Chapter 68 - Management of Patients With Neurologic Trauma

Chapter
Chapter 68
68
Management
Management of
of Patients
Patients With
With
Neurologic
Neurologic Trauma
Trauma
Head Injury
• A broad classification that includes injury to the scalp,

skull, or brain
• 2.5 million people receive head injuries every year in the
United States
• The most common cause of death from trauma
• Most common cause of brain trauma is falls
• Groups at highest risk for brain trauma include: children
0 to 4 years old, adolescents ages 15 to 19 years, and
adults 65 years and older
• Prevention is the best approach
Copyright © 2018 Wolters Kluwer · All Rights Reserved

Pathophysiology of Brain Damage
• Primary injury: consequence of direct contact to

head/brain during the instant of initial injury
– Contusions, lacerations, external hematomas, skull
fractures, subdural hematomas, concussion, diffuse
axonal
• Secondary injury: damage evolves over ensuing days and
hours after the initial injury
– Caused by cerebral edema, ischemia, or chemical
changes associated with the trauma

Pathophysiology of Traumatic Brain Injury

Question
Is the following statement true or false?
Contusion is a temporary loss of neurologic function with

no apparent structural damage to the brain

Answer
False
Concussion is a temporary loss of neurologic function with

no apparent structural damage to the brain. Contusion is
a bruising of the brain surface

Scalp Wounds and Skull Fractures
• Manifestations depend on the severity and location of the

injury
• Scalp wounds
– Tend to bleed heavily and are portals for infection
• Skull fractures
– Usually have localized, persistent pain
– Fractures of the base of the skull
• Bleeding from nose pharynx or ears
• Battle sign—ecchymosis behind the ear
• CSF leak: halo sign—ring of fluid around the blood
stain from drainage

Basilar Fractures Allow CSF to Leak From
the Nose and Ears

Question
Clear rhinorrhea from the nose is a sign of a basilar

fracture

Answer
True
Signs of basilar fracture include CSF drainage from the ears

or nose, bleeding from the nose or ears, Battle sign
(ecchymosis found on the mastoid), and halo sign (ring
of fluid around blood stain from drainage)

Management of the Patient With a Head
Injury
• Assume cervical spine injury until it is ruled out

• Therapy to preserve brain homeostasis and prevent
secondary damage
– Treat cerebral edema
– Maintain cerebral perfusion; treat hypotension,
hypovolemia, and bleeding; monitor and manage ICP
– Maintain oxygenation; cardiovascular and respiratory
function
– Manage fluid and electrolyte balance

Supportive Measures
• Respiratory support; intubation and mechanical

ventilation
• Seizure precautions and prevention
• NG tube to manage reduced gastric motility and prevent
aspiration
• Fluid and electrolyte maintenance
• Pain and anxiety management
• Nutrition

Manifestations of Brain Injury
• Altered LOC
• Pupillary abnormalities
• Sudden onset of neurologic deficits and neurologic
changes; changes in sense, movement, reflexes
• Changes in vital signs
• Headache
• Seizures

Initial Management of the Patient With
Traumatic Brain Injury

Brain Injury
• Closed brain injury (blunt trauma): acceleration/deceleration

injury occurs when the head accelerates and then rapidly
decelerates, damaging brain tissue
• Open brain injury: object penetrates the brain or trauma is so
severe that the scalp and skull are opened
• Concussion: a temporary loss of consciousness with no
apparent structural damage
• Contusion: more severe injury with possible surface
hemorrhage
– Symptoms and recovery depend on the amount of
damage and associated cerebral edema
– Longer period of unconsciousness with more symptoms of
neurologic deficits and changes in vital signs

Brain Injury (cont.)
• Diffuse axonal injury: widespread axon damage in the

brain seen with head trauma. Patient develops immediate
coma.
• Intracranial bleeding
– Epidural hematoma
– Subdural hematoma
• Acute and subacute
• Chronic
– Intracerebral hemorrhage and hematoma

Concussion
• Patient may be admitted for observation or sent home

• Observation of patients after head trauma; report
immediately
– Observe for any changes in LOC
– Difficulty in awakening, lethargy, dizziness,
confusion, irritability, anxiety
– Difficulty in speaking or movement
– Severe headache
– Vomiting
• Patient should be aroused and assessed frequently

Location of Subdural, Intracerebral, and
Epidural Hemorrhages

Epidural Hematoma
• Blood collection in the space between the skull and the

dura
• Patient may have a brief loss of consciousness with
return of lucid state; then as hematoma expands,
increased ICP will often suddenly reduce LOC
• An emergency situation!
• Treatment includes measures to reduce ICP, remove the
clot, and stop bleeding (burr holes or craniotomy)
• Patient will need monitoring and support of vital body
functions; respiratory support

