Angeles University Foundation

Angeles City

College of Nursing

“Traumatic Brain Injuries

& Chest Trauma”
(A Case Report)

Submitted By:

Ano, Carl Elexer C.

BSN IV- 11, Group 41

Submitted To:

Jeremiah Buenafe RN, MN

August 26, 2009

Introduction
 Traumatic brain injury is an insult to the brain that is capable of producing
physical, intellectual, emotional, social, and vocational changes (J. Black, 2202).
Chest trauma on the other hand may be minor and have little effect on
respiratory status, but then again, chest wall trauma that damages the
underlying lung tissue is a major health threat (AUF-CON NCM 104 handouts).
These two traumatic injuries are mainly brought about by motor accidents.
Statistics shows that in the United States, head injuries happen every 15
seconds.

Recent innovations regarding traumatic brain injuries especially those of

with hematoma include Decompressive Craniotomy. The benefits of
decompressive crainotomy (DC) in the treatment of traumatic brain injury
patients with increased intracranial pressure (ICP) are controversial. A recent
study Williams R. F. et al. 2009, showed that DC resulted in good functional
outcome in over 50% of patients with severe TBI. The maximum benefit was
observed in younger patients with demonstrable reduction in ICP after
decompression. These are factors to consider when the choice of DC arises after
injury. (http://www.braininjury.com/research.html accessed on August 23, 2009)

More so, a new innovation on the diagnosis of pneumothorax was

presented by Dr. Stewart Siu Wa Chan. A relatively new application of
emergency ultrasound is its use in the diagnosis of pneumothorax. In patients
with major trauma, early detection and treatment of pneumothorax are vital.
Chest radiography in these patients is limited to anteroposterior (AP) supine
films, in which radiographic features of pneumothorax may be quite subtle.
Hence, rapid and accurate bedside ultrasonography can expedite resuscitation.
Sonographic features of pneumothorax have been identified in a number of
studies. The technique involves identification of the pleural line and observation
for features such as "lung sliding" and comet-tail artifacts, which are absent in
pneumothorax.
(http://www.pneumothorax.org/pneumo.nsf/SBH/DB1D4EC902D5C55585256CE4
0055AD35?OpenDocument accessed on August 23, 2009)

II. Nursing Assessment

 Motor vehicle accidents are the leading cause of head injuries. This is
common among males younger than 30 years old especially those who
ingest alcohol or those who have a history of substance abuse and those who
drive recklessly.

Chest trauma in the other hand may be Idiopathic, or caused by blunt

or penetrating trauma to the chest such as gunshot wounds, stab wounds,
penetrating foreign object. Falls, motor accidents which may bring about
fracture, or this maybe also iatrogenic in nature such as COPD, tuberculosis,
diseases that may cause brittleness of the bone, complication due to
insertion of central IV line, complications of chest surgery, complications of
thoracentesis, or accidental removal of chest tube.

III. Pathophysiology

Acute Brain Injuries/ Traumatic Brain Injuries

 Risk factors
Modifiable: Non-
modifiable:
>reckless driving > Age: <30
y/o
Blow to the surface of the
head

Penetrating Scalp Kinetic energy is

injury injury transmitted to the
Suturing brain
Skull
fracture
Headache,
Linea N/V Diffuse Contreco
Basila Depress
(coup) injury up injury
r r ed
Raccoon’s Retrograde
Eye Amnesia Rapid tissue
displacement
Loss of
Battle’s consciousness Concussi
Sign on
Contusi
on

Brain Tearing of veins Changes in Cranial Diffus

tissue from the capillary & nerve & e
bruising cortical surface arterial nerve tracts Axona

