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- Winter 2013
BY: Don Kautz, C.C.R.N.; Linda Holtzclaw, C.C.R.N.; Angelica Ford, B.S.N.; Kimberly Shuster, B.S.N. and Edited by: Kathy Helmick, MS.ARNP.
Reviewed by: Daveé Wilson, RN, MSN and Stephanie Giacalone, RN, BSN, Charge Nurse, Neuroscience ICU
When a patient who has experienced a brain injury arrives in the ER (Emergency Room), staff will want to quickly find out how serious the injury is and start the treatments necessary to prevent further injury. As the treatments are started, the doctors and nurses will be asking lots of questions. If the patient was in an automobile accident they will want to learn all they can about the accident. How fast was the car going? Were they thrown from the car? Were they wearing a seat belt? Did their head hit the windshield? Answers to these questions help the doctors and nurses predict what kinds of injury the patient has. These answers also help them to predict how serious the brain injury is.
Often by the time the patient reaches the ER, they may be unresponsive, may appear to be in a coma, or deep sleep. They may be confused. If they are like that in the ER, the staff will want to know how they were right after the accident. Did the patient lose consciousness; if so, for how long? The staff will also ask if the patient has had a history of seizures. Had the patient been drinking or taking any drugs, especially mind altering drugs, such as cocaine and marijuana. Even though it may be embarrassing to have these questions asked, the staff needs to know in order to provide the best care for the patient.
Shortly after the patient arrives in the ER he/she will be taken away to an examining room. All family and friends will be asked to wait in the waiting room. They will not see the patient again until all the doctors have finished their exams and treatments, the patient will never be left alone. During this time the nurses and doctors will be monitoring the patient very closely.
Neurosurgeons will examine the patient to determine the extent of the brain injury; trauma surgeons will examine the patient for additional injuries; and internal medicine doctors, ophthalmologists (eye doctors), or neurologists, may be called in to examine the patient. Lots of tests will be ordered. The patient will have one or two IVs started. The patient will have blood tests and x-rays, and will be taken for CT scans and MRIs. CT Scans (sometimes call “CAT scans”) are tests similar to x-rays, which are done to see if there is any swelling or bleeding of the brain. A similar type of test is called MRI. Both the CT scan and MRI can be very useful and may be done several times while the patient is in the ICU (Intensive Care Unit). The machines that perform the CT scans and the MRIs may not be located in the ER or ICU so the patient may need to be transported in their bed to the place where these tests are done. Nursing and other staff will take the patient to these tests and stay while the tests are being performed.
The ER or ICU staff will keep family and friends informed about the patient’s condition and where the patient is going. Doctors may be asking for family consent for some procedures. During the time all these tests are being done, the doctors will be treating the patient.
The test results may indicate the patient needs surgery in which case the patient will be taken directly to the operating room. If the patient doesn’t need surgery, the doctors will keep treating him/her. These treatments may occur in the ER or after the patient has been transferred to the ICU depending on how critically ill the patient is. If the patient is stable, he may be transferred up to the ICU. If the doctors feel the patient needs treatment before being moved, then the treatments will occur in the ER.
After a brain injury, there may be swelling of brain tissue. The pressure of the brain and fluid inside the skull may rise. The blood circulation to the brain may decrease. All three of these problems will be treated to try to prevent further brain damage. A small tube, called an intra-ventricular catheter (also called an intracerebral pressure or “ICP” catheter) may need to be surgically placed through the skull into the brain to monitor the pressure inside the skull and drain excess cerebral spinal fluid. The ICP catheter is connected to a transducer, a device that transmits signals to a monitor above the bed. This allows the doctors and nurses to tell what the pressure is inside the head. The transducer is often taped to a rolled up towel or washcloth and placed to the patient’s head. The ICP catheter is also connected to a drainage bag. This bag is hung on an IV pole at the head of the bed. Surgery may be done to remove a blood clot, or even a part of the brain tissue, to reduce swelling.
If the pressure inside the skull remains too high, medications may be given into the vein, through an IV, to treat the swelling of brain tissue and speed up the drainage of cerebral spinal fluid.
The brain controls and coordinates all of the body functions. A severe brain injury often affects the ability of the body to function. Often a patient will need to breathe. An ET (endotracheal) tube may be put through the nose or mouth into the lungs and hooked up to a ventilator, a machine that assists breathing.
If the ventilator is needed for more than two weeks, a tracheostomy may be performed. A small cut is made in the windpipe, or trachea, directly above the “Adam’s Apple.” A tube called a “trach” is placed in the opening. The ventilator is then hooked up to the trach, similar to the ET tube. Usually a patient on a ventilator will have wrist restraints to prevent him from pulling out the ET tube. Extra fluids and medications may be needed to regulate the amount of water, salt and potassium in the body. Blood pressure, if too high or too low, may also need to be regulated with medications. An IV inserted into the upper chest (called a Swan Ganz catheter) will be monitoring how effective the heart is beating and the amount of fluid in the body. Blood pressure is monitored by another catheter placed in an artery (called an Arterial Line or A Line), usually placed in the wrist or foot.
