Head Injury, Cranial Surgery and IICP NUR 2549

Head Injury, Cranial Surgery and IICP NUR 2549 Unconsciousness An abnormal state in which client is unaware of self or environment Can be for very short time to long term coma Care is designed to

Determine the cause Maintain bodily functions Support vital functions Protect client from injury Etiology Arousal

State of being awake that depends on a group of neurons in the brainstem Can maintain level of wakefulness even without functioning cortex From Human Physiology RAS is located in brain stem

Etiology Content part of consciousness Ability to reason, think and feel Also to react to stimulus with purpose and

awareness Controlled by cerebral hemispheres (higher centers) Intellect and emotional function are also controlled in the same area. Major Reactions Two reactions affecting cerebral metabolism occur:

Cerebral ischemia /anoxia brain isnt getting enough oxygen and compensatory mechanisms take place Cerebral edema results because the brain compensates by dilating blood vessels trying to get more oxygen Behavior Document accurately what the clients behavior is. Example: if the client opens eyes on command but not spontaneously,

chart it as such. Be descriptive. Glascow Coma Scale Used to document assessment in three areas Eyes Verbal response

Motor response Normal is 15 and less than 8 indicates coma From Rehabilitation Nursing From Rehabilitation Nursing Other Assessment

Assess bodily function including respiratory, circulatory and elimination Pupil checks are pupils equal and how they react to light Extremity strength Corneal reflex test Intracranial Pressure

Monro-Kellie hypothesis (applies only to children with a rigid skull and not neonates) Skull is an enclosed space with three variables Brain tissue Blood Cerebrospinal fluid Intracranial Pressure

The skull cannot expand to allow for extra space occupying tissue or fluid If one of the three components increases the other two must decrease in order to compensate Intracranial Pressure Other factors that influence intracranial

pressure Arterial pressure Venous pressure Intraabdominal and intrathoracic pressure Posture Temperature Blood gases (left off handout)

Normal Intracranial Pressure Pressure exerted by total volume from: Brain tissue Blood Cerebrospinal fluid

Normal manometer reading 80-180 Normal transducer reading 0-15mm Hg Cerebral Blood Flow Amount of blood going through 100g of brain tissue in 1 minute cerebral blood flow is 50ml/min per 100g Brain uses 20% of the bodys oxygen Brain uses 25% of bodys glucose

Autoregulation of Cerebral Blood Flow Blood vessels alter their diameter to ensure a constant cerebral blood flow Lower limit for MAP is 50mm Hg. Below this, cerebral flow decreases and there is risk

of ischemia Upper limit is MAP of 150mmHg. Above this the cerebral blood vessels are maximally constricted. Blood vessels cannot constrict more to control high pressure. Blood brain barrier is disrupted and cerebral edema and ICP results MAP= DBP + 1/3 Pulse Pressure Cerebral Perfusion Pressure (CPP)

Pressure needed to maintain blood flow to the brain MAP-ICP=CPP Normal CPP is 60-100 CPP>100 is hyperperfusion and IICP CPP< 60 hypoperfusion CPP<30 incompatible with life Elastance stiffness of the brain High elasticity high elastance ICP increases with small increases in volume Low elasticity brain compensates and ICP stays stable Compliance

Low compliance is same as high elastance High compliance ICP remains stable Blood pressure If MAP is low, blood vessels in brain dilate to bring in more blood If MAP is high, blood vessels constrict to shunt away blood from brain Metabolic Factors affecting cerebral blood flow

Oxygen tension When oxygen tension (PaO2) falls below 50, cerebral arteries dilate to increase cerebral blood flow. If this fails to happen, the brain metabolism changes to anaerobic metabolism and lactic acid builds up Carbon dioxide tension - If the blood becomes acidic, the blood vessels dilate to increase cerebral blood flow (increased CO2 and acidosis are potent vasodilators)

Metabolic Factors Globally extreme cardiovascular changes (asystole) Pathophysiologic states (diabetic coma) Focally

Trauma and tumors Stages of Increased ICP Stage 1 High compliance and low elastance. Autoregulation is functioning Stage 2 Compliance is lower and elastance

is increased. An increase in volume places client at risk for IICP Stage 3 High elastance and low compliance. Small changes in volume will cause large increase in ICP Stages of Increased ICP Stage 4 ICP rises to terminal levels with little increase in volume. Brain herniates leading to

REST IN PEACE Increased Intracranial Pressure From an increase in cranial volume that results from increase in one or more of the following:

Brain tissue Blood Cerebrospinal fluid Increased Intracranial Cerebral edema regardless of cause, increases Pressure tissue volume, can lead to IICP Types Vasogenic-most common (tumors, abscesses, ingested toxins)

Cytotoxic-local disruption of cell membranes (lesions or trauma) Interstitial-uncontrolled hydrocephalus, hyponatremia Complications of IICP Inadequate cerebral perfusion Cerebral herniation

