NRNP Finals 6560
1. coup-contre- Dual impacting of the brain into the skull; coup injury
coup injury occurs at the point of impact; contrecoup injury occurs on
the opposite side of impact, as the brain rebounds.
2. Scalp lacera- Primary head injury
tion: what, effect,
management profuse bleeding - signs of hypovolemia
Apply direct pressure
Suture/ staple laceration
Lidocaine 1% with epi to control bleeding, not close to
nose/ ears
3. Skull fracture: Primary head injury
types, effect,
management Simple: no displacement of bone. Observe and protect
spine
Depressed: bone fragment depressing thickness of scull
Surgery for debridement. Give tetanus and seizure pre-
cautions
Basilar: fracture at floor of skull
Raccoon eye - periorbital bruising
battle's sign: mastoid bruising
otorrhea/ rhinorrhea - halo sign: do not obstruct flow
Give Ab's
Oral intubation and oral gastric instead of nasal
4. Brain injury: Primary head injury
types, effect,
management Concussion: reversible change in brain functioning
loss of consciousness, amnesia
Do not give opioids, admit for unconsciousness greater
than 2min
Contusion: bruising to surface of brain with edema
Frontal and temporal region
Brainstem contusion: posturing, variable temp, variable
, NRNP Finals 6560
vital signs
N/V, dizziness, visual changes
seizure precautions
5. Hematoma - neu- Epidural hematoma: commonly temporal/ parietal region
ro: types, effect, with skull fracture, causing bleeding into epidural space
management Loss of consciousness
Rapid deterioration: obtunded, contralateral hemiparesis,
ipsilateral pupil dilation
CT scan (non contrast)
Treatment based on Brain trauma foundation. Surgical if
greater than 30cm
Subdural hematoma
most common type of intracranial bleed
Acute (hours): drowsy, agitated, confused, headache,
pupil dilation,
CT scan (noncontrast)
surgery for 10mm thickness or 5mm midline shift or for
worsening GCS
Chronic (days): headache, memory loss, incontinence
CT scan (noncontrast)
Surgery: burr holes/ crani
6. Cerebral ede- decreased level of consciousness
ma/ ICP elevat- Blown pupil
ed/ herniation: Cushing triad: HTN (widening pulse pressure), decreased
symptoms, man- resp rate, bradycardia (means increased intracranial
agement pressure)
7. Neuro exam AVPU: awake, response to verbal stimuli, painful stimuli,
components unresponsive
GCS: 8 or below is comatose
Posturing:
decorticate = arms, legs in
decerebrate = arms, legs out
8.
, NRNP Finals 6560
Electrolyte im- Hyponatremia: SIADH and cerebral salt wasting
balances in brain Hypernatremia: DI (give mannitol)
injury
9. Management of - Consult neurosurgery
traumatic brain - Limit secondary injury
injury - Prevent hypotension (syst 90) and hypoxemia (PaO2
60). May give blood to improve tissue perfusion.
- Treat cerebral edema: elevate bed, sedate, paralyse,
mannitol, hyperventilation (PaCO2 25-30), during first
24hrs.
- sedation and analgesia: opioids to reduce ICP (Fen-
tanyl) with propofol. Could give Nimbex or Vec. to help
oxygenate/ ventilate
- steroids: avoid
- Give mannitol or hypertonic saline for herniation: bolus
then gtt. monitor serum osmolality, sodium, and bp.
- Seizure precautions: give phenytoin or keppra
- DVT prophylaxis: stockings, LMWH
- head injury means spine injury until proven otherwise
- hypothermia: can control ICP (89 - 91F)
- decompressive crani: ICP refractory to tx
- brain O2 monitoring (jugular vein O2 sats)
10. ICP monitoring For: GCS 3-8 with abnormal CT and comatose pt's with
normal CT and older than 40, posturing, hypotension.
Normal value: 5-10 mmHg
Recommend initiating treatment if ICP > 20 mmHG.
Can calculate CPP (CPP = MAP - ICP). Should be 60
11. Brain death crite- Must have all:
ria No spontaneous movement
Absence brain stem reflexes (fixed/ dilated pupils, no
corneal reflexes, absent doll's eyes, absent gag, absent
vestibular response)
Absence breathing drive/ apnea
, NRNP Finals 6560
can't be declared brain dead when: hypothermia, drug
intoxication, severe electrolyte/ acid-base imbalance
EEG, CTA of brain, Cerebral angiography, transcranial
doppler
12. Spinal cord trau- - MVA, falls, acts of violence, sports, wounds
ma: cause and - Rapid acceleration/ deceleration causes hyperextension
who (fall, rear-end collision)(central cord syndrome), hyper-
flexion (bilateral facet dislocation), vertical column loading
(compression and then shattering from falls/ dive lands on
butt, at C1 from diving), whiplash
- Distraction injury: from hanging
- penetrating trauma: from wound
- pathologic fractures (osteoporosis/ cancer)
mainly cervical spine. High mortality.
More common in men
more common in young than old
13. Fractures and Cervical: C1-C7. Flexible and small diameter so many
vertebrae fractures
Thoracic (T1-T12): connected to ribs. Not common in
fractures
Lumbar: L1-L5: Very mobile, requires great force to frac-
ture
Sacral
14. Spinal cord trau- - History: mechanism of injury, pt's complaints, pre-hospi-
ma assessment tal tx
- Physical assessment: treat airway, breathing, circulation
(ABC) first. Pulm complication common in quadriplegia.
Assess respiratory status: injury above C3 is resp arrest.
C5 - C6 spares diaphragm so breathing exists.
