T/F Skull fractures are rarely accompanied by brain injury.
F; often
Besides the actual impact from the skull fracture, what else is damage to the brain tissue a result of?
Decreased oxygen
With skull fracture, ___ levels are negatively affected in the brain, resulting in alteration in neurological synaptic ability.
glucose
List the 3 types of head injury-related hemorrhages.
epidural
subdural
intracerebral
Any collection of fluid, or foreign objects, that occupies the space w/in the skull consequently poses a risk for what 3 things?
cerebral edema
cerebral hypoxia
brain herniation
What should always be suspected when a head injury occurs?
cervical spine injury
List 3 things that may indicate head injury.
presence of alcohol/drugs
amnesia
loss of consciousness
List 8 signs of increased intracranial pressure.
severe headache
deteriorating level of consciousness, restlessness, irritability
dilated/pinpoint pupils, slow/nonreactive
altered breathing battern
deterioration in motor function, abnormal posture
cushing reflex
crebrospinal fluid leakage from nose/ears
seizures
Decerebrate posture
An abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards
Decorticate posture
A person is stiff with bent arms, clenched fists, and legs held out straight; the arms are bent in toward the body and the wrists and fingers are bent and held on the chest
Cushing reflex
Late sign of increased intracranial pressure characterized by severe HTN w/ widening pulse pressure, and bradycardia
"halo" sign
Yellow stain surrounded by blood on paper towel from cerebrospinal fluid leakage; tests positive for glucose
There is a ___ hr "golden window" for treatment of head injuries.
1
Emergency treatment provided during the 1 hr "golden window" is especially effective for ___.
epidural hematomas
What is the PRIORITY assessment with head injuries?
Respiratory status
The brain is dependent on oxygen to maintain function and has little reserve available if oxygen is deprived. Brain function begins to diminish after ___ minutes of oxygen deprivation.
3
Besides respiratory function, list 6 other assessments.
cranial nerve function
pupillary changes
signs of infection
sensory and/or motor responses if spinal injury present
changes in LOC
ICP
What is a sign of infection commonly associated with meningitis?
nuchal rigidity
Nuchal rigidity
neck stiffness
In brain injury, when assessing for changes in LOC, use the ___, which provides the earliest indication of neurological deterioration.
GCS
What is the expected reference range for ICP level?
10-15 mmHg
List 7 things that may increase ICP.
hypercarbia
endo/oral trach suctioning
coughing
forceful nose blowing
extreme neck/hip flexion/extension
maintaining HOB <30 degrees
increasing intraabdominal pressure
Hypercarbia increases ICP by causing ___.
cerebral vasodilation
List 2 things that increase intraabdominal pressure.
restrictive clothes
Valsalva maneuver
List 12 ways to decrease ICP.
elevate head
avoid extreme flexion, extension, rotation of head and maintain body in midline neutral position w/ HOB at 30 degrees
maintain patent airway
administer oxygen to maintain >92
hyperventilate to keep PaCO2 b/w 30-35 mmHg
maintain cervical spine stability
report CSF
provide calm, restful environment
prevent immobility complications
monitor fluid and electrolytes
provide adequate fluids to maintain cerebral perfusion
maintain safety and seizure precautions
Even if the LOC is decreased in a head injury, explain actions being taken and why b/c ___ is the last sense affected by a head injury.
hearing
List 5 meds/classes commonly used in head injuries.
corticosteroids
mannitol (Osmitrol)
pentobarbital (Nembutal)
phenytoin (Dilantin)
morphine sulfate/fentanyl (Sublimaze)
List 2 common corticosteroids used for head injuries.
dexamethasone (Decadron)
methylprednisolone (Solu-Medrol)
Why are cotricosteroids used for head injury?
reduce cerebral edema
Corticosteroids should be used cautiously in the presence of what 4 disease processes?
diabetes mellitus
HTN
glaucoma
renal impairment
What is mannitol and why is it used for head injury?
osmotic diuretic used to treat cerebral edema
Why is pentobarbital used for head injury?
to induce barbiturate coma to decrease cerebral metabolic demands
This med is used when the ICP in head injury is refractory to treatment, has exceeded 25 mmHg for 30 min, 30 mmHg for 15 min, or 40 mmHg for 1 min
pentobarbital
A barbiturate coma is a treatment of last resort and aims to decrease elevated ICP by inducing ___ and decreasing ___.
vasoconstriction
cerebral metabolic demands
Treament of increased ICP with pentobarbital continues until the ICP remains below ___ mmHg for ___ hr.
20
48
T/F Pentobarbital for ICP can be abruptly d/c.
F; slowly withdrawn
Why is phenytoin used for head injury?
prophylactically to prevent or treat seazires that can occur
What is morphine sulfate/fentanyl and why is it used for head injury?
analgesic used to control pain and restlessness
Why should opioids be avoided (unless pt on ventilation) for treatment of head injury?
CNS depressant effect will make neuro assessment difficult
Craniotomy
removal of nonviable brain tissue that allows for expansion and/or removal of epidural or subdural hematomas
What is a common complication of head injury?
brain herniation
Brain herniation
downward shift of brain tissue d/t cerebral edema
What does the Monroe-Kelle doctrine state
regarding brain herniation, any alteration in the volume of brain matter, CSF, intravascular blood results in compromise in other components
What happens when trauma creates a shift in brain matter, CSF, intravascular blood and other components can't accomodate?
brain shifts from cranial vault, or herniates
Brain herniation results in brain tissue moving downward, through the ___.
foramen magnum
List 5 clinical signs of brain herniation.
fixed dilated pupils
deteriorating LOC
Cheyn-Stokes respirations
hemodynamic instability
abnormal posturing
List 2 things indicated for brain herniation.
urgent mannitol
surgical debulking
T/F Recovery from brain herniation is quite common.
