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Transcript of Intracranial Regulation
What is TBI?
Types of TBI
How do they happen?
Populations at Risk
What are the symptoms?
What are the different types of TBI?
How do they happen?
Populations at Risk
Traumatic brain injury is broadly defined as an
alteration in brain function.
Caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts normal function of the brain" (CDC, 2016).
Manley, G.T., & Maas, A.R. (2013). Traumatic Brain Injury: An International Knowledge-Based Approach.
Mccrory, P., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R. J., . . . Sills, A. (2013). Consensus Statement on Concussion in Sport—the 4th International Conference on Concussion in Sport Held in Zurich, November 2012. Clinical Journal of Sport Medicine, 23(2), 89-117
Each year in the United States, at least 1.7 million people seek medical attention for TBI
CDC, 2006-2010 data, Lewis,2013
Centers for Disease Control and Prevention, QuickStats (2010). Injury and Traumatic Brain Injury (TBI)-Related Death Rates, by Age Group – United States, 2006. MMWR 59: 303.
Most likely to acquire TBI through being struck by or against an opposing force
Motor vehicle crashes are the most common cause of TBIs
Fall-related TBI visits comprise 61% of all TBIs for persons within the age group of 65 years old and older
0–4 years old
15 - 24 years old
65+ years old
Causes of TBI
of traumatic brain injuries including those caused after birth by cerebral vascular accidents as well as those caused by external forces.
Acquired Brain Injury (ABI)
Traumatic Brain Injury (TBI)
Alteration in brain function or other evidence of brain pathology caused by an external force
Post-Concussion Syndrome (PCS)
Benson et al., 2011; Chen et al.,2008; Echlin et al., 2010; Johnston et al., 2004; McCrory et al., 2009
sensitivity to light
Mortimer, J., van Duijn, C., Chandra, V., & EURODEM Risk Factors Research Group. (1991). Head trauma as a risk factor for Alzheimer’s disease: a collaborative re-analysis of case-control studies.
Int J Epidemiol
, 20(2), S28–35.
Concussions are the most common type of TBI
Concussions can occur when there is significant impact force delivered to the head, either through direct or indirect contact
The impact force can be linear, rotational, or angular
- football, *hockey, rugby, and boxing are the most risky, but non-contact athletes can be concussed as well
People involved in motor vehicle collisions
People involved in slips, trips, or falls
Skiing / snowboarding and water skiing / wake boarding
- difficulty balancing
- visual problems
- lack of motor coordination
- difficulty focusing and paying attention
Post-concussion Syndrome-Can develop 2 weeks to 2 months after injury. It can affect the patients ability to perform ADL's.
The ability of the brain, blood, & CSF to maintain normal intracranial pressure.
Levels of Protection to the Brain:
What are some examples that
the function of the central nervous system?
Anesthesia, alcohol, lack of oxygen (perfusion), drugs, bleeding, tumor, trauma, low blood sugar, etc.
Complications: blood loss & infections
50,000 die from TBI & 275,000 are hospitalized
Linear or Depressed
Closed or Open
Simple, Comminuted, or Compound
Location of the fracture depends on the clinical manifestations.
CSF can leak from nose or ear.
Contusion-bruising of the brain tissue
Epidural-bleeding between the dura & inner surface of the skull
Subdural-bleeding between dura mater & arachnoid layer of the meninges (slower to develop)
Epidural hemotama's happen quickly and typically need surgical interventions
S&S: unconsciousness or decreased LOC, headache, nausea, vomiting
What diagnostics would you anticipate we need for Tyler?
How will you, as the nurse help decrease Tyler's stimuli?
How are we going to Monitor ICP?
How will you help maintain normal ICP?
How is Tyler recovering ?......
Ensure patent airway
Do they need O2
Do they need to be intubated
Stabilize cervical spine
IV access and fluids
Assess LOC, use GCS
Monitor vital signs and heart rhythm
Keep patient warm
Assess for wounds and CSF leaking
Let's meet your first patient....Tyler.
You arrive on the scene of Tyler's accident....What's your priority assessment?
Tyler..18 year old male brought to the ER after MVA.
Multiple family members in waiting room
Girlfriend died on scene
Hospital chaplain available
Glascow coma scale 8
You are the ER nurse receiving the trauma. What else will you assess when taking over Tyler in the ER?
Give him familiar objects
Keep family involved
Keep the patient and staff safe
Initial A,B,C's and history is done
Glasgow Coma Scale
Pupil response (PERRLA)
History of event, Loss of consciousness, and behaviors.
How would you know if there's a change in ICP?
Change in VS
Positioning- HOB 30 degrees
Decrease metabolic demand-no fever, agitation, pain, shivering
Nutritional needs-avoid hyperglycemia
Monitor I&0's, NS preferred IV fluid-dextrose can increase cerebral edema
Review from last week......
Maintaining Normal ICP
Managing long-term health issues
Who would be candidates for surgical interventions?
Cranial surgery-remove tumor, CNS infection, trauma, seizure disorder, vascular abnormalities, intracranial bleeding, shunting abnormalities.
What preoperative teaching should you include?
What will be your post-operative nursing assessments & interventions?
Burr holes-remove fluid or blood
Craniotomy- relieve ICP (multiple causes)
Craniectomy-cut away bone flap
Cranioplasty-repair defects from trauma or malformations
Helps relieve anxiety of unknown
Removal of hair
Monitoring ICP (
Prevent increased ICP
Head protection-if bone flap removed
I & O's-monitor for SIADH & diabetes insipidus
Monitor LOC, Neuros, VS etc.
Sodium regulation is important
What's the best position for your patient?
Mannitol (Osmitrol)-osmotic diuretic, decrease ICP, give IV
Hypertonic solutions-decrease ICP, but need run slow, frequent monitoring and Na checks
Corticosteroids (dexamethasone (Decadron)-NOT head injuries, more for tumor to decrease edema
Barbiturates-decrease ICP & cerebral metabolism, monitor with EEG
Pain-opioids (morphine & fentanyl) rapid onset and minimal effect to CSF
Anxiety or sedation (Dexmedetomidine (Precedex) or (propofol (Diprivan)
Anti-hypertensives-to control BP & anti-seizure meds if needed
The BAD and the ugly:
As review: What would be your very concerning assessment findings (think increasing ICP)?
LOC change is your MOST sensitive indicator to increased ICP
Cushings Triad- systolic hypertension, bradycardia, irregular respiration
Pupils-fixed and dilated
Diagnostic of brain death...
The GOOD.... Rehabilitation
From the video what are Tyler's Rehab needs?
Absence of brainstem reflexes
Absence of ocular movements
Unable to manage core temperature
Unable to maintain BP alone
Apnea-no breathing drive
Ancillary tests: EEG, Cerebral angiography, transcranial dopplers
Physical & Occupational Therapy
Mobility-pelvic fx and great toe amputee
Speech Therapy & Psychologist
Cognitive process speed
Problem solving skills
Increased risk from open wound & CNS leak
S&S: fever, headache, N & V, nuchal rigidity, cranial nerve dysfunctions
Diagnostics: blood culture, CT scan, Lumbar puncture
Bacterial or Viral?
A few NCLEX style Questions in turning point.......
Rancho Los Amigos Scale
Drainage CSF-amount how fast
Patient's neuro status
What would the potential complications be?
Infection biggest risk factor
Draining CSF off too fast
I & O's
Fluid & Electrolyte imbalances
Position & activity
Rupture of intracerebral vessels
What are ways to quickly assess for injuries?
What are your subjective and objective findings?