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NRNP Finals 6560 Certified Guide 2023
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NRNP Finals 6560 Certified Guide 2023 coup-contrecoup injury Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. Scalp laceration: what, effect, management Primary head injury p...

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  • 14 februari 2023
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NRNP Finals 6560 Certified Guide 2023
coup-contrecoup injury

Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury
occurs on the opposite side of impact, as the brain rebounds.

Scalp laceration: what, effect, management

Primary head injury

profuse bleeding - signs of hypovolemia

Apply direct pressure
Suture/ staple laceration
Lidocaine 1% with epi to control bleeding, not close to nose/ ears

00:0801:41

Skull fracture: types, effect, management

Primary head injury

Simple: no displacement of bone. Observe and protect spine

Depressed: bone fragment depressing thickness of scull
Surgery for debridement. Give tetanus and seizure precautions

Basilar: fracture at floor of skull
Raccoon eye - periorbital bruising
battle's sign: mastoid bruising
otorrhea/ rhinorrhea - halo sign: do not obstruct flow
Give Ab's
Oral intubation and oral gastric instead of nasal

Brain injury: types, effect, management

Primary head injury

Concussion: reversible change in brain functioning
loss of consciousness, amnesia
Do not give opioids, admit for unconsciousness greater than 2min

Contusion: bruising to surface of brain with edema
Frontal and temporal region
Brainstem contusion: posturing, variable temp, variable vital signs

,N/V, dizziness, visual changes
seizure precautions

Hematoma - neuro: types, effect, management

Epidural hematoma: commonly temporal/ parietal region with skull fracture, causing bleeding into
epidural space
Loss of consciousness
Rapid deterioration: obtunded, contralateral hemiparesis, ipsilateral pupil dilation
CT scan (non contrast)
Treatment based on Brain trauma foundation. Surgical if greater than 30cm

Subdural hematoma
most common type of intracranial bleed
Acute (hours): drowsy, agitated, confused, headache, pupil dilation,
CT scan (noncontrast)
surgery for 10mm thickness or 5mm midline shift or for worsening GCS
Chronic (days): headache, memory loss, incontinence
CT scan (noncontrast)
Surgery: burr holes/ crani

Cerebral edema/ ICP elevated/ herniation: symptoms, management

decreased level of consciousness
Blown pupil
Cushing triad: HTN (widening pulse pressure), decreased resp rate, bradycardia (means increased
intracranial pressure)

Neuro exam components

AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive

GCS: 8 or below is comatose

Posturing:
decorticate = arms, legs in
decerebrate = arms, legs out

Electrolyte imbalances in brain injury

Hyponatremia: SIADH and cerebral salt wasting
Hypernatremia: DI (give mannitol)

Management of traumatic brain injury

- Consult neurosurgery
- Limit secondary injury
- Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion.
- Treat cerebral edema: elevate bed, sedate, paralyse, mannitol, hyperventilation (PaCO2 25-30), during

,first 24hrs.
- sedation and analgesia: opioids to reduce ICP (Fentanyl) with propofol. Could give Nimbex or Vec. to
help oxygenate/ ventilate
- steroids: avoid
- Give mannitol or hypertonic saline for herniation: bolus then gtt. monitor serum osmolality, sodium,
and bp.
- Seizure precautions: give phenytoin or keppra
- DVT prophylaxis: stockings, LMWH
- head injury means spine injury until proven otherwise
- hypothermia: can control ICP (89 - 91F)
- decompressive crani: ICP refractory to tx
- brain O2 monitoring (jugular vein O2 sats)

ICP monitoring

For: GCS 3-8 with abnormal CT and comatose pt's with normal CT and older than 40, posturing,
hypotension.

Normal value: 5-10 mmHg

Recommend initiating treatment if ICP > 20 mmHG.

Can calculate CPP (CPP = MAP - ICP). Should be 60

Brain death criteria

Must have all:
No spontaneous movement
Absence brain stem reflexes (fixed/ dilated pupils, no corneal reflexes, absent doll's eyes, absent gag,
absent vestibular response)
Absence breathing drive/ apnea

can't be declared brain dead when: hypothermia, drug intoxication, severe electrolyte/ acid-base
imbalance

EEG, CTA of brain, Cerebral angiography, transcranial doppler

Spinal cord trauma: cause and who

- MVA, falls, acts of violence, sports, wounds
- Rapid acceleration/ deceleration causes hyperextension (fall, rear-end collision)(central cord
syndrome), hyperflexion (bilateral facet dislocation), vertical column loading (compression and then
shattering from falls/ dive lands on butt, at C1 from diving), whiplash
- Distraction injury: from hanging
- penetrating trauma: from wound
- pathologic fractures (osteoporosis/ cancer)

, mainly cervical spine. High mortality.
More common in men
more common in young than old

Fractures and vertebrae

Cervical: C1-C7. Flexible and small diameter so many fractures

Thoracic (T1-T12): connected to ribs. Not common in fractures

Lumbar: L1-L5: Very mobile, requires great force to fracture

Sacral

Spinal cord trauma assessment

- History: mechanism of injury, pt's complaints, pre-hospital tx
- Physical assessment: treat airway, breathing, circulation (ABC) first. Pulm complication common in
quadriplegia. Assess respiratory status: injury above C3 is resp arrest. C5 - C6 spares diaphragm so
breathing exists.
- grade strengthening (0= no muscle contraction, 5 = full strength)
- complete lesion: pt lacks all function below level of spinal cord damage. Poor prognosis.
- incomplete lesion: parts of spinal cord intact
- sensory function: start at no feeling then go to feeling
- evaluate back (log-roll)

Motor assessment in spinal cord trauma

If unable to do, # above:

Deltoids (C4): shrug shoulder
Biceps (C5): flex arm and push arms away
Wrist (C6): try to straighten wrist while pt tries to flex
Triceps (C7): extend arm and try to bend while pt prevents that
Intrinsic (C8): fan fingers and push together
Hip flexion (L2 - L4): bend knee and apply pressure
Knee extension (L2-L4): extend knee with hip/ knee flexed

key signs of spinal cord injury - various levels

C2-C3: resp paralysis, flaccid paralysis, deep tendon reflexes loss

C5-C6: diaphragmatic brething, paralysis of intercostal muscles, quadriplegia, anaesthesie below clavicle,
areflexia, fecal/ urinary retention, priaprism

T12-L1: paraplegia, anesthesia legs, areflexia legs, fecal/ urinary retention, priaprism

L1-L5: flaccid paralysis, ankle/ plantar areflexia

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