TRAUMATIC BRAIN INJURY (TBI)

Written by: Beth Frisby, RN, BSN, CEN, CCRN, CFRN, RNC-OB

Julia Sandoval RN, BSN, CFRN, CCRN

06/20/2019

Objectives

1. Discuss common mechanism of TBI.

2. Identify common TBI.

3. Identify clinical presentation of the patient

with a TBI.

4. Discuss medical management of patient

diagnosed with TBI.

5. Scenario training.

Disclaimer

• No financial disclosures

Common mechanisms in TBI

• MVC

• Falls

• Occupational

• Recreational

• Assaults

• Risk factor: Being male

Acceleration/Deceleration

• Video

COUP - CONTRECOUP INJURY

• Primary injury

• Secondary injury

Primary vs. Secondary Brain Injury

Secondary Brain Injury

• Occurs in the minutes, hours, and days

following impact.

ABRUPT SYMPTOMS and RISK FACTORS. • Unwitnessed or unrecognized Seizure with post-ictal deficits

• Migraines

• Systemic Infections

• Tumors (more often a slower presentation)

• Psychogenic Paralysis (Diagnosis of exclusion) (Conversion disorder)

• Chronic SDH

• Cardiac Failure

• Toxic-metabolic disturbances (Hyperglycemia; Hypoglycemia< 45mg/dl,often improves with glucose; Hyponatremia, Hepatic Encephalopathy)

• Syncope

• Vertigo

Differential Diagnosis

Concussion

No identifiable lesion;

N/V, confusion,

disorientation, memory

loss, seizure

• Post-concussion

syndrome: symptoms

remain for an

extended time;

• Head CT: Negative

Post Concussion Symptoms

• Neuropsychiatric Impairments– Headaches

– Slow/difficulty responding to questions

– Inability to focus attention

– Emotionally labile

– Memory deficits

– Disruption in speech

– Must have resolution of all impairments before returning to sport• Second impact syndrome

Assessment for CT scan

• Canadian CT head Rule (CCHR)

• New Orleans/Charity Head Trauma/Injury

Rule (NOC)

• National Emergency X-Radiography

Utilization Study II (NEXUS II)

• Pediatric Emergency Care Applied

Research Network (PECARN)

Canadian CT Head Rule CCHR

https://canadiem.org/head-injuries-getting-it-right/

Pediatric Emergency Care Applied Research

Network PECARNS

https://www.aliem.com/2017/06/pecarn-pediatric-head-trauma-official-visual-decision-aid/

PECARNS over 2 years

https://canadiem.org/the-pecarn-pediatric-head-ct-rule-project/

• Etiology: acceleration-

deceleration thus the

shearing of axons

• A widespread disruption

of neurologic function

without focal lesions

• 12-24hrs later tiny

punctate lesions are seen

on CT

• Diffuse swelling, white

matter degeneration,

axon damage

• Immediate LOC, last days

to months with normal

ICP

• Posturing

• Loss of brainstem

reflexes

Diffuse Axonal Injury

Diffuse Axonal Injury

• 12-48 hours later

• Initial scan often WNL

Epidural

• Hemorrhage between skull and dura mater

• Most common is temporal impact, middle meningeal artery

• (+) LOC, can have brief lucid period then rapid decline

• Need evacuation emergent

• Prognosis if bleed

evac’d early can be

good! Delays bring

mortality rate to 50%.

• Often Lens shaped in

appearance on CT

scan

Epidural Hematoma

Middle Meningeal ArteryTemporal blow, middle meningeal artery

Epidural Hematoma

Protectors of the brain…

THE “B” TEAM: THE SKULL

Thinnest

portions

Epidural Hematoma

Epidural Hematoma with shift

Epidural Hemorrhage

• Cranial fractures are present in 70% to

90% of cases.

• 90% of epidural hematomas are caused

by head trauma with a skull fracture that

crosses a portion of the middle meningeal

artery or vein.

• The middle meningeal artery is torn in

60% of cases.

• Collection of blood between the dura mater and the arachnoid layer of the meninges

• Bridging veins torn

1. Acute (48hrs)

2. Subacute (2-14days)

3. Chronic (>14days)

Generally needs emergent evacuation

Subdural Hemorrhage

Subdural Hematoma

Subdural Hematoma

Subarachnoid Hemorrhage

• A diffuse collection of

blood between the

arachnoid mater and

the pia mater, from

SA vessels

• Seizure, vomiting,

LOC?

• 50% of traumatic

bleeds have SAH

Subarachnoid Hemorrhage

Brain Stem Hemorrhage

• Primary: direct blow or torsion

• Secondary: Compression from elevated

ICP’s, edema

– Midbrain: deep coma, fixed pupils at midpoint,

posturing (decerebration)

– Pons: Coma, small (pinpoint) nonreactive

pupils, opthalmophlegia, decerebration.

