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Acute Care and Management of Acquired Brain Injury
These are my VERY VERY VERY basic and summarised notes on this topic. Obviously there is LOADS you could read around this subject and it is very interesting - probably worth a look if you’re working in A&E or ITU.
The cranium holds blood (12%), cerebrospinal fluid (8%) and the brain (80%), which consists of water, neurons and glial cells.
Normal intracranial pressure is between 0-15 mmols of mercury. A pressure of >20 mmols requires intervention.
Causes of raised ICP include tumours, haemorrhage, oedema, hydrocephalus (excess cerebrospinal fluid), abscess, infection (such as meningitis) and encephalitis (swelling of the brain tissue).
The body employs compensatory measures to reduce ICP such as a decrease in the volume and rate of cerebrospinal fluid production (the normal rate being 10-15mls per hour) and an increased rate of venous return to the heart, although these measures will eventually fail if no intervention occurs.
Symptoms of increased ICP include a reduced level of consciousness, headache, nausea and vomiting (projectile vomiting in the morning is a common sign - don’t ask me why though), motor dysfunction and focal signs such as dysphagia. Later symptoms such as unreactive pupils and Cushing’s triad (widening blood pressure, bradycardia and a change in respiratory pattern) are also common.
Tramatic brain injury is associated with a high morbidity and mortality rate, and usually is attributed to young men. Alcohol is often the cause of acquired brain injury (unsurprisingly). The Glasgow Coma Scale (GCS) is usually used to determine if the injury is mild/moderate/severe. Injuries include haemorrhage, concussion, fractures - basically the physical disruption of delicate brain tissue.
Symptoms of basal skull fractures include swelling of both eyes and bruising around the ears.
Early Nursing and Medical Management involves early identification with a CT scan, prompt assessment and neuro observations.
Using the ABCD(E) model:
Airway and Breathing
- If GCS <8, the patient should be intubated.
- Maintain SPO2 of >96% - hypercapnia will cause increased blood volume in the skull as CO2 is a vasodilator.
- Deep breathing should be encouraged in the unconscious patient.
- Regular observations of rate and depth should be carried out.
- Maintain BP within set parameters to provide a CPP between 50-70, ideally above 60.
- If BP is too low, brain tissue will be underperfused and IV fluids should be administered.
- If BP is too high, this could contribute to increased ICP. Normal volaemia (+500mls at the end of the day) should be aimed for.
- Dextrose fluids such as glucose should never be given as they will upset the osmotic balance and contribute to ICP. Isotonic fluids such as saline can be given.
The patient MUST have a doctor review if the following symptoms occur:
- Development of agitation/abnormal behaviour
- Sustained (ie. 30 mins+) drop of one or more points in GCS
- Any drop of more than 2 points in GCS level regardless of duration or GCS subscale
- Development of severe or increasing headache/vomiting
- New/evolving neurological symptoms like pupil unreaction
Factors that increase ICP include neck flexion (the head should be kept up at 30 degrees), excessive hip flexion, increased temperature, coughing, straining, suctioning, noxious stimuli, pain and anxiety.
Medical interventions include administration of mannitol (an osmotic diuretic given via IV bolus which draws fluid away from the brain - the patient MUST be catheterised as it is very fast-acting), ventriculostomy (insertion of a drain into the cranial cavity), intubation and sedation of the patient (as this reduces metabolic requirements), mild hypothermia, control of CO2, and as a last resort a decompressive craniectomy (surgical removal of a section of the skull across the frontal lobe - THIS IS WORTH GOOGLING, IT’S WEIRD.)
There you have it. Told you they were basic notes.
(A re-post of a question & answer, to allow for reblogging at nikitaanneli’s request)
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