A B C Cerebral Brain
stem

Hemiparesis,↓ LOC
Hemiplegia,
Front Tempor frontotempo Occipit Parietal alterations in
al al ral al Respiratory
perception,
Disturbances
sensory loss
Hemipares Agitated, Aphasi Visual Disturbanc (anomia,
is confused, a Disturban Pupillary
es on agnosia,
unsteady gait, ces Abn’s
sensual ageusia,
hearing
perception slurred
disturbances
speech,
Loss of normal Eye
B dysphagia,
mov’t C
A microphonia,
mask – like
face,
asymmetry of
Escape of blood facial
Escape of blood between the features, eye
to the subdural skull and dura mov’t Pooling of blood
space matter, paralysis, in Pooling
Pooling of
of in
the subdural in
cerebral area ptosis, the epidural
the
space
anisocoria, intracerebral
space
Distortion
Manifestations
weakness, &
Client
Subdural
of subdural
Alterations
Brain and
ofin
hernation
Loss
Intracereb
Epidural
compressi
Brain
awakens
blurred vision,epidural stem
Further
Hemato
Headac thermoregulati
(+ Setting
consciousn
onand
of Sun
Com
hemato
ral
brain
compression
urinary andhematoma
increase quite
he onessina
ma
Sign)
 incontinence.

Fluctuati
ng LOC
Pupillary
responses
rapidly
deteriorates
Changes in Eye mov’t LEGEN
speech, pupillary paralysis on the D:
reactivity, same side as of
alteration in that of the Mechanism of
motor and hematoma injury
sensory ability
Cushing’s Sign and
Triad
symptoms
>Systolic HPN
>Widened
Pulse Death
Pressure
>
Bradycardia

Chest Trauma
Death
Risk Factors
Modifiable: Non- modifiable:
>ingestion of alcohol > Age: <30 y/o (traumatic) advanced
ages (pathologic)
>reckless driving >Male (traumatic) Female (pathologic)
>fall
>bone deformity/abnormality and diseases that causes brittleness of the

Trauma to thoracic

Paradoxic
Instability of the Contracting
Bulging upon
al chest
affected upon
Penetrati Blunt expiration
breathing
wall inspiration
 Open Multiple rib
chest FX
Tear to (Flail
pleura and
lung tissue
Inflammat
ory
process

Communicatio Internal Pulmonar

n to Bleedin y
atmospheric g Contusion
Pneumothor Hemothor ↓ Gas
ax ax
Crackle
s exchange
↓ Tidal
LEGEN ability
Frothy Volume
D:
red Hypoventilat
Mechanism of mucus Hypox
ion
ia
injury
Diminished Hypercap
Sign and
Breath nia
symptoms
sound
Hypotensio Respirato
↓ Vascular ry
n
Acidosis
Cardiac
> ↓ Cardi
Dysrhythmias Hypoxemi
Tremors Myocardial
a
> contractilit
Seizures ↓Cerebral tse.
> perfusion Acidemia
Lethargy Neurolog
↓neurotransmission
> Pneumothorax/Hemothorax
Stupor
> Coma

Risk Factors
Modifiable: Non- modifiable:
>ingestion of alcohol > Age: < 30 y/o (traumatic) advanced
ages (pathologic)
>reckless driving >Male (traumatic) Female (pathologic)
>fall
>COPD
>Tuberculosis
>Insertion of central line, thoracentesis
>gunshot wound, stab wound, penetrating foreign object, fractures rib
↓ cerebral Diminishe
↓tidal
Respirato
Depressed
↓ system
Entry
Open
Pneumothor
ofchest
air in
Loss
theof
Disruption
pleural
negative
Pneumohemothor
of
pressure
normal lung
Tear on
inhemothor
internal respiratory d breath
A Cardiac
Hypotensio
wound
ax space the
tissue
Neurotransmis
Myocardial
expansion
↓pleura
axEntry of blood in the
Vascular
perfusion
sion
structure
axpleural
Neurologic
Cardiac
volum ry
Hypercapn
Hypoxi
Acidemi
Hypoxe
sounds
aAcidosis
e
mia
a
ea
Dysrhythmias
n
 Hypoventilati
on

