral changes which are not evident on CT scans in at least a proportion of mild TBI cases. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Moreover, recent studies have provided evidence of greater likelihood of abnormal imaging findings and more significant ongoing neuropsychological problems in individuals with “complicated” mild TBI, suggesting that these injuries occur on a continuum of severity. In a modeling study of concussion, Viano and colleagues (2005) showed 4–5 mm displacements of the hippocampus, caudate, amygdala, anterior commissure and midbrain, which were associated with cognitive and physical symptoms in football players. Bigler (2008) suggests that these same regions are likely to be involved in most concussive injuries to variable degrees, with long-coursing axons such as those in the corpus callosum and anterior commissure particularly vulnerable, and concomitant irritation to the vasculature and the meninges, the extent of which depends on the direction and magnitude of force associated with the injury. These forces disrupt the cytoskeletal architecture, affecting cell function transiently or permanently. According to Giza and Hovda (2004), within 25–50 msec of such an impact there is evidence of transient biomechanically induced ionic disturbance and upregulation of cellular glycolysis, followed by a downregulation in glucose metabolism. The degree to which there are lasting changes depends on the nature and extent of the force applied, and also on factors associated with the person, which may include genetic factors. McAllister and colleagues (2006) have identified genetic polymorphisms modulating central dopaminergic tone, that appear to affect cognitive performance on tests of processing speed, attention and memory following mild or moderate TBI. Findings regarding the effects of multiple concussive head injuries, most of which have come from sports concussion studies, have been mixed. Results of a recent meta-analysis have suggested that multiple self-reported concussions were associated with poorer performances on tests of delayed memory and executive function. However, the clinical significance of these differences is unclear. Outcomes are likely to depend on the severity of each injury. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Overall, it appears that a number of factors interact to determine the likelihood of continuing post-concussive symptoms. These relate to the person who is injured (age, sex, physical, psychological, cultural, genetic), injury factors (injury force, direction and site, its cause or circumstances, other injuries), and post-injury factors such as pain, post-traumatic stress, environmental demands and expectations, other stressors, and litigation/compensation issues. Moderate and Severe In the case of moderate and severe TBI, where coma has persisted for more than an hour, and PTA for more than 24 hours, cognitive and behavioral changes are more extensive and persistent than in the case of mild head injury. The nature and degree of these changes vary widely, according to the site and extent of injury. Disorders of language, perception or praxis may result from lesions disrupting the systems responsible for these neuropsychological functions. However, because of the high incidence of DAI, and damage to the frontal and temporal lobes, problems with fatigue, attention, memory, executive function and behavioral regulation are particularly common. While some “executive” problems would be termed “cognitive” and some “behavioral” problems, they will be considered together. Fatigue Numerous follow-up studies have reported fatigue to be one of the most common symptoms experienced following mild, moderate and severe TBI, with a reported frequency ranging from 32.4 per cent to 73 per cent. Despite this, the nature and causes of fatigue remain relatively poorly understood. Results of recent studies suggest that fatigue may result from a number of factors, including impairments of information processing speed, attention and vigilance, sleep disturbance, pain and emotional factors. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Attentional Deficits Attentional problems also occur very frequently at all levels of severity of injury following TBI. This is not surprising, given the neuropathology of TBI, which frequently disrupts attentional neural networks via injury to the fronto-striatal areas, the reticular formation, DAI and disruption of catecholaminergic and serotonergic pathways. An attentional difficulty most commonly reported is reduced speed of information processing, leading to a reduced information processing capacity, with consequent difficulties in focusing on more than one thing at once, or coping with complexity. Poor selective attention (the capacity to focus on some things and screen out others), which can manifest itself as distractibility or poor attention to detail is also reported, along with problems in sustaining attention over time, and difficulty in the allocation of attentional resources in a goal-directed fashion. Learning and Memory Problems It has already been noted that people with TBI usually have a period of confusion, disorientation and inability to remember ongoing events immediately following their emergence from coma, lasting for days, weeks, or, in the most severe cases, months, known as posttraumatic amnesia (PTA). There is also frequently impairment of memory for events, which immediately preceded the injury, termed retrograde amnesia. The period of retrograde amnesia is variable, being broadly related to the period of unconsciousness. There may be “islands of memory” within the period over which retrograde amnesia extends, and the period of retrograde amnesia tends to “shrink” over time. The period of persistent retrograde amnesia is usually too brief for it to give a reliable indication of the severity of injury or probable outcome. After emergence from PTA, many people who have sustained TBI report ongoing difficulties with learning and memory. Follow-up studies conducted from six months up to seven years after injury have found this to be one of the most frequent subjective complaints of TBI individuals and/or their relatives. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com As with attentional difficulties, there is potential heterogeneity in the nature and severity of memory difficulties experienced by TBI individuals, depending on the site and extent of injury. Memory problems may manifest as a severe amnesic syndrome, affecting the ongoing storage and retrieval of all types of material, difficulty with either verbal or non-verbal material, or most commonly an inefficient or unreliable memory due to lack of use of organizational strategies and/or attentional problems characteristic of frontal lobe injury. Whatever the nature of the problem, there is usually a marked contrast between the capacity to remember events and skills learned prior to the injury, and the ability to learn and retain new material since the time of injury, the former being relatively preserved. Implicit memory, such as procedural learning, is also relatively spared in many individuals. Impaired Planning and Problem-Solving The high frequency of damage to the frontal lobes associated with TBI means that many of those who have sustained TBI have difficulties in analyzing, planning and executing the solutions to problems or complex tasks. They may perform well in structured activities, which require little initiative or direction. However, although there may be a willingness and ability to perform each component of a task, people with planning and problem-solving deficits are frequently unable to generate strategies for efficient task performance, to follow through with the organization and implementation of complex tasks, or to check for and correct errors. TBI individuals often have difficulty in sustaining performance on tasks. Complex behaviors may dissolve into inert stereotypes. There can be a tendency to lose track of the task at hand, and to respond to distractions or inappropriate cues in the environment. There also tends to be a failure to look ahead, and to use past experience to prepare for anticipated events. People with executive dysfunction have particular difficulty in adapting to new situations. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Concrete Thinking Difficulties in forming or dealing with abstract concepts are common. This can result in an inability to generalize from a single instance, or distil the essence of a situation or a conversation, with a tendency to focus on specific, concrete aspects, or be “stimulus-bound”. There may also be difficulties in understanding humor or other forms of indirect language. An inability to understand the implications of situations or events is common. There may be problems in benefiting from experience – in applying old solutions to new situations. Alternatively, there may be an inability to think creatively and generate different solutions to a given problem, with a tendency to repeatedly apply an old, unworkable solution, resulting in failure and frustration. Lack of Initiative Some of those who have sustained TBI show a lack of initiative or drive in some or all aspects of their behavior and thought processes. In severe cases there may be a complete inability to initiate speech or any activity without prompting. At a more subtle level, there may be a tendency to lack spontaneity, to be somewhat passive in conversation, to fail to move on to the next task once one is completed, or to move from one step to another within tasks. Relatives may report that the TBI person who was previously active achieves very little in a day and may sit for hours in a chair watching television. Inflexibility Inflexibility in thought processes and behavior may be manifested as difficulty in switching from one task to another, in changing train of thought or shifting “mental set”. This may lead to frequent repetition or “perseveration” of the same responses, comments, demands or complaints. There may be an inability to see other people’s points of view and a tendency to rely on rigid adherence to routines. Sudden changes in routine may cause the TBI individual to become upset. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Dissociation Between Thought and Action It is frequently reported that there is dissociation between what people who have sustained TBI know or say, and how they actually behave. This results in an inability to follow through with instructions, to correct errors or modify behavior in the light of feedback. This, together with the next few problems, appears to result from a reduced capacity to control, regulate and monitor thought processes and behavior. Impulsivity A reduced capacity to control and monitor behavior commonly results in impulsivity. There is a difficulty in inhibiting the tendency to respond to problems or situations before taking account of all relevant information, and before thinking of all the possible consequences of one’s actions. Irritability/Temper Outbursts One of the most commonly reported problems following TBI is a low tolerance for frustration. Those who have sustained TBI are prone to become irritable and to lose their temper easily. The anger may be completely out of proportion to the situation, and there may be physical aggression. Communication Problems While aphasia is uncommon following TBI, discourse problems are frequently encountered. These can include excessive talking, with poor turn-taking skills, a tendency to repeat oneself or have difficulty keeping to the point. Word-finding difficulties and impaired auditory processing are also common. Socially Inappropriate Behavior Lack of behavioral control can also lead to an inability to inhibit inappropriate responses, such as swearing, sexual disinhibition, tactlessness or other socially inappropriate behaviors. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com There may be a failure to respond to non-verbal cues given by others, which normally let a person know when it is time to finish a conversation or move on to another topic, or when someone else is feeling uncomfortable with a certain behavior. Self-centeredness Those who have sustained severe TBI can be egocentric. This results in a tendency towards demanding, attention-seeking and sometimes manipulative behavior. It can also lead to jealousy, and insensitivity to the feelings or emotional needs of others, as well as a failure to see other people’s points of view. This is the source of many relationship problems following TBI. Changes in Affect TBI can result in a flatness of affect, where there is reduced emotional responsiveness, or an elevation of affect, with euphoria. Reduced emotional control can also lead to a tendency to laugh or cry for no apparent reason, or to show emotions which are quite out of proportion, or inappropriate, to the situation. Lack of Insight/Self-Awareness Severe TBI frequently results in difficulty perceiving, or a lack of awareness of, changes in cognitive function and behavior. This leads to a tendency to attempt work or other tasks, which are beyond their capabilities. There may also be a failure to recognize how impulsive, irritable, childish or demanding they are in certain situations, with disastrous consequences for interpersonal relationships. This results in a degree of perplexity in the TBI person, who fails to understand the reasons for failure at work or in social relationships. Occasionally, one sees the emergence of frank delusions. Another unfortunate consequence of lack of insight is the inability to understand the need for rehabilitation or other forms of assistance in overcoming limitations. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The cognitive and behavioral changes described above frequently coexist in a complex fashion, being difficult to disentangle in an individual, particularly as they are imposed upon varying premorbid personality characteristics. Planning and problem-solving, abstract thinking, initiative, mental flexibility, and control and regulation of thought processes and behavior have been termed “executive functions” by Lezak et al. (2004), Baddeley (1986) and Stuss and Benson (1986), and this term is now commonly used. Lezak (1978), who has so ably described the problems of those who have sustained TBI, referred to the “characterologically-altered” brain-injured patient. TBI Symptoms An individual will experience a variety of symptoms as the result of a head injury. Each patient will experience symptoms differently, and symptoms will vary depending on the type and severity of the injury. The following are the most common symptoms of a head injury. Mild head injury: Raised, swollen area from a bump or a bruise Small, superficial (shallow) cut in the scalp Headache Sensitivity to noise and light Irritability Confusion Lightheadedness and/or dizziness Problems with balance Nausea nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Problems with memory and/or concentration Change in sleep patterns Blurred vision "Tired” eyes Ringing in the ears (tinnitus) Alteration in taste Fatigue/lethargy Moderate to severe head injury (requires immediate medical attention) symptoms may include any of the above plus:19 Loss of consciousness Severe headache that does not go away Repeated nausea and vomiting Loss of short-term memory, such as difficulty remembering the events that led right up to and through the traumatic event Slurred speech Difficulty with walking Weakness in one side or area of the body Sweating Pale skin color Seizures or convulsions Behavior changes including irritability Blood or clear fluid draining from the ears or nose One pupil (dark area in the center of the eye) looks larger than the other eye Deep cut or laceration in the scalp Open wound in the head Foreign object penetrating the head nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Coma (a state of unconsciousness from which a person cannot be awakened; responds only minimally, if at all, to stimuli; and exhibits no voluntary activities) Vegetative state (a condition of brain damage in which a person has lost his thinking abilities and awareness of his surroundings, but retains some basic functions such as breathing and blood circulation) Locked-in syndrome (a neurological condition in which a person is conscious and can think and reason, but cannot speak or move) The above is a list of the general symptoms of mild to severe head injuries. The following section will provide more detailed information on each of the most common symptoms. Bleeding Bleeding is common with head injuries. With penetrating head injuries, bleeding can occur externally or internally.46 Internal bleeding is most common in the brain tissue or between the cranial layers.47 In blunt trauma injuries, bleeding typically occurs internally, although there may be minimal bleeding at the site of impact.36 Bleeding is not always apparent when it is internal. Therefore, it is important to utilize radiologic imaging to identify any internal areas of bleeding.2 Bruising Bruising is common in instances of blunt head trauma.48 Most patients will experience external bruising at the site of impact.23 External bruises can range in severity and appearance, depending on the amount of force used and the area of the head that is bruised. Some patients will experience internal bruising, otherwise known as contusions.49 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com A contusion is defined as bruising of the brain, and it is caused by bleeding and edema within the brain tissue.50 It is a secondary injury, as it is caused by a primary injury that swells, bleeds and results in increased intracranial pressure.23 Contusions can occur in instances of blunt and penetrating trauma.36 In some patients, the contusion will appear at the site of impact as a coup injury. In other patients, the contusion will appear on the opposite side of the injury as a contrecoup injury.51 It is most common for patients to experience a contusion in the frontal or temporal lobes.5 Neurological Deficits Many patients will experience cognitive deficits as a result of head trauma. The specific deficits will vary depending on the location and severity of the injury. The following is a list of the most common cognitive deficits experienced by head trauma patients:52 Arousal or over-stimulation Attention and filtering issues Information coding and retrieval (memory) issues Learning, both using old information and acquiring new information Problem solving Higher-level thinking skills also known as “executive skills” Some of the cognitive deficits listed above will be short-term problems and will be eliminated over time with the aid of therapy and rehabilitation services.53 However, other cognitive deficits will persist long term and may not ever resolve themselves.46 In some instances, persistent cognitive deficits can be