The arterial line is used so that the doctors and nurses can tell what the blood pressure is at all times. It is likely the patient will be hooked up to a heart monitor, and will have EKG electrodes taped to the chest to monitor the heart rate rhythm. The patient may need medications to keep the heart beating normally. The patient usually is not alert enough to eat, and so he may be getting nutrients through a feeding tube.
Other IVs may also be run through pumps, so there may be several around the bed. Since the stomach may produce too much gastric juice, there may be a tube that goes into the stomach called a nasogastric, or NG, tube. This tube may be hooked up to a suction bottle to remove these gastric juices.
The stress of a brain injury may make some individuals prone to some bleeding from the stomach. This bleeding is called a stress ulcer. The patient may be treated with medications to prevent these stress ulcers from forming. Medications may also be given to help combat any infections in the bloodstream. A catheter may be placed in the bladder to drain urine.
By now it may seem that everything can go wrong. The important thing to remember is that the nurses and doctors will be monitoring the patient very closely, so they can treat all these problems as soon as they occur.
If the patient was in an accident, there might be other injuries beside the brain injury that require treatment. Often, patients have broken bones, therefore may have splints or casts, or may be placed in traction. A broken rib can puncture a lung. If this happens, the patient may have a chest tube to drain off blood or fluid from around the lungs. The patient may have internal bleeding and need medications or surgery to stop that bleeding.
Once stabilized in the ER, the patient will be transferred to the ICU. If surgery was necessary, the patient will go from the Operating Room to the ICU. The patient’s family and friends will be allowed to see him or her, but because he or she is so sick, visiting hours will be limited and there will be rules about how many people can come at one time. These rules ensure that the nurses can provide the patient with the best care. Family and friends are usually directed to wait in a nearby lounge between the times for visiting. The times for visiting are usually posted on a sign outside the ICU, in special circumstances, it may be possible to visit at times other than those posted times. This must be arranged with a person at an information desk outside the ICU.
Most patients with a severe brain injury will initially appear to be in a deep sleep. They may not be able to move or open their eyes or talk. The nurses and physicians monitor the ability of the patient to respond using a scale, called the Glasgow Coma Scale (GCS). (See the page in the reference section of this book.)
After testing the patient’s eye, motor and verbal response, the patient is assigned a score that best describes the nature of the response. The patient may respond in a strange way, arms and legs may spasm into strange positions. He or she may say strange things. The GCS is helpful for the doctors and nurses to evaluate how well the patient is doing and whether further treatment or tests are needed. Ask the physicians and nurses what the patient’s score is. Sometimes patients are more responsive to family and friends than the doctors and nurses, so family and friends may get a different score than the doctors and nurses.
It may be very hard to visit a patient in the ICU who cannot talk or respond. Even if the patient cannot respond, act as if he or she can understand you. Speak to the patient each time you go into the ICU. Call the patient by name. Tell the patient who you are and that you care about him or her, and are hoping he or she will get better. The patient may be able to hear even if they are not able to respond, so do not say things that you do not want the patient to hear or know. You may feel awkward talking to a person who doesn’t appear to be awake, but the more you talk to the patient the less strange it will seem.
The patient will stay in ICU until the doctors determine that the equipment and constant monitoring are no longer necessary. The ICP catheter in the head will have been removed and the ventilator may no longer be needed. The patient may not need to have heart rate and blood pressure monitored and may not need as many IV medications that have to be monitored closely.
How long will this take? Some patients may be ready to leave the ICU in only a few days; others may require weeks or months. This is usually a very tough time for families and friends. Ask the doctors and nurses any questions you have to be sure you understand what is happening. Although both the nurses and doctors are busy, they want to keep you informed. Write questions down if that helps. If you don’t understand, ask again.
Families and friends will also want to know how much damage was done to the brain, and when the patient will “wake up.” Will the patient be like he/she was before the accident? Will he/she be able to go back to work? Will he/she be able to come home? Unfortunately, it’s usually difficult for doctors to answer these questions. Some patients “wake up” and become responsive while in the ICU. Other patients may leave the ICU still unresponsive. A patient who is still unresponsive or comatose will leave the ICU and be transferred to a regular nursing unit when he no longer needs the ventilator, the heart monitor, and his condition is considered stable.
Some hospitals have “Family Groups” or “Family Support Groups” to help family members talk about what is going on and share how they feel. These groups are an excellent place to get information about what is happening, or to talk about your concerns. If you feel the need to talk to someone, the nurse will be able to put you in contact with a counselor or chaplain.
Usually after severe brain injury, patients will be different than they were before the injury. They may think, act, or speak differently. They may have trouble remembering. As the patient starts becoming more responsive, he/she may become agitated and may try to pull out the tubes, making it necessary to use restraints. Because of these changes, the doctors usually ask a rehabilitation medical doctor to evaluate the patient.
The doctors, nurses, social worker or discharge planner may all be talking with the family and friends about rehabilitation needs following discharge from the acute care hospital. Arranging for an admission to an appropriate rehabilitation facility takes time. The doctors and discharge planner often start talking with families about rehabilitation before the patient is out of ICU. This may seem to you too early to be talking about a rehabilitation referral. However, these early referrals need to be made to ensure that arrangements are in place when the patient is ready for discharge from the acute care hospital.