12/2/2015

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Traumatic Bleeds

Cynthia Blank-Reid, RN, MSN, CEN

Trauma Clinical Nurse Specialist

Temple University Hospital

Philadelphia, PA

Disclosure

• I have no relevant commercial relationships to

disclose.

My Impressions of Miami

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Objectives

• Identify the most common types of traumatic

bleeds and their mechanism of injury.

• Describe the various diagnostic studies for a

patient who is suspected of having a traumatic

bleed.

• Describe the treatment options and nursing

care for a patient who has had a traumatic

bleed.

Epidemiology

• 1.5 million TBIs each year in

the United States

• 1.1 million are mild forms

• Sports-related injuries

account for 300,000 cases of

mild TBI each year.

• Highest incidence in those

aged 15-45 years old

• Disability

Epidemiology

• Incidence – 40-50% of all trauma deaths

• Sex- males more than females

• Causes – mvc, falls, assaults, firearm use, recreational and sports

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Epidemiology

• Behaviors that increase risk– alcohol, drugs– recklessness

– incorrect or nonuse of safety restraints

– sports participation without protective equipment

What Would A Famous NS Do?

• If you can find a NS to

deal with TBI –

• Scan

• Operate

• ICU

• Monitor ICP

• Pharmacological

Therapy

• Rehab consult

Traumatic Bleeds

• Subarachnoid

hemorrhage

• Contusions

• Epidural hematoma

• Subdural hematoma

• Intracerebral

hematoma

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Case Study

• 24 yr med student mugged and struck with blunt object

• Walks a block to hospital - 2-3 hours later shows signs of increased ICP (n/v, h/a, etc.)

• Diagnosed with concussion and CT reveals SAH

• Admitted to NSICU for overnight observation

• Sent home 3 days later

• Had s/s of concussion for weeks

Traumatic Subarachnoid Hemorrhage

• Tearing of meningeal

blood vessels

• It is a diffuse bleed (not

a focal one)

• Find traumatic SA blood

over convexities and in

basal cisterns

• 50% of CHI pts have

blood in CSF

Traumatic Subarachnoid Hemorrhage

• Signs and Symptoms

- severe HA and restlessness

- nuchal rigidity

- increased temperature

- photophobia

- nausea and vomiting

- hydrocephalus

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Traumatic Subarachnoid Hemorrhage

• Monitor for s/s of:

– vasospasm

– other injuries

(concussion, contusion,

EDH, SDH, etc.)

– Hydrocephalus

– Increased ICP

• Watch the pt does not

over do it

Cerebral Contusion

• Focal area of bruised and damaged tissue

• Most common areas are frontal and temporal

• Peak effects 18 to 36 hours after injury

• Significant contusions can cause shift of intracranial contents

• With aging, contusions form cortical defects where the tissue has been lost.

Cerebral Contusion

Signs and symptoms

• Altered level of consciousness

• Unusual behavior, motor, or speech deficits

• Abnormal motor posturing

• Signs of increasing intracranial pressure

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Cerebral Cortical Contusion

• Gross natural color

lateral view of left

hemisphere with large

parietooccipital

contusion

• Operative clip in field

slide is close-up view of

this lesion

Cerebral Contusions

• Reduce local swelling

around contusion

(reduce vasogenic

edema)

• Extent of cerebral

edema is minimized by

controlling secondary

injury (oxygenation,

ventilation and BP)

• Reduce intracranial

HTN, ICP

• Monitor blood sugars,

temperature,

metabolism

Coup Contrecoup Contusions

• Coup contusion – Contusion of brain beneath the point of impact underlying an intact skull; injury related to stationary head struck by an impact.

• Contrecoup contusion –pattern of contusions caused by falling head impacting on a firm surface. Heaviest distribution of contusion is opposite the point of impact. Caused by movement of the brain over the bony ridges of the anterior and middle cranial fossae.

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Contrecoup Contusions

• Horizontal section of

cerebral hemisphere in

27-year-old man who

was punched and fell

backward.

• Very heavy contrecoup

contusions extending

through the cortex into

the underlying white

matter are shown.

Natasha Richardson

• Born: May 11, 1963,

Marylebone, United

Kingdom

• Died: March 18, 2009,

New York City, NY

• Actress

• Sustained EDH while

skiing without a helmet

outside Quebec

Epidural Hematoma

• A focal brain injury

• Collection of arterial blood between the skull and dura

• Associated with fxs of temporal or parietal area that lacerate the middle meningeal artery

• Immediate surgical intervention required

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Epidural Hematoma

Signs and symptoms

• Transient loss of consciousness followed by a lucid period followed by rapid neurologic decline (classic presentation)

• Persistent decreased level of consciousness

• Severe headache

• Sleepiness

• Dizziness

• Hemiparesis or hemiplegia on the opposite side of the hematoma

• Abnormal motor posturing

• Unilateral fixed and dilated pupil on the same side as the hematoma

Epidural Hematoma

• Bleeding usually arterial

• Immediate surgical intervention required

• Prognosis excellent if treated early (to OR)

• ICU – avoiding secondary injury

• May or may not need rehab, neuro psych testing depending on deficits

Case Study

• 10 yo m riding bicycle – no helmet and fell, striking head on pavement.

