Brain Injury Final

8/9/2019 Brain Injury Final

1/38


2/38

DEFINITION

damage to the brain resulting from

external mechanical force, such as rapid

acceleration or deceleration, impact, blast

waves, or penetration by a projectile

Usually classified based on severity and

mechanism

fall under the classification of central

nervous system injuries and neurotrauma


3/38

EPIDEMIOLOGY

(TBI) is a leading cause of death for persons under

age 45

Approximately 5 million Americans currently suffer

some form of TBI disability

The leading causes of TBI are motor vehicle

accidents, firearm injuries and falls


4/38

ANATOMY AND PHYSIOLOGY


5/38


6/38

Closed (blunt) brain injury

occurs when the head accelerates and

then rapidly decelerates or collides with

another object (eg, a wall or dashboard

of a car) and brain tissue is damaged

Scalp is intact and there is no

communication between the intradural

contents and the atmosphere


7/38

Concussion

temporary loss of neurologic function with noapparent structural damage

involves a period of unconsciousness lastingfrom a few seconds to a few minutes

jarring of the brain may be so slight as tocause only dizziness and spots before theeyes (seeing stars), or it may be severeenough to cause complete loss ofconsciousness for a time

postconcussion syndrome - headache,dizziness, lethargy, irritability, and anxiety

frontal lobe - is affected, the patient may exhibit bizarre irrationalbehavior

temporal lobe - can produce temporary amnesia or disorientation


8/38

contusion

more severe injury in which the brain is bruised,with possible surface hemorrhage

signs and symptoms depend on the size of thecontusion and the amount of associatedcerebral edema

patient may be aroused with effort but soonslips back into unconsciousness

patients with severe brain injury may haveabnormal motor function, abnormal eyemovements, and elevated ICP have pooroutcomesthat is, brain damage, disability, ordeath

patient may recover consciousness but pass

into a stage of cerebral irritability


9/38

COUP CONTRECOUP INJURY

associated with cerebral contusion

coup injury

occurs under the site of impact with

an object

Typical when a moving object

impacts the stationary head

Contrecoup injury

occurs on the side opposite the

area that was impacted

typical when a moving head strikes

a stationary object


10/38


11/38

DIFFUSE AXONAL INJURY

involves widespread damage to axons inthe cerebral hemispheres, corpus

callosum, and brain stem

patient has no lucid intervals andexperiences immediate coma, decorticate

and decerebrate posturing and global

cerebral edema

Recovery depends on the severity of the

axonal injury


12/38


13/38

Open brain injury

occurs when an object penetrates the

skull, breaches the dura mater, the

outermost membrane of the brain

(penetrating injury), or when blunt

trauma to the head is so severe that itopens the scalp, skull, and dura to

expose the brain


14/38


15/38

Intracranial Hemorrhage

Hematomas (collections of blood) that develop

within the cranial vault

may be epidural (above the dura), subdural(below the dura), or intracerebral (within thebrain)

Major symptoms are frequently delayed untilthe hematoma is large enough to causedistortion of the brain and increased ICP

signs and symptoms of cerebral ischemiaresulting from the compression by a hematomaare variable and depend on the speed withwhich vital areas are affected and the area thatis injured


16/38

EPIDURAL HEMATOMA

blood may collect in the epidural (extradural)

space between the skull and the dura

from a skull fracture that causes a rupture or

laceration of the middle meningeal artery (runs

between the dura and the skull inferior to a thin

portion of temporal bone)

momentary loss of consciousness at the time

of injury, followed by an interval of apparent

recovery (lucid interval)

considered an extreme emergency because

marked neurologic deficit or even respiratory

arrest can occur within minutes.


17/38


18/38

SUBDURAL HEMATOMA

collection of blood between the dura and

the brain, a space normally occupied by a

thin cushion of fluid

More frequently venous in origin due tothe rupture of small blood vessels

may also occur from coagulopathies or

rupture of an aneurysm


19/38


20/38

ACUTE SUBDURAL HEMATOMA

associated with major head injury involvingcontusion or laceration

symptoms develop over 24 to 48 hours

changes in the level of consciousness

(LOC), pupillary signs, and hemiparesis

Cushings triad


21/38

SUBACUTE SUBDURAL HEMATOMA

result of less severe contusions and head

trauma

manifestations usually appear between 48

hours and 2 weeks after the injury


22/38

CHRONIC SUBDURAL HEMATOMA

Can develop from seemingly minor head injuriesand are seen most frequently in the elderly

time between injury and onset of symptoms may

be lengthy ( 3 weeks to months)

