• Seizures
1. CEREBRAL CONTUSION • Drowsiness
Definition Focal Neurologic Signs
A cerebral contusion is a localized traumatic injury to Frontal lobe injury
the brain characterized by bruising of brain tissue, • Personality changes
capillary hemorrhage, edema, and neuronal • Behavioral abnormalities
damage. • Motor weakness
It is considered a moderate to severe traumatic brain Temporal lobe injury
injury (TBI) and involves structural damage to the • Memory impairment
brain parenchyma. • Aphasia
Etiology / Causes • Emotional disturbances
Common causes include: Occipital lobe injury
• Motor vehicle accidents • Visual disturbances
• Falls • Visual field deficits
• Physical assault Signs of Increased ICP
• Sports injuries • Severe headache
• Blast injuries • Vomiting without nausea
High-risk groups: • Decreased level of consciousness
• Young adults • Pupillary changes
• Elderly individuals Cushing's Triad (Late Sign)
• Individuals involved in high-impact activities 1. Hypertension
Mechanism of Injury 2. Bradycardia
Coup Injury 3. Irregular respirations
Damage occurs directly under the site of impact. This indicates impending brain herniation.
Contrecoup Injury Diagnostic Evaluation
Damage occurs on the opposite side of impact as CT Scan (Primary Diagnostic Tool)
the brain rebounds inside the skull. Findings:
Rotational Injury • Hyperdense areas (bleeding)
Rotational forces produce shearing of axons and • Edema
blood vessels. • Mass effect
Pathophysiology • Midline shift
Primary Brain Injury MRI
Occurs immediately at the moment of trauma. Detects:
Processes include: • Small contusions
1. Mechanical disruption of neurons • Diffuse axonal injury
2. Rupture of capillaries Neurologic Assessment
3. Intracerebral bleeding Includes:
4. Tissue bruising • Glasgow Coma Scale (GCS)
Secondary Brain Injury • Motor strength testing
Occurs hours to days later due to biochemical • Cranial nerve examination
cascades: ICP Monitoring
• Cerebral edema Indicated in severe TBI.
• Hypoxia Pharmacologic Management
• Ischemia 1. Osmotic Diuretics
• Release of excitatory neurotransmitters Mannitol
(glutamate) Mechanism:
• Oxidative stress • Increases plasma osmolality
• Increased intracranial pressure (ICP) • Draws fluid out of brain tissue
Normal ICP: 5–15 mmHg • Reduces ICP
Increased ICP leads to: Nursing considerations:
• Decreased cerebral perfusion pressure • Monitor serum osmolality
• Brain ischemia • Monitor urine output
• Brain herniation • Watch for dehydration
Clinical Manifestations 2. Hypertonic Saline
Symptoms vary depending on location and severity. Used to reduce cerebral edema and ICP.
General Symptoms 3. Anticonvulsants
• Headache Examples:
• Nausea and vomiting • Phenytoin
• Confusion • Levetiracetam
• Loss of consciousness
Purpose: 5. Reduced cerebral blood flow
Prevent post-traumatic seizures. This produces an energy crisis in neurons.
4. Sedatives Clinical Manifestations
Examples: Immediate Symptoms
• Propofol • Brief loss of consciousness
• Midazolam • Confusion
Used to: • Dizziness
• Reduce cerebral metabolic demand • Headache
• Control agitation • Amnesia
5. Analgesics Cognitive Symptoms
Examples: • Difficulty concentrating
• Fentanyl • Memory problems
• Morphine • Slowed thinking
Purpose: Emotional Symptoms
Pain control and reduction of stress response. • Irritability
Surgical Management • Mood swings
Indications: • Anxiety
• Large hematoma Physical Symptoms
• Severe swelling • Nausea
• Brain compression • Vomiting
Procedures: • Blurred vision
• Craniotomy • Sensitivity to light and noise
• Decompressive craniectomy Pharmacologic Management
Nursing Management Usually supportive.
Key priorities: Analgesics
Neurologic monitoring: • Acetaminophen (preferred)
• Glasgow Coma Scale Avoid initially:
• Pupillary reaction • NSAIDs
• Motor strength • Aspirin
Prevent increased ICP: because they increase bleeding risk.
• Elevate head of bed 30° Antiemetics
• Avoid neck flexion Examples:
• Control coughing and agitation • Ondansetron
Maintain: • Metoclopramide
• Adequate oxygenation Sleep aids (if necessary)
• Normal blood pressure • Melatonin
• Proper fluid balance • Short-term sedatives
Complications Management
• Intracranial hemorrhage Cognitive Rest
• Brain herniation Avoid:
• Post-traumatic epilepsy • screen time
• Cognitive impairment • studying
• Permanent neurologic deficits • reading
Physical Rest
2. CONCUSSION Avoid:
Definition • sports
A concussion is a mild traumatic brain injury • strenuous activity
characterized by transient neurological dysfunction Gradual Return-to-Play Protocol
without structural brain damage. Patients must be symptom-free before returning to
It results from rapid acceleration or deceleration of activity.
the brain inside the skull. Complications
Pathophysiology Post-Concussion Syndrome
Concussion primarily involves functional disturbances Symptoms persist for weeks to months.
rather than structural damage. Second Impact Syndrome
Sequence of events: Second concussion occurs before recovery from first,
1. Mechanical force disturbs neuronal causing severe cerebral edema.
membranes Chronic Traumatic Encephalopathy (CTE)
2. Ionic shifts occur (potassium efflux) Seen in athletes with repeated concussions.
3. Increased glutamate release
4. Increased glucose demand
3. INTRACRANIAL HEMORRHAGE • Vasospasm
Definition • Stroke
Intracranial hemorrhage refers to bleeding inside the • Death
skull caused by rupture of cerebral blood vessels.