• At scene, awake and combative.

• Transported to a hospital - became lethargic and intubated to protect his airway.

• X-rays showed R temporal bone. CT scan showed EDH over the right lateral convexity.

• Rapidly decompensated and died enroute to pediatric trauma center (2 hours after injury)

• Autopsy - linear fx R temporoparietalcalvarium and EDH of 90 mL of blood over the right frontotemporalconvexity.

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William Holden

• Born: April 17, 1918 in O’Fallon, IL

• Died: Nov 12, 1981 in Santa Monica, CA

• Actor - Academy Award winner

• Alcoholic - slipped on rug, fell and hit his head.

• Crawled around apartment but unable to get help. Phone off hook.

• Died of acute/chronic SDH.

Subdural Hematoma

• Focal brain injury

beneath the dura

resulting from blunt

trauma

• More common than

epidural hematomas

• More lethal than most

other brain lesions

Subdural Hematoma

Causes

• Usually venous in origin; tearing of the bridging veins

• Also from injuries to tissue or vessels of cerebral cortex

• Direct injury to brain tissue

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Subdural Hematoma

Signs and Symptoms (onset varies)

• Steady decline in level of consciousness

• Hemiparesis or hemiplegia on opposite side of hematoma

• Unilateral fixed and dilated pupil on same side as hematoma

Subdural Hematoma

• Onset may be acute

(24-72 hrs) or chronic

(up to 2-3 weeks)

• High-risk patients

– Elderly

– Those on anticoagulants

– Chronic alcohol users

– Those who have had

tumor removed, crani or

removal of brain tissue.

Case Presentation #1

• 79 yo m reportedly fell at dentist – Repetitive speech when

EMS arrived

– Reported taking Coumadin

• 10:38: Seen at OHS

• 11:18: In CT scan

• 11:47: ED physician at bedside:– Needs to be transferred

and orders Vit. K

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Case Study

• Pt awake and alert the whole time

• 12:07: Vit. K bolus started

• 12:21: ED physician orders FFP - then cancels it (transport will be here shortly)

• LABS:

– Hgb = 11.9

– INR = 3.3

• 12:38: Transferred

• 1:07pm: Arrival in the trauma bay

• GCS = 15

• VSS

• INR = 3.1

• 2:18: 1st unit of FFP started

• 2:35: 2nd unit of FFP given

• 3:10pm: TO CT scan

• 3:30pm: Arrives in ICU

• 4:50pm: INR = 1.7

Case Study

• 4:55pm: 3rd Unit of FFP

started

• 5:15pm: 4th unit of FFP

started

• Patient had a decrease

in his mental status

• 5:25pm: STAT OR for

Hemicraniectomy

Decrease in Mental Status

Post-OP

Hosp LOS = 12 days

ICU LOS = 6 days

Vent Days = 5 days

Discharged to Rehab

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Intracerebral Hematoma

• Bleeding deep within the

brain tissue

• Can result in significant

mass effect and increased

ICP

• Caused by delayed

hemorrhage or evolution

of hematoma

Intracerebral Hematoma

Signs and Symptoms

• Altered level of consciousness

• Progressive decline in level of consciousness

• Unusual behavior

• Abnormal motor posturing

• Contralateral hemiplegia

• Signs of increasing intracranial pressure

• Pupil abnormalities

Case Study

• 40 yo f driver high speed MVC; survived 3 days unconscious in hospital.

• Autopsy - punctuate hemorrhage in L centrum semiovale adjacent to the lateral margin of the corpus callosum

• Numerous streak hemorrhages present in frontal white matter, corpus callosum, and thalamus.

• Tearing of axons cannot be seen grossly, but torn vessels may be seen as streak like hemorrhages.

• After 24 hours, axonal damage may be visible microscopically .

• Small areas of vascular damage initially appear as streak and punctate hemorrhages - enlarge over time if pt survives.

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Intracerebral Hemorrhage • 62 YO F assaulted with hammer.

Survived 23 hours, was initially conscious and able to describe attacker.

• Became lethargic and then unconscious. To OR - debrided but died of increased ICP.

• Autopsy - traumatic ICH in R frontal and temporal lobes arising from contusional bleeding in the cortex .

• Multiple comminuted and depressed fxs of R frontal and temporal bones with underlying fracture contusions of the frontal and temporal lobes.

• Several of the deepest contusions showed hemorrhage extending from the cortex into the underlying white matter, producing traumatic ICH.

Ethical Considerations• penalties for not

caring for these pts

• effects on practice (aggressive, end of life, organ donation)

• bed utilization (ICU, nsg care)

• cost

• long-term placement

• are we making a difference

Just When You Stop Believing

We Make a Difference –

• A pt or family comes

back to visit and you

believe again.

• “Now wait a minute,

Susie. Just because

every child can't get his

wish that doesn't mean

there isn't a Santa

Claus.”

– Kris Kringle

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Thank You!

• Thank you for having

me.

• Enjoy the rest of the

conference.

• Safe travels home.

• Enjoy the holiday

season.