- grade strengthening (0= no muscle contraction, 5 = full
1. coup-contre- Dual impacting of the brain into the skull; coup injury
coup injury occurs at the point of impact; contrecoup injury occurs on
the opposite side of impact, as the brain rebounds.
2. Scalp lacera- Primary head injury
tion: what, effect,
management profuse bleeding - signs of hypovolemia
Apply direct pressure
Suture/ staple laceration
Lidocaine 1% with epi to control bleeding, not close to
nose/ ears
3. Skull fracture: Primary head injury
types, effect,
management Simple: no displacement of bone. Observe and protect
spine
Depressed: bone fragment depressing thickness of scull
Surgery for debridement. Give tetanus and seizure pre-
cautions
Basilar: fracture at floor of skull
Raccoon eye - periorbital bruising
battle's sign: mastoid bruising
otorrhea/ rhinorrhea - halo sign: do not obstruct flow
Give Ab's
Oral intubation and oral gastric instead of nasal
4. Brain injury: Primary head injury
types, effect,
management Concussion: reversible change in brain functioning
loss of consciousness, amnesia
Do not give opioids, admit for unconsciousness greater
than 2min
Contusion: bruising to surface of brain with edema
Frontal and temporal region
Brainstem contusion: posturing, variable temp, variable
, NRNP Finals 6560
vital signs
N/V, dizziness, visual changes
seizure precautions
5. Hematoma - neu- Epidural hematoma: commonly temporal/ parietal region
ro: types, effect, with skull fracture, causing bleeding into epidural space
management Loss of consciousness
Rapid deterioration: obtunded, contralateral hemiparesis,
ipsilateral pupil dilation
CT scan (non contrast)
Treatment based on Brain trauma foundation. Surgical if
greater than 30cm
Subdural hematoma
most common type of intracranial bleed
Acute (hours): drowsy, agitated, confused, headache,
pupil dilation,
CT scan (noncontrast)
surgery for 10mm thickness or 5mm midline shift or for
worsening GCS
Chronic (days): headache, memory loss, incontinence
CT scan (noncontrast)
Surgery: burr holes/ crani
6. Cerebral ede- decreased level of consciousness
ma/ ICP elevat- Blown pupil
ed/ herniation: Cushing triad: HTN (widening pulse pressure), decreased
symptoms, man- resp rate, bradycardia (means increased intracranial
agement pressure)
7. Neuro exam AVPU: awake, response to verbal stimuli, painful stimuli,
components unresponsive
GCS: 8 or below is comatose
Posturing:
decorticate = arms, legs in
decerebrate = arms, legs out
8.
, NRNP Finals 6560
Electrolyte im- Hyponatremia: SIADH and cerebral salt wasting
balances in brain Hypernatremia: DI (give mannitol)
injury
9. Management of - Consult neurosurgery
traumatic brain - Limit secondary injury
injury - Prevent hypotension (syst 90) and hypoxemia (PaO2
60). May give blood to improve tissue perfusion.
- Treat cerebral edema: elevate bed, sedate, paralyse,
mannitol, hyperventilation (PaCO2 25-30), during first
24hrs.
- sedation and analgesia: opioids to reduce ICP (Fen-
tanyl) with propofol. Could give Nimbex or Vec. to help
oxygenate/ ventilate
- steroids: avoid
- Give mannitol or hypertonic saline for herniation: bolus
then gtt. monitor serum osmolality, sodium, and bp.
- Seizure precautions: give phenytoin or keppra
- DVT prophylaxis: stockings, LMWH
- head injury means spine injury until proven otherwise
- hypothermia: can control ICP (89 - 91F)
- decompressive crani: ICP refractory to tx
- brain O2 monitoring (jugular vein O2 sats)
10. ICP monitoring For: GCS 3-8 with abnormal CT and comatose pt's with
normal CT and older than 40, posturing, hypotension.
Normal value: 5-10 mmHg
Recommend initiating treatment if ICP > 20 mmHG.
Can calculate CPP (CPP = MAP - ICP). Should be 60
11. Brain death crite- Must have all:
ria No spontaneous movement
Absence brain stem reflexes (fixed/ dilated pupils, no
corneal reflexes, absent doll's eyes, absent gag, absent
vestibular response)
Absence breathing drive/ apnea
, NRNP Finals 6560
can't be declared brain dead when: hypothermia, drug
intoxication, severe electrolyte/ acid-base imbalance
EEG, CTA of brain, Cerebral angiography, transcranial
doppler
12. Spinal cord trau- - MVA, falls, acts of violence, sports, wounds
ma: cause and - Rapid acceleration/ deceleration causes hyperextension
who (fall, rear-end collision)(central cord syndrome), hyper-
flexion (bilateral facet dislocation), vertical column loading
(compression and then shattering from falls/ dive lands on
butt, at C1 from diving), whiplash
- Distraction injury: from hanging
- penetrating trauma: from wound
- pathologic fractures (osteoporosis/ cancer)
mainly cervical spine. High mortality.
More common in men
more common in young than old
13. Fractures and Cervical: C1-C7. Flexible and small diameter so many
vertebrae fractures
Thoracic (T1-T12): connected to ribs. Not common in
fractures
Lumbar: L1-L5: Very mobile, requires great force to frac-
ture
Sacral
14. Spinal cord trau- - History: mechanism of injury, pt's complaints, pre-hospi-
ma assessment tal tx
- Physical assessment: treat airway, breathing, circulation
(ABC) first. Pulm complication common in quadriplegia.
Assess respiratory status: injury above C3 is resp arrest.
C5 - C6 spares diaphragm so breathing exists.
- grade strengthening (0= no muscle contraction, 5 = full