Cyanosi
s

> Tremors
> Seizures
> Lethargy
> Stupor
> Coma
>
Restlessne
ss
> Anxiety

Entrapment of air in the

pleura

intrapleural pressure >

lung tissue pressure

LEGEN
Compression of the lung D:
and the surrounding
Mechanism of
structures
injury
Respiratory Tracheal shift & mediastinal
Severely Ischemi
compromised
Severe
instability ↓tissue
Cardiac ↓ Venous
shiftHypotension Sign and
Coma
Death Output Return
hypoxemia
perfusion
a symptoms
 Traumatic Open Pneumothorax and Mediastinal Flutter

Risk Factor

Large Bore
Pneumothorax

Air moves in and out of the pleural

LEGEN cavity
D:
Mechanism of Lung compression, forward
injury backward mov’t of the
mediastinum
Sign and Respiratory and Cardiac
Neck Vein
AcuteProgressive
Subcutaneous
chest Tachypne
Severe Great
instability Severe
bloodAsymmetrical
vessel Diminished
Muffled
chest
Restlessn
heart
Hyper
Breath
Shock
Death PMI Shift
distention symptoms
Pain
cyanosis
emphysema Dyspnea
a Hypotension
compressionMovement soundSound
ess
resonance
Acute Brain Injuries/Traumatic Brain Injuries

Acute brain injuries or traumatic brain injuries are caused by a sudden

impact force to the head causing a penetrating injury to the head, a scalp
injury and a blunt injury through a kinetic energy transmitted against the
head usually brought about by high velocity objects which may bring
contusion or concussion injury.

Acute brain in juries/ Traumatic brain injuries may be classified in to four:

 Scalp Injuries – scalp injuries can cause laceration to the skin and
usually needs suturing.

 Skull injuries- often caused by a force sufficient to fracture the skull

and cause brain injury. The fracture themselves do not signal that
brain injury is present.

o Linear fracture- this is usually seen as a thin line on radiographic

visualization and does not require any treatment.

o Depressed skull fracture- this type of skull injury may be

observed and palpated and evident in radiographic studies. This
type of fracture usually injures the brain by bruising it resulting
to contusion, or it may lacerate the brain by driving bone
fragments into it.

o Basilar skull fracture- occurs in bones over the base of the frontal
and temporal lobes. These are not observable on plain
radiographs but may be manifested as ecchymosis around the
eyes (raccoon’s eye) or behind the ears (battle’s sign) or by
blood or CSF leakage either from the ears (otorrhea) or from the
nose (rhinorrhea).

 Brain injuries

o Concussion- a head trauma that may result in loss of

consciousness for 5 minutes or less and retrograde amnesia.
There is no break in the skull or dura and no visible damage on
CT scan and MRI.

o Contusion- are associated with more extensive damage that from

concussions. With contusion the brain itself is damaged, often
 with multiple areas of petechial and punctate hemorrhage and
bruised areas in the brain tissue.

o Diffuse axonal injury- most severe form of head injury because

there are no focal lesions to remove. The injury involves the
tissue of the entire brain and occurs in microscopic level.

 Mild- loss of consciousness lasting 6 to 24 hours and short

– term disability.

 Moderate- coma lasting less than 24 hours with incomplete

recovery upon awakening.

 Severe- immediate loss of consciousness, prolonged coma,

abnormal flexion or extensor posturing, hypotension, and
fever.

 Focal injuries- these are injuries involving the protective covering of

the brain.

o Epidural Hematoma- leakage of blood from the space between

the skull and the dura mater specifically the epidural space.
Epidural hematoma occurs from injury to the cerebral blood
vessels, most often the middle meningeal artery. Bleeding is
usually continuous, and a large clot forms. Manifestations are
usually acute in onset because the bleeding is arterial in nature.

 Unconsciousness immediately after head trauma.

 Awakens and quite lucid.

 Loss of consciousness occurs, pupillary dilation response

rapidly deteriorates, wit onset of eye movement paralysis
on the same side as that of the hematoma.