minimized or eliminated through the use of more intensive rehabilitation services.44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Cognitive deficits have a direct correlation with neurobehavioral problems.54 Therefore, it is important to discuss the two together. Neurobehavioral problems are directly related to specific components of head trauma. Depending on the injury, the patient may experience neurobehavioral problems that cause changes in behavior and attitudes. The following is a list of the common neurobehavioral problems experienced by brain injury patients:55 Reduced inhibitions and judgment Difficulty with self-regulation or self-control Impulse control Over-arousal Frustration tolerance Problems in perception Overreaction to situations Anger without provocation Socially inappropriate behaviors Treatment for neurobehavioral problems includes therapy, medication, and behavior modification.56 Some patients will experience neuromotor problems. These are also a direct result of specific head injuries and will vary depending on the type and location of injury. Neuromotor problems affect the patient’s physical movement and ability to control the body.57 The following is a list of the most common neuromotor problems:8 Initiating or starting a movement Maintaining muscle control nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Sustaining a movement Executing a complex movement, such as walking If a patient experiences neuromotor problems, he or she will be treated using specific therapies and strategies that will help improve motor functions and regain skills.58 Amnesia Patients who sustain head injuries may experience some degree of amnesia. Amnesia is defined as a loss of memory for any period of time.59 Amnesia is broken into two categories, depending on the way that it presents itself. Retrograde Amnesia The patient loses memories of events that occurred prior to the injury. Some patients may only lose a few seconds or a minute of memory.60 In these instances, the patient may remember part of the accident, but not the entire accident. Other patients may experience the loss of a longer duration of time, up to days or years.61 In some instances, patients may not remember the accident at all, or even the year prior to the accident.46 Most patients will recover their memories as the damage heals. However, there is no standard time period or pattern that the return of memories follow.59 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Anterior Amnesia Patients who experience anterior grade amnesia will lose memories of the events that occurred following the injury. In these instances, they will continue to lose new memories, while still retaining memories of events that occurred prior to the injury.61 Changes in Pupil Shape and Size Different complications of head trauma can cause changes in the shape and size of the pupil. Therefore, a standard examination should include an assessment of the patient’s pupils. Any changes should be noted and used to determine the extent of injury. The following table provides information on the areas of the pupil that may experience changes.62 Area of Change Pupil Size and Equality Description Pupil size is reported as the width or diameter of each pupil in millimeters. A standardized pupil gauge should be used to report the pupil size in millimeters. The use of this gauge aids in decreasing subjectivity, particularly when serial assessments are performed. The normal diameter of the pupil is between 2 and 5 mm, with the average pupil measuring 3.5 mm. Although both pupils should be equal in size, a 1-mm discrepancy is considered a normal deviation. This condition is known as anisocoria and is present in 15% to 17% of the population without any known clinical significance. Pupil size should be assessed both before and after the pupil responds to direct light. Pupil Shape Pupil shape is reported as round, irregular, or oval. The normal shape of the pupil is round. An irregular-shaped pupil may be the result of ophthalmological procedures such as cataract surgery or lens implants, and this should be noted on the initial assessment and confirmed with the patient or family. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com A pupil that is oval in shape may indicate the early compression of cranial nerve III due to increased intracranial pressure (ICP), and thus should be addressed immediately. If an oval pupil is detected, measures should be taken to decrease ICP. As ICP is reduced, the oval-shaped pupil should resolve. However, if ICP continues to rise or is not treated, the oval-shaped pupil will become further dilated and will eventually become nonreactive to light. Pupil Reactivity Pupil reactivity is reported as the response or reflex of each pupil to direct light. Reactivity is assessed through shining a low-beam flashlight inward from the outer canthus of each eye. Each eye should be checked separately. The light should not shine directly into the pupil because the glare or reflection may obscure visualization. The reaction that each pupil has to the light stimulus should be recorded. The speed of pupillary reactivity is recorded as brisk, sluggish, or nonreactive. Normally, pupils should constrict briskly in response to light. A sluggish or slow pupillary response may indicate increased ICP, and nonreactive pupils are often associated with severe increases in ICP and/or severe brain damage. A complete pupillary reactivity examination also includes assessment of the consensual pupillary response and accommodation. The consensual pupillary response is the constriction that normally occurs in a pupil when light is shown into the opposite eye.6 Because of this response, the trauma nurse should wait for several seconds before assessing pupillary light reflex in the second eye, as that pupil may be temporarily constricted. Accommodation is the constriction of pupils that occurs when a conscious patient is focusing on a close object. Pupils should normally constrict bilaterally when an object is held within 4 to 6 inches of a patient's nose. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com General Pupil When performing pupillary examinations in patients with TBI, Abnormalities trauma nurses may detect abnormalities, such as an irregular pupil size, shape, or a sluggish or nonreactive pupil. When an abnormality is detected, the trauma nurse should first identify whether the abnormality was present on the previous pupillary examination. If an abnormal pupil is present on the initial pupillary examination, it should be clearly documented, and a physician should be immediately notified. Immediate notification of a physician should occur with changes in pupillary response. Comparing the current examination with the previous to provide time-oriented data for the physician is wise but should never delay immediate physician notification. General Indications A complete neurologic examination should be performed and any changes in the patient's condition should be noted and reported to a physician. An abnormal pupil in a patient with TBI is often indicative of increasing ICP due to progression of the hematoma/hemorrhage or cerebral edema. However, the trauma nurse should be aware of other clinical factors that may cause an abnormal pupil response. Abnormal pupils may be seen in TBI patients and due to both physiologic and clinical factors contributing to the abnormalities. Regardless of the cause of an abnormal pupil, the trauma nurse should always notify a physician immediately when an abnormal pupil is detected. A CT scan and continuous ICP monitoring will aid in definitively identifying the cause of the abnormal pupil. Stiff Neck Within the twenty-four hours following a head injury, a patient may experience a stiff neck. This is often indicative of a more serious complication and should be monitored closely.43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Headache It is common for a patient to experience a headache immediately after experiencing a blow to the head. Most patients will experience headaches within the first few weeks following a head injury.63 However, most headaches should stop within four weeks of the injury.64 Headaches are not cause for concern as long as they do not get worse over time.43 Headaches are classified using three distinct categories:64 Mild: A mild headache improves or goes away completely with home treatment, medication, or rest. It may return when the medication wears off. Moderate: A moderate headache improves with home treatment, medication, or rest, but it never completely goes away. The patient is always aware that the headache is present. Severe: A severe headache is incapacitating. Home treatment, medication, and rest do not relieve this headache. If a patient experiences a continuous headache that gets worse over time, it should be taken into consideration. These headaches are often indicative of swelling and/or bleeding on the brain, or within the areas surrounding the brain.65 In some instances, the blood and swelling will occur between the nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com brain and the covering of the brain. The bleeding may occur rapidly, or it may slowly develop.64 Some patients will display symptoms within minutes of hours of the injury, while other patients will not experience symptoms until weeks after the injury.66 If a patient reports a new and persistent headache that does not develop immediately following the injury, he or she may have a blood clot. Along with the headache, the patient may experience confusion and sleepiness.46 While most headaches are not cause for alarm, any headache that is persistent and accompanied by other symptoms (i.e., drowsiness and personality changes) is concerning and must be assessed immediately. This type of headache is often indicative of an increase in pressure around the brain, which can be life threatening if left untreated.67 Physical Deficits Many patients will experience physical deficits as a result of a brain injury. The most common physical problems experienced after injury include:30 Hearing loss Tinnitus (ringing or buzzing in the ears) Headaches Seizures Dizziness Nausea Vomiting Blurred vision Decreased smell or taste Reduced strength and coordination in the body, arms, and legs nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Vomiting/Nausea Vomiting and nausea are common symptoms in instances of head trauma and can occur with mild to severe trauma. When a patient experiences vomiting or nausea, it is important to make sure he or she is comfortable and that there is no chance of asphyxiation.68 Loss of Consciousness It is common for TBI patients to experience loss of consciousness immediately following a head injury. Some patients will only lose consciousness for a few seconds, while others may remain unconscious for hours or days.69 Loss of consciousness can affect the patient even after he or she awakens. The following is a list of the most common side effects a patient will experience after a loss of consciousness:70 Drowsiness Confusion Restlessness Agitation upon waking Vomiting Seizures Impaired balance Lack of coordination Impaired ability to think Inability to control emotions Difficulty moving Inability to feel things Difficulty with speech Loss of vision Hearing impairment Memory impairment or loss nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Altered Consciousness A coma is defined as a deep state of unconsciousness.71 A patient who experiences a coma is alive, but loses the ability to move or respond to the environment and external stimulation.47 Most comas last an average of two to four weeks, but some patients can remain in a coma for an extended period of time. The duration of a coma and the extent of recovery will vary depending on the cause, severity and location of the damage.72 Some patients will recover completely from a coma, while others will experience long-term physical, mental, intellectual and emotional problems.71 A patient who remains in a coma for an extended period of time (months or years) is at an increased risk of developing an infection such as pneumonia, which can be life threatening.73 During a coma, a patient is completely unconscious and cannot be aroused. The patient is also unresponsive and unaware of his or her surroundings.71 Patients will not respond to external stimuli and do not experience sleepwake cycles.74 A coma is typically the result of severe trauma to the brain, and is most common with injuries to the cerebral hemispheres of the upper brain and the lower brain or brainstem.72 In most instances, a coma will only last for a few days or a few weeks. However, in some extreme situations, a patient may progress to a vegetative state.75 When a patient appears to be in a coma, the trauma team will first stabilize the patient and assess the vital signs and basic neurological signs. After the vital signs and basic neurologic functions are assessed, the emergency medical provider will assess the patient’s level of consciousness and neurologic functioning.74 This assessment is done using the Glasgow Coma Scale, which is a standardized, 15-point test that measures neurologic functioning using three assessments: eye opening, best verbal response, nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com and best motor response. A patient will be determined to be in a coma if he of she meets the criteria on the coma scale.4 The Center for Disease Control provides guidelines for the Glasgow Coma Scale. This will be discussed later on in more detail within the section on Diagnosis Of TBI; however, in brief, when assessing patients’ level of consciousness the provider or nurse caring for the TBI patient may use the Glasgow Coma Scale to measure the following: Eye Opening Response Spontaneous - open with blinking at baseline 4 points To verbal stimuli, command, speech 3 points To pain only (not applied to face) 2 points No response 1 point Verbal Response Oriented 5 points Confused conversation, but able to answer questions 4 points Inappropriate words 3 points Incomprehensible speech 2 points No response 1 point Motor Response Obeys commands for movement 6 points Purposeful movement to painful stimulus 5 points Withdraws in response to pain 4 points Flexion in response to pain (decorticate posturing) 3 points nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Extension response in response to pain (decerebrate posturing) 2 points No response 1 point Categorization includes: Coma: No eye opening, no ability to follow commands, no word verbalization (3-8) Head Injury Classification: Severe Head Injury ---- GCS score of 8 or less Moderate Head Injury ---- GCS score of 9 to 12 Mild Head Injury ---- GCS score of 13 to 15 The following is a standard disclaimer that accompanies the Glasgow Coma Scale: Based on motor responsiveness, verbal performance, and eye opening to appropriate stimuli, the Glasgow Coma Scale was designed and should be used to assess the depth and duration coma and impaired consciousness. This scale helps to gauge the impact of a wide variety of conditions such as acute brain damage due to traumatic and/or vascular injuries or infections, metabolic disorders (i.e., hepatic or renal failure, hypoglycemia, diabetic ketosis), etc.75 The coma is one form of altered consciousness that occurs during brain injury. If the trauma is severe enough, patients may experience one of the other types of altered consciousness. These altered states of consciousness are often considered different types of comas, even though they have different symptoms. The symptoms are briefly described as follows: nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Stupor When a patient experiences a stupor, he or she is often unresponsive but is able to be aroused, if only briefly, by a strong stimulus.11 Vegetative State When a patient is in a vegetative state, he or she is completely unaware of the surroundings. However, unlike with a coma, patients in a vegetative state continue to have a sleep-wake cycle. In addition, patients may experience periods of alertness.6 Patients in a vegetative state will often open their eyes and show other signs of movement and function, which may include groaning and some reflex responses.11 In many instances, a vegetative state is the result of trauma to the cerebral hemispheres with the absence of injury to the lower brain and brainstem.76 Most patients will only remain in a vegetative state for a few weeks, but some may progress to a persistent vegetative state, which is defined as longer than thirty days.11 Once a patient has been in a vegetative state for a year, the chances of recovery are extremely low.7 Minimally Conscious State This term (coined by the Aspen Neurobehavioral Workgroup) accommodates the need to differentiate between patients who meet criteria for the diagnosis of vegetative state and those who display some, albeit limited and inconsistent, meaningful responses. As such, the minimally conscious state shares with the vegetative state a severe alteration of consciousness, but is differentiated by evidence of nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com “… minimal but definite behavioral evidence of self or environmental awareness”. In this respect it is clinically differentiated from the vegetative state by virtue of a small but demonstrable and reproducible repertoire of behaviors, such as following simple commands, gestural or verbal yes/no responses (even if inaccurate), intelligible verbalization, and some form of purposeful behavior, such as contingent vocalization, smiling or crying in response to input that has some emotional salience, and reaching for objects in a way that signals awareness of the object’s size and shape. As noted by participants at the Aspen Neurobehavioral Workgroup (ANW) in 1994, however, clear differentiation of the border-zones of the vegetative and minimally conscious state may not be straightforward at all. The ANW participants suggested that clinicians need to consider the relative weight of consistency and complexity in the patient’s responses, where there is less need to demonstrate consistency of a complex response such as verbalization than of a simple response such as a finger movement to command. When patients are able to demonstrate consistent and reliable functional communication, they are deemed to have emerged from the minimally conscious state. In spite of the concerted efforts of multidisciplinary working parties in recent years, there are some persisting tensions around the use of terminology. Older terms such as apallic syndrome, coma vigile, and akinetic mutism are no longer in use. However, the locked-in syndrome must be clearly distinguished from vegetative/minimally responsive states. This rare syndrome has been discussed in some detail in the literature and usually results from a lesion (infarction, nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com