Whether the trauma is physical assault, car crash or personal injury, the primary brain injury is damage that occurs as a direct result of the initial impact.
However, there is also a risk of secondary brain injury; the damage caused by inadequate cerebral perfusion (limited oxygen or blood flow), seizure, increased intracranial pressure (ICP) and cerebral edema.3
TBI treatment depends on timely interventions and nurses must organize the complex care required to increase the chances for a positive outcome. The essential tips listed below will help you provide the best possible care for TBI patients:
Always cover the basics: airway, breathing and circulation. TBI can result in impaired consciousness that prevents the patient from protecting his airway. Emesis is a common partner with TBI, either from alcohol use or as a direct result of the injury. Patients with an altered level of consciousness are at a risk for aspiration pneumonia. There is a low threshold for endotracheal intubation and mechanical ventilation for the TBI patient.
Ensuring adequate oxygen perfusion to the brain is fundamental to treating the TBI patient. The patient with TBI who is not breathing, or not breathing adequately, requires immediate intubation and mechanical ventilation. Assess the adequacy of breathing. Note the depth and type of respirations and observe for cyanosis.
A pulse oximeter should be immediately placed to obtain an oxygen saturation (SpO2). A decreasing SpO2 trend, or an SpO2 value < 93% likely requires supplemental oxygen.4 If, for any reason, a basilar skull fracture or facial fracture is suspected, oxygen by nasal cannula or nasotracheal intubation is an absolute contraindication, as it could go directly into the cranial cavity.5
Establishing the adequacy of circulation is vital to TBI survival. Nurses should ensure that there is an adequate blood pressure and at least two large bore intravenous (IV) lines for fluid resuscitation.
When starting a new IV, experienced nurses often obtain baseline labs, including a complete blood count and basic metabolic profile. Fluid resuscitation due to blood loss should be initiated with 0.9% Sodium Chloride or Ringers Lactate solution.6 Hypertonic solutions have also shown useful; however, avoid any solutions containing dextrose, as they may increase ICP.6,7
In the A-B-C-D mnemonic, D “disability” is a cue for the neuro exam. It is important to quickly and accurately establish the baseline neurological status. All future exams will be compared to this baseline to determine whether the patient is stable and responding to treatment, or deteriorating and requires intervention.
Use of a validated scale such as the Glasgow Coma Scale (GCS) or Full Outcome of Unresponsiveness (FOUR) scale is recommended.6,8 The GCS measures best eye, verbal and motor response. The highest score possible is 15. Scores of 13-15 are considered either normal or a mild brain injury, 9-12 may is a moderate brain injury, and 3-8 is a severe TBI. A score of 8 or less indicates the need for intubation.
Many severe brain injuries also present with decorticate or decerebrate posturing with autonomic dysfunction, including tachycardia, tachypnea and hypertension. Any severe TBI would necessitate resuscitative measures, and those who survive will remain with persistent neurological deficits. Pupillary reactivity, size and shape should also be assessed. Equal pupils with round shape and constriction to light is optimal. Cat-like or oval pupil shape, or any irregularity including asymmetry or fixed and dilated pupils can indicate neurologic dysfunction or increased ICP.9
Diagnose the Cause
A detailed narration of the mechanism of injury is helpful because the extent of trauma may not be immediately obvious. For example, if the patient was in a motorcycle accident, there is a very real risk of road rash and broken bones. Upon arrival, physician notification and a stat non-contrast brain computed tomography (CT) should be ordered along with a skull x-ray to rule out cranial fracture.
Time is of the essence with TBI because any bleeding can cause compression and possible brain herniation. It is important to establish if the injury was followed by any loss of consciousness or memory loss. Brain trauma can occur as the result of several different injuries. These include concussions; skull fractures; epidural, subdural and subarachnoid bleeds; intraventricular hemorrhage; and diffuse axonal injury.
Concussions can be caused by blunt force trauma or acceleration/deceleration injuries. Skull fractures are mostly caused by some form of blunt force trauma. Epidural, subdural, and subarachnoid hemorrhages occur from intracerebral bleeding after veins are arteries have been sheered or ruptured and bleed into the closed space of the brain within the skull.6 Some bleeds will occur rapidly, while others may bleed slowly for up to two weeks.6