Skull Fractures

• Depressed

– Pushes the skull into the brain

• Basilar

– Occurs most commonly in temporal bone

• Middle meningial artery and vein

– Raccoon eyes

– Rhinorrhea or Otorrhea

– Hemotympanum

– Facial nerve palsies

• Linear

Pneumocephalus and CSF leak

• Most often seen with Basilar skull fracture

– CSF leak is slightly increased risk of

meningitis

• Not usually given antibiotic prophylaxis

• Usually resolve in 7 days

• Prompt recognition and treatment can improve

outcome

• Minimize secondary injury….

TBI: Goals

• Elevated ICP

• Low CPP

• Systemic hypotension/shock

• Hypoventilation/hypoxemia

• Hyperventilation

• Brain edema

• Brain herniation

• Brain hemorrhage

• Cerebral arterial vasospasm

• Inflammation

• Hyperthemia

• Chronic systemic illness

Secondary Brain Injury

• Inadequate fluid or blood

resuscitation

• Inadequate oxygen

delivery

• Hyperventilation

• Nosocomial infections

• Alcohol and other drug

intoxication

• Anticoagulants

Intrinsic Extrinsic or Iatrogenic

• Remember neuro exams can change fast

so use for first exam as a base to follow!

Glasgow Coma Scale

Primary Survey

• A irway: Patent?

• B reathing: tachypnea common, SpO2>94%

• C irculation: normotensive

• D isability: (before medication/RSI)

Directed Neuro: GCS, Pupils, motor Strength, gross sensory

• E xposure: Trauma?

• Comatose?

• Posturing: abnormal flexion or extension of extremities in response to pain (Brainstem)

• Preferential gaze?

• Abnormal changes in breathing

• VS changes: CUSHINGS TRIAD:

– HTN with widened pulse pressure, BRADY-CARDIA, RESPIRATORY CHANGES (decreased) (Brainstem). (THIS IS A SIGN OF IMPENDING HERNIATION!!!! )

RSI

• Place pt on high flow

N/C for intubation can

increase reservoir

and buy you extra

time during intubation.

• Lidocaine

– May decrease ICP

– May do nothing

• Ketamine/Etomidate

• Succinylcholine/

• Rocuronium

Management of TBI

• HOB elevated

• Neck aligned, no knee / hip flexion

• C-collar (too tight??)

• Keep ETCO2 35

• PaCO2 35-38

• Normothermic

• Sat’s >94% (avoid hypoxia / hyperventilation)

• Control Pain / Keep sedated

• Mannitol if needed

• Euvolemic– Foley

• Normotensive

• Benzodiazepines – Levetiracetam (Keppra)

– 1000mg IVPB over 15min

then Q12hr.

– Fosphenytoin (Cerebryx)

load (15mg/kg, max

150mg) then Q 8hr. OR

Seizure

Prevention

Coagulopathies

• Release of

thromblplastin and

tissue-activating

proteins from TBI.

• PT, PTT

• treat with FFP

• S/S of elevated ICP? Intubate and control ETCO2

• Maintain neck alignment

• HOB 30

• Analgesics IVP or gtts

• Midazolam IVP or gtt

• Proprofol gtt

• Paralyze (Nimbex, rocuronium)

• Mannitol if showing S/S of potential herniation. – 1mg/kg

Manage Increase Cerebral Pressure (ICP)

https://www.iemoji.com/view/emoji/2493/smileys-people/exploding-head

Hyperventilation and TBI

• Decrease in PaCO2 leads to decrease in

cerebral blood flow

• Linked to worse outcomes

• Goal is to have PaCO2 at 35

Hypotension and TBI

• Spaite et al

– Increased mortality with decreased blood

pressure

– Threshold of 90mmHg may be too low

– Increased mortality with every 10 point

grouping decrease in blood pressure

– Prevent secondary injury

• Even one low blood pressure can increase

mortality as blood flow to brain decreases.

Hypoxia

• Brain doesn't get enough oxygen and cells

will start to die

In Summary

• Treat primary injury and prevent

secondary injury

• Rememer the "H" Bombs

– Hypotension

– Hyperventilation

– Hypoxia

Bibliography

• https://www.uptodate.com/contents/emergency-airway-management-in-the-patient-with-elevated-

icp?source=history_widget

• https://www.uptodate.com/contents/management-of-acute-severe-traumatic-brain-

injury?source=history_widget

• https://www.uptodate.com/contents/pretreatment-medications-for-rapid-sequence-intubation-in-

adults-outside-the-operating-room?source=history_widget

• https://www.uptodate.com/contents/cerebrospinal-fluid-physiology-and-utility-of-an-examination-in-

disease-states?source=history_widget

• https://www.uptodate.com/contents/skull-fractures-in-children-clinical-manifestations-diagnosis-

and-management?source=history_widget

• https://www.uptodate.com/contents/acute-mild-traumatic-brain-injury-concussion-in-

adults?source=history_widget

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637731/

• https://www.uptodate.com/contents/severe-traumatic-brain-injury-in-children-initial-evaluation-and-

management?search=blood%20pressure%20traumatic%20brain%20injury&source=search_result

