PATHOPHYSIOLOGY OF A TBI. 1. Brain _______ occurs. 2. swelling or bleeding _________ intracranial volume. 3. ____ increases due to the blood or edema having nowhere to go. 4.This pressure on the blood vessels causes blood flow to the brain to slow/ stop, resulting in cerebral ________ + ____________. 5. ICP will continue to rise causing the brain to _______. 6. cerebral blood flow ________.

1. injury 2. increases 3. ICP 4. hypoxia + ischemia 5. herniate (the brain is being pushed out of its normal placement) 6. ceases

TBI Powerpoint Flashcards by Christina Fiorelli

Coup is the ________ impact and contrecoup is the _________ impact. This type of injury s most common with w/ car accidents.

primary, secondary

this is where damage is present at the site of impact and on the opposite side

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is this the definition of Primary or Secondary injury?

the consequence of direct contact to brain or head during initial injury.

this is primary injury

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are these examples of primary or secondary injury?

-contusions
-lacerations
-external hematomas
-skull fractures
-subdural hematomas
-concussion
-DAI

PRIMARY

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is this the definition of Primary or Secondary injury?

damage that develops hours or days after the initial injury.

this is secondary injury

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___________ injury occurs due to cerebral edema, ischemia or chemical changes associated with the injury/ trauma.

secondary

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PATHOPHYSIOLOGY OF A TBI.

Brain _______ occurs.
swelling or bleeding _________ intracranial volume.
____ increases due to the blood or edema having nowhere to go.
4.This pressure on the blood vessels causes blood flow to the brain to slow/ stop, resulting in cerebral ________ + ____________.
ICP will continue to rise causing the brain to _______.
cerebral blood flow ________.

injury
increases
ICP
hypoxia + ischemia
herniate (the brain is being pushed out of its normal placement)
ceases

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what are 4 S/S of increasing ICP?

-severe headache
-seizures
-changes in LOC
-N/V

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when a patient has increased ICP or is at risk of developing increased ICP, their HOB can’t be any lower than ___ degrees.

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_________________ is a temporary loss of
neurologic function/ consciousness with no apparent structural damage to the brain.

Concussion

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__________ is a bruising of the brain surface. symptoms and recovery depend on damage + edema present; there can be longer periods of unconsciousness, deficits and changes in vital signs.

Contusion

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scalp wounds tend to bleed _______ and are portals for ________.

heavily, infection —> this is why it is important to make sure your patient gets PROPHYLACTIC ANTIBIOTICS

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what are 4 characteristics of skull fractures to the base of the skull?

-localized, persistent pain
-bleeding from nose, pharynx or ears
-battle sign
-halo sign (CSF leak)

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what is the “battle sign” associated with a skull fracture?

ecchymosis or bruising behind the ears

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what is the “halo sign” associated with a skull fracture?

this is indicating there is a CSF leak - there will be a ring or “halo” around the blood stain

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How long does the C-Collar stay on the patient after they experienced injury or possible injury to the brain and/or head?

the cervical collar stays on until there is an x ray done to rule out injury

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what is the “racoon sign” associated with head injury + TBI, more specifically basilar skull fractures?

this is periorbital ecchymosis (bruising around the eyes)

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What is another name for an acceleration/ deceleration injury?

Coup - Contrecoup

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Closed TBI’s are caused by blunt trauma to the head WITHOUT anything penetrating the skull. what are 4 examples of this type of injury?

-concussion
-contusion
-coup-contrecoup
-DAI

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An open TBI is when an object ______________ the brain or a trauma is so severe that the skull and scalp are open.

penetrates

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A head trauma is labeled a __________ when abnormal loss of consciousness lasts less than 6 hours, but when it lasts more than 6 hours it’s labeled as an ________ ________ __________.

concussion; diffuse axonal injury

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diffuse axonal injuries are TBI’s where lesions are widespread through the white matter (deep parts of the brain) - affecting the ______, which normally allow the patient to function properly.

axons

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how do diffuse axonal injuries (TBI) occur?

DAI’s occur frim acceleration/ deceleration injuries like MVA’s, motorcycle accidents, falls, sports injuries and shaken baby syndrome. this specific injury occurs due to a twisting or rotating that damages the axons in the white matter (subcortical tissue); this is severe and life-threatening, these patients often don’t wake up and if they do they have severe deficits

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DAI is caused by acceleration/ deceleration injuries. What kinds of things cause that movement?

-MVA/ motorcycle accidents
-falls
-sports injuries
-shaken baby syndrome

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what are the S/S o a DAI? (6)

N/V
loss of consciousness
headache
loss of balance
disoriented
confusion

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What is the imaging test that can diagnose DAI?

MRI

The goal of treatment for a DAI, is to reduce swelling/ ICP, what kinds of things are we going to give and do for these patients?

-steroids + anti-inflammatory's -diuretics (mannitol) -hyperoxygenation -anti-seizure meds + seizure precautions -OT/PT/ ST -nutrition

true or false? -majority of concussions resolve on their own with the proper physical and cognitive rest.

true

Translational, Rotational and Angular are the 3 types of concussions, which 2 are the most severe because they result in a loss of consciousness?

Rotational and angular

a concussion an be a result or a direct forceful blow from an object or an indirect blow, what are 2 examples of indirect blows?

whiplash and shaken baby syndrome

what are 4 examples of causes of a concussion?

falls contact sports MVA physical abuse

after a concussion is diagnosed, what needs to be monitored for that would indicate worsening and the need for emergency care? (8)

loss of consciousness increasing headache repeated vomiting slurred speech confusion unusual behaviors seizures limb weakness/ numbness

what are 6 s/s indicating a concussion?

headache light sensitivity drowsiness dizziness memory loss difficulty concentrating

what are 2 complications of a concussion that should be monitored due to constriction of blood vessels and ionic imbalances from stretching or shearing of neurons?

impaired blood supply and impaired calcium/ potassium

what is a DAI?

