TBI & Organ Donation

Intracranial Regulation
TBI/Organ Donation

By Miranda Smith

Multiple Choice

Which is NOT part of the GCS?

• Heart rate
• Eye opening

• Communication

• Motor

Multiple Choice

Which is part of the Cushing's Triad?

• Fever
• Pinpoint pupils

• Hypotension
• Widening pulse pressure

Multiple Choice

Which diagnostic image is important to obtain upon arrival of a client after sustaining a head injury?

• MRI with angi

• CT w/o contrast

• CT with contrast

• Xray of skull

Multiple Choice

Which finding would cause the nurse to be most concerned the client has suffered a basilar skull fracture?

• CSF leaking from ears

• Headache

• Brief LOC

• Decreased GCS

Racoon Eyes
Battle Signs
CSF-EARS

Interventions:
Cover drainage site loosely
NO NG TUBES
High risk for meningitis

​

Basilar Skull Fracture

Multiple Choice

What is NOT a RED FLAG of a concussion?

• Dizziness

• Nunbness in arms

• Tachycardia

• Vomiting

Shearing and rotational force

Severe:
No lucid interval
Immediate coma
Posturing
Global cerebral edema

​

Diffuse Axonal Injury

​Tear of middle meningeal artery
Ipsilateral pupil fixed dilated
Brief LOC-> Lucid-> DEC LOC

​​Epidural Hematoma

Acute vs chronic

Acute- symptoms may be more severe and intense

Chronic more vague

Subdural Hematoma

In the parenchyma of the brain, can extend into the ventricles
Can result from aneurysm, HTN, vascular anomalies, tumors

Decreased Neuro dysfunction and s/s of Increased ICP

​​Intracerebral Hemorrhage
Intraparenchymal (IPH)

Aneurysm rupture or trauma at the Circle of Willis
S/S Triad: EXPLOSIVE HA, dec LOC, nuchal rigidity
Triple H therapy: hypervolemia, hemodilution, hypertension

​Major complication: rebleed and vasospasm

​Subarachnoid
hemorrhage

Interventions

ABCs
Supportive Care
Surgical removal: craniotomy and craniectomy
ICP monitoring
Drains &/or Bolts

NEVER flush the drain
Assess the drainage (CSF)

Ventriculostomy Drain

​Monitor's ICP only

​​Intraparenchymal Bolt

Surgery in the skull in which a bone flap is removed in order to access the brain, but then the bone is replaced

Craniotomy

​The bone flap is removed in order to access the brain, but is not immediately replaced, it allows for swelling for increased ICP

Craniectomy

Multiple Choice

For a client who is on a vent and has increased ICP, which statement below is true?

• The goal is to keep PaCO2 > 45 to help increase the blood flow to the brain to help perfusion

• Reducing the levels of CO2 reduce cerebral blood flow and can help decrease ICP

• Keep the FiO2 at 100% to ensure the brain tissue is getting enough oxygen

• Increasing tidal volume helps to improve oxygenation and the perfusion and oxygenation to the brain

Multiple Choice

Cerebral perfusion pressure and intracranial pressure are the same thing!!! (Normal CPP 80-100)

• True

• False

Multiple Choice

What would be an EARLY SIGN of increasing intracranial pressure?

• Agitation

• Nausea and vomiting
• Blurred vision
• Decreased LOC

Multiple Choice

When a client develops Cushing's Triad, what should the nurse be concerned about?

• herniation

• sepsis

• renal failure

• shock

Multiple Choice

A client has a ICP of 34. Which treatment would be the most appropriate?

• D5W

• 1/2 NS

• LR

• 3%NS

Multiple Select

Which medication(s) would the nurse anticipate to administer for the increased ICP?

• levetiracetam

• mannitol

• dexamethasone

• morphine

• furosemide

Multiple Choice

The nurse is administering mannitol to the client. Which outcome would indicate the medication is working?

• Improved vision
• Decreased heart rate
• Increased blood pressure
• Increased urine output or decreased intracranial pressure.

Organ Donation

What to do and when?

3 Signs of brain death:
1. Coma
2. Absence of brain stem reflexes (cough, gag, pupils, cornea, oculovestibular)
3. Apnea

​brain stem functions, body on autopilot, can breath, sleep wake. Eyes open to pain do not track initially, but can start tracking after time, can perceive pain, but cannot communicate

​​Vegetative State

​Not awake nor asleep
Deep unconscious nap

Coma

​No reflexes, no bodily functions

Death

Legacy of Hope

Vision and Mission:
"We will end the wait and the suffering by shepherding the gift of life to those in need of organ and tissue transplants."

LOH Referral PROCESS

REFERRAL -> APPROACH -> DONOR MANAGEMENT -> ORGAN ALLOCATION -> PROCUREMENT

Multiple Choice

John Raines is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take Mr. Raines to a treatment room.

What should the nurse do initially once Mr. Raines is placed on the bed?

• Assess airway

• Attach cardiac monitor

• Initiate an IV

• Apply oxygen

Multiple Choice

Case Progression

You complete your neurologic examination and find the following: GCS score of 15; pupils equal, round, reactive to light; and full sensation intact. Mr. Raines complains of a headache and is somewhat drowsy. His vitals are BP 120/72 (88), HR 114, RR 30, Temp 98.7 ° F (37.1 ° C) and SpO2 94%. As the radiology technician performs a portable cervical spine x-ray, Mr. Raines begins to speak incoherently so the tech notifies you. You come to the bedside and assess that his pupils are unequal, with the right pupil larger than the left and does not respond to light. Mr. Raines has now become unresponsive to verbal stimuli and his eyes and motor response to pain is shown in the illustration.

What is his GCS score now?

• 7

• 4

• 10

• 5

Multiple Choice

His vital signs are now BP 160/72 (101), HR 64, RR 10, Temp 98.7 ° F (37.1 ° C), and SpO2 94%. What are you concerned Mr. Raines is developing?

• Increased Intracranial pressure

• Cardiac failure

• Hypertension
• Respiratory distress or failure

Multiple Choice

He is transported to radiology for a CT scan; he is found to have a large epidural hematoma on the right with a hemispheric shift to the left. He is taken straight to the operating room for evacuation of the hematoma. Postoperatively Mr. Raines is admitted to the neurological intensive care unit. Which nursing intervention would be important for the nurse to implement upon arrival to the NICU?

• Keep HOB flat

• Provide all the nursing care when he gets there

• Calm the environment

• Place a pillow behind his head to provide flexion

Multiple Choice

Which independent nursing action would the nurse need to implement to monitor ICP?

• Frequent neuro exam

• ICP monitor

• Accurate intake and output

• Capnography

Open Ended