Usually deep blood vessels are affected by the shearing force of the head injury.
Primary Brain Injury- Diffuse brain injury
Affects the entire brain and is caused by the swirling or twisting movement of the brain within the cranium.
This category includes concussion and diffuse axonal injury.
Concussion (p. 1377 box at bottom)
Temporary axonal injury that results in an interruption of brain function.
Concussions are graded (I-V) from mild to severe
May be discharged home- teach signs of IICP
Post Concussion Syndrome may persist for several weeks or months. Only closest friends may notice the change in behavior, which include headache, general tiredness, dizziness, irritability, memory and concentration difficulties, learning difficulty, insomnia, etc. May occur after other brain injuries, and severity of symptoms are not related to severity of brain injury.
Diffuse axonal injury
Caused by high speed acceleration-deceleration injury resulting in widespread disruption of axons and generally causing a very poor prognosis.
Secondary brain injury
Localized edema around the primary brain injury or diffuse edema throughout the whole brain.
May be the result of closed head injury (CHI), open head injury with or without bleeding in the brain, or anoxia resulting from an MI or near drowning.
Increased intracranial pressure (IICP) (Refer to Module #10)
Herniation syndromes (Refer to Module #10)
Comparsion of intracranial hematomas- manifestations (p. 1376 Table 42-7)
Increased intracranial pressure symptoms.
Restlessness may occur as a result of hypoxia, increase intracranial pressure or the client is trying to wake up.
Manifestations of concussion and post concussion syndrome (p. 1377 box at bottom)
Systemic effects of acute brain injury (p.1375 Box 42-3)
CSF leak from nose (rhinorrhea)/ ear (otorrhea)– may be seen with basal skull fractures.
‘Brainstorming’ is hypothalamic stimulation with autonomic nervous system and adrenals increasing circulation corticoids and catecholamines. Ambiguous symptoms such as hyperthermia (neurogenic temperature), hypertension, diaphoresis, etc.
Post concussion Syndrome (refer to Patho 6 and p. 1377)
Positing- head of bed 30 degrees, no flexion of neck/hips
Medications- Osmotic diuretics
Prevention of complications
Medications to treat/prevent IICP; prevent/treat seizures; to treat other complications such as stress ulcer, stool soltners to prevent straining, and to treat ‘brainstorming- such as Morphine, thorazine, haldol, Inderal, antipyretics (also cooling individual with fans)
Diet/calories- TBI causes a hypermetoblic state. Initially the GI tract may not absorb feedings, swallow/gag reflexes maybe lacking. May need TPN, progressing to NG tube feedings to oral with supplements. Calorie count essential.
CSF leak- assess for glucose (not found in mucous drainage)/ assess for ‘halo’ affect on linens or a pad. Treat- HOB 30 degrees, do not blow nose/sniff, no nasal suctioning, do not pack, lightly cover- change when wet, prophylactic antibiotics. Physician may insert lumbar drain to decrease pressure, or surgically plug the leak with a piece of muscle.
Other systemic effects (p. 1375) including SIADH a self-limiting syndrome the causes hyponatremia.
Depressed and comminuted fractures- remove bone fragments. Basilar with CSF leakage may require surgery.
Evacuation of the clot through burr holes (p. 1379 Fig 42-7)
Craniotomy usually necessary for chronic subdural because of the normal changes that blood goes through with time- calcification.
Intracerebral bleed may bleed diffusely throughout the brain, rather than a formed hematoma. This makes it difficult to remove.
Placement of intracranial pressure monitoring devices. (refer to ICP module)
Nursing Assessment Specific to Traumatic Brain Injury (TBI)
Description of the accident, past medical history.
Description of the neuro vital signs- esp. level of consciousness changes.
Neuro Vital Signs- describe the level of consciousness, pupils, movement of extremities. How often done depends on potential for developing ICP.
Glasgow Coma Scale-(p. 1299 Table 40-4) Scale works best with traumatic brain injured individuals. Allows health care workers to communicate what the patient is like by a number. Based on eye opening, verbal, and motor response. Scores range from lowest level of 3 to highest functioning level of 15. Coma = 8.
Brainstem reflexes- cornea, cough, gag, pupil, extra ocular movements (EOM’s)