Diffuse Axonal Injury - this is where the axons in the brain are damaged and it is very widespread damage - most likely in a coma and not recovering

why do we want to hyper-oxygenate a patient with a DAI?

-getting oxygen to the brain tissue to promote repair + functioning -reduce secondary injuries related to hypoxia -supporting metabolic needs

what is a normal ICP?

5-15

How often should a patient with a concussion be aroused and assessed?

Q2 hours

what are the basic care management steps for a patient with a head injury?

1.initial physical + neurological assessments 2.CT + MRI 3.PET scan to assess brain function 4.C-collar stays in place until c-spine injury is ruled out - it is assumed their is injury until there is proven not to be

How are we making a low stimulation environment for a patient with a head injury like a concussion?

-no TV, phone, computer -low lights -reduce noise -limit physical activity -avoid multitasking activities -calm, uncluttered environment

what is the only diagnostic imaging scan that can rule out a Diffuse Axonal Injury?

MRI

why we do we want to monitor temperature frequently in a patient with a TBI and them to be in a slightly hypothermic state? **We want to reduce secondary injury - we are going to use things such as cooling blankets or a Bair hugger**

-hypothermia helps reduce ICP by lowering metabolism, reducing inflammation and by vasoconstriction -neuroprotection - cooling slows down the brains metabolic rate to reduce the oxygen demand -prevent fever (a fever can worsen condition)

what are the 6 main supportive measures that are priority in a patient with a severe brain injury?

-respiratory support/ mechanical ventilation -seizure precautions/ prevention -NG tube placement (reduces motility + prevents aspiration) -fluid/ electrolyte balance -pain/ anxiety management **do not give opioids in acute phase** -NUTRITION **needs to be started within 24 hours**

why should we stay away from giving patients opioids to manage pain in the acute phase of a TBI?

-sedation can hide neurological findings during assessment -respiratory depression + hypercapnia

what are 5 complications we need to be assessing for in a patient with a TBI?

-seizures -decreased cerebral perfusion -cerebral edema/ herniation -impaired oxygenation -fluid/electrolyte imbalances

what is the medication of choice to help treat ICP related to a TBI to: -promote diuresis -increase cerebral perfusion -reduce swelling

Mannitol

How can cardiac and/ or respiratory arrest result from an increased ICP?

this can put pressure on the brainstem and cause Cushing's triad which can lead to cardiac or respiratory arrest 1.bradycardia 2.hypertension 3.irregular respirations

what 2 interventions, when done early, have been shown to improve outcomes in patients with TBI's?

-hyperoxygenation w/ 100% O2 + ambu bag -early nutrition - TPN/PPN *TPN is given through a central line*

what are 5 ways we can assess and monitor a patients cerebral perfusion?

-level of consciousness -pupils -NIHSS -GCS -neuro. checks

what are some secondary injuries we want to be aware of and monitor for in patients with TBI's?

-seizure -stroke -risk of aspiration

Even though skin integrity is important in patients with a TBI, and you'd normally Q2 turn them; we want to reduce stimulation, so how often are we turning these patients?

Q4 hours

NURSING INTERVENTIONS for a patient with a TBI?

1. ongoing assessment 2. maintaining the airway 3. assess bladder function w/ I/O's, kidney function + daily weights **foley placement 4. fluid/ electrolyte balance

A patient with a TBI who is being mechanically ventilated will require in line suctioning to some degree - BUT we need to minimize the number of times and do it as little as possible. WHY?

ICP can be increased when suctioning - do it as LITTLE as possible **hyper-oxygenate before hand ---- there is a button on the vent to do this, make sure to turn it OFF**

an ________ _______ + ABG's is preferred over pulse ox/ O2 sat for assessing oxygenation.

arterial line

what are some ways we can reduce ICU psychosis/ delerium?

-reduce environmental stimuli -adequate lighting (night/day) - this will help w/ hallucinations -try to ensure adequate sleep/ wake cycles -skin care + infection prevention (to reduce secondary illness/ injury)

Maintaining adequate body temperature is a vital priority in TBI treatment and recovery, what are some ways to do this?

-monitor environmental temp. -appropriate blankets -acetaminophen for fever -cooling blankets **but it's important to avoid shivering because that can increase ICP** **sweating can also increase ICP**

why would we give a patient with a TBI a cough suppressant medication?

because coughing can increase ICP

What is being defined? -a form of aphasia due to damage to the left side of the brain; affecting receptive and expressive language, auditory and visual skills and comprehension.

global aphasia

What is being defined? -a common and disabling condition following damage to the brain, where patients aren't aware of one side of space. This is most common with damage to the right side of the brain.

unilateral neglect

Define homonymous hemianopsia.

this is where a person sees only one side – right or left- of the visual world of each eye. -right sided damage = left visual loss -left sided damage = right visual loss

What is being defined? -difficulty swallowing foods or liquids; ranges in severity

dysphagia

what is being defined? -a condition that takes away a persons ability to communicate; can affect their ability to speak, write or understand language, written or verbal.

aphasia

What is hemiparesis?

ranging from a slight weakness like loss of muscle strength to paralysis of one side of the body.

in regards to a stroke, what does it mean to assess their residual?

this is what abilities they have left after the stroke

what is hemiplegia?

this is complete loss of function/ paralysis of one side of the body

Dysarthria is weakness in the muscles used for ________, causing it to be slowed or slurred.

speech

what is it called when you lose the ability to recognize familiar faces, objects, voices or places?

agnosia