Traumatic Brain Injury
What are the types of skull fractures?
Which types change how you assess your patient?
Linear- simple fracture, entire bone thickness, no bone movement. Most benign, low velocity blunt trauma,
* often no interventions, you might hear the term “cracked skull”
Open- scalp laceration, communication between skull and open environment. Exposes brain to possible infection or contamination
*surgical repair, debridement of contaminated wound
* Nursing interventions; maintain asepsis of area, antibiotics, monitor for wound or systemic infection
Depressed- high force depresses skull inward; bone can be fragmented, can be open or closed,
*Surgical repair, evacuation of associated hematomas
* monitor neurologic status, palpate for asymmetry
Basilar- usually temporal or occipital regions, at base of skull, usually with high force impact, can result it rhinorrhea or otorrhea depending on location
*Raccoon eyes- periorbital ecchymosis
*Battle sign – mastoid ecchymosis
* Rhinorrhea or Otorrhea, can be a sign that there is a tear in the meningeal layer leaking csf through ears or nose.
A nurse notes a patient in the ED is diaphoretic, anxious, has dilated pupils, and reports chest pain after “using something to stay awake for two days.” Which substance is most likely involved?
A. Alcohol
B. Opioids
C. Stimulants
D. Cannabis
C. Stimulants
Types of SCI injuries and give examples
Traumatic: MVC, falls, penetrating wounds
Non-Traumatic: Infarction caused by clots, arthritis, abscesses/tumors
Primary vs Secondary:
Primary occurs when there is a mechanical disruption to the spinal cord caused by a traumatic event.
Secondary will happen hours after primary and is usually caused from swelling, bleeding, ischemia; can last several months
Complete vs incomplete: all sensory and motor capability is lost below the level of injuryàParaplegia is the result of injury to the thoracolumbar region (T1–L1); (quadriplegia) is the result of injury to the cervical regions (C1–C8).
incomplete injuries, some sensory or motor capability remains below the level of injury
Trauma Informed Care
"4 R's"
Realize
Recognize
Respond
Avoid Re-traumatization
Normal time intervals for:
PR Interval
QRS Complex
QT Interval
PR Interval: 0.12-0.2 (Longer means what kind of heart block?)
QRS Complex: less than or equal to 0.12
QT Interval: 0.34-0.44 (dependent on HR)
Focal vs Diffuse TBIs
Focal: Subdural, epidural, intraparenchymal
Subdural Hematoma (SDH): Venous bleed between dura and arachnoid; slow onset of confusion, headache, or behavior change.
Epidural Hematoma (EDH): Arterial bleed between skull and dura; classic pattern of LOC → lucidity → recurrent LOC.
Intraparenchymal Hematoma: Bleeding within brain tissue itself, often from hypertension, aneurysm, or high-impact trauma; managed by controlling ICP/CPP.
Diffuse: concussion, Diffuse Axonal Injury, Anoxic Brain Injury, Subarachnoid Hemorrhage
Concussion: Mild TBI from blunt force causing confusion, amnesia, and lingering cognitive symptoms.
Diffuse Axonal Injury (DAI): Shearing of axons from high-speed trauma (e.g., MVC), often severe and not always visible on imaging.
Anoxic Brain Injury: Global brain injury from lack of oxygen (e.g., hanging, cardiac arrest).
Subarachnoid Hemorrhage (SAH): Bleeding between arachnoid and pia mater from trauma or aneurysm; may cause ↑ ICP and midline shift.
name that substance
This drug is vulnerable to abuse due to its ability to desensitize an individual to both psychological and physical pain and induce a sense of euphoria. Lethargy and indifference to the environment are common manifestations…
Opioids/Heroin
Spinal cord injury emergencies
Spinal: is the permanent or temporary reduction of reflexes that occurs right after an SCI (within 30-60 minutes). Spinal shock can last from 24 hours to 1-6 weeks, making it difficult to classify the initial injury until it has resolved. The return of reflex activity below the level of injury indicates the end of spinal shock. Think of spinal shock as a type of "concussion" to the spinal cord/column
Neurogenic is a distributive type of shock that occurs in patients with an injury above T6. It is caused by the sudden loss of the autonomic nervous system signals to the smooth muscle in the vessel walls. It is classified as a type of hypovolemic shock as blood pools to periphery as a result of loss of smooth muscle tone. In neurogenic shock, the sympathetic pathways to the heart are blocked or damaged, resulting in bradycardia. This bradycardia and hypotension need to be managed judiciously as not doing so will result in poor tissue perfusion and end organ death.
