tbi, sci' s lecture ppt
TRANSCRIPT
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HEAD TRAUMA
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Neurologic Assessment
Levels of consciousness
Glassgow coma scale
Cranial nerve assessment
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Definition – Traumatic Brain Injury (TBI)
is a result of an external mechanical
force to the brain that leads in a change to
cognitive, physical, psychosocial
functioning associated with
altered state of consciousness.
The impairments can be temporary or permanent
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Risk Factor
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Risk Factor
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Risk Factor
• Firearms
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Primary Brain Injury
Results from what has occurred to the brain at the time of the injury
Traumatic Brain Injury
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Traumatic Brain Injury
Secondary Brain Injury
Physiologic and biochemical events which follow the primary injury
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Categories of Brain Injuries Closed (Blunt) Brain Injury
Acceleration/Deceleration
If a moving object hits a movable head (e.g. head gets hit with a bat)If a moving head hits something stationaryShaken type of movement
(e.g. when head rocks back and forth in skull).
Non-AccelerationMuch more rare, referred to as a crushing injuryIf a moving object hits a head that is fixed (e.g. car falls on head while you’re working under it).
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Low VelocitySkull is no longer intact, part of skull or debris gets into the brain.
High VelocityBullets penetrate the skull and goes into the brain matter.
Categories of Brain Injuries Open Brain Injury
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CAUSES OF BRAIN INJURIESCAUSES OF BRAIN INJURIES
Coup and Countercoup InjuriesConcussion vs ContusionDiffuse Axonal InjuryEpidural HematomaSubdural HematomaIntracerebral HemorrhageCompound fracture Penetrating injury
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Contusion Bruising type of injury to the brain resulting to
sudden loss of consciousness or coma. Contusion may occur with subdural/ extradural collection of blood, intracerebral hemorrhage.
Contusion is considered severe form of axonal injury with shearing of blood.
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ConcussionMild bruising to the cerebral tissue
cause by jarring of the brain resulting in transient
loss of consciousness.
Concussion is considered a mild form of diffuse axonal injury
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Categories of Diffuse Brain Injury
Mild Concussion (ŝ LOC) Grade I - confusion disorientation with amnesia. Grade II - confusion and retrograde amnesia (5-10 min)
Grade III - confusion with retrograde and anterograde.
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Classic Cerebral Concussion (Grade IV) - Diffuse cerebral disconnection from brain. - LOC is lost for up to 6 hours. - Confusion for hours to days. - Retrograde and anterograde amnesia. - May experience post-concussive syndrome.
Categories of Diffuse Brain Injury
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Categories of Diffuse Brain Injury
5
Mild DAI - Coma > 6 -24 hrs - Persistent residual cognitive, psychologic, sensorimotor deficit.
Decorticate and decerebrate posturing Prolonged period of stupor
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Decorticate vs Decerebrate
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Moderate DAI
- Widespread impairment cerebral cortex,
diencephalon, tearing of axons both
hemisphere
- Transitory decortication or decerebration.
- Unconsciousness lasting days or weeks.
Categories of Diffuse Brain Injury
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Severe DAI
- LOC more than weeks
- Severe mechanical disruptions of axons in
both hemisphere, diencephalon and brain
stem. - compromised coordinated movements, ver bal, written communication, inability to learn and reason, modulate behavior.
Categories of Diffuse Brain Injury
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Diffuse Axonal InjuryDiffuse axonal injury is characterized by
extensive generalized damage to the white matter of the brain
Strains during high-speed acceleration/deceleration produced in lateral motions of the head may cause
the injury.
Video
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Compound Fracture Object strikes the head with great force or head
strike the object forcefully temporal or occipital blow upward
impact of cervical vertebrae (basilar skull
fracture)
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Penetrating Injury
Missile (bullets) or sharp projectile (knives, axes, screwdriver)
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CENTRIPETAL APPROACH(outside to inside)
• –Scalp• –Cranium • –• –Subdural• –Subarachnoid• –Intra-parenchymal• –Intra-ventricular
- Epidural
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Subgaleal
Subdural – ‘Epi-arachnoid’
Subarachnoid Parenchymal Hemorrhage Intra-ventricular
Cephalohematoma – Subperiosteal Outer Table
Epidural (Extradural) – Subperiosteal Inner Table
Traumatic Hemorrhage:
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EPIDURAL HEMATOMASource of Bleeding
Arterial (high pressure)Venous (low pressure)
High flow, low pressure
Diploic veins (Fx)Marrow sinusoids
MENINGEAL VESSELS
DURAL SINUS
OTHERS
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Epidural Hematoma:
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Trauma -> fracture & concussionTearing/stripping of both layers from inner tableLaceration of outer periosteal layerLaceration of meningeal vesselsInner (meningeal dura) intactBlood between naked bone and duraNORMAL arterial pressurecontinues to dissect
EPIDURAL HEMATOMA
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EPIDURAL HEMATOMA
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EPIDURAL HEMATOMASignificant traumaFracture & concussion (l.o.c)
Delayed neurologic Sx (hrs. Later)
Herniation, coma and death
Lucid Interval – pt Wakes Up – 40% pts.
