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Acute Care Interventions of Brain Injuries

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ACUTE CARE INTERVENTIONS OF BRAIN INJURIES NEUROSCIENCE CRITICAL CARE JASSIN M. JOURIA, MD Dr. Jassin M. Jouria is a practicing Emergency Medicine physician, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT Brain injuries can be devastating and their impact is frequently felt deeply by family and friends as well as the patient. The trauma of a brain injury can continue not just in the initial days and weeks after occurrence but for months and years afterward. The neuroscience critical care team caring for a patient immediately following a traumatic event involving brain injury can have a profound impact on the patient’s outcome and quality of life. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Clinicians need to understand the different types of treatment a patient with an acute brain injury may receive. Because the treatment for head injury will differ depending on the severity and type of injury, patient care will need to be individualized. Treatment goals for each type of head injury need to be identified by the full neuroscience treatment team. Course Purpose To provide health clinicians with knowledge of the types and treatment of acute brain injury. 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. When swelling and fluid accumulation occur within the brain, it can be extremely dangerous for the patient primarily because this accumulation a. creates lesions within the brain. b. creates pressure in the brain. c. blocks the brain-blood barrier. d. may lead to infection. 2. True or False: Once intracranial pressure (ICP) becomes elevated, the only option for treatment is a ventriculostomy. a. True b. False 3. Patients with low risk head injuries may display symptoms such as a. persistent emesis. b. severe headache. c. anterograde amnesia. d. None of the above 4. When a patient is released to a caregiver for monitoring the injury at home, the home caregiver should a. check the patient once a day. b. assess the patient every two hours. c. assess the patient each morning. d. take the patient for outpatient assessment. 5. Cranial nerve and pupillary examination includes assessing a patient’s a. level of consciousness. b. posture. c. gag reflex. d. pain sensations. 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction The intensive care management of patients with a brain injury is a dynamic process, and starts in the pre-hospital period. During the early stages of hospital care, the patients may be managed in a variety of locations including the emergency department, radiology department, and the operating room before they are admitted to the intensive care unit (ICU). The continuum of acute care, during the golden hour, from the time of injury through the start of definitive care, should be ensured and based on established medical guidelines and recommendations. The fundamental principles of critical care management of patients with a brain injury in the acute phases of hospital care are raised in the following sections. Critical Care Strategies In The Neuroscience Unit An initial assessment and diagnostic imaging are used to determine the level of severity of a brain injury and to determine any specific complications. Once this information is obtained, and the patient is stabilized, medical personnel can begin to treat specific injuries. Treatment is individualized based on the injuries and the severity of the damage. In some instances, a patient with head trauma may require initial surgical interventions. These surgical interventions are conducted immediately following the initial assessment and treatment to minimize some of the immediate complications that are most dangerous or threatening to the patient.35 When a patient requires an initial surgical intervention, he or she is typically admitted to the intensive care unit for further treatment and monitoring. Initial surgical interventions are used to remove or repair hematomas and contusions.66 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com A patient may experience swelling in the brain. When this occurs, fluid accumulates within the brain and pressure begins to build. This causes additional swelling and disruption to the fluid balance.45 With injuries to other parts of the body, swelling and fluid accumulation is normal and may pose little risk; however, when swelling and fluid accumulation occur within the brain, it can be extremely dangerous for the patient. The danger arises because the skull limits the space for the brain to expand so that swelling and fluid accumulation elevates intracranial pressure (ICP).11 When a patient is evaluated with swelling in the brain, it is necessary to monitor the swelling to ensure that it does not cause additional damage. This is accomplished using a probe or catheter.66 The instrument is inserted into the skull and is placed at the subarachnoid level to ensure accurate measurements. Once the instrument is properly placed, it is connected to a monitor that displays information regarding the patient’s ICP. This information is closely monitored so that action can be taken if the ICP reaches an alarming level.28 If this occurs, the patient may have to undergo a ventriculostomy. This procedure is used to drain cerebrospinal fluid as a way to reduce pressure on the brain.30 In some instances, pharmacological agents may be used to decrease ICP. These drugs include mannitol and barbiturates.66 While the above information provides an overview of the different types of treatment a patient may receive, it is important to note that the treatment for head injury will differ depending on the severity and type of injury. A patient will require different care for a penetrating head injury than a blunt head injury. In addition, a mild head injury will be treated differently than a severe head injury. It is important to understand the treatment goals for each type of injury. 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Mild, Moderate or Severe Head Injuries When a patient experiences a mild head injury, minimal treatment is required. Most mild head injuries will resolve on their own and will not progress in severity.114 However, there is a chance that the head injury can progress to a more serious injury.71 During the initial assessment, the risk level of the head injury will be assessed and it will be categorized as either low risk or moderate risk.18 Low Risk injuries typically include symptoms of headaches, dizziness, and nausea.115 Patients who display symptoms of low risk injuries will not require extensive treatment. They rarely require the level of assessment that moderate or high risk patients do, and it is not common to utilize radiologic imaging to evaluate the injury.116 In most instances, patients will be released and will require monitoring at home until the window for developing additional injuries has passed.117 When a patient is released, thorough instructions should be given to the patient and caregivers for monitoring the injury at home. The home caregiver should wake the patient every two hours to provide a thorough assessment. Caregivers should watch for symptoms in the patient of severe headaches, persistent nausea, vomiting, seizures, confusion, unusual behavior, and watery discharge from the nose or ear.110 Moderate risk injuries typically include the following symptoms of persistent emesis, severe headache, anterograde amnesia, loss of consciousness, and signs of intoxication.118 When a patient shows signs of a moderate risk head injury, assessment should be made using a computed tomography (CT) scan. Once the CT scan findings are reviewed, the patient is eligible for release, assuming the findings were clear.
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