Caring for patients with closed traumatic brain injury in rural settings.

The Centers for Disease Control and Prevention (CDC) has acknowledged closed traumatic brain injuries (cTBIs), a form of traumatic brain injury (TBI), as being a major public health matter in the United States. Statistical analysis, as well as public health data, has suggested that there are approximately 1,300 cases of cTBI per year in the United States alone. The standard of care for patients with a cTBI is to undergo diagnostic imaging, most commonly computerized tomography, which is considered to be a luxury and seldom exists in rural clinics. Despite increasing TBI awareness and publicity, healthcare providers, including advanced practice registered nurses, have yet to have a full understanding of the severity of damages that can result from a cTBI. The purpose of this article is to provide an understanding of cTBI and concise clinical best practice guidelines that will aid healthcare providers in rural settings to properly diagnose, treat, and provide education for patients with cTBIs.

Does emergency department observation impact the rate of computed tomography in children with minor blunt head trauma?

Review of recent evidence with translation to practice for the advanced practice nurse (APN) role is presented using a case study module for "The Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Blunt Head Trauma." The study results showed that 49% of the patients were "observed" in the emergency department (ED). Of those "observed" (N = 676) in the ED, the authors found that 20% had a computed tomographic (CT) scan performed. However, "observed" patients did experience a lower rate of CT scan (5%) than "nonobserved" patients. The implications and clinical relevance of these findings for APNs are discussed, highlighting best practice evidence.

Nurse and physician agreement in the assessment of minor blunt head trauma.

OBJECTIVE: The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) clinical prediction rules identify children with minor blunt head trauma who are at low risk for clinically important traumatic brain injuries. We measured the agreement between the registered nurse (RN) and physician (MD) assessments. METHODS: We performed a cross-sectional study of all children <18 years of age with minor blunt head trauma who presented to a single emergency department. RNs and MDs independently assessed each child and recorded age-based PECARN predictors. As symptoms can change over time, we included cases only when both evaluations were completed within 60 minutes. We used the κ statistic to measure RN-MD agreement, with the main analysis focusing on the overall PECARN rule agreement. RESULTS: Of the 1624 eligible children, 1191 (73%) had evaluations completed by both RN and ED providers, of which 437 (37%) were in children <2 years of age. The median time between completions of the provider forms was 12 minutes (interquartile range 4-25 minutes). The overall agreement between the RN and MD was higher for the older children (κ 0.55, 95% confidence interval 0.49-0.61 for children 2-18 years versus κ 0.32, 95% confidence interval 0.23-0.41 for children <2 years). CONCLUSIONS: The overall agreement between RN and MD for the PECARN TBI prediction rules was moderate for older children and fair for younger children. Initial RN assessments should be verified by the MD before clinical application, especially for the youngest children.

Empowering the primary care provider to optimally manage mild traumatic brain injury.

PURPOSE: This article provides current, evidence-based information regarding the management of mild traumatic brain injuries for the primary-care provider. DATA SOURCES: Literature review of the evidence-based literature, including peer-reviewed articles and reviews of published randomized controlled trials and clinical practice guidelines. CONCLUSIONS: There are lessons to learn from the civilian and military care of mild traumatic brain injuries. As acute injury management improves and more patients survive their trauma to live in the chronic-care community setting, primary care clinicians will be responsible for providing and coordinating total care. A team approach is required to meet the unique clinical and personal challenges these patients face. IMPLICATIONS FOR PRACTICE: These patients are at risk of receiving suboptimal care once released to the community, in part due to an incomplete understanding of the condition by primary care providers. Other difficulties in recommending care for these patients include nonuniform clinical terminology, the lack of a uniform set of diagnostic criteria, and the lack of endorsed professional society guidelines. A clinical practice toolkit is provided to assist the primary care provider to optimize delivery of comprehensive care for this population in the community.

Case discussion in blood glucose variability.

