Presented by: Dave Jay S. Manriquez, BSN.RN.
Traumatic brain injury, often referred to as TBI, is most often an acute event similar to other
injuries. In other aspects, TBI is very different, since our brain defines who we are, the
consequences of a brain injury can affect all aspects of our lives, including our personality. Brain
injuries do not heal like other injuries. Recovery is a functional recovery, based on mechanisms
that remain uncertain. Symptoms may appear right away or may not be present days or weeks
after the injury
The most important consideration in any head injury is whether or not the brain is injured. Even
seemingly minor injury can cause significant brain damage secondary to obstructed blood flow
and decreased tissue perfusion. Because the cerebral cells need an uninterrupted blood supply,
irreversible brain damage and cell death occur when blood supply is interrupted for even a few
One of the consequences of brain injury is that the person often does not realize that a brain
injury has occurred.
Brain Injury Statistics
Annual number of people who experience a traumatic brain injury:
1. 4 million annually in the United States
• Among children ages 0 to 14 years
Deaths: 26, 850
Number of Americans living with a traumatic brain injury: Approximately 5.3 million
Groups at risk:
• Males are about twice as likely as females to sustain a TBI.
• The two age groups at highest risk for TBI are 0 to 4 year olds and 15 to 19 year olds.
• Adults age 75 years or older have the highest rates of TBI-related hospitalization and
• Certain military duties (e.g., paratrooper) increase the risk of sustaining a TBI.
• African Americans have the highest death rate from TBI.
The leading causes of TBI :
• Falls (28%);
• Motor vehicle-traffic crashes (20%)
• Struck by/against events (19%)
• Assaults (11%).
Most people are unaware of the scope of TBI or its overwhelming nature. TBI is a common
injury and may be missed initially when the medical team is focused on saving the individual's
TBI is classified into two categories: mild and severe.
A brain injury can be classified as mild if loss of consciousness and/or confusion and
disorientation is shorter than 30 minutes. These injuries are commonly overlooked. Even though
this type of TBI is called "mild", the effect on the family and the injured person can be
Severe brain injury is associated with loss of consciousness for more than 30 minutes
and memory loss after the injury or penetrating skull injury longer than 24 hours. The deficits
range from impairment of higher level cognitive functions to comatose states.
The effects of TBI can be profound. Individuals with severe injuries can be left in long-term
unresponsive states. For many people with severe TBI, long-term rehabilitation is often
necessary to maximize function and independence. Even with mild TBI, change in brain
function can have a dramatic impact on family, job, social and community interaction.
SYMPTOMS OF TRAUMATIC BRAIN INJURY
There are a few different systems that medical practitioners use to diagnose the symptoms of
Traumatic Brain Injury. This section discusses the Glasgow Coma Scale. The Glasgow Coma
Scale is based on a 15 point scale for estimating and categorizing the outcomes of brain injury on
the basis of overall social capability or dependence on others.
The test measures the motor response, verbal response and eye opening response with these
I. Motor Response
6 - Obeys commands fully
5 - Localizes to noxious stimuli
4 - Withdraws from noxious stimuli
3 - Abnormal flexion, i.e. decorticate posturing
2 - Extensor response, i.e. decerebrate posturing
1 - No response
II. Verbal Response
5 - Alert and Oriented
4 - Confused, yet coherent, speech
3 - Inappropriate words and jumbled phrases consisting of words
2 - Incomprehensible sounds
1 - No sounds
III. Eye Opening
4 - Spontaneous eye opening
3 - Eyes open to speech
2 - Eyes open to pain
1 - No eye opening
This number helps medical practitioners categorize the four possible levels for survival, with a
lower number indicating a more severe injury and a poorer prognosis:
Mild (13-15): See notes on the signs and symptoms below.