Brain shift : Lateral, downward, or both Irreversible Edema and ischemia further increased Compression of brainstem and cranial nerves may be fatal Cerebellum and brainstem forced through foramen magnum Clinical Manifestations

Change in level of consciousness is the most sensitive and important indicator of neuro status May be pronounced or subtle Early signs may be nonspecific: restlessness, irritability, generalized lethargy Clinical Manifestations

Changes in vital signs-this is ominous sign This is a late sign Cushings triad Increasing systolic blood pressure Pulse slowing and is bounding Irregular respiratory pattern May also have a change in temperature Clinical Manifestations

Ocular signs Pupil changes are from pressure on third cranial nerve Pupils become sluggish, unequal. This is because of brain shift. May also be pressure on other cranial nerves Clinical Manifestations

Decrease in motor function May have hemiparesis or hemiplegia May see posturing either decorticate or decerebrate Decerebrate more serious from damage in

midbrain and brainstem Decorticate from interruption of voluntary motor tracts Clinical Manifestations Headache From compression on the walls of cranial nerves,

arteries and veins Worse in the morning Straining and movement makes worse Clinical Manifestations Vomiting NOT preceded by nausea- unexpected May be projectile Diagnostic Tests

CT MRI Cerebral angiography EEG PET

No lumbar puncture if there is ICP because sudden release of pressure can cause brain to herniate ABGs keep O2 at 100% (Lewis 1615) and PCO2 as related to ICP (25-35) Drug Therapy Mannitol Rapid short acting diuretic that decreases ICP. Decreases total brain water

content Watch fluids and electrolytes closely (I and O and labs) Dont give in cases of renal failure or if serum osmolality increased Drug Therapy Loop diuretics reduce blood volume and tissue volume Corticosteroids Decadron most common

steroid used. Watch for side effects. Should be on antacids or H2 receptor blockers to prevent ulcers. Drug Therapy Barbiturates causes decrease in metabolism and ICP. Causes reduction in cerebral edema and blood flow to brain. Watch for hangover effects and drowsiness. Side effects make it harder to check LOC. Watch for

constipation do not want client straining. Skeletal muscle paralyzers may be used (Pavulon) Antiseizure drugs - Dilantin Nutrition

Clients need higher amounts of glucose to survive. Will need nutritional support quickly. Watch sodium if on Mannitol may need to give additional salt. Also may need additional free water if dehydrated watch I and O closely. Give low CHO diet to help with CO2 Nutrition

Fluid balance is controversial Do not want too dry Keep normavolemic Give saline either .45% or normal saline not glucose to help prevent additional cerebral edema Laboratory Work ABGs regularly

Electrolytes daily Nursing Interventions Airway and respiratory suction only as needed and for 10 seconds at a time, only 2 passes. Give 100% O2 prior to suctioning. Avoid abdominal distention may need NG tube to decompress stomach

Sedate with care if not on a vent, use sedation that will not interfere with respiration or mask any neuro changes Nursing Interventions

Keep HOB elevated 30 degrees if BP is normal If BP is low will need to put HOB flat Keep head in alignment to prevent cutting off venous flow from the head Dont elevate knees this will increase intrathoracic pressure Turn gently from side to side if turning raises ICP, client will need to stay on back Nursing Interventions

If client is posturing frequently during care, will need to sedate first and then do only one thing at a time. Minimize stimulation These clients can become agitated and combative avoid over stimulating them Restraining them will make them MORE AGITATED and RAISE THEIR ICP! Nursing Interventions

Use minimal stimulation perhaps one family member that is particularly calming not the entire neighborhood can stay with client Use a calm voice when talking to the client Calmly tell the client what you are going to do when providing care NO TV IN ROOM Keep room darkened if needed

Nursing Interventions Keep body temperature within normal limits Give ordered PRN antipyretics (probably Tylenol) May need to use cooling blanket Do not use ice on client

Nursing Interventions Hygiene keep skin clean and dry. Watch for skin breakdown May need to be on a special bed Keep mouth clean and moist

May need eye drops to moisten eyes Families need a lot of support even after client leaves ICU Client may benefit from rehab to help him adapt and progress Nursing Interventions Prevent infection Protect from injury

Avoid factors that increase ICP Psychological support Pediatric Considerations Open fontanels allow expansion of skull Neuro changes may be harder to detect because child cannot communicate as well Cushings triad rarely seen in children Compare childs behavior with their

developmental level Pediatric Considerations Assess for developmental differences and physical anomalies Is child appropriate for age? Look for physical injuries such as bites,

bruises Use special Glascow coma scale for child Pediatric Considerations Allow parent to stay with child as much as possible Avoid unnecessary stimulation Crying will increase ICP

Head Trauma Usually signifies craniocerebral trauma Includes alteration in consciousness High potential for poor outcome Death at injury

Death within 2 hours after injury Death 3 weeks after injury Head Trauma statistics 3 million/year in the U.S. Mortality rate is 19 per 100,000 MVAs and falls have decreased as causes Firearm-related head injury deaths have increased

