Videos for my classmates...Traumatic Brain Injury

Another video pertaining to my paper and presentation on brain injury.

Hyper-Acute Subdural Hematoma

This is horrifying! YouTube

Craniotomy

A video from YouTube to go with the topic I have written a paper on and am preparing a presentation for. Not for the squeemish!

Neurologic Injury Research Paper

I recently was assigned a research paper on the topic of mechanical ventilation and neurologic injury.  I spent approximately 16 hours researching and writing this paper. It was written in APA format (re-formatted for the purpous of this blog post, the copy and paste was not quite as successful as the original formatting) and I've included a list of sources that I drew my information from. I'm a student and don't pretend to be a genius on this subject nor in the mechanics of writing a paper. I did recieve a 100% on this paper based on its meeting all of the assignment criteria.  There was absolutely no plagerism intended, so if there's an issue please bring it to my attention so that I may rectify the situation. Happy reading!

Neurologic Injury

The Roll of Mechanical Ventilation

Neurological injuries are commonly known as traumatic brain injuries, or TBI. In the United States alone TBI is reported in over 200 cases per 100,000. This means that with the US population being over 300 million that just about 600,000 cases of TBI are reported each year. This does not account for those cases not reported in an Emergency Department, or ED. As can be imagined, each person is very different, so each case of TBI can vary greatly from person to person.

There are three stages of brain injury. Included in these three stages are mild TBI, moderate TBI, and severe TBI. According to David W Crippen, MD “almost 100% of persons with severe head injuries and as many as two thirds of those with moderate head injury will be permanently disabled”. Economically this means that the cost of TBI is staggering on the public. A mild TBI is referred to as a concussion sometimes. Most patients diagnosed with TBI are mild. Losing consciousness briefly after a concussion is normal as is a general feeling of dizziness, confusion, and perhaps small losses in memory and physical abilities. The brains ability to send messages is temporarily blocked when the trauma occurs. Losing consciousness is the brains way of shutting down and restarting. Of course not every patient with a concussion will lose consciousness. Other conditions possibly associated with a mild TBI are post-traumatic amnesia that is short lasting and a slightly lower Glasgow Coma Score, or GCS. A moderate TBI has similar factors as a mild TBI but the symptoms last longer. Unconsciousness can last up to a full day as can memory loss and amnesia. A person with a moderate TBI would have a GCS ranging from 9-12. Finally a severe TBI will mean a patient is in a coma. All symptoms are elongated further and more severely. GCS score is lower than 8. A patient with a sever TBI will have trouble functioning normally after the incident. They may have trouble with attention span, memory and other cognitive problems. These patients could have loss of senses, like taste, touch, smell, etc and my develop seizures, pain, and lose some motor functions. The speed of which a body recovers from a TBI is also indicative of the type (Traumatic Brain Injury, 2011). A first sign of increasing ICP in a conscious TBI victim is a change in their level of consciousness. Careful observation of the pupils is important to see changes in pupillary mismatch and decreasing reaction to light.

There are many treatments for brain injuries with increased intracranial pressure. The most critical goal of managing neurological injury and adjacent intracranial pressure (ICP) is to reduce brain volume. The practitioner must decrease cerebrospinal fluid, or CSF, along with blood volume while maintaining cerebral perfusion in order to reduce ICP (Crippen, 2011). Normal ICP is 0-15 millimeters of mercury (mmHg). ICPs elevated to 35mmHg for prolonged amounts of time can be potentially harmful and once pressures increase above 40mmHg it is impossible not to have sustained some damage. There are three parts that make up the intracranial space. The brain, or parynchyma, consists of 1400ml of the space inside the skull while the CSF and blood both make up another 75ml each. The change in volume of the brain is interdependent on the change in the volume of either of the other two parts of the intracranial space (Sharma, 1999). Cerebral perfusion pressure is measured by taking the mean arterial pressure and subtracting the intracranial pressure, or CPP=MAP-ICP. According to Egan's MAP is normal at about 93mmHg if arterial blood pressure is in a normal range. ICP normally sits at 10mmHg or less. A good range for CPP is 83-93mmHg. If a bleed is present then MAP may be kept slightly higher in order to keep perfusion levels where they need to be. Ischemia, or insufficient blood flow to the brain, is caused by a decreased CPP in a vicious cycle that can possibly eternilize itself. If the CPP is reduced the body reacts by raising the blood pressure which in turn dilates the blood vessels in the brain. By dilating, or widening, the vessels the venous flow is increased and the blood volume increases in the brain. According to the CPP equation this process then increases ICP, which decreases CPP and the body starts all over with raising the blood pressure and so on (Tolias et al, 2003). So the higher the ICP the higher the practitioner has to increase the patient's MAP to prevent herniation, blockages of the ventricles, which leads to increasing CSF.

Closed brain traumas can be caused by many things. Tumors in the brain, falls, accidents, sporting activities, and blows to the head are the main cause of these types of injuries (Pillbeam, 1998). Other more specific causes can be shaken baby syndrome, stroke, intracranial bleeding,

hydrocephalus, Lyme Disease, etc.

In the news recently has been the discovery of high occurrences of concussions received by elite athletes, especially football players, over many years of playing. Statistically a professional athlete's life expectancy is about 1/3 that of the average human being and the average professional football player will live approximately 20 years shorter than average (Strength Planet, 2011). This statistic alone is evidence of how devastating closed head injuries and increased ICP can be. The focus of this topic is going to be mechanical ventilation and hyperventilation as a treatment for increased ICP but that will be discussed later.