Moderate Disability (9-12):
• Loss of consciousness greater than 30 minutes
• Physical or cognitive impairments which may or may resolve
• Benefit from Rehabilitation
Severe Disability (3-8): Coma: unconscious state. No meaningful response, no voluntary activities
Vegetative State (Less Than 3):
• Sleep wake cycles
• Aruosal, but no interaction with environment
• No localized response to pain
• Persistent Vegetative State: Vegetative state lasting longer than one month
• Brain Death:
• No brain function
• Specific criteria needed for making this diagnosis
There are a few different systems that medical practitioners use to diagnose the symptoms of Traumatic
The Ranchos Los Amigos Scale measures the levels of awareness, cognition, behavior and interaction
with the environment.
Ranchos Los Amigos Scale
Level I: No Response
Level II: Generalized Response
Level III: Localized Response
Level IV: Confused-agitated
Level V: Confused-inappropriate
Level VI: Confused-appropriate
Level VII: Automatic-appropriate
Level VIII: Purposeful-appropriate
A traumatic brain injury (TBI) can be classified as mild if loss of consciousness and/or confusion
and disorientation is shorter than 30 minutes.
Mild Traumatic Brain Injury is:
• Most prevalent TBI ; Often missed at time of initial injury
• 15% of people with mild TBI have symptoms that last one year or more.
• Defined as the result of the forceful motion of the head or impact causing a brief change
in mental status (confusion, disorientation or loss of memory) or loss of consciousness for
less than 30 minutes.
• Post injury symptoms are often referred to as post concussive syndrome.
Common Symptoms of Mild TBI
• Visual disturbances
• Memory loss
• Poor attention/concentration
• Sleep disturbances
• Dizziness/loss of balance
• Irritability-emotional disturbances
• Feelings of depression
Other Symptoms Associated with Mild TBI
• Loss of smell
• Sensitivity to light and sounds
• Mood changes
• Getting lost or confused
• Slowness in thinking
The person looks normal and often moves normal in spite of not feeling or thinking normal. This
makes the diagnosis easy to miss. Family and friends often notice changes in behavior before
the injured person realizes there is a problem. Frustration at work or when performing household
tasks may bring the person to seek medical care.
Brain injuries can range in scope from mild to severe. Traumatic brain injuries (TBI) result in
permanent neurobiological damage that can produce lifelong deficits to varying degrees.
Moderate to severe brain injuries typically refer to injuries that have the following
• Moderate brain injury is defined as a brain injury resulting in a loss of consciousness
from 20 minutes to 6 hours and a Glasgow Coma Scale of 9 to 12
• Severe brain injury is defined as a brain injury resulting in a loss of consciousness of
greater than 6 hours and a Glasgow Coma Scale of 3 to 8
Cognitive deficits including difficulties with:
• Speed of Processing
• Language Processing
• "Executive functions"
Speech and Language
• not understanding the spoken word (receptive aphasia)
• difficulty speaking and being understood (expressive aphasia)
• slurred speech
• speaking very fast or very slow
• problems reading
• problems writing
• difficulties with interpretation of touch, temperature, movement, limb position and
• partial or total loss of vision
• weakness of eye muscles and double vision (diplopia)
• blurred vision
• problems judging distance
• involuntary eye movements (nystagmus)
• intolerance of light (photophobia)
• decrease or loss of hearing
• ringing in the ears (tinnitus)
• increased sensitivity to sounds
Smell and Taste
• loss or diminished sense of smell (anosmia) and taste
• the convulsions associated with epilepsy that can be several types and can involve
disruption in consciousness, sensory perception, or motor movements
• Physical paralysis/spasticity
• Chronic pain
• Control of bowel and bladder
• Sleep disorders
• Loss of stamina
• Appetite changes
• Regulation of body temperature
• Menstrual difficulties
• Dependent behaviors
• Emotional ability
• Lack of motivation
• Denial/lack of awareness
X-rays, CT scans and MRI's of brain are pictures of the inside of the head. The picture
will show if there is bleeding and/or swelling, skull fractures and where the damage has
Often, Cervical Spine and other spinal films may be completed. When someone is
involved in trauma, the neck and back may also be injured.
EEG: this test shows the presence of brain waves, their intensity and frequency. It is also
used to determine if the patient is having seizures.
TREATMENTS FOR TBI
The nursing staff's responsibility is to assess, monitor and interpret vital physiologic or body functions,
notify the physician of changes, repeat assessments at regular intervals and provide information for the
family. The patient will be monitored for signs of infection and pain.
