Trauma TiaraLintoco Batch 8
Trauma • Trauma is a physical injury or wound caused by external force or violence. • Trauma to the brain is the most common cause of motor & sensory symptoms including brain damage, coma and paralysis.
Trauma • Normally, the skull’s thick bones, as well as the tough membrane of the meninges (dura), protect the brain, in addition, CSF acts as a shock absorber. • However, violent blow to the head can cause several kinds of seizures and epilepsy later in life.
Trauma • If one of the normal contents of the cranial or the spinal cavity (brain, tissue or CSF) increased in size, volume or shape and pressure; this increase in pressure can cause the delicate structure to be moved, damaged or destroyed. There are 2 types of trauma: • Craniocerebral Trauma • Spinal Cord Trauma
CRANIOCEREBRAL / HEAD TRAUMA • A broad classification that includes injury to the scalp, skull, or brain. • A traumatic insult to the brain capable of causing physical, intellectual, emotional, social, and vocational changes.
ETIOLOGY • Craniocerebral trauma or head injury is the 2nd most common cause of neurological injuries & the major cause of death between ages 1 to 35. • - Effects of severe head injury include cerebral edema, sensory and motor deficits and increased ICP (intracranial pressure). • - Motor vehicle & motorcycle accidents, falls, industrial accidents, assaults and sports trauma.
Etiology/Craniocerebral Injuries can be direct or indirect Direct occurs when the head is directly injured. This results in an acceleration-deceleration injury, with rotation of the skull and its content. Bruising/contusion of the occipital and frontal lobes, the brain stem and cerebellum may occur.
Etiology/Craniocerebral acceleration-deceleration injury is caused when the body at motion abruptly comes to a stop and the body structures are contused from within. (whiplash or brain contusion, rupture of the spleen or hepatic capsules) Indirect is caused by tension strains and shearing forces transmitted to the head by stretching of the neck.
Types of Brain Injury • Concussion – a temporary loss of neurologic function with no apparent structural damage • Contusion – more severe than concussion; brain is bruised, with possible surface hemorrhage • Diffuse Axonal Injury – widespread damage to axons in the cerebral hemispheres, corpus callosum, and brain stem • Intracranial hemorrhage
PATHOPHYSIOLOGY Brain suffers traumatic injury Brain swelling or bleeding increases intracranial volume Rigid cranium allows no room for expansion of contents so ICP increases Pressure on blood vessels within the brain causes blood flow to the brain to slow Cerebral hypoxia or ischemia occurs Intracranial pressure continues to rise. Brain may herniate. Cerebral blood flow Ceases
CLINICAL MANIFESTATIONS 1. Concussion – difficulty in awakening or speaking, confusion, severe headache, vomiting, weakness on one side of the body, amnesia, visual disturbances 2. Contusion – altered LOC, nausea, vomiting, ataxia, speech problems, seizures, cool, pale skin, shallow respirations, faint pulses. Full recovery may be delayed for months.
ClinicalManifestations 3. Head injuries may be open or closed. Open injuries may result from a skull fractures or penetrating wound. The amount of injury from this type of wound is determined by the velocity, mass, shape and direction of the impact. Closed injuries include concussions (a violent jarring of the brain against the skull), contusions (brain tissue is bruised) and lacerations (tearing of the brain tissue).
Clinical Manifestations • Skull fractures maybe linear, comminuted, depressed or compound. Linear fracture occur when the impact causes the area of the skull that was stuck to bend inward, making the area around it buckled outward. Depressed fracture is a severe blow to the head. The fracture breaks the bone and forces the broken edges to press against the brain, resulting in significant increase in ICP and meningitis.
Clinical manifestations Compound/open fracture expose the brain into external microorganisms which could lead to meningitis and encephalitis. Open fractures are less likely to produce rapid elevations in the ICP because, the fracture allows the brain to swell. Comminuted/fragmented fracture is when the bone is broken or splintered into pieces which can result in bits of bone being driven into the brain, lacerating it.
Clinical manifestations 5. Hematoma refers to the blood clot within the skull. Hemorrhage resulting from craniocerebral trauma may occur in the following sites: scalp, epidural, subdural, intracerebral and intraventricular. Epidural hematomas, resulting from arterial bleeding forms as blood collects rapidly between dura & the skull. If lethargy or unconsciousness develops after the patient develops consciousness, an epidural hematoma may be suspected and needs immediate treatment.
Clinical manifestations Subdural Hematomas form as venous blood collects below dura. Hematoma formation is slow, because the bleeding is under venous pressure. The clot will cause pressure on the brain surface and will displace brain tissue. Patient who has been conscious for several days after head injury, loses consciousness or develops neurological signs and symptoms, a subdural hematoma should be suspected.
Clinical manifestations Intracranial Hematoma, which form within the brain due to hemorrhage & edema. The cause may be a fracture of a delicate blood vessels due to HTN or cerebral aneurysm. Rapture blood vessels are one of the causes of CVAs. Intraventricular hematoma is a bleeding into the brain’s ventricular system, cerebrospinal fluid is produced and circulates through towards the subarachnoid space.