 Client lapses to coma.

o Subdural hematoma- collection of blood in the subdural space.

This is usually brought about by tearing on the bridging veins
over the brain.

 May remain unconscious after the injury or may have a

fluctuating LOC.
  Headache (on conscious client)

 Irritable, confused

 Manifestations of increasing ICP

 Development of lateralizing changes such as hemiparesis,

pupillary dilation, eye movement paralysis.

 Coma

o Intracerebral hematoma- occurs less often as to compare with

epidural and subdural hematomas. They are caused by bleeding
directly into brain tissue and may occur at the area of injury.
Clinical manifestations are the same with the epidural and
subdural hematomas.

Chest Trauma

The chest is a large exposed portion of the body that is vulnerable to

impact injuries. Because the chest houses the heart, lungs, and great vessels,
chest trauma frequently produces life threatening disruptions. Injury to the
thoracic cage and its contents can restrict the heart’s ability to pump blood or
the lung’s ability to exchange air and oxygenate blood.

 Flail chest- it is a thorax in which multiple rib fracture causes instability in

part of the chest wall and paradoxic breathing, with the lung underlying
the injured area contracting on inspiration and bulging on expiration. It is
also manifested by decreased tidal volume which is brought about by
hypoventilation which eventually may lead to hypercapnea, hypoxia,
hypoxemia and acidemia.

 Pneumothorax- is the presence of air in the pleural space that prohibits

the complete lung expansion, which may lead to decreased tidal volume
which is brought about by hypoventilation which eventually may lead to
hypercapnea, hypoxia, hypoxemia and acidemia. This may be classified
either primary which is idiopathic in nature or secondary which is brought
about by an injury to the lungs. It may also be classified as hemothorax
(blood accumulation) pneumohemothorax (air and blood accumulation).
Mediastinal flutter is the most serious complication of Pneumothorax.
Manifestations are as follows:

o Moderate
  Tachypnea

 Dyspnea

 Chest pain

 Diminished or absent breath sounds

 Hyper resonance

 Restlessness

 Anxiety

 Tachycardia

o Severe

 All s/sx of moderate

 Distended neck vein

 Shifting of PMI

 Subcutaneous emphysema

 Tracheal deviation

 Progressive cyanosis
Medical Management

 Traumatic Brain Injuries

A. Diagnostics/Laboratory procedures

o Skull x- ray – to visualize if there is a fracture involve.

o Cerebral angiography- this is to visualize the cerebral perfusion/

circulation

o CT scan/ MRI- to visualize presence of hematoma and shifting of

brain structures

o Lumbar puncture- this is to note for bleeding to subarachnoid space

and to note for CSF pressure.

B. Treatment

Objectives:

1. Maintain Cerebral perfusion

2. Prompt recognition and treatment of hypoxia and acid – base

disturbances

3. Control of increase ICP

4. Management of nutritional and gastrointestinal functions

5. Stabilization of other conditions

Specific Management

1. Application of cervical collar

2. Covering of open wound application of pressure to control bleeding

unless there is an underlying depressed skull fracture

3. Complete bed rest

4. Oxygen therapy

5. Restricted oral intake 24- 48 hours

6. Give medication as ordered:

Analgesic: acetaminophen
 Antipyretic

Anesthetic: Lidocaine

Anticonvulsant: Phenytoin

Barbiturate: Pentobarbital (Nembutal) if unable to control ICP with

diuresis

Diuretics: Mannitol

Inotropic agents: Dopamine

Glucocorticoid: Dexamathasone

Histamine Receptor Antagonist: cimetidine

Surgical management:

1. Ventriculostomy- insertion of drain into the ventricles

2. Craniotomy- surgical incision into the cranium

3. Cranioplasty- use of acrylic plates to replace the removed skull section

Nursing Management:

