23 y o. Aam auto vs ped



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23 y.o. AAM

  • 23 y.o. AAM

  • Auto vs. ped

  • 8/10/08



Dancing on I-35 under the influence of crack cocaine and ETOH.

  • Dancing on I-35 under the influence of crack cocaine and ETOH.

  • Hit by 2 cars > 50mph

  • GCS 12 on arrival, but declined to 4

    • Eyes 4>1
    • Verbal 3>1
    • Motor 5>2


PMH

  • PMH

    • Denies, but GSW (metallic pellets CXR)
  • PSH

    • Denies
  • Social Hx

    • Single, no children, unemployed, unfunded
    • +ETOH, +amphetamines, +cannibis
    • Recently released from jail for drug possession
  • Meds

    • Denies










R frontotemporoparietal SDH

  • R frontotemporoparietal SDH

    • Craniectomy
    • EVD
    • Monitor/treat ICP
  • Paraplegia/paresis

  • L2 burst fracture c subluxation L2-L3

  • T11 lamina/TP fracture

    • T10-L3 posterior fusion when stable
    • PT/OT/ST…rehab


10th & 11th rib fractures

  • 10th & 11th rib fractures

  • R femur fracture

  • Acetabular fracture

  • Mediastinal hematoma







Neuro checks/VS q1h

  • Neuro checks/VS q1h

  • ICP monitoring

  • CPP monitoring

    • IVF
    • Vasopressors
  • MAP monitoring

  • Sedation/analgesia

  • Seizure prophylaxis

  • Infection prophylaxis

  • Skin care



Trauma

  • Trauma

  • Pulmonary/CC

  • Orthopedics

  • ID

  • SW/CM



Rehabilitation

  • Rehabilitation

  • Assessment

    • Decreased short term memory
    • Paraparesis
      • DF 2/5, PF 2/5, HF 4-/5


Occurs every 15 seconds

  • Occurs every 15 seconds

  • 500,000 annual ED visits

  • Most common causes: MVAs, falls, assaults

  • Males 15-24, elderly > 75

  • Accounts for 40% of traumatic deaths



1st

  • 1st

    • Primary Injury: initial insult … i.e. from bleed


Secondary Injury: delayed injury from hypoxia, ischemia, and release of neurotoxins

  • Secondary Injury: delayed injury from hypoxia, ischemia, and release of neurotoxins

  • Excitatory amino acids can cause swelling and neuronal death

  • Endogenous opioids cause increased metabolism, using glucose supplies

  • Increased ICP, especially > 40 leads to brain hypoxia, ischemia, hydrocephalus, herniation

  • Hydrocephalus: clotted blood obstructs CSF outflow tracts and absorption of CSF, disrupts blood-brain barrier



Concussion

  • Concussion

  • Contusion

  • Epidural hematoma (EDH)

  • Subdural hematoma (SDH)

  • Basilar skull fracture

  • Diffuse axonal injury (DAI)





Mild Traumatic Brain Injury:

  • Mild Traumatic Brain Injury:

    • Concussion: brief change in mental status with axonal swelling
  • Moderate to Severe Brain Injury:

    • Contusion: “bruising”
    • Fractures: linear,comminuted, depressed, basalar
    • Bleeds: epidural, subdural, intracerebral


Period of LOC < 30 mins with a GCS of 13-15 after this LOC

  • Period of LOC < 30 mins with a GCS of 13-15 after this LOC

  • Amnesia to the event

  • Alteration in mental status at the time of the event (dazed and confused)



Grade I (confusion, no amnesia, no LOC)

  • Grade I (confusion, no amnesia, no LOC)

    • Remove from activity (may return when asymptomatic)
    • 3 concussions in 3 months: no activity that risks head trauma for 3 months
  • Grade II (confusion and amnesia)

    • Remove from activity for day
    • Recheck in 24 hours
    • No activity for 1 week
    • Two grade II concussions in 3 months, no activity for 3 months
  • Grade III (LOC)

    • To ED for CT
    • Symptom free for 2 weeks, then another 30 days
    • Two grade III concussions, no activity for 3 months


Somatic symptoms: headache, sleep disturbance, dizziness, vertigo, nausea, fatigue, sensitivity to light or noise

