Clinical care
Acute Care Nursing of Adults II
(University of South Carolina)
NEURO EXAM 3
TRAUMATIC BRAIN INJURIES STUDY NOTES
, Traumatic Brain Injuries (TBI)
Classifications:
Mild
- Loss of consciousness for up to 30 minutes
o Loss of memory for events immediately prior to accident
o No focal neurologic deficits (specific part of body affected)
o No evidence of injury on CT/MRI
Moderate
- GCS 9-12
- Loss of consciousness > 30 min to 6 hours
- Injury may or may not be visible on CT/MRI
Severe
- GCS 3-8
- Loss of consciousness > 6 hrs
*Assume pt w/TBI have spinal cord injury until proven otherwise*
Chronic Traumatic Encephalopathy (CTE)
- Progressive degenerative disease affecting those who have suffered repeated concussions or TBI’s
- Persists over period of years or decades because of traumatic impacts to brain
o Accumulation of tau protein
o Shrinking of brain
- Only identified post-mortem
Post skull fracture
- Leads to poor impulse control, aggression, depression, suicide risk
- No blowing nose
- No nasal suctioning
- No Valsalva or coughing
- Do not drink w/straw
, Basilar Skull fracture
CSF can leak through skull fracture
CSF does have glucose – test fluid
for glucose to see if it is CSF
Leaking CSF
- Tears in dura lead to rhinorrhea or otorrhea
- Tests for CSF:
▪ Dextrostix – if drainage is clear – if glucose present = + CSF
▪ Halo sign – if drainage is bloody – if separates = + CSF
- May be seen with basilar skull fx
Acute Care Nursing of Adults II
(University of South Carolina)
NEURO EXAM 3
TRAUMATIC BRAIN INJURIES STUDY NOTES
, Traumatic Brain Injuries (TBI)
Classifications:
Mild
- Loss of consciousness for up to 30 minutes
o Loss of memory for events immediately prior to accident
o No focal neurologic deficits (specific part of body affected)
o No evidence of injury on CT/MRI
Moderate
- GCS 9-12
- Loss of consciousness > 30 min to 6 hours
- Injury may or may not be visible on CT/MRI
Severe
- GCS 3-8
- Loss of consciousness > 6 hrs
*Assume pt w/TBI have spinal cord injury until proven otherwise*
Chronic Traumatic Encephalopathy (CTE)
- Progressive degenerative disease affecting those who have suffered repeated concussions or TBI’s
- Persists over period of years or decades because of traumatic impacts to brain
o Accumulation of tau protein
o Shrinking of brain
- Only identified post-mortem
Post skull fracture
- Leads to poor impulse control, aggression, depression, suicide risk
- No blowing nose
- No nasal suctioning
- No Valsalva or coughing
- Do not drink w/straw
, Basilar Skull fracture
CSF can leak through skull fracture
CSF does have glucose – test fluid
for glucose to see if it is CSF
Leaking CSF
- Tears in dura lead to rhinorrhea or otorrhea
- Tests for CSF:
▪ Dextrostix – if drainage is clear – if glucose present = + CSF
▪ Halo sign – if drainage is bloody – if separates = + CSF
- May be seen with basilar skull fx