1. Ineffective airway clearance r/t coma or bleeding into airway

2. Altered cerebral tissue perfusion r/t hypotension, intracranial

hemorrhage, hematoma or other injuries

3. Impaired physical mobility r/t motor, sensory, or proprioceptive

deficits, depressed consciousness level

4. Altered thought processes r/t memory deficits, impaired reasoning

ability, altered level of consciousness, confusion, speech impairment,
sensory deprivation

5. Pain r/t altered brain or skull tissue

6. Anxiety r/t the threat of permanent neurologic injury or death

7. Altered urinary elimination r/t lack of awareness of bladder distention,

unconsciousness

8. Altered Nutrition less than body requirement

9. Risk for paralysis r/t undiagnosed cervical fracture

 10. Risk for seizures r/t brain injury, hypoxia, electrolyte imbalance,
hyperthermia, fluid volume alterations

11. Risk for impaired skin integrity r/t immobility and lack awareness to
turn

12. Risk for injury r/t restlessness and confusion, complications of head
injury

Common nursing interventions:

1. Maintain patent airway, assist with endotracheal intubation or

tracheostomy, as necessary

2. Assess neurologic and respiratory status

3. Observe for signs of increasing intracranial pressure

4. Monitor and record vital signs and intake and output

5. Administer IV fluidsto maintain hydration and maintain intravenous

access

6. Protect patient from injury secondary to his condition. Use of side rails
and unsteady patients

7. Assess for CSF leak as evidenced by otorrhea or rhinorrhea. CSF leak

could leave the patient at risk for infection: elevate HOB

8. Provide suctioning; if patient is able, assist with TCDB exercises

9. Institute seizure precaution

10. Speak calmly

 Chest Trauma

A. Diagnostics/ laboratory procedures:

o ABG analysis

o Chest x- ray

B. Treatment

1. Oxygen therapy

2. ET intubation
3. Mechanical ventilation

4. Muscle relaxant

5. Analgesics

6. Promote breathing and coughing

7. Fluid replacement

8. Thoracentesis

9. Chest tube insertion

Surgical management

1. Internal and external fixation- realignment of fractured ribs

2. Thoracotomy- incision to the pleural space in the chest

3. Chest Tube insertion/thoracostomy- insertion of a flexible tube to drain

fluids or air in the pleural space.

4. Pleurodesis- removal of the pleural space by either surgically removing

one of the layers of the pleural cavity or irritating it by chemicals
leading to closure of the space between the parietal and visceral layer.

Nursing management

1. Impaired Gas exchange r/t poor chest expansion and loss of alveolar
ventilation/ loss of negative pressure in the pleural cavity and resulting
to collapse lung tissue

a. Assess and document VS and respiratory status

b. Place the patient in fowler’s and high – fowler’s position

c. Encourage adequate rest

d. Assess chest tube system

e. Administer oxygen as ordered

2. Risk for injury r/t presence of chest tube

a. Secure loop of drainage tubing

b. Make sure that neither the chest tube nor drainage tubing is
kinked
 c. Teach the client how to ambulate with drainage system

d. Observe insertion site for insertion for sign of infection

3. Decreased Cardiac output r/t great vessel compression secondary to

mediastinal shift

a. Immediately cover the wound securely

b. Ask the patient to take a deep breath and try to blow it out while
keeping the mouth and nose closed

c. Closed chest drainage

4. Risk for fluid volume deficit r/t bleeding

Sources:

Black PhD, RN, CPSN, CWCN, Joyce M., and Jane H. Hawks DNSc, RN, BC. Medical -
Surgical Nursing: Clinical Management for Positive Outcomes. 7th ed. Vol. 2.
Singapore: Elsevier Saunders, 2005. Print.

Smeltzer, Suzanne C., Brenda G. Bare, Janice L. Hinkle, and Kerry H. Cheever.
Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Brunner & Suddarth's
Textbook of Medical-Surgical Nursing). 11th ed. Vol. 1&2. Philadelphia: Lippincott
Williams & Wilkins, 2006. Print.

Handouts from NCM 104 and NCM 102 Angeles University Foundation