Traumatic Brain Injury
•Usually caused by a sudden and violent blow or jolt to the head (closed injury) or a penetrating (open injury) head wound that disrupts the normal brain function•The injury can bruise the brain, damage nerve fibers, and cause hemorrhaging•Can be focal of diffuse (one spot vs whole brain)•Focal more common and are caused by closed and open trauma•Diffuse Axonal Injury involves neurons in widespread areas of the brain•Vary from mild to severe•Persons at highest risk: males, children 0-4-year-olds, adolescents 15-19-year-olds, adults 75 years of age or older, certain military personnel (e.g., paratroopers), and African Americans (highest death rates)
TBI complications
•Can occur from one significant event or multiple mild events like concussions in contact sports•Changes in thinking, sensation, language, or emotions•Seizures•Alzheimer's disease•Parkinson's disease•Memory decline•Depression•Death
concussion
momentary interruption of brain function•Usually results from a mild blow to the head that causes sudden movement of the brain, disrupting neurologic functioning. Can shear axons too.•May or may not lead to a loss of consciousness. The longer they are unconscious, the more serious the concussion is.•Amnesia, confusion, sleep disturbances, and headaches may occur for weeks or months•CM: HA, N&V•Treatment: No cureVomiting center is in brain, any pressure on it = vomiting/ nauseous
Cerebral contusion
bruising of the brainMost result from a blunt blow that causes the brain to make sudden impact with the skullCoup - initial area brain impacts with skullCountercoup - area opposite side of the brain where it rebounds and impacts with skullVary in severity depending on the extent of damage and the amount of bleedingResidual effects depend on severity
Fractures
•Open or closed•Direct and contrecoupBone fragments penetrating brain = need surgery to get them outOutward appearance of head is not an indication of severity**
TBI Manifestations
•May be vague and develop slowly, or they may be sudden and severe•Symptoms may improve and then suddenly worsen•The outward appearance of the head is not an indication of the injury severity•Not being able to recall event details•Indications of a concussion•Changes in or unequal pupil size•Seizures•Asymmetrical facial features•Fluid draining from the nose, mouth, or ears - basilar skull fracture•Fracture in the skull or face•Bruising of the face•Swelling at the site of the injury•Scalp wound•Impaired hearing, smell, taste, speech, or vision
Traumatic Brain Injury Manifestations
•Inability to move one or more limbs•Irritability (especially in children)•Personality changes•Unusual behavior•Loss of consciousness•Bradypnea•Hypotension•Restlessness•Lack of coordination•Lethargy•Stiff neck•VomitingPersonality and behavior in frontal lobe of brain, see more s/s if this area affectedBradypnea and hypotension = especially with brain stem
TBI diagnosis and treatment
•Diagnosis: history, physical examination (including using the Glasgow Coma scale), Head CT or MRI•Treatment: rest, analgesics (specifically acetaminophen [Tylenol]), cold compresses, osmotic diuretics antiseizure agents, sedatives, surgery, rehabilitation (e.g., physical, speech, and occupational therapy)
Traumatic Brain Injury Prevention
•Wearing a seat belt when driving or riding in a motor vehicle•Using appropriate child safety seats, wearing a helmet when appropriate (e.g., when playing sports, riding a bicycle, or skating)•Making the home safe (e.g., removing tripping hazards, having adequate lighting, using safety gates)•Storing firearms in locked cabinets•Never driving impaired•Supervising children when playing
Secondary Brain Injuries
intracranial = epilepsy, infection, hematoma (epidural, subdural), cerebral edema, increased ICPextracranial = hypoxia, hypotension, hypercapnia, acidosis - vasodilation and increased ICP, hyponatremia - brain doesn't like sodium changes, hyperglycemia, febrileA complication; goal with TBI is to prevent a secondary brain injuryBrain stem injury= lose ability to autoregulate, need rapid treatment**
Hematoma
•A collection of blood in the tissue that develops from ruptured blood vessels•Hematomas can develop immediately or slowly because of a TBI or surgeryAnticoagulants - another big cause of hematoma if they fall and hit their head.Epidural , subdural (above and below dura), intracerebral = bleed inside brain tissue.
layers of the brain
PADSPia materArachnoid materDura materSkull
epidural hematoma
develops between the dura and skull, usually caused by an arterial tear; develops with in a few hours of injury; manifestations are typical symptom pattern with brief loss of consciousness followed by a short period of alertness, then loss of consciousness again.
subdural hematoma
develops between the dura and the arachnoid, frequently caused by a small venous tear; develops slowly; manifestations are present within 24 hours of an injury and progress rapidly, and has high mortality. venous tears, a lot of bleeding before symptom manifestations so high mortality rate once sx presentChronicsubdural= slow leak, several weeks, more common in an older person bc they have brain atrophy, have more space, can tolerate more bleeding
hematoma types
subdural, intracranial, epidural
Intracerebral Hematoma
•Result from bleeding in the brain tissue itself•Caused by contusion or shearing injuries but can also result from hypertension, cerebral vascular accidents (strokes), aneurysms, or vascular abnormalities
hematoma dx and tx
•Bleeding leads to localized pressure on nearby tissue and increases ICP•Blood may coagulate and form a solid mass•Bleeding can trigger vasospasms, worsening ischemia•Can result in herniation•Diagnosis: history, physical examination (including completing the Glasgow Coma scale), head computed tomography, head magnetic resonance imaging , cerebral angiogram, and intracranial pressure monitor•Treatment:•May require no treatment or removal of the blood may not be possible•Surgical removal of the blood through a burr hole or a craniotomy•Physical, speech, and occupational therapy•Additional strategies similar to those for TBIs and increased ICP (e.g., respiratory management, seizure precautions, and thermoregulation)Want to vasodilate and prevent spasm* put on vasodilators; vasospasms are commonly what cause deathHerniation when all spaces are overcrowded ; can put ICP monitor in in ICU, can turn into blood clot. Surgical removal of blood from drilling in and making hole.
Subarachnoid hemorrhage
•Results from bleeding in the space between the arachnoid and pia•The primary clinical presentation is a severe headache with a sudden onset and that is worse near the back of the head
Spinal Cord Injuries
•Result from direct injury to the spinal cord or indirectly from damage to surrounding bones, tissues, or blood vessels•Causes: motor vehicle accidents, falls, violence, sports injuries, and weakening vertebral structures (e.g., rheumatoid arthritis or osteoporosis)From damaging the actual spinal cord or bones breaking and damaging it
Spinal Cord Injury Complications
1. Loss of neurologic functioning2. Varying degrees of paralysis3. Autonomic dysreflexia- a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above).4. Neurogenic shock•an abnormal vasomotor response secondary to disruption of sympathetic impulses•MASSIVE VASODILATION5. Respiratory failure - indicates severity most often; 1/3 of neck injuries require vent for rest of life6. Effects of immobility (e.g., constipation, pulmonary infections, urinary infections, thrombus, impaired skin integrity, contractures)7. Changes in bowel and bladder function8. Sexual dysfunction9. Chronic pain10.DeathMost spinal cord injuries don't completely sever it, more like compression of vertebrae or crushing
Autonomic Dysreflexia
Bladder full, fecal impaction, UTI, wrinkle in sheet or stimuli somewhere below T6 causes them to have symptoms. Vasodilate above level of injury, vasoconstrict below level of injury
Neurogenic Shock
Distributive shock with massive vasodilationInjuries above T6, no sympathetic response so BP and HR go down**
Spinal Cord Injuries diagnosis
•: history, physical examination (including a neurologic assessment), spinal computed tomography, spinal magnetic resonance imaging , spinal X-ray, and spinal myelogram
Stroke
•Cerebral Vascular Accident An interruption of cerebral blood supply•Ischemic damage is permanent•Causes: total vessel occlusion (e.g., thrombus, embolus, or plaque) or cerebral vessel rupture (e.g., cerebral aneurysm, or hypertension)•Major types of CVA•Ischemic strokes are the most common - clot; 85% of all strokes•Hemorrhagic strokes are the most fatal - aneurysms and hypertension, 15% of strokes•Complications: neurologic deficits and death•Most common in African Americans and those living in the Southeast region•Additional risk factors: physical inactivity, obesity, hypertension, smoking, hypercholesterolemia, diabetes mellitus, atherosclerosis, oral contraceptive usage, excessive alcohol consumption, and illicit drug use