Subdural Hematoma
• Collection of blood between the dura and the brain

• Acute or subacute
– Acute: symptoms develop over 24 to 48 hours
– Subacute: symptoms develop over 48 hours to 2
weeks
– Requires immediate craniotomy and control of ICP
• Chronic
– Develops over weeks to months
– Causative injury may be minor and forgotten
– Clinical signs and symptoms may fluctuate
– Treatment is evacuation of the clot
Intracerebral Hemorrhage
• Hemorrhage occurs into the substance of the brain

• May be caused by trauma or a nontraumatic cause
• Treatment
– Supportive care
– Control of ICP
– Administration of fluids, electrolytes, and
antihypertensive medications
– Craniotomy or craniectomy to remove clot and control
hemorrhage; this may not be possible because of the
location or lack of circumscribed area of hemorrhage

Diagnostic Evaluation
• Physical and neurologic exam

• Skull and spinal radiography
• CT scan
• MRI
• PET

Nursing Process: The Care of the Patient
With Brain Injury—Assessment
• Health history with focus on the immediate injury, time,

cause, and the direction and force of the blow; refer to
Figure 68-4 and Table 68-1
• Baseline assessment: refer to Chart 68-3
• LOC—Glasgow Coma Scale: refer to Chart 68-2
• Frequent and ongoing neurologic assessment
• Multisystem assessment

With Brain Injury—Diagnoses
• Ineffective airway clearance and impaired gas exchange

• Ineffective cerebral perfusion
• Deficient fluid volume
• Imbalanced nutrition
• Risk for injury
• Risk for imbalanced body temperature
• Risk for impaired skin integrity
• Disturbed thought patterns
• Disturbed sleep pattern
• Interrupted family process
• Deficient knowledge

Collaborative Problems and Potential
Complications
• Decreased cerebral perfusion

• Cerebral edema and herniation
• Impaired oxygenation and ventilation
• Impaired fluid, electrolyte, and nutritional balance
• Risk of posttraumatic seizures

With Brain Injury—Planning
• Major goals may include:

– Maintenance of patent airway and adequate CPP
– Fluid and electrolyte balance
– Adequate nutritional status
– Prevention of secondary injury
– Maintenance of normal temperature
– Maintenance of skin integrity
– Improvement of cognitive function
– Prevention of sleep deprivation
– Effective family coping
– Increased knowledge about rehabilitation process
– Absence of complications

Interventions
• Ongoing assessment and monitoring are vital

• LOC
• Vital signs
• Maintenance of airway
• Motor function

Interventions (cont.)
• I&O and daily weights

• Monitor blood and urine electrolytes and osmolality and
blood glucose
• Measures to promote adequate nutrition
• Strategies to prevent injury
– Assessment of oxygenation
– Assessment of bladder and urinary output
– Assessment for constriction caused by dressings and
casts
– Pad side rails
– Mittens to prevent self-injury; avoid restraints

• Strategies to prevent injury

– Reduce environmental stimuli
– Adequate lighting to reduce visual hallucinations
– Measures to minimize disruption of sleep–wake cycles
– Skin care
– Measures to prevent infection
• Maintaining body temperature
– Maintain appropriate environmental temperature
– Use of coverings: sheets, blankets to patient needs
– Administration of acetaminophen for fever
– Cooling blankets or cool baths; avoid shivering
• Support of cognitive function

• Support of family
– Provide and reinforce information
– Measures to promote effective coping
– Setting of realistic, well-defined short-term goals
– Referral for counseling
– Support groups
• Patient and family teaching

Spinal Cord Injury
• 276,000 persons in the United States live with disability

from SCI
• Causes include MVAs, falls, violence (gunshot wounds),
and sports-related injuries
• Males account for 80% of SCIs
• Average age of injury is 42
• Risk factors include; young age, male gender, alcohol
and drug use
• Primary prevention

Spinal Cord Injury (cont.)
• The result of concussion, contusion, laceration or

compression of spinal cord
• Primary injury is the result of the initial trauma and
usually permanent
• Secondary injury resulting from SCI include edema and
hemorrhage
• Major concern for critical care nurses
• Treatment is needed to prevent partial injury from
developing into more extensive, permanent damage

Spinal and Neurogenic Shock
• Spinal shock
– A sudden depression of reflex activity below the level
of spinal injury
– Muscular flaccidity, lack of sensation and reflexes
• Neurogenic shock
– Caused by the loss of function of the autonomic
nervous system
– Blood pressure, heart rate, and cardiac output
decrease
– Venous pooling occurs because of peripheral
vasodilation
– Paralyzed portions of the body do not perspire
Autonomic Dysreflexia
• Acute emergency!
• Occurs after spinal shock has resolved and may occur
years after the injury
• Occurs in persons with SC lesions above T6
• Autonomic nervous system responses are exaggerated
• Symptoms include severe pounding headache, sudden
increase in blood pressure, profuse diaphoresis, nausea,
nasal congestion, and bradycardia
• Triggering stimuli include distended bladder (most
common cause), distention or contraction of visceral
organs (e.g., constipation), or stimulation of the skin