hemorrhage or demyelination) in the ventral pons or medulla. The person is typically quadriparetic and mute, but can demonstrate significantly preserved cognitive abilities via vertical eye movements and/or blinking. Unlike the person in a vegetative or minimally responsive state, the person in a locked-in state is able to give clear signs of awareness of self and the environment. Furthermore, measures of cerebral glucose metabolism in these patients are near normal. It is also important (but less difficult) to differentiate vegetative/minimally responsive states from brain death, which results in the absence of both brainstem and supratentorial function. Brain death is confirmed by the presence of various combinations of coma, apnea, dilated pupils, absent cephalic reflexes and electrocerebral silence on EEG recording, and is not compatible with survival once artificial respiration is removed. Locked-In Syndrome With Locked-In Syndrome, the patient is unable to move or communicate normally as the result of paralysis of the body. However, the patient is fully aware and awake.4 Locked-In Syndrome is caused by damage to areas in the lower brain and brainstem, but not by damage to the upper brain.47 Typically, patients use movements and eye blinking to communicate. Ultimately, most patients do not gain their motor control back once they are in a locked-in state.11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Brain Death Brain death is a newer diagnosis that has occurred due to the development of assistive devices that artificially maintain blood flow and breathing.11 Brain death is defined as a lack of measurable brain function. This is typically caused by injuries to the cerebral hemispheres and brainstem.7 There is also a loss of integrated activity within specific areas of the brain.11 This condition is irreversible. If a patient does not remain on assistive devices, he or she will experience immediate cardiac arrest and will stop breathing.28 The various unconscious states listed above are easy to diagnose as the result of advancements in imaging and other technologies. Using these new technologies, practitioners can identify the area of the brain affected and diagnose the patient based on the level of activity present in different regions of the brain.6 Most commonly, doctors use CT and MRI to identify the affected areas of the brain. However, other diagnostic imaging tools such as cerebral angiography, electroencephalography (EEG), transcranial Doppler, ultrasound, and single photon emission computed tomography (SPECT) may be used.77 Complications of TBI Traumatic brain injuries can cause a number of complications that may occur during the onset of the injury, as well as after the injury has been treated and resolved. In some instances, these complications may be mild and easily treatable and manageable; whereas, in other instances, these complications can pose a significant threat to the individual. Some complications can be life threatening, while others may cause long-term disability.10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com A traumatic brain injury can cause some significant initial complications within the following categories:7 Arousal Consciousness Awareness Alertness Responsiveness The above conditions are complications that are specific to traumatic brain injury. However, there are also conditions that can occur immediately after a traumatic brain injury that are not specific to TBI, but that occur as a direct result of the injury. These complications increase in prevalence in direct correlation to the severity of the injury. Complications of TBI include:47 Immediate seizures Hydrocephalus or posttraumatic ventricular enlargement CSF leaks Infections Vascular injuries Cranial nerve injuries Pain Bed sores Multiple organ system failure in unconscious patients Seizures It is common for patients with TBI to experience seizures. In fact, 25% of patients with brain contusions or hematomas will experience seizures, while approximately 50% of patients with penetrating head injuries will experience nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com seizures.78 In these patients, seizures typically occur within the first 24 hours of the injury.79 While some patients who experience immediate seizures will have an increased risk of developing seizures that occur within hours or days of the injury, there is no risk of the patient developing posttraumatic epilepsy. Typically, patients who experience immediate or early seizures are treated with anticonvulsants if the seizures are persistent and recurring.78 Hydrocephalus and Posttraumatic Ventricular Enlargement Hydrocephalus or posttraumatic ventricular enlargement is a condition that is caused by the accumulation of cerebrospinal fluid in the brain. This excess fluid causes dilation of the cerebral ventricles and an increase in intracranial pressure (ICP).80 This condition is common during the acute stage of traumatic brain injury, but it can also occur during later stages.5 It is most common within the first year of the injury.81 It is characterized by worsening neurologic outcome, behavioral changes, incontinence, axtaxia, and impaired consciousness.52 This condition typically develops as a result of meningitis, subarachnoid hemorrhage, intracranial hematoma, or various other injuries that have the potential to produce pressure.11 Typical treatment involves shunting and draining the fluid.6 Infections Individuals with traumatic brain injury are prone to a number of infections that can occur within the intracranial cavity. Depending on the type of injury, infections can occur in a variety of locations in the brain, including the dura, below the dura, below the arachnoid, and within the space of the brain.5 The majority of infections will develop within a few weeks of the trauma. They can result from penetrating injuries or from skull fractures. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Patients are typically treated with antibiotics. However, surgery may occasionally be used to remove sections of the infected tissue.11 Vascular Injuries Traumatic brain injury patients are especially prone to vascular injuries due to the damage caused to the head and/or brain. While damage to small blood vessels rarely has a significant impact on the patient, damage to the large blood vessels can result in severe complications. For instance, damage to a major artery may result in a stroke due to bleeding from the artery or as a result of the formation of a clot.81 Common types of vascular injuries include:82 Hemorrhagic stroke – bleeding directly from the artery Ischemic stroke – blocked blood flow to the brain Thrombus or thrombosis – the formation of a clot at the site of the injury Vasospasm – an exaggerated, persistent contraction of the walls of the blood vessel Aneurysms – blood filled sacs caused by stretching of an artery of blood vessel Patients with the above conditions may experience headaches, vomiting, partial paralysis (often on one side of the body) and semi-consciousness. These symptoms often appear several days after the injury.5 Depending on the specific complication, different treatments will be used. For example, anticoagulants are often used to treat ischemic strokes. However, surgery is typically used to treat hemorrhagic strokes.11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The conditions included above occur immediately following the onset of a traumatic brain injury. Therefore, they are often identified and treated during the initial stage of injury.6 In addition to injuries that occur during the initial stage of injury, there are other complications that will develop over time and that will typically last throughout the individual’s lifetime, or at least for a significant period of time.7 These complications are considered TBI related disabilities. Traumatic brain injury related disabilities vary depending on the location of the injury, the severity of the injury and the age and general health of the patient. The most common types of TBI related disabilities affect the following areas:80 cognition (thinking, memory, and reasoning) sensory processing (sight, hearing, touch, taste, and smell) communication (expression and understanding) behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness) It is quite common for TBI patients to develop a range of symptoms and complications as a result of the injury. In fact, approximately 40% of all TBI patients develop post concussion syndrome (PCS), which is defined simply as a collection of symptoms, within days or weeks of suffering an injury.83 PCS is common in all TBI patients, not just those who have experienced a concussion or loss of consciousness. In fact, a number of patients who are being treated for mild TBI are diagnosed with PCS.84 The following symptoms are common in patients with PCS:41 Headache Dizziness nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Vertigo (a sensation of spinning around or of objects spinning around the patient) Memory problems Trouble concentrating Sleeping problems Restlessness Irritability Apathy Depression Anxiety These symptoms may last for a few weeks after the head injury. Typical treatment involves the use of medicines and therapy to reduce the impact of the symptoms and help the patient cope.85 Cognitive Impairments It is common for patients with traumatic brain injury to experience cognitive disabilities, especially if they have lost consciousness. In many patients, the impairments include a loss of higher level mental skills.54 Of the different cognitive impairments, memory loss is the most common, with patients experiencing the loss of specific memories and the inability to form or store new memories. In some instances, patients may develop posttraumatic amnesia. There are two types of posttraumatic amnesia:86 Anterograde – impaired memory of events that happened after the TBI Retrograde – impaired memory of events that happened before the TBI It is common for patients with cognitive impairments to become confused easily or to have problems with distraction. These patients will typically nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com experience difficulty concentrating and focusing their attention. Some patients may also experience problems with higher level functions, which includes planning, organizing, abstract reasoning, problem solving, and making judgments.54 Patients experience the greatest recovery during the first six months, after which the recovery becomes more gradual. Cognitive impairments are more common in patients with moderate or severe TBI.11 Sensory Problems Sensory impairments are common in TBI patients. The most common form of sensory impairment is with vision. It is common for TBI patients to experience difficulty registering what they are seeing or recognizing various objects.52 TBI patients are also prone to problems with hand eye coordination. Due to these impairments, TBI patients often experience difficulty maneuvering through spaces and often bump into objects or drop them.90 Sensory impairments produce a general instability in TBI patients. As a result, many TBI patients are unable to operate a motor vehicle or complex machinery.52 Many of these sensory issues cannot be treated and remain with the patient indefinitely. However, in some instances, optometric vision therapy has produced good results in patients with oculomotor dysfunctions.87 While vision impairments are the most common form of sensory impairment in TBI patients, some patients will also develop problems with hearing, smell, taste, or touch. These impairments are the result of damage to the areas of the brain that controls these senses. These conditions are difficult to treat.52 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Language and Communication Problems Many TBI patients experience language and communication problems. Some patients only experience difficulties with subtle aspects of communication, such as body language and emotional, nonverbal signals.88 However, others will actually experience difficulty understanding and producing spoken and written language. This type of impairment is called aphasia.89 The following is a list of the different forms of aphasia:88 Broca’s Aphasia (nonfluent/motor): Broca’s aphasia involves difficulty recalling words and/or speaking in complete sentences. Characterized by broken phrases and frequent pauses. Patients often experience extreme frustration. Wernicke’s Aphasia (fluent/sensory): Patients display little meaning in their speech, but typically they speak in complete sentences and use correct grammar. Wernicke’s aphasia is characterized by the use of flowing gibberish and sentences that include nonessential and invented words. Patients are often unaware that they are not making sense and express frustration when others do not understand them. Global Aphasia: In global aphasia there is extensive damage to the portions of the brain responsible for language. It is characterized by severe communication disabilities. In some instances, TBI patients may experience difficulties with spoken language as a result of damage to the section of the brain that controls the speech muscles. This disorder is called dysarthria, and it affects patients nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com differently than other impairments. With dysarthria, the patient is able to understand and think of appropriate words/language. However, the patient is unable to speak the words because of damage to the speech muscles.93 Therefore, speech may be slurred and garbled. Some patients experience difficulty with intonation or inflection. This is called prosodic dysfunction.90 Emotional and Behavioral Problems Many TBI patients experience emotional and behavioral difficulties, which are often classified as general psychiatric issues.91 It is common for a TBI patient to exhibit personality changes and behavioral issues. The following is a list of the common psychiatric problems experienced by TBI patients.56 Depression Apathy Anxiety Irritability Anger Paranoia Confusion Frustration Agitation Insomnia or other sleep problems Mood swings Typically, behavioral problems include the following:92 Aggression and violence Impulsivity Disinhibition and acting out Noncompliance Social inappropriateness nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Emotional outbursts Childish behavior Impaired self-control Impaired self-awareness Inability to take responsibility or accept criticism Egocentrism Inappropriate sexual activity Alcohol or drug abuse/addiction In some instances, the personality issues may be severe enough to warrant a diagnosis of borderline personality disorder.93 Other TBI patients may experience developmental stagnation. When this occurs, the patient fails to mature emotionally, socially, or psychologically after the trauma.92 This is especially problematic for children and young adults who suffer from a TBI. Typical treatment for the various emotional and behavioral problems includes medication and therapy.6 Coup and Contrecoup Effect In some instances, the patient will experience a coup or contrecoup injury to the head. These terms are used to identify a range of head injuries, but they are most commonly used in instances of cerebral contusions.51 The two terms are used to identify the specific injury pattern and the location of the damage. The following is a description of the different types of injury. Coup Injury Damage to the brain at the point of initial impact or blow. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Contra Coup Injury Damage to the brain on the side opposite the side that received the initial impact or blow. Coup- Contrecoup Injury Damage to the brain on both sides- the side that received the initial impact or blow and the side opposite the initial impact. This occurs when the force of the initial blow is great enough to cause brain damage at the site of initial impact between the skull and brain and is also great enough to cause the brain to move in the opposite direction and hit the opposite side of the skull, causing damage at that site.94 Diagnosis Of TBI Assessment and treatment of traumatic brain injury should begin as soon as possible. Therefore, emergency personnel are often the first individuals who assess and treat the injury.11 Typically, treatment begins as soon as emergency responders arrive on the scene or as soon as an individual arrives at the emergency room. Initial brain damage that is caused by trauma cannot be reversed. So, initial treatment involves stabilizing the patient and administering treatment that will prevent further damage.6 The key components of the trauma assessment are as follows: 1. ABC’s: Assess the airway with stabilization of the cervical spine, breathing, circulation, heart rate and blood pressure before the neurological exam. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2. Examination of the Skull: Assess for periorbital and postauricular ecchymosis, cerebrospinal fluid otorrhea and rhinorrhea, hemotympanum, penetrating injury or depressed fracture, and lacerations. 3. History: Gather information related to the mechanism of injury and care prior to hospitalization. 4. Neurological Exam:37 Cerebral function Assess the level of consciousness, mental status, awareness, arousal, cognitive function, and behavior. Cranial Nerve and pupillary This reflects brainstem function. examination Assess the pupils, eye movements, cough reflex, corneal reflex and gag reflex. Motor and cerebellar function Assess strength, movement, gait, and posture. Each extremity must be assessed separately. It is important to document the degree and type of stimulus applied to elicit the motor activity. Central stimuli include sternal rub, trapezius pinch and/or supraorbital pressure. Abnormal findings include abnormal posturing, flaccidity, and focal motor movements. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Sensory examination Assess tactile and pain sensations. Reflex examination Assess superficial and deep tendon reflexes. Glasgow Coma This is a valuable component of the Scale neurological exam because it is nationally and internationally recognized. It is only one part of the neurological exam. Severe Head Injury: GCS # 8 or a decrease in 2 points or more after admission. Moderate Head Injury: GCS 9-12 Mild Head Injury: GCS 13-15 Due to the diverse causes of head injury and the differing needs of patients, initial contact with the patient involves an assessment of the cause of the injury and a screening to determine the extent of the injuries.6 This is important, as the mechanism of injury will determine the type of treatment needed. For example, blast trauma related head trauma is more complex than other forms of head trauma.95 Due to the complexity of the blast related head injury, the assessment and treatment can be difficult to administer and determine. Therefore, in combat, it is more common to evaluate all service members who have been exposed to a blast and identify those that present symptoms of head injury.95 However, in civilian instances nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com of head trauma, it is more common to assess each patient individually based on the symptoms present as non blast related causes of head trauma tend to be less complicated.6 Prior to conducting a full assessment of an individual who is suspected of having a traumatic brain injury, the primary concern is ensuring that the patient is stabilized and that any further injury is prevented. During the initial stage of contact, medical personnel are primarily concerned with ensuring that the patient has a proper supply of oxygen to the brain and the rest of the body.96 Another priority is to maintain an adequate blood flow while controlling blood pressure. This will help stabilize the patient while minimizing further damage to the brain.6 Once a patient is stabilized, medical personnel will assess the patient and determine the extent of the injury. Primary assessment includes measuring vital signs and reflexes, as well as administering a thorough neurological exam. The initial exam includes checking the patient’s temperature, blood pressure, pulse, breathing rate, pupil size and response to light.35 After the vital signs and basic neurologic functions are assessed, the emergency medical provider will assess the patient’s level of consciousness and neurologic functioning. This assessment is done using the Glasgow Coma Scale, as previously stated, which is a standardized, 15-point test that measures neurologic functioning using three assessments: eye opening, best verbal response, and best motor response. These measures are used to determine the severity of the brain injury. A test score of 13 to 15 is classified as mild, 9 to 12 as moderate, and 3 to 8 as severe. Though well known and widely used, this classification scheme is most useful in predicting acute survival and gross outcome, and performs more poorly in nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com predicting later and more detailed functional outcomes, particularly in cognitive and emotional realms.97 The Center for Disease Control provides the following guidelines for the Glasgow Coma Scale. Medical responders should use this scale to assess the level of severity of brain injury when performing a diagnostic work-up, as mentioned in the prior section and also highlighted in the table below. The Glasgow Coma Scale is frequently available as a quick access guide within many flow-charts or documentation templates and electronic health records so that health teams can easily trend patient care outcomes. After the Glasgow Coma Scale is administered, further testing is conducted to determine the level of damage and the severity of the injury. Imaging tests are used to assist with the diagnosis of the patient as well as to make a determination about the prognosis of the patient.6 Skull and neck x rays are used to check for bone fractures and spinal instability in patients with mild to moderate injuries.98 In patients with mild head injuries, a diffusion tensor imaging is sometimes used. This device can reliably detect and track brain abnormalities and is sensitive enough to be used on patients with mild injury.8 In some cases, a magnetoencephalography may be used to obtain further information regarding a mild case of head trauma.99 Additional diagnostic imaging is used in cases of moderate to severe head injury. In these instances, patients will be assessed using a computed tomography (CT) scan. This scan creates cross sectional X-ray images of the head and brain and is used to identify any bone fractures that might be present in the skull. The CT scan also indicates if there is the presence of hemorrhage, hematomas, contusions, brain tissue swelling, and tumors.100 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Glasgow Coma Scale Eye Opening Response Spontaneous--open with blinking at baseline 4 points To verbal stimuli, command, speech 3 points To pain only (not applied to face) 2 points No response 1 point Verbal Response Oriented 5 points Confused conversation, but able to answer questions 4 points Inappropriate words 3 points Incomprehensible speech 2 points No response 1 point Motor Response Obeys commands for movement 6 points Purposeful movement to painful stimulus 5 points Withdraws in response to pain 4 points Flexion in response to pain (decorticate posturing) 3 points Extension response in response to pain (decerebrate posturing) 2 points No response 1 point Categorization Coma: No eye opening, no ability to follow commands, no word verbalizations (3-8) Head Injury Classification: Severe Head Injury ---- GCS score of 8 or less Moderate Head Injury ---- GCS score of 9 to 12 Mild Head Injury ---- GCS score of 13 to 15) nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Once the initial assessment is complete, in addition to the diagnostic testing already mentioned, other imaging may be conducted. In these instances a magnetic resonance imaging (MRI) is often used to determine if there is additional damage beyond the scope of the initial assessment. The MRI is used to determine if there have been any subtle changes in the brain tissue and are used when more detail is needed than standard X-rays can provide.29 MRI’s are not used during the initial emergency assessment as they require a significant amount of time and are not always available during the initial assessment.17 However, an MRI is an important diagnostic tool and should be used when appropriate and available. Examination When a patient presents with a head injury, he or she will undergo a complete examination with the purpose of assessing the trauma and identifying specific injuries. While the examination will vary depending on the patient’s needs, there are standard examination methods that are typically used during the initial examination. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Regardless of the type of injury (blunt or penetrating, open or closed) the initial examination will be conducted as soon as possible and will often occur in conjunction with resuscitation.101 It is important to conduct the initial assessment as soon as possible to identify any life-threatening injuries and to minimize any additional damage. Early identification of any complications will reduce the likelihood of the patient developing secondary injuries.85 While it is important to manage any damage caused by an open head wound, it should not interfere with the initial stabilization of the patient. Therefore, the initial stage of the patient examination will include assessing and managing the airway, breathing, circulation, and related components.43 Once that is complete, the emergency provider will begin the primary survey. The primary survey or examination will focus on identifying any complications or secondary injuries.102 The following table includes the guidelines provided for the primary and secondary examination of the patient.101 Primary Examination As part of the primary survey, the pupillary size and reactions are noted and the conscious state is assessed. Disturbances of consciousness may follow focal damage to the reticular formation, which extends from the rostral midbrain to the caudal medulla. It receives input from all sensory pathways and projects widely to the cerebral cortex and limbic system. Focal cortical lesions do not affect consciousness, but coma may result from general depression of the cerebral cortex. Using purely descriptive methods to assess conscious state is problematic. One observer’s “somnolent” is another’s “drowsy”. When is a person stuporous and when are they obtunded? What is semi-conscious and when does a clouded conscious state become coma? Consciousness is a continuum and the Glasgow Coma Scale (GCS) is used as a measure (albeit crude) of level of consciousness. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Secondary Examination Once the primary survey is complete, the secondary survey should include a more thorough neurological examination, starting with a reassessment of the Glasgow Coma Scale, and an examination of the head, face and neck. The head and face should be examined for lacerations and fractures. Scalp lacerations can be palpated with a gloved finger. If there is an underlying depressed fracture, surgery will be required. Profuse bleeding may occur from a scalp laceration and this can be controlled with a pressure dressing or by a few temporary full-thickness sutures. The nose and ears are inspected for leaks of cerebrospinal fluid (CSF). This is usually mixed with blood and results in a thinner discharge that will separate on blotting paper. If this is not available, the separation can also be observed on a sheet or pillowcase. If there is CSF rhinorrhea or otorrhoea, a basal skull fracture is present (regardless of whether it can be seen on radiographs). Bilateral periorbital hematomas (raccoon eyes) and subconjunctival hemorrhages where the posterior margin cannot be seen are both indicators of anterior fossa fracture. Hemotympanum or bruising over the mastoid (Battle’s sign) suggests a middle fossa fracture. Battle’s sign usually takes several hours to develop. The nose, mid face and orbits should also be palpated for fractures that may require treatment later. When the patient is logrolled, the back of the head and cervical spine should also be examined. The neurological examination will be limited because of the lack of cooperation of the patient, but it should still be possible at least to determine if there are lateralizing signs such as a hemiparesis or a third cranial nerve palsy. Higher functions are assessed first. Most often this will be limited to level of consciousness and, in particular, the “voice” component of the GCS. In a relatively cooperative patient with a focal injury it may be possible to assess language further, but in the early period after a head injury it will be difficult to differentiate dysphasia from confusion. Memory becomes important later and the period of post-traumatic amnesia is used as an indicator of injury severity. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Cranial Nerves Many of the cranial nerves can be assessed even in the unconscious patient. These are outlined below. I (olfactory): Assessment obviously requires cooperation, but this nerve should be examined when possible, as it is the most commonly affected cranial nerve after head injury and is often ignored. Anosmia may seem trivial but it has significant effects beyond enjoyment of food and wine. Anosmic patients will not be able to smell smoke from a fire or leaking gas, both of which may potentially put them at risk. II (optic): The pupillary reactions to light depend on the integrity of the optic and oculomotor nerves, as well as their connections. Normally both pupils should constrict when light is shone in either eye or when the patient looks at a near object (accommodation reflex). A pupil that responds to direct light implies that the ipsilateral optic and oculomotor nerves are intact. If it responds to direct light, but not consensually, this implies damage to the contralateral optic nerve. A pupil reacting only consensually suggests ipsilateral optic nerve damage. An oculomotor nerve injury will produce an ipsilateral dilated pupil, which does not respond directly or consensually, but the contralateral pupil will constrict when light is shone in either eye. One must remain aware that the most common cause of a dilated pupil after head injury is traumatic mydriasis due to local ocular trauma. This should be suspected if the dilated pupil was present right from the time of injury and there is local trauma to the globe or orbit. During examination of the eyes the fundi are assessed. One would not expect to see papilledema in the early hours after a head injury, and funduscopy is done more for the purpose of assessing the integrity of the eye itself (checking for retinal detachment or hemorrhage, vitreous hemorrhage, corneal laceration, etc.). Contact lenses should be looked for and removed. Visual fields can be checked by confrontation in a cooperative patient or by menace in an uncooperative patient. They are not clinically assessable in the unconscious patient. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com III, IV and VI (oculomotor, trochlear and abducens): The pupils are assessed as above. Ptosis (III) is difficult to assess in patients who are unconscious. Ocular movements can be observed and any dysconjugate movements noted. If the patient is cooperative this is easy. An alert but uncooperative patient can be made to look at objects quite readily by placing them in their field of vision. This also applies to children. Oculocephalic reflexes test the third, fourth and sixth cranial nerves and their connections. Movement of the head from side to side or up and down will be accompanied by movement of the eyes in the opposite direction, resulting in a constant point of fixation. The term “doll’s eyes” is often used to describe oculocephalic reflexes but this frequently leads to confusion. Whether doll’s eyes are normal or abnormal depends on the sophistication of the doll. One with eyes painted on would describe the abnormal and one with eyes free to rotate would better approximate the normal situation. It is preferable to avoid the term altogether and describe oculocephalic reflexes as being normal or abnormal. It is not usually recommended to test oculocephalic reflexes in a head-injured patient owing to the high risk of associated cervical spinal injury. If it is important to know if these reflexes are intact (i.e., in assessing brain death). V (trigeminal): The motor component of the trigeminal nerve can be tested in a cooperative patient, but the sensory part can be assessed even in the unconscious. Painful stimuli applied to the supraorbital nerve should usually produce a response and the corneal reflex tests trigeminal function as well as facial nerve function. VII (facial): Facial movements are readily assessed in the cooperative patient, but can also be observed when painful stimuli are applied and as part of the corneal reflex. Facial nerve palsies are often seen with middle fossa fractures and this nerve should be assessed early in any patient with CSF otorrhoea or Battle’s sign. Taste is not usually tested. Patients often complain of loss of taste after a head injury (usually due to anosmia). nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com VIII (acoustic): This is hard to test clinically in the unconscious patient. An alert but uncooperative patient can be observed for reaction to sudden noises. Assessment in the unconscious usually requires brainstem auditory evoked potential monitoring. This nerve is also often injured in middle fossa fractures. IX (glossopharyngeal), X (vagus): There is usually little more to do than observe swallowing and test the gag reflex, either directly or by moving an endotracheal tube. XI (accessory): Sternomastoid and trapezius function can be tested, but it is unusual for the accessory nerve to be injured intracranially. XII (hypoglossal): A hypoglossal nerve injury will force the protruded tongue to the ipsilateral side. Over time the ipsilateral side of the tongue becomes wasted. Motor Function The sophistication of motor testing depends on the level of cooperation of the patient. At the least, it is possible to detect asymmetry in movement or responses to pain as described above in assessing the GCS. Reflexes are often brisk but may be absent with associated spinal cord injury (spinal shock). Plantar reflexes will usually be extensor after a significant head injury. Priapism and loss of anal tone are other indicators of spinal cord injury that should be sought. Sensory Function The same applies as for motor function. If there is a response to pain, this can be compared in different areas. This is important when a spinal cord injury is suspected and one is attempting to determine at what level. Sometimes there can be movement of limbs through local spinal cord reflexes; hence, when assessing a patient for brain death, it is mandatory that the painful stimulus be applied to a cranial nerve distribution. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Traumatic Brain Injury Assessment If traumatic brain injury is suspected, the patient will undergo a more thorough examination, which will include the following physical and mental evaluation.103 Cognitive Orientation Command following (single, multistep) Attention Concentration Memory (short- and long-term) Naming/repetition Abstract thinking Judgment Behavioral Depression Anxiety Irritability Agitation Restlessness Disinhibition Musculoskeletal Manual muscle (strength) testing Joint range of motion (including temporomandibular joint) Muscle tone Mobility nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Balance — sitting, standing, dynamic Transfers Gait — indoor, outdoor, stair Neurologic Cranial nerve testing Sensory function Special sensory o Vision o Hearing o Smell/taste Deep tendon reflexes Primitive reflexes (frontal release signs) o Palmomental reflex o Snout reflex o Glabellar (tap) reflex o Palmar grasp reflex Brainstem reflexes o Oculocardiac reflex o Horizontal oculocephalic/oculovestibular reflex o Pupillary light reflex o Vertical oculocephalic/oculovestibular reflex o Fronto-orbicular reflex Bowel/bladder reflexes o Cremasteric reflex o Bulbocavernosus reflex o Anal wink reflex nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Cerebellar testing o Finger to nose (upper extremity dysmetria) o Heel to shin (lower extremity dysmetria) Fine and gross motor coordination (tremor) Autonomic nervous system General Medical Exam Skin Heart/circulation Lung Abdomen o Digestive o Bowel Genitourinary Endocrine Radiologic Imaging In many instances, the examination will include radiologic imaging. The following tables,104 provided by the American College of Radiology (ACR), give specific recommendations for the different radiologic procedures that are used in head trauma situations. The rating scale for each procedure is shown and explained at the end of each table; for example, the numerical rating relative to the level of appropriateness to perform a specific procedure for a particular condition. Additionally, the relative radiation level (RRL) is shown using the symbol [ ] or [O] (zero) to indicate the amount of exposure during the procedure. Each table title identifies the specific condition and corresponding GCS score. Major recommendations to evaluate nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com the appropriateness of a radiologic procedure, as shown in the tables below, include: ACR Appropriateness Criteria® and Clinical Condition/ Head Trauma. Abbreviations used in the tables are not reviewed in depth here, but may be referenced at the ACR website: http://www.acr.org/QualitySafety/Standards-Guidelines. Variant 1: Minor or mild acute closed head injury (GCS ≥13), without risk factors or neurologic deficit. Radiologic Procedure Rating Comments RRL* CT head without contrast 7 MRI head without contrast 4 MRA head and neck without 3 contrast MRA head and neck without Known to have low yield. O Rarely indicated with mild O trauma. 3 O and with contrast CT head without and with 3 contrast CTA head and neck with 3 contrast MRI head without and with Rarely indicated with mild trauma. 2 O contrast CT head with contrast 1 X-ray head 1 FDG-PET/CT head 1 US transcranial with Doppler 1 Arteriography cervicocerebral 1 Tc-99m HMPAO SPECT head 1 O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be *Relative appropriate; 7,8,9 Usually appropriate Radiation Level nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Variant 2: Minor or mild acute closed head injury, focal neurologic deficit and/or risk factors. Radiologic Procedure Rating Comments RRL* CT head without contrast 9 MRI head without contrast 6 For problem solving. O MRA head and neck without contrast 5 If vascular injury is O suspected. For problem solving. MRA head and neck without and with 5 contrast If vascular injury is O suspected. For problem solving. CTA head and neck with contrast 5 If vascular injury is suspected. For problem solving. MRI head without and with contrast 3 CT head without and with contrast 2 CT head with contrast 1 Tc-99m HMPAO SPECT head 1 FDG-PET/CT head 1 US transcranial with Doppler 1 X-ray head 1 Arteriography cervicocerebral 1 O O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be *Relative appropriate; 7,8,9 Usually appropriate Radiation Level nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Variant 3: Moderate or severe acute closed head injury. Radiologic Procedure Rating Comments RRL* CT head without contrast 9 MRI head without contrast 6 O MRA head and neck without contrast 5 O MRA head and neck without and with 5 O contrast CTA head and neck with contrast 5 CT head without and with contrast 2 MRI head without and with contrast 2 X-ray head 2 CT head with contrast 1 US transcranial with Doppler 1 FDG-PET/CT head 1 Arteriography cervicocerebral 1 Tc-99m HMPAO SPECT head 1 O O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be *Relative appropriate; 7,8,9 Usually appropriate Radiation Level nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Variant 4: Mild or moderate acute closed head injury, child <2 years old. Radiologic Procedure Rating CT head without contrast 9 MRI head without contrast 7 Comments RRL* Diffusion weighted imaging O especially helpful for nonaccidental trauma. MRI head without and with 4 contrast MRA head and neck without Potentially useful in suspected O nonaccidental trauma. 4 If vascular abnormality suspected. O 4 If vascular abnormality is O contrast MRA head and neck without and with contrast CTA head and neck with suspected. 4 contrast X-ray head If vascular abnormality is suspected. 2 Appropriate as part of skeletal survey in suspected nonaccidental trauma. May be appropriate when screening for patients suspected of having penetrating head trauma or foreign bodies. CT head without and with 2 contrast CT head with contrast 1 FDG-PET/CT head 1 Tc-99m HMPAO SPECT head 1 US transcranial with Doppler 1 Arteriography cervicocerebral 1 O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be *Relative appropriate; 7,8,9 Usually appropriate Radiation Level nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Variant 5: Subacute or chronic closed head injury with cognitive and/or neurologic deficit(s). Radiologic Procedure Rating Comments RRL* MRI head without contrast 8 O CT head without contrast 6 Tc-99m HMPAO SPECT head 4 For selected cases. FDG-PET/CT head 4 For selected cases. MRA head and neck without 4 For selected cases. O 4 For selected cases. O 4 For selected cases. contrast MRA head and neck without and with contrast CTA head and neck with contrast MRI head without and with 3 O contrast CT head without and with 2 contrast CT head with contrast 2 X-ray head 2 MRI functional (fMRI) head 2 O US transcranial with Doppler 1 O Arteriography cervicocerebral 1 without contrast Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be *Relative appropriate; 7,8,9 Usually appropriate Radiation Level nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Variant 6: Closed head injury, rule out carotid or vertebral artery dissection. Radiologic Procedure CTA head and neck with Rating Comments RRL* 8 contrast MRA head and neck without 8 Add T1 neck images. O 8 Add T1 neck images. O MRI head without contrast 8 Include diffusion-weighted images. O CT head without contrast 8 CT head without and with 6 Consider perfusion. Arteriography cervicocerebral 6 For problem solving. MRI head without and with 6 contrast MRA head and neck without and with contrast contrast O contrast CT head with contrast 4 X-ray head 2 Tc-99m HMPAO SPECT head 1 US transcranial with Doppler 1 FDG-PET/CT head 1 Consider perfusion. O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be *Relative appropriate; 7,8,9 Usually appropriate Radiation Level nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Variant 7: Penetrating injury, stable, neurologically intact. Radiologic Procedure Rating CT head without contrast 9 CTA head and neck with 7 Comments RRL* contrast MRA head and neck 6 If there is no MRI contraindication. O 6 If there is no MRI contraindication. O 5 If vascular injury is suspected. 5 If there is no MRI contraindication. 4 Consider perfusion. 4 If there is no MRI contraindication. without contrast MRA head and neck without and with contrast Arteriography cervicocerebral MRI head without O contrast CT head without and with contrast MRI head without and O with contrast X-ray head 4 CT head with contrast 2 US transcranial with 1 O Doppler Tc-99m HMPAO SPECT 1 head FDG-PET/CT head 1 Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be *Relative appropriate; 7,8,9 Usually appropriate Radiation Level nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Variant 8: Skull fracture. Radiologic Procedure Rating CT head without contrast 9 CTA head and neck with 7 Comments RRL* If vascular injury is suspected. contrast MRI head without 6 O contrast X-ray head 5 For selected cases. MRI head without and 4 Useful if infection suspected. O with contrast CT head without and with 4 contrast MRA head and neck 4 O 4 O without contrast MRA head and neck without and with contrast CT head with contrast 2 US transcranial with 1 O Doppler Tc-99m HMPAO SPECT 1 head Arteriography 1 cervicocerebral FDG-PET/CT head 1 Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be *Relative appropriate; 7,8,9 Usually appropriate Radiation Level nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The tables above list the guidelines and recommendations for all forms of radiologic imaging used in head trauma situations. However, the two most commonly used diagnostic assessments are the Non-contrast CT and the MRI.77 Computed Tomography Computed tomography (CT scan) is a diagnostic imaging procedure that produces horizontal, or axial, images of the body. These images are often called “slices.”105 The CT scan uses a combination of X-Ray imaging and computer technology to obtain the images in a noninvasive format.106 A CT scan is an important diagnostic tool as it is able to provide detailed images of different parts of the body. It is especially useful in obtaining images of the bones, muscles, fat and organs.107 Computed tomography scans are used more frequently than standard X-Rays because the images are more detailed.100 Standard X-Rays use a single beam of energy that is aimed at the specific body part being analyzed. The image is captured on a plate that is placed behind the body, once the beam of light passes through the various body parts (skin, bone, muscle, and tissue).2 X-Rays are limited in their ability to provide detailed imaging, as they cannot capture images of internal organs and other structures of the body. Therefore, a CT scan is often the primary assessment used. A CT scan uses a moving X Ray beam to capture the images. The beam circles around the body, thereby capturing a number of different views of the same body part.106 The information is transmitted to a computer, which then interprets the data and creates a two dimensional form. The form is displayed on a monitor, which is then reviewed by the radiologist.108 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com CT scans are conducted in two ways, as contract and non-contract. Contrast Patients ingest a substance orally or receive an injection intravenously. The contrast solution enables the radiologist to view the specific body part or region more clearly.105 Non-Contrast The CT scan is conducted without the use of any solution. In instances of head trauma, the patient will undergo a non-contrast CT scan.109 A CT scan is especially useful in instances of head trauma as it can provide detailed images of the brain structure and brain tissue. CT scans can help the treating physician identify any underlying injuries or infections of the brain, especially when other examinations of images are inconclusive.107 The scan is often used to identify the following complications of head trauma:110 Intracranial bleeding Structural anomalies Infections Clots The following are the CDC Guidelines for using a CT scan with patients that have mild traumatic brain injury. The guidelines provide recommendations for determining which patients with a known or suspected mild brain injury require a head CT and may be safely discharged.111 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com CDC Brain Injury Guidelines for Adults: Fact Sheet A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia in presence of specific symptoms. A noncontrast head CT should be considered for head trauma patients with no loss of consciousness or posttraumatic amnesia in presence of specific symptoms. Even without a loss of consciousness or amnesia, a patient could still have an intracranial injury. Identifying those patients at risk is key. A patient with an isolated mild TBI and a negative CT is at minimal risk for developing an intracranial lesion and may be safely discharged. Discuss discharge instructions with patients and give them a discharge instruction sheet to take home and share with their family and/or caregiver. Be sure to: Alert patients to look for post concussive symptoms (physical, cognitive, emotional, and sleep) since onset of symptoms may not occur until days after the initial injury. Instruct patients on what to expect, what to watch for, and when it is important to return immediately to the emergency department. Emphasize that getting plenty of rest and sleep is very important after a concussion, as it helps the brain to heal. Patients should gradually return to their usual routine only after they start to feel better. The CDC also provides leveled recommendations for determining which patients in the emergency department should undergo a non-contrast CT scan. They are outlined below.111 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com CDC Brain Injury Guidelines for Adults: Fact Sheet Level A recommendations: A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age > 60 years old, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score < 15, focal neurologic deficit, or coagulopathy. Level B recommendations: A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, ≥ 65 years old, physical signs of a basilar skull fracture, GCS score < 15, coagulopathy, or a dangerous mechanism of injury. Dangerous mechanism of injury includes ejection from a motor vehicle, a pedestrian struck, and a fall from a height of > 3 feet or 5 steps. Level C recommendations: None specified. Magnetic Resonance Imaging Magnetic Resonance Imaging (MRI) is a radiologic scan that produces images of various body structures using a combination of magnetism, radio waves and computer technology. The MRI is conducted using a large circular magnet that surrounds a scanner tube.112 Images are obtained by placing the patient on a movable surface and inserting him or her into the magnetic tube. Once the patient is in the tube, a strong magnetic field is created. This magnetic field aligns the protons of the hydrogen atoms. Once the hydrogen atoms are aligned, they are exposed to a beam of radio waves. The radio nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com waves impact the protons within the body, causing them to spin, thereby producing a faint signal, which is easily detected by the MRI receiver. The information obtained by the scanner is sent to a computer, where it is processed to produce an image.106 An MRI utilizes high-resolution technology, which allows it to produce highly detailed images that will show changes in many of the structures in the body.113 In some instances, additional agents will be used to enhance the accuracy of the images. It is most common to use contrast agents such as gadolinium.29 Due to the MRI’s high level of sensitivity, it is able to detect many brain injuries that are undetectable using other methods.17 In fact, an MRI is often used to identify asymptomatic brain damage in patients who appear to be normal.113 While an MRI and CT scan both use the slicing technique for obtaining images, the process is different for each. The MRI uses a magnetic field while the CT scan uses X Rays.110 As a result, the MRI provides more detailed images than a CT scan and is able to detect damage that is as small as 1 – 2 mm. A CT scan cannot detect damage this small.106 The CT scan is more appropriate for identifying fresh blood in and around the cranial region.114 However, an MRI better detects old blood that has been hemorrhaged into the cranial cavities.17 Whether or not to use an MRI will depend on the type, cause and location of the head injury. Other Diagnostic Imaging Procedures While the CT scan and the MRI are the most widely used forms of diagnostic imaging for a head injury, there are a number of other procedures that are being used more frequently as the technology is developing and as the diagnostic needs of the patient and the provider are changing. The following nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com table provides a list of the more commonly used alternate forms of diagnostic imaging.106 Diagnostic Description Procedure SUSCEPTIBILITY This is a software program that enables an MRI to more accurately WEIGHTED show tiny hemorrhages known as micro hemorrhages. These small IMAGING (SWI) white dots actually show up on the MRI because of the iron content MRI left behind after blood has been in an area through injury. These tiny capillaries in the brain are torn and the small amounts of blood can be seen on SWI-MR. In persons fifty or older, there are white dots, which can often be from aging. In the younger person, or in an older person, where these abnormalities are clustered at the grey-white junction (where the grey matter meets the white matter) these are generally traumatically caused. For those undergoing a MRI after a trauma, especially a trauma involving a high-speed collision or a fall from a height, make sure to ask your doctor to prescribe an SWI MRI so that these abnormalities can be detected. There can be as many as several hundred of these small injuries throughout the brain, but they are an objective unarguable type of evidence for brain injury and are exceedingly helpful in any brain injury litigation. They can also identify the areas of the brain that have been shaken, and aid in rehabilitative strategies. DIFFUSION Diffusion Tensor Imaging is a type of MRI that uses special software to TENSOR view parts of the brain a normal MRI cannot. The interesting premise IMAGING (DTI) of this new technology is that it measures the movement of water molecules in relation to the white track fibers of the white matter of the brain. If the fibers are healthy and untorn, then the water molecules will show parallel movement along those tracks as they slide along them. Torn or missing white matter fiber will allow perpendicular movement of the water molecules. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com This new technology allows for visualization of natural damage to the white matter. It is a very impressive technology and will be impressive to jurors and others involved in TBI litigation. Most radiology groups do not have this software, so if you would like to have this test run, try University centers first. DTI will be especially helpful in cases involving high velocity change injury, such as high speed car accidents, falls from a height, and other accidents in which the injury is suspected to be Diffused Axonal Injury (DAI). MRA (MAGNETIC MRA, or magnetic resonance angiography, is a means of visualizing RESONANCE the carotid and vertebral arterial systems in the neck and brain ANGIOGRAPHY) without having to inject contrast into the bloodstream. The resolution is not as good as with conventional arteriography, but the patient is spared the risks of catheterization and allergic reactions to the dye. (In conventional arteriography, a catheter is threaded from the femoral artery in the groin backward up the aorta into a carotid or vertebral artery in the neck, and then dye is injected up the catheter. As the dye flows into the brain, x-rays are taken of the cerebral vasculature). EEG Monitors the brain's electrical activity by means of wires attached to (ELECTROENCEP the patient's scalp. These wires act like an antenna to record the HALOGRAM) brain's electrical activity. Normally, the resting brain emits signals at a frequency of 8 to 13 cycles per second (cps), called alpha activity, which is best seen in the occipital regions. Anything faster than 8-13cps is called beta activity. Slower rhythms include theta activity (6-7 cps) and delta activity (3-5 cps). Theta and delta activity occur in the normal brain as the patient descends into sleep. If the patient is awake, any slowing of electrical activity in a focal area of the brain may indicate a lesion there. Similarly, widespread slowing indicates a widespread disturbance of brain function, often due to a blood borne insult like low blood sugar, drug intoxication, liver failure, etc. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com "Spiking" (sharp waves of electrical activity) discharges indicate an irritable area of cerebral cortex. If allowed to spread, the spikes can produce a seizure. It is not uncommon for an EEG to be normal between seizures in patients with bonafide seizures. During a seizure, however, the EEG is almost invariably abnormal. Conversely, 15% of the population shows mild abnormalities on EEG, representing old head trauma, old strokes, migraine, viral infections, and most of the time for unknown reasons. QUANTITATIVE This test is performed in a way similar to EEG. Brain wave activity EEG (QEEG, varies throughout the day depending on the state of alertness. Each BEAM, BRAIN area of the brain normally spends a characteristic amount of time in MAPPING) alpha, beta, theta, and delta activity. Brain mapping computers are now capable of creating a map of the brain's electrical activity depicting how long each area of the brain spends in each of the basic rhythms. By comparing the patient's map with that of a control population, it is possible to localize areas of focal slowing of electrical activity. Alone, a QEEG is insufficient to diagnose brain damage but in conjunction with other neurologic tests, QEEG can be confirmatory. PET SCAN PET scanning (positron emission tomography) is based on the fact that (POSITRON the brain uses glucose for energy. By labeling a glucose molecule with EMISSION a radioactive "tag," and then inhaling radioactive glucose and placing TOMOGRAPHY) the patient's head under a large geiger counter, one can identify abnormal areas of the brain that are underutilizing glucose. Because cyclotrons are needed to generate the radioactive gas, PET scanning is not widely available. SPECT SCAN SPECT scanning (single photon emission computed tomography) is (SINGLE similar to PET scanning in that a radioactive chemical is administered PHOTON intravenously to the patient, but the radioactive chemical remains in EMISSION the bloodstream and does not enter the brain. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com COMPUTED As a result, the SPECT scan maps the brain's vascular supply. Because TOMOGRAPHY) damaged brain tissue normally shuts down its own blood supply, focal vascular defects on a SPECT scan are circumstantial evidence of brain damage. The advantage of a SPECT scan over a PET scan is its ready availability and relatively cheap cost. Recent studies have demonstrated abnormal SPECT scans after head trauma when the CAT and MRI were normal, suggesting that the SPECT scan is more sensitive to brain injury then either CT or MRI scans. Because the radioactive chemicals used in SPECT and PET scans are carried to all parts of the body by vascular tree, SPECT scans and PET scans are used judiciously in patients of reproductive age. EVOKED Evoked studies take advantage of the fact that each time a sensory POTENTIALS system of the body -- vision, hearing, touch -- is stimulated, an electrical signal is generated in the brain. These electrical signals can be detected with electrical wires on the scalp. Thus, visual evoked recordings (VER) are recorded over the occipital lobes; brainstem auditory evoked recordings (BAER) over the temporal lobes; and somatosensory potentials (SSEP) over the parietal lobes. LUMBAR A lumbar puncture (spinal tap - not the band) is used to analyze PUNCTURE cerebrospinal fluid. An analysis of the fluid can help tell doctors, for example, if there is any bleeding in the brain and spinal cord areas. MAGNETIC This is an exciting new tool, used in conjunction with MRI that detects RESONANCE the intra-cellular relationship of brain metabolites. Studies show that SPECTROSCOPY in an injured brain, the relationship between the amount of certain (MRS) compounds in the brain changes in predictable ways, which can be picked up, non-invasively, by MRS. While MRS is in its early stages, it holds great promise in the "objectification" of brain injury. THIS DATA CAN AND SHOULD BE CAPTURED ON MRI WITHIN SIX WEEKS OF INJURY. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Treatment Many individuals experience long-term complications and disabilities as the result of a traumatic brain injury.115 Therefore, long-term treatment is often needed beyond the emergency treatment that is provided initially. Initial treatment for patients with moderate to severe traumatic brain injury is focused on stabilizing the patient and is often done within the emergency department or intensive care unit. Once the patient is stabilized, further treatment may be required depending on the type and severity of the injury. Most long-term treatment involves rehabilitation, as the goal is to have the patient regain the appropriate neurologic functions. This component of treatment is often conducted in a subacute unit of the hospital or in an independent rehabilitation center.11 In addition, some long-term treatment will be conducted through outpatient services.6 Treatment at this stage is diverse and is tailored to the specific recovery needs of the patient. Most long term treatment includes physical therapy, occupational therapy, speech and language therapy, psychiatric care, psychological services, social support and life skill development, and physiatry.116 The specific rehabilitative program will utilize the services of experts in the above areas to develop a comprehensive program that addresses the specific treatment needs of the program. Initial treatment will most likely be extensive, with longer-term treatment being less frequent.53 As the patient regains the appropriate skills, treatment will be reevaluated and modified to continue to meet the needs of the patient.93 The goal of long-term treatment is to bring the patient to a level of functioning that enables him or her to live independently and integrate with society. When patients experience a long-term or permanent disability as nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com the result of a head injury, the rehabilitation team will provide treatment and therapy that focuses on adapting to the disability and developing new skills that will enable the patient to function within the constraints of the disability.115 Long-term rehabilitation will typically be conducted in a variety of settings, including hospital outpatient programs, inpatient rehabilitation centers, day treatment programs, hospital outpatient programs and independent living centers. The specific setting will be determined based on the rehabilitation needs of the patient and the specific services available in the geographic area.54 Pressure Monitoring In many instances, a patient will experience swelling in the brain. When this occurs, fluids accumulate within the brain and pressure begins to build. This causes additional swelling and disruptions to the fluid balance.4 With other injuries, swelling and fluid accumulation is normal and poses little risk. However, when this occurs within the brain, it can be extremely dangerous. The skull limits the space for expansion, so the brain is unable to expand. Therefore, the accumulation of fluid causes unnecessary pressure on the brain, referred to as intracranial pressure (ICP).22 When a patient presents with swelling in the brain, it is necessary to monitor the swelling to ensure that it does not cause additional damage. This is accomplished using a probe or catheter.11 The instrument is inserted into the skull and is placed at the subarachnoid level to ensure accurate measurements. Once the instrument is properly placed, it is connected to a monitor that displays information regarding the patient’s ICP. This information is closely monitored so that action can be taken if the ICP reaches an alarming level.6 If this occurs, the patient may have to undergo a ventriculostomy. This procedure is used to drain cerebrospinal fluid as a way nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com to reduce pressure on the brain.39 In some instances, pharmacological agents may be used to decrease ICP. These drugs include mannitol and barbituates.11 Rehabilitation To enhance recovery of brain injury survivors, clinicians and researchers utilize cognitive as well as physical rehabilitation. They employ a range of therapies for patients with nontraumatic brain injuries, such as stroke, that causes language (aphasia) or visuospatial skill impairments. Likewise, for traumatic brain injury (TBI), clinicians and researchers include a range of therapies for attention, memory, and executive function impairments; and for treatments for social and behavioral problems and programs for adjusting to disability.115 Rehabilitation is often considered in regard to improving physical disabilities. For a person with paralysis, rehabilitation might examine whether the individual’s strength could be improved through exercise, whether the tendons of nonparalyzed muscles could be surgically transferred to a mechanically useful site, whether braces or a wheelchair might allow the person to navigate the community despite the paralysis, and even whether architectural modifications, urban planning, or transportation services could help overcome barriers to mobility. The treatment interventions used in physical rehabilitation include traditional drug and surgical treatments, as well as physical exercise, technology (i.e., braces, wheelchairs), skill training (i.e., learning how to use a wheelchair), and social policies and services (i.e., accessible transportation).52 However, rehabilitation is not limited to improving physical disability. Cognitive rehabilitation attempts to enhance functioning and independence nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com in patients with cognitive impairments as a result of brain damage or disease, most commonly following TBI or stroke. As with physical rehabilitation, cognitive rehabilitation may include interventions that aim to lessen impairments, or interventions that aim to lessen the disabling impact of those impairments. Interventions are applied through technology and other compensatory strategies that may allow the individual with cognitive impairment to accomplish important life activities and more fully participate in society.55 Cognitive rehabilitation therapy (CRT) is used to rehabilitate thinking skills (i.e., attention, memory) impaired by a brain injury. Cognitive behavioral therapy is commonly used for a variety of emotional and psychiatric disorders, including mood, anxiety, and psychotic disorders, as well as sleep disturbance and chronic pain. Cognitive behavioral therapy typically centers on modifying maladaptive thoughts and emotional behaviors and using psychoeducation regarding symptoms and expectations for recovery.89 Patients with TBI often have multiple identifiable cognitive impairments, coupled with mood or other behavioral disturbances, a reduced awareness of their own cognitive and behavioral limitations, and reductions in social competence. Although some patients with isolated impairments may achieve substantial treatment benefits in terms of activities and participation from treatment of a single deficit, others may require a combination of treatments aimed at multiple problems to achieve comparable outcomes.52 Rehabilitation is a long term process for individuals and occurs in the following stages, depending on the specific needs of the patient, as outlined below.35,67,71,88,115,117,118 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Acute Rehabilitation As early as possible in the recovery process, individuals who sustain brain injuries will begin acute rehabilitation. The treatment is provided in a special unit of the trauma hospital, a rehabilitation hospital or another inpatient setting. During acute rehabilitation, a team of health professionals with experience and training in brain injury work with the patient to regain as many activities of daily living as possible. Activities of daily living include dressing, eating, toileting, walking, speaking and more. Postacute Rehabilitation When patients are well enough to participate in more intensive therapy, they may be transferred to a postacute rehabilitation setting, such as a residential rehabilitation facility. The goal of postacute rehabilitation is to help the patient regain the most independent level of functioning possible. Rehabilitation channels the body's natural healing abilities and the brain's relearning processes so an individual may recover as quickly and efficiently as possible. Rehabilitation also involves learning new ways to compensate for abilities that have permanently changed due to brain injury. There is much that is still unknown about the brain and about brain injury rehabilitation. Treatment methods and technologies are rapidly advancing as knowledge of the brain and its function increases. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Subacute Rehabilitation Patients who cannot tolerate intensive therapy may be transferred to a subacute rehabilitation facility. Subacute rehabilitation programs are designed for persons with brain injury who need a less intensive level of rehabilitation services over a longer period of time. Subacute programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing but are not making rapid functional gains. Subacute rehabilitation may be provided in a variety of settings, often a skilled nursing facility or nursing home. Day Treatment (Day Rehab or Day Hospital) Day treatment provides rehabilitation in a structured group setting during the day and allows the person with a brain injury to return home at night. Outpatient Therapy Following acute, postacute or subacute rehabilitation, a person with a brain injury may continue to receive outpatient therapies to maintain and/or enhance their recovery. Individuals whose injuries were not severe enough to require hospitalization or who were not diagnosed as having a brain injury when the incident occurred may attend outpatient therapies to address functional impairments. Home Health Services Some hospitals and rehabilitation companies provide rehabilitation therapies within the home for persons with brain injury. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Community Re-entry Community re-entry programs generally focus on developing higherlevel motor, social, and cognitive skills in order to prepare the person with a brain injury to return to independent living and potentially to work. Treatment may focus on safety in the community, interacting with others, initiation and goal setting and money management skills. Vocational evaluation and training may also be a component of this type of program. Persons who participate in the program typically live at home. Independent Living Programs Independent living programs provide housing for persons with brain injury with the goal of regaining the ability to live as independently as possible. Usually, independent living programs will have several different levels to meet the needs of people requiring more assistance and therapies as well as those who are living independently and being monitored. Pharmacological Treatment Many patients will require pharmacological treatment as part of the rehabilitation process. Some medications may be given short term to assist with acute recovery, while others may become part of the patient’s long-term treatment plan. The following is a list of the most common pharmacological nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com treatments used with TBI patients.53 Analgesics may be used for pain relief and pain management. Anti-anxiety agents may lesson feelings of uncertainty, nervousness, and fear. Anti-coagulants may be used to prevent blood clots. Anti-convulsants may be used to prevent seizures. Anti-depressants may be used to treat symptoms of depression. Anti-psychotics may be used to target psychotic symptoms of combativeness, hostility, hallucinations, and sleep disorders. Muscle relaxants may be used to reduce muscle spasms or spasticity. Sedative-hypnotic agents may be used to induce sleep or depress the central nervous system in areas of mental and physical response, awareness, sleep, and pain. Stimulants may be used to increase levels of alertness and attention. Surgery In some instances, surgery may be required as part of the treatment process. Surgery is most common in the acute stage of treatment, as it is often used to minimize additional damage to brain tissue or to address other complications associated with head injury. The following types of surgery are most common in instances of traumatic brain injury.27 Removing clotted blood (hematomas) Bleeding outside or within the brain can result in a collection of clotted blood (hematoma) that puts pressure on the brain and damages brain tissue. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Repairing skull fractures Surgery may be needed to repair severe skull fractures or to remove pieces of skull in the brain. Opening a window in the skull Surgery may be used to relieve pressure inside the skull by draining accumulated cerebral spinal fluid or creating a window in the skull that provides more room for swollen tissues. Prognosis The natural process of recovery following TBI depends upon the initial injury severity, as described with the GCS, though there can be considerable variability even within categories. With most injuries there is a gradual resolution of symptoms. For most mild, single concussive injuries, the majority of patients are symptom-free within several weeks. Several metaanalyses indicate the path to preinjury symptom levels following a mild TBI is approximately 2 weeks, and no more than 3 months. Development of new symptoms following resolution of the initial symptoms in individuals with mild TBI occurs infrequently. However, with multiple mild TBIs, both the number and duration of symptoms are likely to increase.44 The course of recovery from severe TBI is more prolonged, with greatest function recovery occurring within 1 to 2 years of injury. One study reported that an increasing number of people were independent at 6 to 12 months, and up to 5 years, post injury and following rehabilitation. In another study assessing recovery in people with severe TBI, approximately 22 percent of individuals were found to have improved from year 1 to year 5; however, 14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com to 15 percent declined, and approximately 62 percent remained unchanged.80 Impact On The Patient’s Family Traumatic brain injury can create a significant burden for the families of those who are injured, as it is they who most frequently must provide long-term support, socialization and assistance to the TBI individual. Indeed the impact of TBI for relatives can be as devastating as for the person who is injured. It is therefore essential to extend rehabilitation efforts to the family, as well as to the person with TBI.37 The occurrence of TBI creates an immediate crisis for relatives, potentially disrupting established relationships, roles, expectations and goals within the family unit. Emotional reactions are likely to be heightened by the fact that the injury occurred suddenly and may have been avoidable. Family responses include (1) the initial shock response; (2) emotional relief, denial and unrealistic expectations; (3) bargaining, mourning or working through; and, (4) acceptance and restructuring. There are likely to be differences in the sequence and rate at which families pass through such phases, and not all families will experience any or all of these emotional responses. Factors such as the pre-existing family structure, cohesion, coping skills and available resources significantly influence family responses.47 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Initially, families tend to experience a state of shock. Once the immediately life-threatening phase is passed there is frequently a sense of relief. As the TBI family member emerges from coma, and initially recovers relatively rapidly, there are likely to be feelings of expectancy, optimism, and hope for full recovery. In many instances, there is a tendency to deny or ignore obvious changes in cognition and behavior. It is much easier to focus on physical disability, which may show relatively rapid improvement, than on cognitive and behavioral changes, which tend to be more persistent but are less readily apparent.88,119 Denial can be a source of considerable conflict in the relationship between family members and rehabilitation staff. However, denial may serve a beneficial purpose in the early stages of recovery, as families are trying to cope emotionally with the idea that life may never be the same again. Professionals working with families need to understand and respect this. Attempts to confront denial frequently undermine the relationship between rehabilitation staff and family. Awareness of the reality of the impact of the injury tends not to come until after the TBI individual has been discharged from hospital, at which point families experience more directly the injured family member’s coping difficulties and cognitive-behavioral changes.120 There is likely to be significant disruption of relationships and roles, which existed in the family prior to injury. Middle-aged or elderly parents, who were making plans for retirement, or enjoying new-found freedom since adult children have left the family home, may be faced with caring for a newly dependent son or daughter at the expense of their own health and needs. They will be concerned as to what will happen to the injured child or adult when they can no longer provide the care that is needed. However, nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com where both parents are still alive they are able to support each other and share the burden to some extent.121 Spouses carry a somewhat different burden from that of parents. Where there are children, the spouse of an injured individual must take on the role of both parents, supporting the children as well as the newly injured husband or wife. Additionally, there are responsibilities for running the household, dealing with financial matters and earning an income for the family. The spouse who is injured may be childish, self-centered and irritable, and therefore unable to offer the emotional support that formed an integral part of the relationship prior to injury.122 Children of an individual with TBI may also have to take on new responsibilities. The uninjured parent is frequently absent, visiting at the hospital. When at home, he or she is likely to be tired, irritable and emotionally drained, having limited energy to devote to dealing with issues of importance to the children. The children may experience, therefore, not only a loss of affection and support from the injured parent, but also from the one who is not injured. The mother or father who has sustained an injury may be irritable or aggressive towards the children, unpredictable in his or her responses and no longer willing or able to share activities with them.123 Faced with such changes, children may find it difficult or embarrassing to invite their friends into the home. As a consequence, children might drift away from home and withdraw from their parents, particularly if they are adolescents. They may be reluctant to share their feelings with others and tend to deny what is happening and avoid dealing with it. Younger children can develop behavior problems in such circumstances. Siblings of those nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com injured may also feel neglected and forced to take on additional responsibilities. Given their crucial long-term role as caregivers, decision-makers and providers of support to those who sustain TBI, families will need to be involved, supported and assisted throughout the phases of acute care, rehabilitation and beyond. Involvement with and assistance to families may take a number of forms. These include provision of information regarding TBI and its impact on the injured family member, active involvement in goalsetting and the therapy process itself, supportive counseling and, if deemed necessary, family therapy. The amount of intervention required may depend on the nature and extent of disability in the TBI individual, how the family was functioning prior to the injury, and how the “family system” is affected by the injury.116,120 The following table provides an overview of the different approaches and considerations:116,120-122,124 Early Provision of information and support should begin in the intensive care Intervention unit. High rates of anxiety, depressive and post-traumatic stress symptoms have been identified in the relatives of patients treated in intensive care. Families frequently report traumatic memories of how they were treated by medical or other hospital staff in this acute stage, in “being prepared for the worst”, which can have a lasting impact on their attitudes to health professionals. Whether such memories are well founded or reflect their confused state of mind at the time is unclear. However, in view of their fragile state, families are likely to be assisted by the presence of a support worker who understands their situation and has time to explain and interpret the sometimes overwhelming information provided by doctors. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Neurosurgical staff face the difficult and stressful task of minimizing the likelihood of mortality and morbidity in the injured patient. It is difficult for them to look after families as well. This is acknowledged by Marks and Daggett (2006), who evaluated the implementation of a critical care plan for families of patients with severe TBI. This comprised the provision of health information, emotional support, involvement in patient care tasks, encouragement to families to look after themselves, working as a team to train families to take over long-term care of the patient, and linking them with community-based resources for support and assistance. Nursing staff involved in this evaluation suggested that a designated person not involved in caring for the patient should undertake the role of communicating with families. When the TBI individual emerges from coma of significant duration, referral will, hopefully, be made for rehabilitation, either in another unit of the same hospital or at another center. Having just got to know and trust the staff in the neurosurgical unit, families are faced with a new environment, many new faces, and a change in routine. It is important that families are welcomed into the rehabilitation setting by a team member who is identified as someone to whom the family can turn for information, assistance and support throughout the rehabilitation period. Continuity of involvement is important. The designated staff person should provide the family with orientation to the ward and therapy areas, the treatment program and staff who will work with the injured person. These staff should also take time to introduce themselves and explain their role. A written booklet containing information about TBI and its consequences, and how the rehabilitation program works is helpful. It is likely that by this stage close family members are feeling exhausted, having spent day and night at the bedside. There may also be pressure for them to return to work. It will be important to families to see their injured relative settled into the new environment, but once this has been achieved, they should be given permission to spend less time at the hospital, provided they feel comfortable with this. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Family A comprehensive assessment should be made of the family’s Assessment constellation; the roles played by different members, including the one who has been injured, the nature of relationships and communication within the family. It is also important to consider other stresses on the family. The Head Injury Family Interview (Hi-Fi) was developed by Kay and colleagues (1995) as a structured interview to guide the collection of background information from individuals with TBI and their families and document the impact of the injury on family members. Where staff with the appropriate family assessment skills is available, the clinical interview may be supplemented by the use of a standardized assessment tool to examine objectively the family system and the responses of individuals to the injury. Such methods include self-report measures and observational techniques. No such tools have been specifically designed for use with the TBI population. The Family Assessment Device (FAD) is a self-report questionnaire designed to assess the six dimensions of the McMaster Model of Family Functioning and overall level of family functioning. The dimensions assessed include Problem Solving, Communication, Roles Dimension, Affective Responsiveness, Affective Involvement, Behavior Control and General Functioning. It has been the measure most frequently used to study responses of family members across different disability groups, including those with TBI. It has been shown to have good psychometric properties. Numerous recent studies have documented high rates of unhealthy functioning on FAD subscales in families of those with TBI, although there has been some variation in the subscales most affected. In the course of the initial assessment period, families may want to discuss the circumstances of the accident and their feelings about this. The emotional reactions and needs of children and siblings should also be explored. It is important to establish what resources are available to the family, financially, in terms of support and assistance from extended family or friends, and whether they are able to have time off from employment. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Arrangements may need to be made for home help, financial or legal assistance. The family’s cultural background and beliefs and their value system should also be assessed in detail and taken into consideration in planning the rehabilitation process and optimal modes of communicating with the family. Where English is not spoken, it is important to ensure clear communication, using an interpreter, and involving a social worker who understands their cultural background. This person can convey to the rehabilitation team an understanding of family reactions to the injury and attitudes to the rehabilitation process, as well as act as an advocate for the family. Wherever possible, written information should be translated into the family’s native language. Family members usually provide invaluable information regarding the TBI individual’s previous lifestyle, abilities, behavior and personality. Such information is a vital aspect of the REAL approach, to enable the team to set realistic and appropriate goals. It is important to gain an understanding of the family’s perception of the impact of the injury on the injured individual, physically, cognitively and behaviorally. Their expectations regarding the rehabilitation process, its goals and outcome, and their role in that process should also be explored. In many instances families may have quite different priorities and expectations from those of rehabilitation staff. Although these may seem inappropriate or unrealistic, they are likely to be maintained and conveyed to the TBI family member, even in the face of logical argument to the contrary by team members. The views of the family deserve respect and consideration from the rehabilitation team. Wherever possible an attempt should be made to negotiate goals, which incorporate the aims and priorities of the family, as well as the TBI person. In some cases, the family’s wishes and needs may not be congruent with, or in the best interests of the injured person. In others the views of different family members may conflict with one another. Where this is seen to be the case, active family participation in goal setting and therapy is less helpful. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Family It is likely to be helpful to enable families to talk with one another during Education and after the rehabilitation phase, sharing information and emotional and Support support. The general community tends to have little knowledge of TBI Groups and its consequences, so that friends and other family members may not understand what the injured person and family are going through. The issues addressed by family support groups will vary according to the setting, time since injury, and nature of the relationship with the TBI family member. In the acute stages of recovery, families may be less ready to discuss their emotional reactions to the trauma, still focusing intensely on the needs of the injured family member. They may, however, benefit from educational input, both in structured form from members of the rehabilitation team or community agencies, and from other families who have already had the experience. Topics of interest may include mechanisms of TBI, management of coma and PTA, medical complications, such as epilepsy, the nature and management of disorders of mobility, communication, swallowing, cognition, behavior and emotion, vocational issues, accessing community resources, and financial and legal issues. It is wise to tailor the content of educational sessions to the needs of the group. Supplementary notes are also helpful, as many issues may not be fully understood until much later. Such educational sessions may form a basis for broader discussion of issues relevant to individual group members, leading to a sharing of information and support. Depending on the time since injury and their stage of adjustment, families may benefit from the opportunity of sharing their emotional reactions to the situation and discussing the impact of the injury on the family. Suitably trained rehabilitation professionals should take a facilitative role in this process, to ensure that all families are encouraged to participate actively and that all relevant issues are covered. Some issues raised may need to be taken up individually. Such groups may help families to realize that others share their experiences and reactions. This relieves their sense of isolation and provides family members with a feeling that they are accepted and understood. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The issues of importance to spouses of TBI individuals may be somewhat different from those of parents of injured adolescents or adults. Spouses may feel uncomfortable about discussing relationship issues or their feelings about changes in behavior and personality. It is therefore useful to enable spouses to talk with one another, providing relief from the guilt, which many experience regarding their negative feelings about the injured partner. Many families form strong bonds through participation in family groups. Such relationships provide a useful resource for the future, when there is no longer active rehabilitation support. In this respect it is useful for support groups to be ongoing, so that families may return in times of need. If this is not possible within the rehabilitation setting, referral should be made to an accessible community-based group. Indeed it is after return to the community that family support groups may be most helpful, as there is likely to be less support from other sources, and family members may be more ready to benefit from them. Supportive Even those families who show relatively healthy functioning are greatly Counseling stressed by the occurrence of TBI. Provision of supportive counseling is a and Family useful means of assisting them to adjust to the impact of the injury, both Therapy in terms of the emotional reactions of individual family members and of the family system itself. Where there are pre-existing problems in the family, or where family reactions to the injury are considered to be maladaptive, formal family therapy may be appropriate. Supportive counseling should provide an opportunity for family members to express and work through their emotional responses at different stages, including feelings of anxiety, helplessness, hope, denial, depression, guilt, anger, loss and grief. The counselor will need to be flexible in this respect, as individuals within the family are likely to be experiencing differing responses at a given point in time. Many will not be ready to talk about their feelings until long after the injured relative has been discharged. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Counseling also provides a forum in which to raise practical problems, particularly those occurring after discharge, and to discuss issues regarding management of the newly acquired disabilities of the TBI individual within the family. Assistance may be required in restructuring the family system. As the family initially mobilizes itself to deal with the crisis, this involves changes, which are seen as temporary. Family members tend to put aside their own interests and needs in order to give maximum support to the injured relative. Such sacrifices cannot usually be sustained without a significant physical or emotional toll. At some point, longer-term adaptations need to be made. However, it is usually not possible to consider long-term changes until the family has realized the permanency of the situation. A great deal of work may first be required to assist the family in becoming realistic and grieving effectively. As Perlesz et al. (1989) have pointed out, grieving the losses resulting from TBI is complicated by the prolonged period of uncertainty regarding outcome. This tends to encourage unrealistic hope for recovery. It is also very difficult to “mourn in the presence of the one being mourned for”. This is particularly so when the changes being mourned are relatively intangible alterations in personality, behavior and cognition, rather than physical disability or disfigurement. The restructuring process may not begin, therefore, until many years after injury and may never be fully accomplished. Many dimensions of the family system may be affected by TBI. In particular, there is likely to be a need for significant reorganization of roles and relationships, as well as modes of communication, decisionmaking and problem solving. The extent to which such changes can be made successfully will depend on the quality of functioning in these areas prior to the injury, and the family’s level of cohesion and adaptability. Coping with role changes has been identified as a significant source of stress, particularly by spouses of those who have sustained TBI. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The extent to which family members can successfully adopt new roles will depend on the flexibility of family beliefs, which may be influenced by cultural background, individuals’ experience in adopting different roles and the extent to which resources can be utilized to provide information and support. For example, a wife who has never worked, has been reliant on her husband for management of the family finances, and has difficulty asserting herself is going to find it much more difficult to take responsibility in these areas than one who has well-developed professional skills and previously played an active role in decision-making and financial management. Family therapy is one means of assisting families who have not been able to grieve effectively and to resolve maladaptive patterns of communication and interaction, which impede the adjustment of the injured individual and/or the family. A forum is provided in which family conflicts can be re-enacted and more adaptive strategies developed for resolving issues. Cultural influences and family belief systems can be explored. Families are encouraged to understand that the problems they are experiencing are often more related to the resources, coping styles and family system, than to the limitations of the injured family member. Advocacy The heterogeneity and complexity of problems which result from TBI and Support places considerable demands on families, not only in terms of their Agencies interactions with the injured individual, but also in terms of the necessity to deal with many different professionals and agencies. Both they and the person who is injured are likely to be faced with choices regarding appropriate forms of treatment - who will deliver it and how long it should continue. In many instances there is a need for ongoing negotiation with insurance agencies in order to obtain funding. Later, decisions may be required regarding long-term care, guardianship and legal issues. By virtue of limitations in their background knowledge and capacity to comprehend information provided, the majority of families and TBI individuals are ill equipped to make such decisions. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Emotional distress adds further to their difficulties. In order to ensure that the TBI individual receives the best possible services it is important that assistance is offered to both the injured person and the family through explanation, interpretation, and advocacy. Where no family support exists, advocacy for the person who has sustained the injury becomes even more important. This form of support is frequently offered during the rehabilitation phase, but after discharge the TBI individual and the family has few resources on which to draw. In this respect, agencies such as Headway in Britain, the National Head Injuries Foundation (NHIF) in the USA and Brain Injury Australia offer invaluable service, in assisting brain-injured individuals and their families to negotiate their way through rehabilitation services and options for long-term accommodation and support, to become better informed, and to deal with financial, guardianship and legal issues. Some of these organizations also provide a support network in the form of regional support groups. However, the most important function of these organizations is that of drawing the attention of the public and the government to the unique and devastating consequences of TBI, and the policies and services which are required to meet the needs of TBI individuals and their families. Rehabilitation professionals working with TBI have an obligation to contribute to such efforts. Summary Traumatic brain injury has many causes, including sports injuries, violence, vehicular accidents, and falls. Each instance is unique and outcomes can be difficult to predict, which is why every patient with a potential TBI needs to be appropriately assessed and provided with immediate, intensive care to address his or her needs. Traumatic brain injuries can present with a wide nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com array of symptoms and every symptom needs to be treated seriously. Even cases that present as mild can become serious in a matter of seconds. Over 5 million people in the United States are survivors of traumatic brain injuries. Many of them have long-term disabilities as a result of their injury. Medical professionals who understand the unique needs of TBI patients are the key to minimizing the potential impact of these disabilities. Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Head trauma may include an alteration in consciousness that involves any trauma to the a. Scalp b. skull c. brain d. *All of the above. 2. A majority of traumatic brain injury cases occur as the result of a. gunshot wounds b. *transportation accidents c. sports injuries d. domestic violence 3. Mild injuries typically cause all EXCEPT: a. brief, change in mental status. b. *seizure disorder. c. no long-term adverse affects. d. temporary loss of consciousness. 4. The nervous system is comprised of two regions: a. *Central Nervous System and Peripheral Nervous System b. Central Nervous System and Autonomic Nervous System c. Autonomic Nervous System and Peripheral Nervous System d. Autonomic and Parasympathetic Nervous Systems. 5. The cranial bones include the a. frontal, temporal, occipital, parietal, lacrimal b. *foramen magnum, frontal, temporal, occipital, parietal c. maxilla, malar, temporal, occipital, parietal d. foramen magnum, volar, frontal, temporal, occipital nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. The three layers of the meninges are: a. *dura mater, arachnoid, pia mater b. grey matter, white matter, arachnoid c. arachnoid, pia mater, grey matter d. None of the above. 7. The __________________ is the layer of the meninges that is located closest to the surface of the brain. a. arachnoid b. dura mater c. *pia mater d. None of the above. 8. __________ cranial nerves originate in the brainstem. a. Five b. Eight c. *Ten d. Twelve 9. According to the CDC, approximately ____________ Americans are living with a TBI-related disability. a. *5.3 million b. 7.5 million c. 10 million d. 12.5 million 10. Approximately _______ of TBIs are due to violence, such as firearm assaults and child abuse. a. 15% b. *20% c. 25% d. 30% nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11. About _______ of TBIs are due to sports injuries. a. *3% b. 5% c. 10% d. 22% 12. Leading causes of TBI in combat zones include a. bullets b. blasts c. assaults d. *All of the above. 13. __________________ are a leading cause of TBI for active-duty military personnel in war zones. a. *Blasts b. Motor vehicle-traffic crashes c. Fragments d. Falls 14. The left hemisphere controls the following functions: a. *Speech, comprehension, arithmetic, writing b. Creativity, comprehension, spatial ability, artistic ability c. Creativity, musical skills, artistic skills, writing d. Speech, writing, spatial ability, arithmetic 15. The right hemisphere controls the following functions: a. Speech, writing, spatial ability, arithmetic b. Speech, comprehension, spatial ability, writing c. *Creativity, spatial ability, artistic skills, musical skills d. Creativity, comprehension, spatial ability, artistic ability nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16. The _____________ arteries supply the brain with approximately 80% of the blood flow. a. *carotid b. subclavian c. vertebral d. aortic 17. Broca's area, important in language production, is found in a. *the frontal lobe, usually on the left side. b. the frontal lobe, usually on the right side. c. the occipital lobe, usually on the left side. d. the occipital lobe, usually on the right side. 18. True or False. The carotid arteries are responsible for providing circulation to the anterior region of the brain. a. *True b. False 19. The limbic system includes the a. *hypothalamus, thalamus, amygdala, hippocampus. b. thalamus, thyroid, parathyroid, amygdala c. thalamus, hypothalamus, gonadal, thyroid d. None of the above. 20. True or False. Components of the limbic system are involved in hormone and emotional regulation. a. *True b. False nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21. Blunt trauma produces a ____________ a. *closed head injury b. open injury c. penetrating injuries d. both b and c above. 22. With blunt trauma, one of the following types of force will occur: a. *Deceleration, Acceleration, Acceleration-deceleration, Rotational, Deformation b. Acceleration not deceleration c. Deceleration not acceleration d. Rotational and deformation only 23. True or False. Contracoup injury occur at the site of impact and the coup injury occurs at the opposite side or at the rebound site of impact. a. True b. *False 24. Battle’s Sign is a sign that involves a. *closed Injury b. open injury c. raccoon eyes d. leakage of cerebrospinal fluid 25. True or False. Focal brain injuries are confined to one specific region of the brain. They cause localized damage and are easily identifiable. a. *True b. False nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26. Types of Diffuse Injuries include: a. Extradural, intracranial, brain edema b. *Concussion, brain edema, diffuse axonal injury c. Concussion, contusion, intracranial hematoma d. Brain edema, Intracranial, diffuse axonal injury 27. Intracerebral hematoma (ICH ), subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH ) examples of the types of: a. parietal injuries b. diffuse injuries c. *focal injuries d. Both b and c above. 28. Metabolic changes occur following TBI, such as rate of __________ glucose metabolism lasting for days or weeks. a. *glucose b. protein c. fat d. Both b and c above. 29. Cerebral edema may be caused by a. damage to the walls of cerebral blood vessels. b. accumulation of fluid within the cell as a result of ischemia. c. increased intravascular pressure or obstruction to the flow of cerebrospinal fluid. d. *All of the above. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30. Infection, in the subacute phase after TBI, is a complication associated with skull fracture that manifests as: a. Meningitis b. Cerebral abscess c. Intracranial pressure without brain shift d. Both *a and b above. 31. Decompressive craniectomy surgery involves temporarily removing a portion of _____________ skull bone to increase the volume of the cranial cavity and to decrease intracranial pressure. a. posterior b. parietal c. *frontal d. occipital 32. Early post-traumatic epilepsy usually occurs within the first a. 12 hours b. *24 hours c. 1-3 months d. 3-6 months 33. The following anticonvulsants have been found to be relatively free of adverse cognitive effects a. Phenytoin and Keppra b. Keppra and Lamortrigine c. *Carbamazepine and Valproic acid d. Oxcarbamazepine and Keppra nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34. Severity measures graded during the acute phase sometimes reflect variance due to a. medications used during resuscitation b. substance use c. communication issues d. *All of the above. 35. Mild brain injury involves ______________ of all brain injuries. a. *75%-85% b. 50%-65% c. 45-50% d. <50% 36. In mild brain injury cases, 90% of individuals recover within a. *6-8 weeks b. 3 months c. 4-6 months d. 6 months but sometimes lasting more than a year. 37. True or False: Locked-in Syndrome is a condition indicative of moderate TBI. a. True b. *False 38. In a case of mild TBI there may be symptoms of a. headache b. insomnia c. irritability and anxiety/depression d. *All of the above. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39. The most common causes of mild TBI identified include all EXCEPT: a. *Shaken baby syndrome b. Falls c. Motor vehicle accidents d. Sports-related injuries 40. Attentional difficulty most commonly reported is a. reduced speed of information processing b. difficulties in focusing on more than one thing at once c. coping with complexity d. *All of the above. 41. Impairment of memory for events immediately preceded a TBI is termed a. posttraumatic amnesia b. *retrograde amnesia c. antegrade amnesia d. prodromal amnesia 42. Difficulties to form or deal with abstract concepts for TBI individuals also include: a. inability to generalize from a single instance b. a tendency to focus on specific, concrete aspects - “stimulus-bound”. c. inability to think creatively d. *All of the above. 43. True or False. The TBI individual often encounters inflexibility in thought processes and difficulty to switch from one task to another, leading to frequent repetition or “perseveration” of the same responses, comments, demands or complaints. a. True b. *False nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44. TBI can result in a flatness of affect, where there is reduced emotional responsiveness but NOT an elevation of affect, with euphoria. a. True b. *False 45. Some of the most common cognitive deficits experienced by TBI patients include: a. Attention and filtering issues b. Information coding and retrieval (memory) issues c. Problem solving d. *All of the above. 46. Depending on the injury, the patient may experience neurobehavioral problems, such as a. seizures b. *changes in behavior and attitudes c. Both a and b above. d. None of the above. 47. Treatment for neurobehavioral problems includes a. medication b. electroconvulsive therapy c. behavior modification d. *Answers a and c above. 48. A pupil that is oval in shape may indicate the early compression of _____________ due to increased intracranial pressure. a. cranial nerve II b. *cranial nerve III c. cranial nerve IV d. cranial nerve VII nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49. A headache that is persistent and accompanied by other symptoms, such as drowsiness and personality changes, a. must be assessed immediately. b. is often indicative of an increase in pressure around the brain. c. can be life threatening if left untreated. d. *All of the above. 50. A patient in a coma will need to be assessed using the Glasgow Coma Scale, which is a standardized, 15-point test that measures neurologic functioning using three assessments EXCEPT: a. eye opening. b. best verbal response. c. *best auditory response. d. best motor response. 51. Using the GCS, a score of 8 or less is indicative of a a. Mild head injury b. Moderate head injury c. *Severe head injury d. Catatonic patient 52. The person in a locked-in state a. is vegetative. b. *able to give clear signs of awareness of self and the environment. c. has cerebral glucose metabolism that are severely below normal. d. Both a and c above. 53. Rehabilitation involves a range of therapy services for a. nontraumatic brain injuries b. traumatic brain injuries c. *Both a and b above. d. None of the above. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 54. Children with a TBI parent might a. feel embarrassed and avoid inviting friends home. b. drift away from home and withdraw from their parents c. be reluctant to share their feelings and deny what is happening d. *All of the above. 55. The family system is generally affected when a family member has had a TBI with challenges being: a. significant reorganization of roles and relationships. b. modes of communication. c. decision-making and problem solving. d. *All of the above. 56. Most commonly, diagnostic imaging used for a TBI patient may be a. X-Ray and CT b. *CT and MRI c. EEG and SPECT d. EEG and XRay 57. To target psychotic symptoms of combativeness, hostility, hallucinations, and sleep disorders, _________________medication may be used. a. *antipsychotic b. muscle relaxants c. sedative-hypnotic agents d. sleep and pain 58. Medication used to increase levels of alertness and attention is a. antidepressant b. *stimulant c. memory aid d. antipsychotic nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59. Long-term rehabilitation will typically be conducted in a variety of settings, including all EXCEPT a. hospital outpatient programs b. inpatient rehabilitation centers c. *county prisons d. day treatment programs 60. A subacute rehabilitation program involves a. less intensive level of rehabilitation services over a longer period of time. b. persons who are still progressing but not making rapid functional gains. c. a variety of settings, often a skilled nursing facility or nursing home. d. *All of the above. Correct Answers: 1. d 2. b 3. b 4. a 5. b 6. a 7. c 8. c 11. a 21. a 31. c 41. b 51. c 12. d 22. a 32. b 42. d 52. b 13. a 23. b 33. c 43. b 53. c 14. a 24. a 34. d 44. b 54. d 15. c 25. a 35. a 45. d 55. d 16. a 26. b 36. a 46. b 56. b 17. a 27. c 37. b 47. d 57. a 18. a 28. a 38. d 48. b 58. b 19. a 29. d 39. a 49. d 59. c 20. a 30. d 40. d 50. c 60. d nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9. a 10. b References Section The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text. 1. Andrade AF, Paiva WS, Soares MS, De Amorim R LO, Tavares WM, Teixeira MJ. Classification and management of mild head trauma. Int J Gen Med. 2011;4:175–9. 2. Coles JP. Imaging after brain injury. Br J Anaesth. 2007 Jul 1;99(1):49–60. 3. Rosonke S, Legome E. Head trauma. J Emerg Med. 2006;31:421–5. 4. CDC - Traumatic Brain Injury - Injury Center. 5. Dombovy ML. Traumatic brain injury. Continuum (Minneap Minn). 2011 Jun;17(3 Neurorehabilitation):584–605. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. Butler DL, Hurley RA, Taber KH. Assessment and treatment in polytrauma contexts: Traumatic brain injury and posttraumatic stress disorder. 7. Traumatic Brain Injury [Internet]. [cited 2013 Sep 30]. Available from: http://www.pdhealth.mil/tbi.asp 8. Gavett BE, Stern RA, Cantu RC, Nowinski CJ, McKee AC. Mild traumatic brain injury: a risk factor for neurodegeneration. Alzheimers Res Ther. 2010 Jan;2(3):18. 9. Blast Injuries: Traumatic Brain Injuries [Internet]. Available from: http://www.amtrauma.org/data/files/gallery/BlastInjuryResourcesFileG allery/Blast_InjuryBrain.pdf 10. Corrigan JD, Selassie AW, Orman JAL. The epidemiology of traumatic brain injury. J Head Trauma Rehabil. Jan;25(2):72–80. 11. Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitoring. J Neurotrauma. 2007 Jan;24 Suppl 1:S37–44. 12. New York State Department of Health. Fall Injuries [Internet]. [cited 2013 Oct 1]. Available from: http://www.health.ny.gov/prevention/injury_prevention/fall_injury.htm 13. Pape H-C, Sanders RW, Borrelli J. The Poly-Traumatized Patient with Fractures: A Multi-Disciplinary Approach. Springer; 2011. 14. 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Family satisfaction predicts life satisfaction trajectories over the first 5 years after traumatic brain injury. Rehabil Psychol. 2010;55(2):180– 7. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. 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