  • Somatic symptoms: headache, sleep disturbance, dizziness, vertigo, nausea, fatigue, sensitivity to light or noise

  • Cognitive: attention, concentration, memory problems

  • Affective: irritability, depression, anxiety, emotional lability





Small bleeds

  • Small bleeds

  • Cerebral Edema

  • Deficits are based on lobe involved



Linear

  • Linear

  • Comminuted



95% go to surgery

  • 95% go to surgery

  • Antibitoics for infection

  • Brain tissue is involved





Laceration of dural arteries or veins

  • Laceration of dural arteries or veins

  • Classically laceration of middle meningeal artery

  • Temporal bone fractures

  • “Lucid interval” followed by rapid deterioration

  • Acute bleed



60-80% mortality

  • 60-80% mortality

  • Tearing of bridging veins, pial artery, or cortical veins

  • Acute vs chronic



Lacerations of vessels in subarachnoid space

  • Lacerations of vessels in subarachnoid space



Intraventricular hemorrhage

  • Intraventricular hemorrhage

    • Very severe TBI
    • Poor prognosis
  • Intracerebral hemorrhage









Decreased neurologic function is best predictor of brain injury

  • Decreased neurologic function is best predictor of brain injury

  • Pay attention to cranial nerves



Labs: CBC, electrolytes, type and screen, tox and ETOH screen

  • Labs: CBC, electrolytes, type and screen, tox and ETOH screen

  • CT Brain

  • CT angiography or cerebral angiography (penetrating)

  • MRI contraindicated if metallic fragments



Intubate GCS 8 or less or airway protection issue (Cricothyroidotomy if necessary)

  • Intubate GCS 8 or less or airway protection issue (Cricothyroidotomy if necessary)

  • Maintain BP 90 mmHg systolic

  • C-spine precautions

  • Tetanus prophylaxis

  • Sterile dressing to wounds

  • Antibiotics in penetrating injury



  • ICP monitor in patients with GCS < 8

  • Hyperventilation not routinely recommended

  • Elevate head of bed to 30 degrees

  • Sedation

    • Propofol
    • Barbiturate Induced Coma
      • Contraindicated in hypotension
  • Mannitol

    • Reduces ICP by reducing blood viscosity, improves cerebral blood flow
    • Serum osmolality should not be > 320
    • Bolus dosing


GCS < 15

  • GCS < 15

  • Intoxicated

  • Age > 55 or < 2

  • Amnesia to events

  • Witnessed LOC (> 15 minutes)

  • Repeated vomiting

  • Evidence of basilar skull fracture

  • Inability to recall 3 of 5 objects

  • Coagulopathy

  • Penetrating head injury









BP and oxygenation

  • BP and oxygenation

  • Hyperosmolar therapy

  • ICP monitoring

  • CPP

  • Infection prophylaxis

  • DVT prophylaxis

  • http://youtu.be/YQ609Tk-qQI



Stem Cell Therapy

  • Stem Cell Therapy

    • Neural/Glial differentiation
    • Neurogenesis
    • Neuroplasticity
    • Improve motor function
    • Improve cognitive function




AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St.

  • AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St.

  • Davis, F.A. (2001). Taber’s Cyclopedic Medical Dictionary. F.A. Davis, Philadelphia.

  • Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida.

  • Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L. (2007). Medical-Surgical Nursign. Assessment of Management of Medical Problems. Mosby Elsevier, St. Louis, Missouri

  • Silvestri, Linda. (2008). Comprehensive review for the NCLEX-RN Examination. Saunders Elsevier, St. Louis, Missouri.





YouTube - Brain Plasticity

  • YouTube - Brain Plasticity



Organizational changes caused by experience

  • Organizational changes caused by experience



Formation of new nerve cells

  • Formation of new nerve cells



Genetics

  • Genetics

    • 2500 connections
      • “major highways”
  • Environment

    • 15000
      • “avenues & side roads”


“Directed Neuroplasticity”

  • “Directed Neuroplasticity”



YouTube - The Brain Fitness Program (1/8)

  • YouTube - The Brain Fitness Program (1/8)



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