Nursing Interventions
• Place patient in seated position to lower BP

• Rapid assessment to identify and eliminate cause
– Empty the bladder using a urinary catheter or irrigate
or change indwelling catheter
– Examine rectum for fecal mass
– Examine skin
– Examine for any other stimulus
• Administer ganglionic blocking agent such as hydralazine
hydrochloride (Apresoline) IV
• Label chart or medical record that patient is at risk for
autonomic dysreflexia
• Instruct patient in prevention and management
With SCI—Assessment
• Monitor respirations and breathing pattern

• Lung sounds and cough
• Monitor for changes in motor or sensory function; report
immediately
• Assess for spinal shock
• Monitor for bladder retention or distention, gastric
dilation, and ileus
• Temperature; potential hyperthermia

With SCI—Diagnoses
• Ineffective breathing pattern

• Ineffective airway clearance
• Impaired physical mobility
• Disturbed sensory perception
• Risk for impaired skin integrity
• Impaired urinary elimination
• Constipation
• Acute pain

Collaborative Problems and Potential
Complications
• DVT
• Orthostatic hypotension
• Autonomic dysreflexia

Question
Never massage the claves or thighs because of the danger

of dislodging an undetected DVT

Answer
True
Never massage the claves or thighs because of the danger

of dislodging an undetected DVT

With SCI—Planning
• Major goals may include:

– Improved breathing pattern and airway clearance
– Improved mobility
– Improved sensory and perceptual awareness
– Maintenance of skin integrity
– Promotion of comfort
– Absence of complications

Promotion of Effective Breathing and
Airway Clearance
• Monitor carefully to detect potential respiratory failure

– Pulse oximetry and ABGs
– Lung sounds
• Early and vigorous pulmonary care to prevent and
remove secretions
• Suctioning with caution
• Breathing exercises
• Assisted coughing
• Humidification and hydration

Improving Mobility
• Maintain proper body alignment

• Turn only if spine is stable and as indicated by physician
• Monitor blood pressure with position changes
• PROM at least four times a day
• Use neck brace or collar, as prescribed, when patient is
mobilized
• Move gradually to erect position

Roto Rest Bed

Cervical Collar

Halo Systems for Cervical and Thoracic
Injuries

Interventions
• Strategies to compensate for sensory and perceptual

alterations
• Measures to maintain skin integrity
• Temporary indwelling catheterization or intermittent
catheterization
• NG tube to alleviate gastric distention
• High-calorie, high-protein, high-fiber diet
• Bowel program and use of stool softeners
• Traction pin care
• Hygiene and skin care related to traction devices

Question
A patient with a SCI at T5 begins to complain of a severe

headache and is diaphoretic and nauseated. Which
nursing intervention would not be appropriate?
A. Place the patient immediately in a sitting position
B. Lower the patient to a flat, sidelying position
C. Assess for bladder distention
D. Assess the rectum for a fecal mass

Answer
B. Lower the patient to a flat, sidelying position

When a patient with SCI displays symptoms of autonomic
dysreflexia, their body is communicating that there is a
problem needing immediate intervention. The nurse
should complete a rapid assessment to identify and
alleviate the cause. The patient is placed immediately in
a sitting position to lower blood pressure. The bladder is
emptied immediately via a urinary catheter. If an
indwelling catheter is not patent, it is irrigated or
replaced with another catheter. The rectum is examined
for a fecal mass. If one is present, a topical anesthetic
agent is inserted 10 to 15 minutes before the mass is
removed because visceral distention or contraction can
cause autonomic dysreflexia. Other causes may involve
skin pressure or positioning abnormalities

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Chapter

• A broad classification that includes injury to the scalp,

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Primary injury: consequence of direct contact to

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Is the following statement true or false?

Contusion is a temporary loss of neurologic function with

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Concussion is a temporary loss of neurologic function with

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Manifestations depend on the severity and location of the

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Is the following statement true or false?

Clear rhinorrhea from the nose is a sign of a basilar

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Signs of basilar fracture include CSF drainage from the ears

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Assume cervical spine injury until it is ruled out

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Respiratory support; intubation and mechanical

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Closed brain injury (blunt trauma): acceleration/deceleration

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Diffuse axonal injury: widespread axon damage in the

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Patient may be admitted for observation or sent home

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Blood collection in the space between the skull and the

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Collection of blood between the dura and the brain

• Hemorrhage occurs into the substance of the brain

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Physical and neurologic exam

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Health history with focus on the immediate injury, time,

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Ineffective airway clearance and impaired gas exchange

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Decreased cerebral perfusion

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Major goals may include:

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Ongoing assessment and monitoring are vital

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• I&O and daily weights

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Strategies to prevent injury

• Support of cognitive function

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• 276,000 persons in the United States live with disability

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• The result of concussion, contusion, laceration or

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved