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MedSurg II - TBI, Fractures, & Tumors

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olanjones's version from 2017-03-20 15:54

Head Injury

Question Answer
When can death occurImmediately after inj; W/in 2 hrs after inj; 3 wks after inj
Most common causesMVC & falls (other causes: firearms, assault, sports/rec inj, war-related)
ComplicationsInfection, Hematoma, Tissue damage
Rhinorrhea ; OtorrheaCSF drainage from nose; ear
CSF tested byfor glucose with Dextrostix/Tes-tape (cannot use if blood is present – glucose is normally in blood – use halo/ring sign)
TypesDiffuse (generalized); Focal (localized); Minor (GCS 13-15); Moderate (GCS 9-12); Severe (GCS 3-8)
Diffuse1. Concussion: brief LOC disrupt, retrograde amnesia, HA (postconcussion syndrome can occur w/in 2 wks-2mos)
2. Diffuse axonal inj: damage occurs primarily around axons in the subcortical white matter of cerebral hemispheres, basal ganglia, thalamus, & brainstem – ↓LOC, ↑ICP, decort/decree, global cerebral edema
Focal-laceration (tearing of tissue- can lead to hemorrhage)
-contusion (bruising of tissue- can cause infarct/necrosis/edema)
-hematoma – epidural (btwn dura & inner skull surface – Emergency), subdural (btwn dura & arachnoid– can be acute/subacute), intracerebral (w/in brain tissue– usu frontal/temporal)
-Cranial Nerve inj
Ingestion of drugs/ETOH can complicate, why?Can delay manis/symptoms of damage
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Types of Subdural Hematomas

Question Answer
Acute (24-48 hrs after severe trauma)Immediate deterioration; need craniotomy, evacuation & decompression
Subacute (48 hrs – 2 wk after severe trauma) AMS as hematoma develops (progression depends on size/location ); need evacuation & decompression
Chronic (wks – mos, usu >20 days after inj)Nonspecific, nonlocalizing progression (progressive alteration in LOC); evacuation & decompression, membranectomy
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Skull Fractures

Question Answer
LinearBreak in continuity of bone w/out alteration of relationship of parts -Low-velocity injuries
DepressedInward indentation of skull -Powerful blow
SimpleLinear or depressed skull x w/out fragmentation or communicating lacerations -Low to moderate impact
ComminutedMultiple linear fractures w/ fragmentation of bone into many pieces –Direct, high momentum impact
CompoundDepressed skull fracture and scalp laceration w/ communicating pathway to intracranial cavity -Severe head injury
FrontalExposure of brain to contaminants through frontal air sinus, possible association with air in forehead tissue, CSF rhinorrhea, or pneumocranium (air between cranium & dura mater)
OrbitalPeriorbital ecchymosis (raccoon eyes), optic nerve injury
TemporalBoggy temporal muscle because of extravasation of blood, oval-shaped bruise behind ear in mastoid region (Battle’s sign), CSF otorrhea, middle meningeal artery disruption, epidural hematoma
ParietalDeafness, CSF or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, facial paralysis, loss of taste, Battle’s sign
Posterior fossaOccipital bruising resulting in cortical blindness, visual field defects, rare appearance of ataxia or other cerebellar signs
Basilar skullCSF or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, Battle’s sign, tinnitus/hearing difficulty, rhinorrhea, facial paralysis, conjugate deviation of gaze, vertigo
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Head Inj Assess & Tx

Question Answer
ObjectiveAMS, Lacerations/contusions/hematoma, Battle’s sign, Periorbital edema, Leaking CSF, Exposed brain, CN/Motor deficits
SubjectivePast medical hx; drugs/ETOH; HA, mood/behavior changes; Impaired judgment; Speech prob; Fear/denial/anger
Skull fxConservative treatment; Surgery if depressed
Subdural & epidural hematomaSurgical evacuation (Craniotomy/burr-holes; Craniectomy if extreme swelling)
DiagnosticsCT scan (best to determine craniocerebral trauma), MRI, PET, evoked potential, Transcranial Doppler, Cervical spine x-ray, GCS
Emergency tx-Airway; Stabilize spine, O2, IV access, Intubate (if <8), Control external bleeding, Remove clothes, Maintain warmth
-also ongoing monitor, anticipate intubations, assume neck inj, admin fluids cautiously
Major focus of careICP – BOLO: eye problems, hyperthermia (goal 96.8 - 98.6)
Measures for CSF leakage↑HOB, loose collection pad, NO sneezing/blowing nose, NO NG tube/nasotracheal suction
TreatmentMinor injury: repair CSF leak, lacerations
Penetrating wounds: sx repair, abx, anticonvulsants
Mod-severe: supportive care, prophy anticonvulsants, prevent/control - ICP, hypotension, anemia, ↑arterial CO2 levels
Cervical tong userealigns fx of cervical vertebrae & relieves pressure on cervical nerve; traction MUST be continuous, No pillow under head during feeding (hard to swallow, may need suction)
General NIManage ICP/cerebral edema, Neuro assessments, Admin steroids/osmotic/diuretics, barbiturates (↓cerebral metabolic rate), Minimize procedures during acute phase (suction/positioning), prevent complications of immobility
NI (acute)Maintain cerebral perfusion, prevent secondary ischemia, monitor for neuro changes, pt & family teaching
Teaching (first 2-3 days)-Notify provider of ↑drowsiness, N&V, sensory/behavior/motor changes, HR <60
-Have someone stay w/ you
-No ETOH
-Check w/ PCP before meds ↑drowsiness
-Avoid driving/contact sports/hot baths
What is one of the most incapacitating problems w/ TBImental & emotional changes that occur as a result of TBI
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Tumors

Question Answer
Tumors types-Glimoas (30% of all tumors/80% of all malignant tumors)
-Meningiomas (34% of all primary brain tumors – most common, most are benign)
-Acoustic neuroma (usu benign/low-grade malig)
-Pituitary adenoma (usu benign)
-Hemangioblastoma (rare & benign, sx is curative)
-Primary CNS lymphoma (↑incidence in immunosuppressed)
-Metastatic (from another area of the body; lungs/breast – Malignant)
Frontal lobe (unilateral) s/sUnilateral hemiplegia, seizures, memory deficit, personality/judgment changes, visual disturbances
Frontal lobe (bilateral) s/sSymptoms associated with unilateral frontal lobe tumors; Ataxic gait
Parietal lobe s/sSpeech disturbance (if tumor is in the dominant hemisphere), inability to write, spatial disorders, unilateral neglect
Occipital lobe s/sVision disturbances & seizures
Temporal lobe s/sFew symptoms; Seizures, dysphagia
Subcortical s/sHemiplegia; Other symptoms may depend on area of infiltration
Meningeal s/sSymptoms associated w/ compression of the brain, depend on tumor location
Metastatic s/sHeadache, nausea, or vomiting because of ↑ICP; Other symptoms depend on tumor location
Thalamus/sellar s/sHeadache, nausea, vision disturbances, papilledema,nystagmus occur from ↑ICP; Diabetes insipidus may occur
4th ventrical/Cerebellar s/sHeadache, nausea, and papilledema from ↑ICP; Ataxic gait and changes in coordination
Cerebellopontine s/sTinnitus and vertigo, deafness
Brainstem s/sHeadache on awakening, drowsiness, vomiting, ataxic gait, facial muscle weakness, hearing loss, dysphagia, dysarthria, “crossed eyes” or other visual changes, hemiparesis
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Tumors Assess & Tx

Question Answer
AssessMotor signs, Dizziness/Paresthesia/Coordination
Language disturbances, Hearing/Vision
Seizures – frequently 1st presenting sign
Papilledema, N&V, Drowsiness, change in LOC
HeadachesCommon; tend to be worse at night/may waken pt; Usu dull & constant but occasionally throbbing
Types (classified by locations)Supraentorial –incision behind hairline, sx w/in cerebral hemisphere
Infratentorial –incision made at nape of neck around occipital lobe, sx w/in brain stem & cerebellum
Tx goalsIdentify tumor type/location; Remove/decrease mass; Prevent/manage ICP
ManagementIntracranial sx (burr holes, craniotomy, crainoplasty), Radiation (sx removal is preferred tx); Shunts may be placed to tx hydrocephalus
Radiation complicationsCerebral edema & rapidly ↑ICP (tx w/ high-dose steroids)
Manis of shunt malfunctionr/t ↑ICP: ↓LOC, restlessness, headache, blurred vision, vomiting
ChemotherapyEffectiveness is limited by BBB, tumor cell heterogeneity, tumor cell drug resistance; most malignant tumors cause breakdown of BBB in area of tumor, allowing chemo agents to be used to treat the malignancy
Nursing Pre-opDetailed neuro assess for baseline, Head shave, Psychological support, Ed pt on post-op
Nursing Post-op-Maintain airway, ↑HOB 30-45 degrees after supratentorial sx, Position pt flat & lateral on either side after intratentorial sx
-Monitor VS/neuro signs, Observe for complications (resp difficulty, ↑ICP, hyperthermia, meningitis, infection)
-Admin meds (corticosteroids, osmotics, mild analgesics, anticonvulsants, abx, antipyretics, antiemetics, hormone replacements (if needed); NO NARCOTICS! Masks changes in LOC
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Indications for Crainal Sx

Question Answer
Brain abscess Bacteria that caused intracranial infection -Excision or drainage of abscess
HydrocephalusOverproduction of CSF, obstruction to flow, defective reabsorption -Placement of ventriculoatrial or ventriculoperitoneal shunt
Brain tumorsBenign or malignant cell growth -Excision or partial resection of tumor
Intracranial bleedingRupture of cerebral vessels because of trauma or stroke -Surgical evacuation through burr holes or craniotomy
Skull fracturesTrauma to skull -Debridement of fragments and necrotic tissue, elevation/ realignment of bone fragments
Arteriovenous (AV) malformationCongenital tangle of arteries and veins (frequently in middle cerebral artery) -Excision of malformation
Aneurysm repairDilation of weak area in arterial wall (usually near anterior portion of circle of Willis) -Dissection and clipping or coiling of aneurysm
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Types of Sx

Question Answer
Burr holeOpening cranium with a drill; Used to remove localized fluid/blood beneath the dura
CraniotomyOpening cranium w/ removal of bone flap & opening the dura to remove a lesion, repair damaged area, drain blood, or relieve ↑ICP
CraniectomyExcision of cranium to cut away bone flap.
Cranioplasty Repair of cranial defect resulting from trauma/malformation/previous surgical procedure; Artificial material used to replace damaged/lost bone
Stereotactic procedurePrecise localization of specific area of the brain using a frame or a frameless system based on three-dimensional coordinates; Used for bx, radiosurgery, dissection
ShuntAlternate pathway to redirect cerebrospinal fluid from one area to another using a tube or implanted device
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