Rehabilitative Center Treatment :
The Rehabilitation Nurse assists patients with brain injury and chronic illness in attaining
maximum optimal health, and adapting to an altered lifestyle. The Rehabilitation Nurse provides
care for the patient on the nursing unit. The focus of nursing care is on:
• Health maintenance
• Potential for aspiration
• Impaired skin integrity
• Bowel and bladder incontinence
• Impaired physical mobility
• Impaired or limited ability to take care of self
• Ineffective airway
• Sleep pattern disturbance
• Chronic pain
• Impaired cognition
• Impaired verbal communication and comprehension
• Sexual dysfunction
Acute treatment of a Traumatic Brain Injury (TBI) is aimed at minimizing secondary injury and
Mechanical ventilation supports breathing and helps keep the pressure down in the head.
A device may be placed surgically in the brain cavity to monitor and help control
Medications to sedate and put the individual in a drug-induced coma may be used to
minimize agitation and secondary injury. Seizure prevention medications may be given
early in the course and later if the individual has seizures. Behavioral issues also can be
treated with medications. Medications for attention problems and aggressive behavior
are often tried.
• Medications may be used for:
• Attention and concentration- amantadine and methylphenidate, bromocriptine and
• Aggressive behavior- carbamamazapine and amitriptyline
In closed head injury, surgery does not correct the problem. A bolt or ICP (intracranial pressure)
monitoring device may be placed in the skull to monitor pressure in the brain cavity. If there
was bleeding in the skull cavity, this may be surgically removed or drained. Bleeding vessels or
tissue may need to be repaired. In severe cases, if there is extensive swelling and damaged brain
tissue, a portion may be surgically removed to make room for the living brain tissue.
The overall goal of all surgical treatment is to prevent secondary injury by helping to maintain
blood flow and oxygen to the brain and minimize swelling and pressure.
TBI patients are monitored with equipment for breathing, heart rhythm, blood pressure, pulse
and intracranial pressure.
MAINTAINING THE AIRWAY
Keep unconscious patient in a position that facilitates drainage of oral secretion
Establish effective suctioning procedures
Guard against aspiration and respiratory insufficiency
Monitor for pulmonary complications
Dilantin is the usual medication administered through the IV to prevent seizures. A
tetanus shot also may be given.
MAINTAIN HYDRATION AND ADEQUATE NUTRITION
Fluid is administered through the IV for nutrition and liquid. The need for nutritional
support using parenteral (IV) or enteral solutions (a tube placed in the stomach) is
determined by a registered dietician and the doctor.
A urinary catheter is put in the bladder for urine collection. The individual is not aware of
the need to use the bathroom.
It is important to maintain the unconscious patient's blood pressure through IV fluid and
MAINTAINING SKIN INTEGRITY
The patient is turned and positioned in bed to prevent bedsores because most unconscious
people cannot move independently.
The unconscious person may have a compression device wrapped around the legs that
resembles a plastic tub mat. This device prevents blood clots. Daily injections are also
given to prevent blood clots.
TREATMENT OF INCREASED ICP
Controlling body temperature (keeping the temperature low to normal)
Elevating the head of the bed
Using controlled narcotic sedation to cause paralysis, keeping the person still and
Ensuring proper breathing
Administering medication including Mannitol
MONITORING FOR POTENTIAL COMPLICATIONS
I. Decreased Cerebral Perfusion
II. Cerebral Edema and Perfusion
III. Impaired Oxygenation and Ventilation
IV. Post-Traumatic Seizures
These are the indicators the medical team uses for prognosis:
• Duration of Coma. The shorter the coma, the better the prognosis.
• Post-traumatic amnesia. The shorter the amnesia, the better the prognosis.
• Age. Patients over 60 or under age 2 have the worst prognosis, even if they suffer the
same injury as someone not in those age groups.
In 1995, actor Christopher Reeve fell off a horse and severely damaged his spinal cord, leaving
him paralyzed from the neck down. From then until his death in 2004, the silver screen
Superman became the most famous face of spinal cord injury.