Autonomic dysreflexia is a syndrome of massive imbalanced reflex sympathetic discharge occurring in 80% of patients with SCI above the T5–T6 level. Usually caused by some sort of stimulus such as full bladder/bowel, pain, cold/heat, too tight clothing. Symptoms include hypertension, bradycardia, sweating above level of injury, severe HA
Abuse & Neglect Treatment
Crisis Intervention
Safety focus
Therapy for survivors
Therapy for families that use violence
A history of abuse or neglect during childhood, increases the risk of perpetrating abuse and neglect upon others.
Name drugs for and what is the purpose of these?
Paralytics
Sedatives
Analgesics
Paralytics -nium typically used for surgery
Purpose: Intubation & ARDS
Most commonly used:
Nimbex
Vecuronium
Rocuronium
Etomidate
Sedation (address pain FIRST): ex. Fentanyl, Propofol (anesthetic- nurses “cant” give)
Purpose: Procedures, Intubation, Ventilator compliance
Most commonly used Sedation:
Diprivan (Propofol) - use this first because it wears off fast
Midazolam
Fentanyl
Precedex better on hemodynamically unstable
Analgesics
Fentanyl, morphine, etc
What are signs of increased ICP?
•Decreasing GCS
•Irregular breathing patterns
•Cushing's triad
•Vomiting
•Nausea
•Sluggish pupils
•Nonreactive / unequal pupils / irregular shapes
•Headache w/ Lethargy
•Increasing temperature
•Restlessness
•Change in respiratory rate/ use of accessory muscles
•Motor deficits
A patient presents with pinpoint pupils, shallow respirations, and drowsiness after being found unresponsive. What medication does the nurse anticipate administering?
A. Flumazenil
B. Naloxone
C. Naltrexone
D. Methadone
B. Naloxone
What are the other answers choices for?
A patient with a C6 spinal cord injury suddenly develops a severe headache, BP 210/110, bradycardia, and flushing above the injury level. What should the nurse do first?
A. Administer IV labetalol for blood pressure control
B. Check for bladder distention or kinks in the catheter
C. Elevate the head of the bed to 90°
D. Call the provider for additional orders
After elevating the head of the bed for a patient with autonomic dysreflexia, what should the nurse do next?
A. Administer prescribed antihypertensives
B. Loosen tight clothing and assess for bowel impaction
C. Notify the provider immediately
D. Apply cooling packs to reduce flushing
Answer: C. Elevate the head of the bed to 90°
Rationale: Autonomic dysreflexia is a hypertensive emergency. Elevating the HOB decreases intracranial pressure while the nurse searches for the trigger (most often a full bladder or bowel).
Answer: B. Loosen tight clothing and assess for bowel impaction
Rationale: The cause must be removed (bladder, bowel, or skin stimulus). Treating the trigger is the only definitive management for autonomic dysreflexia.
A trauma patient presents after being ejected from a moving vehicle. The nurse notes tachycardia, hypotension, and decreased breath sounds on the left. Which force likely caused this injury?
A. Shearing
B. Compression
C. Deceleration
D. Penetration
Answer: C
Rationale: Deceleration forces occur when a moving body suddenly stops — causing internal organs to continue moving and tear from their attachments (e.g., aortic tear, pneumothorax).
A patient with ARDS is on a continuous cisatracurium (Nimbex) drip and shows no spontaneous movement. Which nursing intervention is most critical?
A. Perform ROM exercises and monitor muscle tone
B. Check RASS every 2 hours
C. Ensure eye protection and use Train-of-Four monitoring
D. Assess for gag reflex before suctioning
Answer: C. Ensure eye protection and use Train-of-Four monitoring
Rationale: Paralytics remove muscle control, including eye blinking. Eye lubrication/protection prevents corneal abrasions, and Train-of-Four ensures appropriate neuromuscular blockade dosing.
What are common complications of TBI patients?