It can occur in several locations within the cranial 4. BRAIN DEATH
cavity. Definition
Major Types Brain death is the complete and irreversible
1. Epidural hematoma cessation of all brain function including the
2. Subdural hematoma brainstem.
3. Subarachnoid hemorrhage It is legally recognized as death.
4. Intracerebral hemorrhage Causes
Pathophysiology • Severe traumatic brain injury
Bleeding causes: • Massive intracranial hemorrhage
1. Hematoma formation • Hypoxic brain injury
2. Increased intracranial pressure • Brain tumor
3. Compression of brain structures • Severe stroke
4. Reduced cerebral blood flow Diagnostic Criteria
5. Neuronal ischemia and death Unresponsive Coma
Clinical Manifestations Patient does not respond to stimuli.
• Severe headache Absence of Brainstem Reflexes
• Vomiting No:
• Altered consciousness • pupillary reflex
• Seizures • corneal reflex
• Neurologic deficits • gag reflex
• Pupillary changes • cough reflex
Subarachnoid hemorrhage often causes: • vestibulo-ocular reflex
“Worst headache of my life.” Apnea Test
Pharmacologic Management Patient cannot breathe independently when
Blood Pressure Control ventilator support is removed.
Drugs: Confirmatory Tests
• Labetalol • EEG (no brain activity)
• Nicardipine • Cerebral blood flow studies
Goal: • CT angiography
Prevent further bleeding. Nursing Role
Anticonvulsants • Maintain hemodynamic stability
• Phenytoin • Monitor organ perfusion
• Levetiracetam • Support family emotionally
Osmotic Agents • Facilitate organ donation procedures
• Mannitol
• Hypertonic saline 5. SUBDURAL HEMATOMA
Calcium Channel Blockers Definition
Used in subarachnoid hemorrhage. A subdural hematoma is a collection of blood
Example: between the dura mater and arachnoid mater
Nimodipine caused by rupture of bridging veins.
Purpose: Risk Factors
Prevent cerebral vasospasm. • Elderly patients
Reversal Agents • Alcoholism
For anticoagulant-induced bleeding: • Anticoagulant therapy
Warfarin: • Repeated head trauma
• Vitamin K Types
• Prothrombin complex concentrate Acute
Heparin: Develops within 24–48 hours.
• Protamine sulfate Subacute
Surgical Management Develops days to weeks after injury.
• Hematoma evacuation Chronic
• Aneurysm clipping Develops weeks to months later.
• Endovascular coiling Clinical Manifestations
Complications • Persistent headache
• Brain herniation • Confusion
• Hydrocephalus • Drowsiness
• Weakness • bowel dysfunction
• Speech problems • sexual dysfunction
• Unequal pupils Spinal Shock
Chronic subdural hematoma may resemble Temporary loss of:
dementia. • reflexes
Pharmacologic Management • motor activity
• Anticonvulsants (seizure prevention) • sensation
• Osmotic diuretics for ICP control Pharmacologic Management
• Analgesics Vasopressors
If on anticoagulants: Examples:
• reversal therapy may be required. • Norepinephrine
Surgical Treatment • Dopamine
• Burr hole drainage Used to maintain spinal cord perfusion.
• Craniotomy Analgesics
• Opioids
6. SPINAL CORD INJURY • NSAIDs
Muscle Relaxants
Examples:
• Baclofen
• Diazepam
Used for spasticity.
Anticoagulants
Example:
Low-molecular-weight heparin
Purpose:
Prevent deep vein thrombosis.
Corticosteroids
Example:
Methylprednisolone
Historically used to reduce inflammation (now
controversial).
Complications
• Respiratory failure
• Pressure ulcers
• Deep vein thrombosis
Definition • Autonomic dysreflexia
A spinal cord injury (SCI) is damage to the spinal • Urinary tract infections
cord resulting in loss of motor, sensory, and Nursing Management
autonomic function below the level of injury. • Maintain spinal alignment
Causes • Prevent pressure injuries
• Motor vehicle accidents • Monitor respiratory function
• Falls • Bladder and bowel training
• Violence • Provide psychological support
• Sports injuries
Types
Complete Injury
Total loss of motor and sensory function below injury.
Incomplete Injury
Some function remains.
Examples:
• Central cord syndrome
• Brown-Sequard syndrome
• Anterior cord syndrome
Clinical Manifestations
Motor deficits:
• paralysis
• weakness
Sensory deficits:
• loss of sensation
Autonomic dysfunction:
• bladder dysfunction