Stress-induced hyperglycemia has been associated with poor outcomes and death in critically ill patients. Blood glucose (BG) variability, a component of stress-related hyperglycemia has recently been reported as a significant independent predictor of intensive care unit and hospital mortality. We sought to evaluate three cases in which intensive insulin therapy was administered using a standardized insulin dosing protocol to normalize the BG and reduce glycemic variability. Point-of-care BG values and other clinical measures were obtained from the medical record of three patients who received intensive insulin therapy. This was a convenience sample of three patients where the BG level had stabilized on a consistent intravenous insulin dose rate for up to 20 hours in a surgical trauma intensive care unit. Data were collected manually and electronically using the Remote Automated Laboratory System-Tight Glycemic Control Module (RALS-TGCM) BG management and monitoring system. Each case presentation describes a critically ill, nondiabetic patient, requiring continuous intravenous insulin therapy for hyperglycemia. In each instance, BG variability was present in a worsening patient condition after a period of normalization of hyperglycemia with intensive insulin therapy. Although decreasing BG variability is an important aspect of hyperglycemia management, new onset events of variability may be a sentinel warning or occur as a physiologic response to a worsening patient condition. If so, these events warrant rapid investigation and treatment of the underlying problem.

Effects of head posture on cerebral hemodynamics: its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation.

OBJECTIVE: Severely head-injured patients have traditionally been maintained in the head-up position to ameliorate the effects of increased intracranial pressure (ICP). However, it has been reported that the supine position may improve cerebral perfusion pressure (CPP) and outcome. We sought to determine the impact of supine and 30 degrees semirecumbent postures on cerebrovascular dynamics and global as well as regional cerebral oxygenation within 24 hours of trauma. METHODS: Patients with a closed head injury and a Glasgow Coma Scale score of 8 or less were included in the study. On admission to the neurocritical care unit, a standardized protocol aimed at minimizing secondary insults was instituted, and the influences of head posture were evaluated after all acute necessary interventions had been performed. ICP, CPP, mean arterial pressure, global cerebral oxygenation, and regional cerebral oxygenation were noted at 0 and 30 degrees of head elevation. RESULTS: We studied 38 patients with severe closed head injury. The median Glasgow Coma Scale score was 7.0, and the mean age was 34.05 +/- 16.02 years. ICP was significantly lower at 30 degrees than at 0 degrees of head elevation (P = 0.0005). Mean arterial pressure remained relatively unchanged. CPP was slightly but not significantly higher at 30 degrees than at 0 degrees (P = 0.412). However, global venous cerebral oxygenation and regional cerebral oxygenation were not affected significantly by head elevation. All global venous cerebral oxygenation values were above the critical threshold for ischemia at 0 and 30 degrees. CONCLUSION: Routine nursing of patients with severe head injury at 30 degrees of head elevation within 24 hours after trauma leads to a consistent reduction of ICP (statistically significant) and an improvement in CPP (although not statistically significant) without concomitant deleterious changes in cerebral oxygenation.

Effect of backrest position on intracranial and cerebral perfusion pressures in traumatically brain-injured adults.

BACKGROUND: Backrest positioning for brain-injured adults is variable. Some data support using a flat backrest to optimize cerebral perfusion pressure; other data support elevating the head of the bed at least 30 degrees to reduce intracranial pressure. OBJECTIVE: To determine whether a flat backrest position or a backrest elevation of 30 degrees provides both optimal cerebral perfusion pressure and optimal intracranial pressure in adults with brain injuries. METHODS: A randomized crossover experimental design was used to collect data on 8 adults 18 to 45 years old who had nonvascular, closed-head, traumatic brain injury. Repeated-measures multivariate analysis of variance was used to analyze the data. RESULTS: Overall, compared with use of a flat/horizontal position, use of a backrest elevation of 30 degrees resulted in significant and clinically important improvements in both intracranial and cerebral perfusion pressures. None of the subjects experienced adverse clinical changes in either intracranial pressure or cerebral perfusion pressure with either backrest position. CONCLUSION: The results strengthen the research foundation for raising the backrest position for adults, 18 to 45 years old, who have nonvascular, nonpenetrating, severe brain injuries.

Minor brain injury: new insights for early nursing care.

More than a million people sustain a minor brain injury (MBI) annually. Recent research shows serious changes in cognitive ability are common consequences of such injuries, yet management of MBI sequelae receives little attention. Expanded assessment and treatment parameters are needed to capture and treat the subtle cognitive changes seen in this type of brain injury. Impaired directed attention (DA) is the most common problem after MBI. Individuals with compromised DA are distractible, impulsive, and often irritable. A new behavioral nursing model of MBI allows targeted assessment of distractibility, impulsivity, and irritability as aspects of impaired attention. The model also offers interventions to conserve or restore attention, which should prove helpful to both patients and practitioners.