1. diabetes insipidus
2. SIADH
3. seizures
4. herniation
5. brain death
name that substance
Within 4-12 hours of cessation or reduction in heavy and prolonged use: tremors of hands and tongue, nausea and vomiting, tachycardia, elevated blood pressure, diaphoresis, anxiety, insomnia, and irritability. Withdrawal can be life-threatening…
Alcohol
Which statement best explains the pathophysiologic difference between neurogenic shock and autonomic dysreflexia?
A. Both cause severe hypertension and bradycardia.
B. Neurogenic shock involves loss of sympathetic tone, while autonomic dysreflexia is excessive sympathetic discharge.
C. Both result from spinal cord injury below T10.
D. Neurogenic shock is temporary, while autonomic dysreflexia is permanent.
Answer: B. Neurogenic shock involves loss of sympathetic tone, while autonomic dysreflexia is excessive sympathetic discharge.
Rationale:
Neurogenic shock: loss of sympathetic input → vasodilation and hypotension.
Autonomic dysreflexia: massive sympathetic overreaction to stimuli below injury → hypertension and bradycardia.
Which findings require the nurse to immediately return to the primary survey during trauma care?
A. Sudden drop in blood pressure
B. Increasing restlessness and confusion
C. New bruising noted on the flank
D. Oxygen saturation falling to 86%
E. Family requesting patient updates
What does ABCDE stand for?
Answers: A, B, D Any change in airway, breathing, or circulation requires restarting the primary survey (ABCDE). Subtle neurologic changes (B) can indicate hypoxia or shock. Bruising (C) is secondary survey data, and family updates (E) are non-urgent.
A – Airway: Ensure the airway is open and clear; assess for obstruction. Protect the cervical spine if trauma is suspected.
B – Breathing: Assess breathing effectiveness, rate, and oxygenation; provide supplemental oxygen or ventilation if needed.
C – Circulation: Check pulse, blood pressure, perfusion, and control any bleeding; establish IV access if necessary.
D – Disability: Assess neurological status (often using AVPU or Glasgow Coma Scale) and look for acute deficits.
E – Exposure / Environment: Fully expose the patient to identify all injuries while preventing hypothermia.
Name the lethal ECGs
Lethal:
V tach
V fib
Torsade de pointes
Asystole
Second degree HB type 2
Third degree HB
A patient with a traumatic brain injury has an ICP of 22 mmHg and a MAP of 70 mmHg. The nurse calculates the CPP as:
A. 92 mmHg
B. 48 mmHg
C. 50 mmHg
D. 38 mmHg
A patient with a CPP of 55 mmHg is showing decreasing LOC. The provider increases MAP with vasopressors. This action supports which physiologic principle?
A. Monro-Kellie hypothesis
B. Autoregulation of cerebral blood flow
C. Blood-brain barrier protection
D. Cushing’s response
Answer: B. 48 mmHg
Rationale: CPP = MAP – ICP → 70 – 22 = 48 mmHg.
Normal CPP = 60–100 mmHg; below 60 means poor cerebral perfusion and risk of ischemia.
Answer: B. Autoregulation of cerebral blood flow
Rationale: Autoregulation maintains stable cerebral blood flow (CBF) by adjusting vessel diameter when CPP changes. Increasing MAP restores CPP and brain perfusion when autoregulation is impaired.
Which clinical finding differentiates methadone from buprenorphine in opioid treatment?
A. Methadone fully activates opioid receptors, while buprenorphine partially activates them.
B. Buprenorphine has higher risk for respiratory depression than methadone.
C. Both drugs produce intense euphoria.
D. Methadone has a lower risk of dependence.
A. Methadone fully activates opioid receptors, while buprenorphine partially activates them.
Rationale: Methadone = full agonist → full opioid effect.
Buprenorphine = partial agonist → limited receptor activation, lower overdose risk.
Clinical manifestations of autonomic dysreflexia include:
A patient presents after being impaled by a high-velocity bullet from a firearm. The wound is deep, with significant tissue destruction along its path. Which term describes this injury?
A. Low-energy missile
B. High-energy missile
C. Secondary missiles
D. Blunt impact
Answer: B
Rationale: High-energy missile injuries involve fast-moving objects (like bullets) that transfer significant kinetic energy, causing deep tissue damage beyond the immediate wound path.
Which type of pacemaker is placed during open-heart surgery and attached directly to the atria and/or ventricles?
A. Transvenous pacemaker
B. Transcutaneous pacemaker
C. Epicardial pacemaker
D. Implantable permanent pacemaker