Spinal cord injuries cause myelopathy or damage to white matter or myelinated fiber tracts that
carry signals to and from the brain. It also damages gray matter in the central part of the spine,
causing segmental losses of interneurons and motorneurons.
A. Stage of spinal shock
• sensation and motor power localized below the vertical height of the lesion are lost. This
stage lasts for 2 to 3 weeks in humans, and hours to days in other animals due to a lesser
degree of encephalitis.
B. Stage of recovery
• after a period typically ranging from 2 to 3 weeks of injury, the nerves partially recover,
and the return of segmental reflexes produce paraplegia-in-flexion.
C. Stage of reflex failure
• after a period of days the recovered reflexes again start to give way due to complete
degeneration of nerve cells.
Spinal cord injury symptoms depend on two factors:
1) The location of the injury. In general, injuries that are higher in your spinal cord produce
more paralysis. For example, a spinal cord injury at the neck level may cause paralysis in
both arms and legs and make it impossible to breathe without a respirator, while a lower
injury may affect only your legs and lower parts of your body.
a) Cervical injuries
Cervical (neck) injuries usually result in full or partial tetraplegia (quadriplegia). Depending on
the exact location of the injury, one with a spinal cord injury at the cervical level may retain
some amount of function as detailed below, but are otherwise completely paralyzed.
• C3 vertebrae and above : Typically lose diaphragm function and require a ventilator to breathe.
• C4 : May have some use of biceps and shoulders, but weaker
• C5 : May retain the use of shoulders and biceps, but not of the wrists or hands.
• C6 : Generally retain some wrist control, but no hand function.
• C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the
hand and fingers. C7 is generally the level for functional independence.
b) Thoracic injuries
Injuries at the thoracic level and below result in paraplegia. The hands, arms, head, and breathing
are usually not affected.
• T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so
control of the trunk is difficult or impossible. Effects are less severe the lower the injury.
• T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good.
c) Lumbar and Sacral injuries
The effects of injuries to the lumbar or sacral region of the spinal canal are decreased control of
the legs and hips, urinary system, and anus.
2) The severity of the injury. Spinal cord injuries are classified as partial or complete,
depending on how much of the cord width is damaged.
a) In a partial spinal cord injury, which may also be called an incomplete injury, the
spinal cord is able to convey some messages to or from your brain. So people with partial
spinal cord injury retain some sensation and possibly some motor function below the
b) A complete spinal cord injury is defined by total or near-total loss of motor function
and sensation below the area of injury. However, even in a complete injury, the spinal
cord is almost never completely cut in half. Doctors use the term "complete" to describe a
large amount of damage to the spinal cord. It's a key distinction because many people
with partial spinal cord injuries are able to experience significant recovery, while those
with complete injuries are not.
• Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal
• Loss of movement
• Loss of sensation, including the ability to feel heat, cold and touch
• Loss of bowel or bladder control
• Exaggerated reflex activities or spasms
• Changes in sexual function, sexual sensitivity and fertility
• Difficulty breathing, coughing or clearing secretions from your lungs
Emergency signs and symptoms
• Fading in and out of consciousness
• Extreme back pain or pressure in your neck, head or back
• Weakness, incoordination or paralysis in any part of your body
• Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
• Loss of bladder or bowel control
• Difficulty with balance and walking
• Impaired breathing after injury
• An oddly positioned or twisted neck or back
Injury may be traumatic or nontraumatic
• A traumatic spinal cord injury may stem from a sudden, traumatic blow to your spine that
fractures, dislocates, crushes or compresses one or more of your vertebrae. It may also
result from a gunshot or knife wound that penetrates and cuts your spinal cord.
Additional damage usually occurs over days or weeks because of bleeding, swelling,
inflammation and fluid accumulation in and around your spinal cord.
• Nontraumatic spinal cord injury may be caused by arthritis, cancer, blood vessel
problems or bleeding, inflammation or infections, or disk degeneration of the spine.
Common causes of spinal cord injury:
• Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal
cord injuries, accounting for almost 50 percent of new spinal cord injuries each year.