Reducing one source of pediatric head injuries.

Evaluation of a school-based, bicycle helmet program was conducted using the PRECEDE model. The intervention targeted schools with low income, high minority, and nonurban fourth grade children. A repeated measures design was used with schools randomly assigned to each treatment: classroom, parent-classroom, or control. Reported helmet use was approximately 18% prior to the program. Following the intervention, between 34% and 98% of intervention students reported helmet use, with the best results reported in schools with parental contact. This educational intervention coupled with the provision of bicycle helmets increased reported helmet use, especially when parental contact was added.

Case study: shaken baby syndrome--one disorder with two victims.

Shaken Baby Syndrome is a complex disorder with implications for family members (especially the victim's mother) that are felt long after the emergency diagnosis and treatment of the child are concluded. The authors conducted a Women's Support Group for parolees over a two year period. Included in its group membership were several women who had been jailed for child abuse related crimes. This article synthesizes the significant progress in the research from the medical, legal, social, nursing, and preventive health perspectives on Shaken Baby Syndrome. A case study is used to illustrate the phenomenon of victimization of the mother, typically the nonoffending parent in Shaken Baby Syndrome. The difficulties of diagnosing Shaken Baby Syndrome in a timely manner are presented with emphasis on the diagnostic ambiguities confronting the various medical and nursing providers and nonoffending perpetrators. The case study attempts to raise the consciousness of nurses, with whom the nonoffending parents come into contact in the vast array of health service settings, as well as provide specific recommendations for enhancing community health nursing practice.

Hope facilitating strategies for the family of the head injury patient.

Approximately 200 new head injuries are reported per 100,000 population each year in the United States. These injuries are more common in younger men and caused most frequently by motor vehicle accidents. Head injuries occur suddenly and unexpectedly. Head injury affects not only the individual but the family as well. The family's functional abilities are threatened by the head injury of a family member. The family's adaptation to head injury and life-threatening events surrounding the injury has a significant impact on the patient's rehabilitation. A family's response of denial or lack of hope in the future has been identified as a major obstacle to successful adaptation. The hopeless family may be unable to make necessary changes at home or learn important aspects of the patient's care. Depending upon the extent of the head injury, the family needs to know that most head trauma patients make significant progress in the first six months. Progress usually continues, less dramatically, for the next two to three years.

One family's experience with head injury: a phenomenological study.

A phenomenological approach was used in this study to describe the lived experience of one family with traumatic brain injury. All seven family members were interviewed regarding their thoughts and memories from the night of the accident through the acute stage and initial rehabilitative stage. Three themes captured the essence of the experience as described by the parents and siblings: "helplessness and the need to hope," "need to be informed and involved" and "impact of intubation/extubation." The victim's unique perspective was captured by the themes: "going home," "concern for others" and "piecing it together." Hermeneutic interpretations examine the transformative and enriching aspects as well as the disruptions and problems associated with the family experience of traumatic brain injury.

Continuous midazolam/atracurium infusions for the management of increased intracranial pressure.

Maintaining the pressure/volume balance in the brain is a challenging goal for the neuroscience team caring for patients with traumatic brain insults. Often, standard therapies are not effective in controlling increased intracranial pressure (ICP). Four severe traumatic brain injury patients given continuous infusions of midazolam and atracurium showed control of otherwise unstable ICPs. Midazolam and atracurium infusions are now considered an acceptable form of therapeutic intervention for our patients requiring such treatment. Intensive nursing care considerations for patients using the combined pharmacologic therapy are essential.

Cerebral hemodynamics: monitoring arteriojugular oxygen content differences.

Arteriojugular oxygen difference (AJDO2) is used to manage the care of acute head-injured patients by monitoring the relationship between cerebral metabolism and blood flow. Blood samples from the jugular bulb and a peripheral artery are monitored either continuously or episodically to calculate AJDO2 and cerebral oxygen utilization. An understanding of cerebral oxygen transport physiology is essential to measuring AJDO2. A case study highlights the use of AJDO2 monitoring.