Closed Head Injury Case Study
Y.W. is a 23-year-old male student from Thailand studying electrical engineering at the university. He was ejected from a moving vehicle, which was traveling 70 mph. His injuries included a severe closed head injury with an occipital hematoma, bilateral wrist fractures, and a right pneumothorax. During his neurologic intensive care unit (NICU) stay, Y.W. was intubated and placed on mechanical ventilation, had a feeding tube inserted and was placed on tube feedings, had a Foley catheter to down drain (DD), and had multiple IVs inserted. He developed pneumonia 1 month after admission. Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage.
1. Define the term primary head injury. A primary head injury (or primary impact) is also known as a “coup injury.” The injury occurs under the site of impact with an object such as a hammer or a rock. The brain strikes the skull after the head strikes the object of impact (Lewis, et al, Fig 57-14). This is the site of the direct impact of the brain on the skull. Often there is edema around the site of impact.
2. Define the term secondary head injury.
The secondary head injury is also known as contrecoup injury occurs on the side opposite the area that was impacted. These injuries tend to be more severe and overall patient prognosis depends on the amount of bleeding around the contusion site (Lewis, et al, 1425). Often it is the secondary brain injuries that show few initial symptoms and then have serious side effects days to weeks later.
3. What is normal intracranial pressure (ICP), and why is increased ICP so clinically important? Normal intracranial pressure ranges from 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal. Pressure changes in the brain effect the brain’s compliance. Compliance is the “expandability of the brain” With low compliance, small changes in volume occur and result in greater increases in pressure. Elevated intracranial pressure is clinically significant because “it diminishes CPP, increases risks of brain ischemia and infarction, and is associated with a poor prognosis” (Lewis, et al, p. 1425-1427).
4. Identify at least five signs and symptoms (S/S) of increased ICP.
5 signs and symptoms of increased ICP are
Decreased LOC (level of consciousness)
Respiratory problems (maintaining a patent airway is critical in the patient with increased ICP. Pt is at increased risk of airway obstruction (Lewis, et al, p. 1434). •
Elevated systolic BP due to ischemia and pressure on the brainstem. •
Bradycardia due to the ischemia and pressure on the brainstem as well. •
Pulmonary edema due to increased sympathetic activity as a result of increased intercranial pressure.
5. List 4 medication classifications that the ICU nurses could use to decrease or control increased ICP. Some of the medications that the ICU nurses could use to decrease or control increased ICP would be: •
Opioids (morphine sulfate and fentanyl)
IV anesthetic sedative propofol (Diprivan) to manage anxiety and agitation. •
Vecuronium (Norcuron), cisatracurium besylate (Nimbex): nondepolarizing neuromuscular blocking agents: achieve complete ventilatory control in the treatment of refractory intracranial hypertension. (These agents paralyze muscles without blocking pain or noxious stimuli, therefore they are used in combination with sedatives, analgesics, or benzodiazepines (Lewis, p. 1436)). •
Dexmedetomidine (Precedex): alpha-2 agonist; used for continuous IV sedation of intubated and mechanically ventilated patients in the ICU setting for up to 24 hours. •
Benzodiazepines are usually avoided in the ICU in management of the patient with increased ICP because of the hypotensive effect and long half-life. (Lewis, et al, p.1436).
6. List 8 nursing...
References: Lewis, et al, (2011). Medical-Surgical Nursing Assessment and Management of Clinical Problems. 8th ed. Vol 1. St Louis, Missouri: Mosby.
Skyscape. (2010). Skyscape Medical Resources (Version 1.9.11) [Mobile application software]. Retrieved from http://itunes.apple.com/
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