• Acts of violence. About 15 percent of spinal cord injuries result from violent encounters,
often involving gunshot and knife wounds.
• Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall, falls make
up approximately 22 percent of spinal cord injuries.
• Sports and recreation injuries. Athletic activities such as impact sports and diving in
shallow water cause about 8 percent of spinal cord injuries.
• Diseases. Cancer, infections, arthritis and inflammation of the spinal cord also cause
spinal cord injuries each year.
Although a spinal cord injury is usually the result of an unexpected accident that can happen to
anyone, some groups of people have a higher risk of sustaining a spinal cord injury. These
• Men. Spinal cord injury affects a disproportionate amount of men. In fact, women
account for only about 20 percent of spinal cord injuries in the United States.
• Young adults and seniors. People are most often injured between ages 16 and 30. But
there is another peak in people older than 60. Motor vehicle crashes are the leading cause
of spinal cord injury for young people, while falls cause most injuries in older adults.
However, in some cities, acts of violence — such as gunshot wounds, stabbings and
assaults — are a major cause of spinal cord injury.
• People who are active in sports. Sports and recreational activities cause 8 percent of the
11,000 spinal cord injuries in the United States each year, although sports-related spinal
cord injury is becoming less common. High-risk athletic activities include football,
rugby, wrestling, gymnastics, diving, surfing, ice hockey and downhill skiing.
• People with predisposing conditions. A relatively minor injury can cause spinal cord
injury in people with conditions that affect their bones or joints, such as arthritis or
TESTS & DIAGNOSIS
• X-rays. Medical personnel typically order these tests on all trauma victims suspected of
having a spinal cord injury. X-rays can reveal vertebral problems, tumors, fractures or
degenerative changes in your spine.
• Computerized tomography (CT) scan. A CT scan may provide a better look at
abnormalities seen on an X-ray.
• Magnetic resonance imaging (MRI). This test is extremely helpful for looking at the
spinal cord and identifying herniated disks, blood clots or other masses that may be
compressing the spinal cord.
• Myelography. Myelography allows your doctor to visualize your spinal nerves more
clearly. This test is used when MRI isn't possible or when it may yield important
additional information that isn't provided by other tests.
• Ineffective breathing patterns related to weakness or paralysis of abdominal and
intercostals muscles and inability to clear secretions
• Ineffective airway clearance related to weakness of intercostals muscles
• Impaired physical mobility related to motor and sensory impairment
• Disturbed sensory perception related to motor and sensory impairment
• Risk for impaired skin integrity related to immobility and sensory loss
Early stages of treatment
• Medications. Methylprednisolone (Medrol) is a treatment option for acute spinal cord
injury. This corticosteroid seems to cause some recovery in people with a spinal cord
injury if given within eight hours of injury. Methylprednisolone works by reducing
damage to nerve cells and decreasing inflammation near the site of injury.
• Immobilization. You may need traction to stabilize your spine and bring the spine into
proper alignment during healing. Sometimes, traction is accomplished by placing metal
braces, attached to weights or a body harness, into your skull to hold it in place. In some
cases, a rigid neck collar also may work.
• Surgery. Often, emergency surgery is necessary to remove fragments of bones, foreign
objects, herniated disks or fractured vertebrae that appear to be compressing the spine.
Surgery may also be needed to stabilize the spine to prevent future pain or deformity.
Controversy exists regarding the best time to perform surgery. Some surgeons believe it
should be performed as soon as possible in most circumstances, while others believe it's
safer to wait for several days before attempting any surgery. Research has not clearly
proved which approach is better.
PROMOTING ADEQUATE BREATHING AND AIRWAY CLEARANCE
Suctioning may be indicated, but caution in doing this because suctioning can stimulate
the vagus nerve, producing bradycardia, which can result in cardiac arrest
Chest physical therapy and assisted coughing may be indicated when patient cannot
Breathing exercises are supervised by the nurse to increase the strength and endurance of
the inspiratory muscles, particularly the diaphragm
Ensure proper humidification and hydration to prevent secretions from becoming thick
and difficult to remove even with coughing
Proper alignment is maintained at all times
Reposition frequently and is assisted out of bed as soon as the spinal column is stabilized
Use various types of splints to prevent footdrop. Trochanter rolls help prevent external
rotation of the hip joints
Range of motion exercises help preserve joint motion and stimulate circulation
MAINTAINING SKIN INTEGRITY
Position is changed every 2 hours assists in the prevention of pressure ulcers and pooling
of blood and tissue fluid on dependent areas that could lead to blood clots
Skin should be kept clean by washing with a mild soap, rinsed well and blotted dry
Pressure-sensitive areas should be kept well lubricated and soft with lotion
Patient should be well informed about the danger of pressure ulcers to encourage
understanding of the reason for preventive measures
IMPROVING URINARY AND BOWEL ELIMINATION
Intermittent catheterization is carried out to avoid overdistention of bladder and UTI
Record fluid intake, voiding pattern, amounts of residual urine after catherterization,
characteristics of urine and any unusual sensations that may occur
As soon as bowel sounds are heard upon auscultation, the patient is given a high-calorie,
high-protein, high-fiber diet with the amount of food gradually increased
Administer prescribed stool softeners to counteract the effects of immobility and pain
PROVIDING COMFORT MEASURES
If pins, tongs and calipers are in place, the skull is assessed for infection, including
drainage. Hair around the tongs is usually shaved to facilitate inspection
The back of the head is checked periodically for signs of pressure, with care taken not to
move the neck
Patient in Halo Traction: areas around the pin sites are cleansed daily and observed for
redness, drainage and pain, notify neurosurgeon if one of the pins becomes detached
while another person stabilized the head in a neutral position, skin under the halo vest is
inspected for excessive perspiration, redness and skin blistering, powder is not used under
the vest because it may contribute to pressure ulcers, the liner should be changed
periodically to promote hygiene and good skin care
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Immobilizarion and the associated venous stasis, as well as varying degrees of
autonomic disruption, contribute to the high risk and susceptibility for DVT
Measures such as ROM exercises, thigh-high elastic compression stockings, adequate
hydration and anticoagulation medications (heparin and warfarin ) as prescribed are
• Orthostatic Hypotension
Activity should be planned in advance and adequate time given for a slow
progression of position changes from recumbent to sitting and upright. Tilt tables
frequently are helpful in assisting patients to make tgis transaction
• Autonomic Dysreflexia
Stimuli that may trigger this: distended bladder ( most common ); distention or
contraction of visceral organs, especially the bowel; or stimulation to the skin
PROMOTING HOME CARE
The ultimate goal of the rehabilitation process is independence. The nurse becomes a
support to both the patient and the family, assisting them to assume responsibility for
increasing aspects of patient care and management.
Survivors of SCI face the changes associated with aging with a disability. Thus,
teaching in the home and community focuses on health promotion and addresses the
need to minimize risk factors.
1. Clinitron Bed - The Clinitron Air Fluidized Bed combines air fluidized therapy and low air loss
therapy on an articulating frame providing patients with relief from bed pressure sores, designed
to prevent pressure ulcers and promote wound healing. The Clinitron II aides patients with
advanced stage or multiple pressure ulcers, flaps, grafts, burns and other skin disorders.
2. Rotarest Bed – Indicated for the treatment and prevention of pulmonary complications as a result
of immobility, thoracic or lumbar fracture. It is not to be used as a primary means of stabilizing
cervical spine fractures, A halo and vest or internal fixation is required.
3. Stryker Frame - A frame that holds the patient and permits turning in various planes without
individual motion of parts, allowing staff to turn a patient easily. The patient is held firmly
between the pieces of material as if part of a sandwich. The device may be rotated around the
patient’s long axis. This permits turning the patient without his or her assistance.
4. Circle Electric Bed – an electrically powered apparatus, which can be used as a turning frame for
5. Tilt Bed – Easy to maneuver, it offers adjustable positions including seated, reclining and
sleeping, plus all positions inbetween. The Tilt chair/bed also offers pressure relief, adjustable
seat with infinite locking, adjustable leg rests, adjustable back and lockable castor wheels.