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SUBDURAL HEMATOMA SUBDURAL HEMATOMA
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SUBDURAL HEMATOMA HEMATOMA
TYPES OF INJURY
ONSET OF S/S
CLINICAL MANIFESTATION
Acute Severe Head Injury
within hours Rapid deterioration to drowsiness, agitation, stuporous, coma, signs of brain stem compression, pupil dilation contralateral hemiparesis.
Subacute Moderate Head Injury
2 hours to weeks after
Lucid , Drowsiness, stuporous coma, Increase ICP
Chronic Mild Head Injury weeks - months after
Dull headache, slowness in thinking, apathy, drowsiness, contralateral hemipareresis, progressive neurologic changes, aphasia, papilledema, LOC changes.
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INTRACEREBRAL HEMATOMAINTRACEREBRAL HEMATOMA
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INTRACEREBRAL HEMATOMA
• Usually frontal and temporal lobes
• May occur in hemispheric deep white matter
• Small blood vessels injured by shearing forces
• Acts as expanding mass, compresses tissue, and causes edema
• May appear 3- 10 days after head injury
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TBI’s TBI’s Pathophysiology Pathophysiology
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COMPLICATIONS of TBI’s
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38
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Cerebral Cortex Lesion Aphasia
Conductive - abnormalities in speech repetition
Global - All language functions are affected.
Receptive (Wernicke’s area) - difficulty to express thoughts.
Expressive (Broca’s area) - difficulty in expressing words and phrases
A defect in either the production or comprehension of vocabulary
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Cerebral Cortex Lesion Apraxia “әprak’ sea”
Types Ideational
- failure in carrying sequences of act
Kinetic - inability to execute fine acquired movements.
- Inability to perform purposeful act or to manipulate object in the absence motor power sensation or coordination. Deficit is present without weakness, sensory loss.
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Cerebral cortex lesion Agnosia - failure to recognize when the appropriate sensory system are functioning adequately
Visual - failure to recognized object visually in the absence of defect of visual acuity.
Tactile - inability to recognized objects by touch when tactile and proprioreceptive sensibilities are intact
Auditory - failure of a patient with intact hearing to recognized what he or she hears.
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Homonymous Hemianopia Homonymous Hemianopia
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Diagnostics
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Radiologic studies
Computed Tomography (CT) or (CAT)
Painless, noninvasive x-ray procedure that has the unique capabilities of distinguishing minor differences in the density of
tissues. It produce a three – dimensional image of the organ or structure.
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Magnetic Resonance
Imaging (MRI)
noninvasive diagnostic scanning technique in which the client is placed in a magnatic
field. MRI provides a better contrast between normal and abnormal tissue than the CT scan. The procedure lasts between 60 and 90 minutes.
Radiologic studies Radiologic studies
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Angiography– invasive procedure requiring informed consent
of the client. A radiopaque dye is injected into
the vessels to be examined.
- Using x-rays the flow through the vessels is
assessed and areas of narrowing or blockage
can be observed.
Radiologic studies Radiologic studies
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The Ring SignThe 'ring sign': is it a reliable indicator for cerebral spinal fluid?
One drop of blood and one drop of either spinal fluid, saline, tap water, or rhinorrhea fluid were placed simultaneously on filter paper, and the
specimens were examined after ten minutes for the development of a ring.
RESULTS: All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not.
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Spinal Cord Injury
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Bowel, Bladderareas of the skin supplied by nerve
fibers originating from a single dorsal nerve root.
Dermatomes
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What causes?
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What causes?
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What causes?
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What causes?
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Pathophysiology
Click Spinal cord injury
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Clinical Manifestations
SPINAL SHOCK STAGEComplete spinal cord transection
Loss of motor function Cervical injury: Quadriplegia Thoracic injury: Paraplegic Muscle placidity below the level of injury Loss of all reflexes Loss of pain, temperature, touch, pressure, and proprioception.