stroke types
ischemic and hemorrhagic (anoxic vs ruptured vessel)
stroke manifestations and diagnosis
•Manifestations are similar those of a TIA except that CVA symptoms do not resolve•Manifestations may improve with time and therapy, but they can remain, creating complications•Additional manifestations, headaches may be present with hemorrhagic strokes because of increasing ICP•Diagnosis: history, physical examination (including a neurologic assessment), head computed tomography, head magnetic resonance imaging, carotid ultrasound,
Stroke Treatment
•Requires prompt treatment to minimize brain damage•Determining whether the CVA is ischemic or hemorrhagic in origin prior to treatment•Treatment should be delivered within 3 hours of symptom onset•Ischemic strokes: thrombolytic agents, aspirin, angioplasty, carotid endarterectomy•Hemorrhagic strokes: surgical repair of aneurysms or arteriovenous malformations as well as blood removal•Antihypertensive may be administered with either type•Multidisciplinary team management because they'll probably have deficits•Strategies to prevent complications of immobilityThe quicker the treatment the better
Meningitis
•Inflammation of the meninges, usually resulting from an infection•CSF may also become affected•Causes: bacteria (e.g., Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae), viruses (e.g., enterovirus, measles, influenza, and herpes), tumors, and allergens•Infection or irritant triggers the inflammatory process, leading to swelling of the meninges•Risk factors: being less than 25 years of age, living in a community setting, pregnancy, working with animals, and immunodeficiencyStrep = common cause of community acquired pna, otitis media, and meningitisViral meningitis is more common and less severeBacterial is a greater concern because it can be associated with significant brain damage and death
meningitis manifestations
fever, headache, stiff neck**•Sudden high fever•Severe headache that isn't easily confused with other types of headache•Stiff neck•Vomiting or nausea with headache•Confusion or difficulty concentrating•Seizures•Sleepiness or difficulty waking up•Sensitivity to light•Lack of interest in drinking and eating•Skin rash in some cases, such as in meningococcal meningitis
meningitis dx and tx
•Diagnosis: history, physical examination, lumbar puncture with CSF analysis•Treatment: antibiotics (if bacterial), hydration, fever management, and vaccinations (prevention) - takes 2 weeks, protects for 3-5 years, no herd immunity
Brain Tumors
•May be malignant or benign•Can be life threatening because due to increased ICP and difficult to access•May be primary, but most are secondary tumors (most commonly breast cancer, colon cancer, kidney cancer, lung cancer, melanoma, and sarcoma)Can cause pressure, movement, herniation•Primary tumors are thought to arise from genetic mutations•Risk factors for primary tumors: advancing age and exposure to radiation and occupational chemicals•Gliomas comprise of 25 % of adult. And 75% of malignant brain tumors•Lt primary tumors•Prevalence and mortality rates highest among Caucasians and males•Complications: neurologic deficits, seizures, personality changes, and deathAlso eating fruits and vegetables, having chicken pox helps preventAny neuro sx depending on where, how big, how much pressure
Brain Tumors Manifestations
•Vary depending on size and location•Include:•New onset or change in pattern of headaches•Headaches, increasing frequency and severity•Unexplained nausea or vomiting - from pressure in brain•Vision problems•Gradual loss of sensation or movement in an extremity•Balance difficulties•Speech difficulties•Confusion•Hearing problems•Hormonal (endocrine) disorders
brain tumor dx and tx
•Diagnosis: history, physical examination (including a neurologic assessment), head magnetic resonance imaging, biopsy, and other tests to determine cancer histology•Treatment:•Depends on the size and location•Surgical, radiation, and chemotherapy•Rehabilitation including physical, occupational, and speech therapy