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Intracranial Regulation

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Alyssa Zweifel

on 2 May 2017

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Transcript of Intracranial Regulation

TRAUMATIC BRAIN INJURY
What is TBI?
CONCUSSIONS
Defined?
Types of TBI
Defined
How do they happen?
Populations at Risk
What are the symptoms?
REFERENCES
What are the different types of TBI?
Defined
How do they happen?
Populations at Risk
Defined
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.
JAMA,
310(5), 473-474.

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

TBI Epidemiology
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
Age Statistics:
0–4 years old
15 - 24 years old
65+ years old
Causes of TBI
Causes
Includes
all

types
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)
causes:
stroke
near drowning
seizure disorders
electric shock
lightning shock
substance abuse
tumor
infectious disease
Alteration in brain function or other evidence of brain pathology caused by an external force
causes:
falls
assaults
motor-vehicle accidents
sports injuries
struck by/against
Post-Concussion Syndrome (PCS)
depression
isolation
anxiety
Benson et al., 2011; Chen et al.,2008; Echlin et al., 2010; Johnston et al., 2004; McCrory et al., 2009
headaches
dizziness
fatigue
sensitivity to light
suicidal ideation
Psychological issues
Social Impacts
Physical Symptoms
memory loss
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


Athletes
- 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
Other Symptoms:

- 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.

Intracranial Regulation:

The ability of the brain, blood, & CSF to maintain normal intracranial pressure.
Review:
Levels of Protection to the Brain:
Visual
Cortex
Balance Receptors
Sensory Cortex
Motor Cortex
Auditory Cortex
Olfactory Cortex
What are some examples that
alter
the function of the central nervous system?
Breathing, BP,
& Consciousness
Anesthesia, alcohol, lack of oxygen (perfusion), drugs, bleeding, tumor, trauma, low blood sugar, etc.
Scalp lacerations
Skull fractures
Concussion
Contusion
Hematoma
Scalp Lacerations

Very vascular
Complications: blood loss & infections
Skull Fractures
50,000 die from TBI & 275,000 are hospitalized
Types
Manifestations
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
braininjury.com, 2017
Hematoma
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
Emergency Management
Nursing Assessment
Prevention
What diagnostics would you anticipate we need for Tyler?
How will you, as the nurse help decrease Tyler's stimuli?
Surgical Interventions
Medication Management:
How are we going to Monitor ICP?
How will you help maintain normal ICP?
Meningitis Risk:
How is Tyler recovering ?......
Ensure patent airway
Do they need O2
Do they need to be intubated
Stabilize cervical spine
IV access and fluids
Control bleeding
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.
TBI Exemplar
You arrive on the scene of Tyler's accident....What's your priority assessment?

Emergency Management
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
Decerebrate posturing


You are the ER nurse receiving the trauma. What else will you assess when taking over Tyler in the ER?
CT scan
MRI-once stable
Skull radiography
PET scan
EEG
Limit visitors
Monitor VS
Decrease noise
Decrease light
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
Neuro Checks
Pupil response (PERRLA)
Cranial nerves
Reflexes
Other
CSF leak
Vital Signs
Thermoregulation
Child-eating, vomiting
History of event, Loss of consciousness, and behaviors.
How would you know if there's a change in ICP?
Change LOC
Change in VS
Posturing
Headache
Vomiting
Hyperthermia
BREAK TIME!
Interventions
Positioning- HOB 30 degrees
Activity management
Airway management
Bowel management
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......
Primary Prevention
Healthy Lifestyle
Injury Prevention
Education
Secondary Prevention
Early recognition
abusive situations
Acute Interventions
Maintaining Normal ICP
Tertiary Prevention
Managing long-term health issues
Rehabilitation
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
Pre-op Teaching
Emotional support
Decrease fears
Expectations post-op
Helps relieve anxiety of unknown
Removal of hair
ICU monitoring
Post-op Cares
Monitoring ICP (
Prevent increased ICP
)
Pain control
Nausea relief
Surgical dressing
Drainage
Prevent infection
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?
Coma
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
Pain
Self care-ADL's
Speech Therapy & Psychologist
Cognitive process speed
Attention-impulsive
Problem solving skills
Judgment 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?
TurningPoint Questions..
Brain Death?
A few NCLEX style Questions in turning point.......
Rancho Los Amigos Scale
Drainage CSF-amount how fast
Site care/dressing
Patient's neuro status
What would the potential complications be?
Infection biggest risk factor
Draining CSF off too fast
Ongoing Monitoring
ICP monitoring
I & O's
Fluid & Electrolyte imbalances
Respiratory function
Position & activity
Safety
Nutrition
Psychological considerations
Break Time!
Break Time!
Rupture of intracerebral vessels
What are ways to quickly assess for injuries?
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