Traumatic Brain Injury and Intracranial Hemorrhage
Traumatic brain injury and intracranial hemorrhage are two common diagnoses for patients admitted to intensive care. Motor vehicle accidents, falls, sports injuries, trauma, and anatomic variances can cause patients to sustain a brain injury or bleed. Critical care nurses should understand the causes of and treatments for these conditions.
Traumatic Brain Injury
Traumatic brain injury (TBI) can occur due to a closed head or penetrating injury. Injuries can occur due to direct or indirect blows to the head or objects passing through the skull into the brain. While some TBIs can be managed with close monitoring at home, others may require significant intensive care intervention. If brain swelling exceeds skull space or if interventions to stabilize the patient and brain damage are unsuccessful, death can occur.
Symptoms of TBI vary based on severity. Low-severity or mild injuries are typically labeled as concussions. Symptoms typically start with a brief loss of consciousness with a complete return to consciousness. Additional symptoms such as headache, confusion, dizziness, blurred vision, tinnitus, and fatigue are common. Mild injuries usually have positive outcomes. Symptoms of moderate and severe TBI can include worsening headache, repetitive nausea and vomiting, seizures, difficulty staying awake, pupil dilation, slurred speech, agitation, and weakness or numbness. The more severe the head injury, the more likely the patient will experience long-term physical and psychological symptoms.
Intracranial hemorrhage can occur anywhere within the cranium. They can occur due to outward trauma, internal blood vessel rupture, tumors, hypertension, and congenital blood vessel formation abnormalities. Four primary types of intracranial hemorrhage are listed below.
Epidural hematomas can develop from trauma to the arteries or veins in the brain. Epidural bleeds are typically associated with injury to the temporal region where the blood infiltrates the epidural space. Arterial epidural bleed most commonly develops from the middle meningeal artery. Venous epidural bleed typically develops due to skull fracture. Venous epidural bleeds are more common in pediatric patients. Classic presentation of this condition is an acute loss of consciousness immediately following injury and then lucid awareness for a short period of time before neurologic deterioration ensues.
Subdural hematomas develop when blood vessels are stretched, broken, or torn causing bleeding into the subdural, arachnoid, space. Subdural hematomas typically occur secondary to blunt force trauma to the head. They can less commonly occur due to penetrating injuries or spontaneously. Symptoms of subdural hematoma include headache, nausea, vomiting, changes in mental status, seizure, and/or lethargy.
Subarachnoid hemorrhage occurs when bleeding and blood accumulation invade the subarachnoid space. Hemorrhage can be traumatic or non-traumatic. Blunt head injury, penetrating trauma, or sudden acceleration trauma are most likely to cause subarachnoid hemorrhage. Non-traumatic hemorrhages are typically related to cerebral aneurysm rupture. Presentation of subarachnoid hemorrhage is often associated with a sudden, severe headache, also known as a thunderclap headache.
Intraparenchymal hemorrhage is bleeding located within the brain parenchyma proper. While trauma can cause intraparenchymal hemorrhage, hemorrhage in this location is more commonly associated with severe hypertension, arteriovenous malformation, aneurysm, amyloid angiopathy, tumor growth, infection, or coagulopathy abnormalities. Stroke-like symptoms are typical of intraparenchymal hemorrhage.
Treatment of all cranial injuries focuses first on securing the patient’s airway, breathing, and circulation. For admitted patients, intravenous access is crucial to provide medications and fluids as needed to hemodynamically support the patient. Nurses should use the Glasgow Coma Score (GCS) to monitor the patient’s neuro status and to help anticipate when intubation may be needed. Ongoing neurological assessment can provide insight into the severity, progression, and recovery from injury.
Patients will often need emergent CT or MRI imaging to determine the degree of injury. These images also help surgeons determine the source of trauma or bleeding and can help prepare them for interventions.
While some TBIs and hematomas may be observed, surgical interventions are often indicated in active bleeds, large hematomas, and increased intracranial pressure. Craniotomy, burr hole(s), and external ventricular drain (EVD) placement may be utilized to help relieve increased brain pressure and manage bleeding. ICU admission is common for patients with TBI.
Traumatic brain injuries and intracranial hemorrhage must be managed efficiently and effectively to help reduce complications. Patients with these conditions are typically unstable and require close monitoring throughout their acute and long-term recovery. Critical care nurses should be prepared to perform accuracy assessments of the patient and understand the clinical pathways of these injuries. For more on brain injuries and critical care nursing, or to test your knowledge, check our practice tests, study guides, and flashcards for the CCRN.
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