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SPINAL SHOCK STAGE
Complete spinal cord transection Below the level of injury
– Pain at injury site caused by zone hyperesthesia– Paralytic ileus and distension – Loss of vasomotor tone; Low and unstable BP– Loss of perspiration– Loss of erection and bulbocavernous reflex. – Dry pale skin, possible ulceration over bony prominences. – Respiratory impairment.
Clinical ManifestationsClinical Manifestations
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Partial spinal cord transection Below the level of injury - Asymmetric flaccid motor paralysis - Asymmetric reflex loss. - Vasomotor instability, bowel, bladder impairment are less severe - Preservation in ability to perspire in some areas of the body.
Clinical Manifestations
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Partial spinal cord transectionBrown Séquard Syndrome Ipsilateral paralysis or paresis. Loss of touch, pressure, vibration Contralateral loss of pain and temperature sensation
Clinical Manifestations
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Central cord syndrome - Loss of motor function is more pronounce in
the hand with bladder dysfunction.
Partial spinal cord transection
Clinical ManifestationsClinical Manifestations
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Partial spinal cord transectionBurning hand syndrome - Severe burning paresthesias dysthesias in the hands or feet. Anterior cord syndrome - Loss of motor function - Loss of pain and temperature sensation - Touch, pressure, position and vibration senses are intact.
Clinical Manifestations
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Partial spinal cord transection
Posterior cord syndrome Impaired light touch and proprioception
Conus medularis syndrome (injury to T12 – L1)
-Flaccid paralysis of legs, bowel and bladder areflexia- If damage is limited to the upper sacral segment erection and micturation reflex is intact.
Clinical Manifestations
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Partial spinal cord transection
Cauda equina syndrome - Injury below conus medullaris - Areflexia of bladder, bowel lower reflexes. Syndrome of neuropraxia - posttraumatic injury) - Transient neurologic deficit including quadriplegia
Clinical Manifestations
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Partial spinal cord transection
Clinical Manifestation of SCI’sClinical Manifestation of SCI’s
Horner’s syndrome - Ipsilateral pupil smaller than contralateral - Sunken ipsilateral eyeball - Ptosis of affected eyeball - Lack of perspiration on ipsilateral side.
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Cervical Injuries • Injury to C2-C5 is fatal
• C4 inervation of the diaphragm
by phrenic nerve.
• above C4 injury causes respiratory difficulty and quardriplegia
• C5 injury, may have movement of shoulder.
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Thoracic Level• Loss of movement of the chest,
trunk, bowel, bladder, and legs
• (T6) Leg paralysis (paraplegia)
• Autonomic dysreflexia
- lesion above T6
- distention bladder or impacted
rectum may cause reaction.
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Lumbar and Sacral Injuries
• lower ext. loss of movement and sensation• S2 – S3 (micturition center) - bladder will contract but will not empty. • Injury above S2
– males allows erection– unable to ejaculate because SN damage.
• Between S2 and S4– preventing erection and ejaculation – due to damages SN and PNS.
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Complications• Loss of locomotion
– Damage of descending and ascending parts of SC
which transmit sensory and motor impulses from
and to the brain.
• Bowel and bladder dysfunction– S1 injury, infection of the bladder, and anal incontinence
• Impaired breathing– damage to thoracic nerve which control intercostal and
abdominal muscle.
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Complications
• Reduced ability regulate BP, HR, sweating, body temp-
ant. intermedial tract of the spinal cord where autonomic functions is regulated.
• Osteoporosis (loss of calcium) and bone degeneration-r/t paralysis and immobility
• Atrophy – due to prolonged immobility
• Pressure sores- areas of skin that have broken down because of continuous pressure on the skin.
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Nursing Diagnosis
• Impaired sensory perception r/t destruction of sensory
tract with altered sensory reception, transmission, and
integration.
• Situitional Low Self-Esteem r/t traumatic injury.
• Constipation r/t denervation to bowel and rectum.
• Impaired urinary elimination r/t denervation of bladder
• Risk for Autonomic Dysreflexia r/t altered nerve function
(T6 SC injury and above)
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Diagnostic exams
• X ray – can reveal vertebral problem, tumors, fracture or degenerative changes in the spine.
• Computerized tomography- better look at abnormalities on x ray.
• Magnetic resonance imaging- extremely helpful
for looking herniated disk, bld clots masses that
may compress the cord.
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Myelography
- visualization of the
spinal nerves
Diagnostic examsDiagnostic exams
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End…