ASSESS FOR: Subjective: headache, nausea, vomiting, abnormal sensations and history of loss of consciousness and of bleeding from any of the orifice (ears or nose).
Objective: status of respiratory system, level of alertness and consciousness, size and reactivity of the pupils, orientation, motor status, vital signs, presence of bleeding or vomiting and abnormal speech pattern. Presence of “battle’s sign” ( A small hemorrhage spot behind the ear.) usually is indicative of a fracture of a bone of the lower skull.
Diagnostic Tests – craniocerebral trauma CT (computed tomography) CAT (computed axial tomography) MRI (magnetic resonance imaging) PET (positron emission tomography) - Used to assess the location and extent of the injury.
Medical management – craniocerebral trauma 1. Ensure a patent airway and ensure adequate oxygenation. 2. Suctioning maybe necessary but, never through the nose because of the possibility of skull fracture. 3. Check ABGs 4. Control elevated temperature.
Medical management – craniocerebral trauma 5. Administer medications to reduce cerebral edema and increased ICP. Medications include: - Mannitol & Dexamethasone to treat cerebral edema - Codeine or analgesics to manage pain - Anticonvulsants to prevent/treat siezures
Nursing Interventions • Prevention of infections 1. Patient’s ears and nose are checked carefully for signs of blood or serous drainage. 2. No attempt should be made to clean out the orifice. 3. If there is evidence of drainage, the patient should not cough, sneeze or blow the nose.
Nursing Interventions • Emotional Support 1. Patients need firm but gentle care, with specific guidelines for what behavior is allowed. 2. It’s not helpful to argue with patients. 3. Log book or written schedule can be useful in assisting with orientation.
Impaired social interactions related to cognitive and affective deficits from neurophysiological trauma Encourage and support verbalization of feelings, medical conditions and current treatment, listen non-judgementally. Build trust through consistency & keep your promises. Give attention to patient during verbal interactions & recognize qualities to promote self-esteem. Nursing diagnosis / Interventions
Patient Teaching • Patient need to be taught about observations for complications such as increased drowsiness, nausea, vomiting, worsening headache or stiff neck, seizures, blurred vision, behavioral changes, motor problems, sensory disturbances or decreased heart rate.
Prognosis • Outcome is often unpredictable • Extent of damage or recovery is not positively correlated with the amount of damage seen in surgery or on CT scan. • Person with head injury is more prone to injuries and problems related to the brain damage.
Etiology – Spinal Cord Trauma/injury • Injury causes microscopic hemorrhages and gray matter to fill with blood • Edema causes spinal cord compression, and blood supply becomes further decreased • Scarring and meningal thickening occurs, nerves are blocked or tangled, sensory and motor deficits occur
Etiology – Spinal Cord Trauma/injury • Spinal cord injuries (SCI) involve losses of motor function, sensory function, reflexes and control elimination. • Accidents is a common and increasing cause of serious disability and death. • Automobile, motorcycle, diving, surfing and other athletic accidents and gunshot wounds are the major causes of spinal cord injury.
Etiology – Spinal Cord Trauma/injury • The level of cord involved dictates the consequences of spinal cord injury. (C3 to C5 poses a great risk for impaired spontaneous ventilation because of proximity of the phrenic nerve. • SCIs range from contusions to complete transection of the cord.
Etiology – Spinal Cord Trauma/injury - Complete SCI means that there is no function below the level of the injury (no sensation and no voluntary movement) and both sides of the body are equally affected. - Incomplete SCI means that there is some functioning below the primary level of the injury. One limb may be able to be moved more than the other, the person may be able to feel parts of the body that cannot be moved and there may be more functioning on one side of the body than the other.
Etiology – Spinal Cord Trauma/injury • Causes of trauma • Hyperflexion forward (head-on collision) • Hyperextention backward (rear-end collision, fall on chin) • Axial loading / vertical compression (land on head or feet) • Rotation beyond normal range • Penetrating injury (gunshot, knife wound)
Clinical Manifestations/SCI • Spinal shock or areflexia • The loss of systemic vasomotor tone that may result in vasodilation, increased venous capacity and hypotension. • Spinal shock is temporary, and during this time the patient may need temporary respiratory support.
Clinical Manifestations/SCI • Autonomic Dysreflexia • Occurs as a result of abnormal cardiovascular response to stimulation of the sympathetic division of the autonomic nervous system as a result of stimulation of the bladder, large intestine or other visceral organs. • Clinical signs include sever bradycardia, HTN, diaphoresis, “gooseflesh”, flushing (above the lesion), dilated pupils, blurred vision, nause restlessness, severe headache and nasal stuffiness.
Clinical Manifestations/SCI • The most common causes of this condition includes: • Distended bladder • Fecal impaction • Cold stress • Tight clothing
Clinical Manifestations/SCI • Emergency care for Autonomic Dysreflexia or Hyperflexia • Unless contraindicated, place patient in sitting position to decrease blood pressure. • Check patency of catheter for kinking. If catheter is occluded, insert new catheter immediately. • Check rectum for impaction. • If it is necessary to remove impaction, an anesthetic ointment should be used.