resembles other conditions and may be mistaken

for a stroke

less profuse bleeding and there is compression

of the intracranial contents

Blood within the brain changes in character in 2

to 4 days, becoming thicker and darker


23/38

INTRACEREBRAL HEMORRHAGE AND

HEMATOMA

bleeding into the substance of the brain

commonly seen in head injuries when

force is exerted to the head over a smallarea

may also result from systemic

hypertension, bleeding disorders


24/38


25/38

PATHOPHYSIOLOGY


26/38

Precipitating factors

Increased intracranial

volume

Compensated by

displacement ofCSF and

venous blood

Traumatic injury

Increase pressure on blood

vessels

intracranial pressure

increases

Rigid cranium allows no

room for expansion

Brain swelling and

bleeding

Predisposing factors


27/38

Brain herniation to the brainstem and pons

FurtherIncrease in ICP

Further expansion of

mass

Small rise in volume

Cerebral hypoxia

Decreased and slowed

blood flow to the brain

Cerebral ischemia

decompensation

infarction

Stroke

Cerebral edema hemorrhage

Brain death


28/38

Manifestations

excessive sleepiness

inattention

difficulty concentrating

impaired memory, faulty judgment,depression, irritability,

emotional outbursts, disturbed sleep,

diminished libido

difficulty switching between two tasks, andslowed thinking


29/38

DIAGNOSTIC EXAMINATIONS

MRI

slice the brain radiographically into

slabs

more detail than the CAT scan Uses magnetic fields

Detects brain damage as small as 1-

2mm in size

Better in detecting the remnants of oldhemorrhaged blood, called hemosiderin

can detect this myelin degeneration as

white matter hyperintensities


30/38

CT SCAN

uses x-rays

CAT scan is superior to the MRI in

detecting fresh blood in and around the

brain

often repeated to insure that a braininjury is not becoming more extensive


31/38

EEG

Monitors the brain's electrical activity bymeans of wires attached to the patient's

scalp

If the patient is awake, any slowing of

electrical activity in a focal area of thebrain may indicate a lesion there


32/38

PET Scan

Positron emission tomography inhaling radioactive glucose and placing

the patient's head under a large geiger

counter, one can identify abnormal areas

of the brain that are underutilizing glucose


33/38

NURSING MANAGEMENT


34/38

Ineffectivecerebraltissueperfusion related

to increased ICP and intracranial bleeding

INTERVENTIONS

Continually assess for presence of visual, sensory/motorchanges, headache, dizziness, and aboratory results

Elevate head of bed to 30-45 degrees and maintain

head/neck alignment

Administer medications and oxygen as ordered by the MD

Avoid measures that may trigger increase in ICP s/a

straining, strenuous coughing, flexing the neck

Identify necessary changes in lifestyle to be incorporated in

his ADLs

CUES:Altered mental status, restless, confusion, weakness, changes in LOC,speech abnormalities, changes in motor response

NOC: Tissue Perfusion: Cerebral

NIC: Cerebral Perfusion Promotion


35/38

Acute Pain relatedto brain injury

CUES:

guarding behavior, narrowed focus, facial grimace, reports a painscale of 6-10 / 10, restless, distracting behavior, increase in BP, HR

NOC: increased comfort level and pain control

NIC: pain management

INTERVENTIONS

Continually assess the PQRST of pain and changes ingeneral condition and vital signs

Provide rest periods to facilitate comfort, sleep, and

relaxation. The patients experiences of pain may become

exaggerated as the result of fatigue.

Provide anticipatory instruction on pain causes, appropriate

prevention, and relief measures

Administer pharmacologic treatment as ordered by the MD


36/38

Deficient fluid volume relatedtodecreased LOC

and bloodloss

INTERVENTIONS

Monitor and document vital signs, skin turgor and mucusmembranes, monitor active fluid loss from wound

drainage and maintain accurate input and output

Document baseline mental status and monitor for any

changes

Administer medications, parenteral fluids and blood

products as ordered and continuously assess for

circulatory overload

Assist in maintaining proper nutrition and hydration

CUES:

Increased pulse rate, Decreased skin turgor, Dry mucousmembranes, Weakness, hypotension, thirst,

NOC: hydration

NIC: fluid resuscitation


37/38

Risk for injury related to disorientation, restlessness, or

brain damage

Imbalanced nutrition, less than body requirements,

related to increased metabolic demands, fluid restriction,

and inadequate intake


38/38

REFERENCES

http://www.braininjury.com/injured.html

http://www.braininjury.com/diagnostic.html

http://www.medscape.com/viewarticle/464

563_4

Documents

Brain Injury Final