Head Trauma Scalp lacerations scalp has many blood vessels and will bleed profusely. Watch for infection Skull fracture types

Linear Depressed Simple Comminuted Compound Skull Fracture Locations

Frontal Orbital fracture Temporal fracture Parietal fracture Posterior fossa fracture Basilar skull fracture Occurs at base of the skull

Watch for rhinorrhea and otorrhea Test fluid leaking from nose or ear for glucose and watch for halo If the drainage is CSF then the fracture has crossed the dura Head Trauma Check head injury client for bruising around

eyes called raccoon eyes Also look at hairline at nape of neck behind ear for bruising called Battles sign Major complications of basilar skull fracture are infection and hematoma Battles sign Minor Head Trauma

Concussion client may not lose consciousness Will be a brief change in LOC, client may not remember the event and will have headache Post-concussion syndrome is 2 weeks to 2 months after injury Post Concussion Syndrome

Persistent headache Lethargy Personality changes Short attention span Decreased short-term memory When client is discharged after concussion nurse should instruct family on what to watch for and when to call Dr. Major Head Trauma

Contusion bruising of brain tissue Has area of necrosis infarction and hemorrhage Often from coup - contrecoup injury Seizures are common after contusion Major Head Trauma Lacerations

Tearing of brain tissue Occurs with depressed skull fracture and penetrating injuries May have bleeding into the brain structuresintracerebral hemorrhage Very difficult to remove blood Major Head Trauma

Epidural hematoma Comes from bleeding between dura and inner surface of the skull Will be unconscious, then awake, and then deteriorate

Headache, nausea and vomiting Needs surgical intervention to prevent brain herniation and death Subdural Hematoma Usually bleeding is from veins, so bleeding is GENERALLY slower than epidurals CAN be from arteries and these require

IMMEDIATE removal Administration of anticoagulants is one of the causes of CHRONIC TYPES esp. in the elderly. Diagnostic Studies Skull xrays routine to r/o or identify fracture CT/MRI are best to determine trauma rapidly Emergency ManagementInitial

Airway Stabilize cervical spine Oxygen administration IV access (2 large bore catheters), LR or NS Control external bleeding with pressure Assess for rhinorrhea, otorrhea, scalp wounds

Remove clothing Emergency ManagementOngoing Maintain patient warmth Monitor VS, LOC, O2 sats, cardiac rhythm, GCS, pupil size and reactivity Anticipate intubation if absent gag reflex

Assume neck injury with head injury Administer fluids cautiously to prevent IICP Rehab Most head trauma requires rehab Some rehab units do coma management Client may have trouble swallowing and need

speech therapy Client may agitate easily and act out sexually May be a flight risk and have to be in a locked ward until passes through the agitation phase From Rehabilitation Nursing From Rehabilitation Nursing Pediatric Client

Child is vulnerable to acceleration deceleration injuries because their neck is supple and moves around easily and the head is larger in proportion to their bodies In a very young child the cranium may be able to expand enough to allow for some edema Pediatric Client

Epidural hemorrhage is rare in children Subdural hemorrhage from shaken baby syndrome, falls Can result in quadriplegia, hyperthermia, bulging fontanels Retinal hemorrhages Dizziness

Unsteady gait Elderly At risk for head trauma from falls Be alert if client has fallen and is taking anticoagulants Cranial Surgery

Brain tumor (benign or malignant) CNS infection Hydrocephalus Vascular abnormalities Craniocerebral trauma

Intracranial bleeding Aneurysm repair Arteriovenous malformation Skull fractures Epilepsy Intractable pain Types of Cranial Surgery: Stereotactic

Stereotactic: neurosurgery Often computer assisted to precisely target area CT and MRI used to image targeted tissue Burr hole or bone flap for entry Can remove small tumors and abscesses, drain

hematomas, perform ablative procedures, repair AV malformation Reduces damage to surrounding tissue Types of Cranial Surgery: Craniotomy Location varies

Frontal Parietal Occipital Temporal Combination Burr holes drilled, saw to remove bone flap Bone flap wired or sutured after surgery Drain may be placed to remove blood or fluid

Nursing Care: Pre-op Compassion Uncertainty and fear about prognosis/complications Teaching

What can be expected Hair will be shaved Client will be in ICU after surgery Nursing Care: Post-op Prevent increased ICP!!!

Frequent assessment of neuro status x 48 hrs. Monitor fluids, electrolytes, osmolality closely Maximum swelling occurs within 24-48 hours Detects changes in sodium regulation, onset of diabetes insipidus, severe hypovolemia Positioning varies depending on procedure

Assess dressing, drainage, incision Care to prevent wound infection Nursing Care: ambulatory Rehab potential depends on reason for and home surgery, post-op course of recovery, and clients general health Nursing considerations

Foster independence for as long as possible to highest degree possible Positioning, skin and mouth care, ROM exercises, bowel and bladder care, adequate nutrition Potential recovery cannot be determined until cerebral edema and IICP subside

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