&selectedTitle=1~150&usage_type=default&display_rank=1

• https://www.uptodate.com/contents/management-of-acute-severe-traumatic-brain-

injury?search=blood%20pressure%20traumatic%20brain%20injury&source=search_result&select

edTitle=2~150&usage_type=default&display_rank=2

• https://www.uptodate.com/contents/sequelae-of-mild-traumatic-brain-

injury?sectionName=Second%20impact%20syndrome&search=second%20impact%20syndrome

&topicRef=91282&anchor=H4093484671&source=see_link#H4093484671

Bibliography

• https://canadiem.org/head-injuries-getting-it-right/

• https://www.aliem.com/2017/06/pecarn-pediatric-head-trauma-official-visual-decision-aid/

• https://www.uptodate.com/contents/evaluation-of-stupor-and-coma-in-

children?search=uncal%20herniation%20and%20pupils&source=search_result&selectedTitle=1~150&usage_type

=default&display_rank=1

• https://www.uptodate.com/contents/minor-head-trauma-in-infants-and-children-

evaluation?search=pecarn%20rules&source=search_result&selectedTitle=1~150&usage_type=default&display_ra

nk=1

• https://www.uptodate.com/contents/internuclear-

ophthalmoparesis?search=external%20ophthalmoplegia%20and%20trauma&source=search_result&selectedTitle

=1~150&usage_type=default&display_rank=1#H15

• https://www.uptodate.com/contents/intracranial-subdural-hematoma-in-children-epidemiology-anatomy-and-

pathophysiology?search=traumatic%20subdural%20hematoma%20injuries&source=search_result&selectedTitle=

1~150&usage_type=default&display_rank=1

• https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-children-clinical-features-diagnosis-and-

management?search=traumatic%20epidural%20hematoma%20injuries&source=search_result&selectedTitle=1~1

50&usage_type=default&display_rank=1

TRANSEXAMIC ACID (TXA)

Written by: Beth Frisby, RN,BSN, CEN, CCRN, CFRN, RNC-OB

Julia Sandoval RN, BSN, CFRN, CCRN

06/20/2019

Objectives

1. Discuss the history of TXA.

2. How does TXA work?

3. Identify clinical applications of TXA.

4. Overview of dosing of TXA.

5. Take home points.

Disclaimer

• No financial disclosures

History of TXA administration in Trauma

• 1962- A Japanese husband

and wife team publish in

Keio Journal of Medicine

• 2010- CRASH-2 in Lancet

• 2012- MATTERs

• 2017- WHO updates

recommendations based

on WOMAN trial

How does TXA work?

• TXA binds to

plasminogen’s lysine

receptor site

• Blocks the conversion

of plasminogen to

plasmin

• Less plasmin, thus

less fibrin (clot) break

down occurs https://hipandkneebook.com/hemostasis

Applications

Approved use in US

• Tooth extraction in

patients with

hemophilias

• menorrhagia

“Off-label” use in the US

• Traumatic

hemorrhage

• Total joint arthroplasty

• Cardiac surgery

• Post partum

hemorrhage

http://s.hswstatic.com/gif/tooth-extraction-1.jpg

https://www.springermedizin.de/polytrauma/755660-themenseite/11070372

Administration

Adult:

• 1gram in 100mL of NS/LR over 10 min WITHIN 3 HOURS of INJURY

• Followed by…

• 1gram in 1000mL NS over 8 hours within 6 hours of first dose

Pediatric:

• 15 mg/kg to a max of 1 gram over 10 min WITHIN 3 HOURS of INJURY

• Followed by…

• 2mg/kg/hour – within 6 hours of first

dose

– For at least 8 hours or until bleeding subsides

Traumatic hemorrhage with SBP<90

Contraindications/precautions

• Greater than 3 hours

since injury

• Hypersensitivity to

TXA

http://clipart-library.com/images/6ir5b8MBT.jpg

Take home points

• Traumatic hemorrhage

• SBP<90

• 1st dose MUST be given WITHIN 3 hours

• Don’t forget the 2nd dose within 6 hours

Bibliography

• https://www.ncbi.nlm.nih.gov/books/NBK532909/

• http://www.txacentral.org/history

• https://maternova.net/blogs/news/txa-recommended-by-who-for-pph-treatment

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086904/

• https://www.ncbi.nlm.nih.gov/pubmed/23477634

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