There is quite a range of treatments for increased ICP. Starting with relatively non-invasive treatments for this disorder patients are put on fluid restriction and specialized diuretics prescribed by a neurologist. A patient with a closed brain injury would be on an ordered dietary NPO, or nothing by mouth, and would not be set up with IV liquids like most patients. A diuretic like Mannitol is delivered directly to the patient in a continual IV drip that removes water from the brain and expels it as waste. A patient with an edematous brain needs to be urinating as much of the fluid out as possible. Not only does Mannitol expel extra fluid as waste it also thins out the blood and increases cerebral blood flow which helps reverse the lowered CPP (Sharma, 1999). Corticosteroids can also be administered via an IV to decrease cerebral swelling. Steroids have many side affects and those should be considered when administering them to any patient.

Another non-invasive treatment for increased ICP is to raise the the head of the patient's bed 30 degrees to recruit gravity in helping improve venous drainage into the the spine. Also by lowering the mean arterial pressure, or MAP, using an anti-hypertensive, such as calcium channel blockers, the practitioner can decrease cerebral blood flow thus reducing CPP. Physiological circumstances that should be avoided or fixed are seizures, high temperatures, and restlessness. These increase the body's metabolic pursuit and oxygen consumption. High body temperatures will also increase vasodilation in the brain and rouse cerebral edema (Sharma, 1999). Keeping a patient sedated will decrease their agitation. However sedation on a patient with a head injury is done very very carefully because it is harder to assess cranial activity after sedation.

Normal laryngeal intubation can be very agitating on a patient. As stated the practitioner wants to keep the patient calm so as not to raise the ICPs any more so it is wise to pre-oxygenate a patient with a closed brain injury so as not to decrease the oxygenation in the bloodstream. Rapid sequence intubation, or RSI, is also indicated for this type of patient because it is quick and the patient is unconscious throughout the entire procedure thus not agitating and raising ICP levels. A quick sequence of drugs is given finishing with a paralyzing agent. RSI can be done within one minute (Lafferty, 2011).

There are much more invasive techniques which are used to treat increased ICP. A small lumbar puncture can be used to drain a small amount of CSF out of the spine. This procedure is helpful with the head of the patient elevated. The catheter inserted in the lumbar does not remove a lot of CSF but with the help of gravity any amount of fluid removal is imperative to severe patients. Both an epidural monitor and subarachnoidal bolts have their place in successfully draining CSF from the brain as well. Along with these there are intraventricular catheters which are one of the most popular devices used to drain CSF. A catheter is inserted directly into the the ventricle and both CSF draining and monitoring is possible (Sharma, 1999). Newer fiber optic technology has recently come out allowing monitoring and draining of CSF by a probe being surgically implanted in the brain, ventricles, and subdural space. A transducer is on the tip of the fiber optic to measure pressure and a catheter is put in place for drainage. The catheter can also be use to for introduction of medicine (Arbour, 2011).

A more serious increase in ICPs might require even more invasive procedures. Something called a burr hole can be drilled in the patients head in the OR or right at bedside. It creates a space just big enough to place and ICP catheter. If that small procedure isn't enough a decompressive

craniectomy can be done. This is where part of the skull is removed to allow the brain to swell without damaging the parynchyma or causing vessels to be crushed further increasing ICPs. The skull piece is surgically stored in the patient's abdomen until they are recovered and it can be put back into place (Egans, 2003).

The IVD or Intraventricular Drain has several names. External Ventricular Drain and ventriculostomy are similar devices. The IVD is a piece of medical equipment that is used in closed neurological injuries. It was designed to decrease elevated ICPs and hydrocephalus when there is something obstructing the normal flow of CFS around the brain. It is a small, plastic tube that is surgically inserted in the side of the brain that is blocked to drain fluids from the ventricles thus reducing ICPs. A ventricular drainage device is designed to shunt cranial fluid from the brain. The small plastic tubing is surgically placed in the ventricle where pressure buildup is taking place using a one-way valve into another portion of the brain that is not blocked and/or down into the stomach where the extra fluid would be excreted as waste (Dempsey, 2012). This type of drain would be internal. The external drains would drain into a bag at bedside. These types of devices are used quite commonly in neonates. Babies have the probability of having the shunt device in their cranium their entire lives, although some may be able to have them removed eventually. Complications can arise such as shunt blockage and infection. Like any surgical procedure infection is highly likely if not cared for properly. Watching for signs of infection such as swelling, fever, and lack of healing is important in these patients. Vomiting and seizures are signs to watch for that indicate the catheter has a blockage. Permanent brain damage can occur if these things occur (Kakarla et al, 2008).

Now is where the respiratory department can aid in decreasing a patient's ICPs. The patient will need to be monitored for clear, patent airways, breathing and oxygenation. A direct cause of vasodilation is low tissue oxygenation, hypoxia, and high levels of carbon dioxide, hypercapnia, in the blood. If the vessels dilate it allows increasing amounts of blood flow to the brain increasing the

vicious cycle of raising the patient’s ICPs. Hyperventilating a patient can temporarily reduce cranial swelling. The brain swells immediately in a patients with TBI. If hyperventilation is applied quickly for less than 48 hours ICP may be able to be reduced. Because the body is always trying to balance itself, or keep itself in homeostasis after 48 hours or more the body adjusts against the settings and normalizes it's blood gas values. Reducing cerebral blood flow is important to reduce ICP. Alkalosis in combination with hypocapnia can help reduce blood flow in the brain therefore keeping the pressure of arterial carbon dioxide levels, or PaCO2, between 25-30mm Hg is important.

Of course as all science and technologies the medical field is constantly advancing and changing. New therapies and procedures are discovered all the time to improve patient care. So as new information is received old information is often shelved or put on a back burner. Such is the case with hyperventilating a patient in order to decrease ICP. All the advance drains, monitors, and drugs combined have much less harmful side affects than keep a person's blood gas levels in a state of alkalosis. Hyperventilation would be a last ditch effort if none of the other procedures or therapies worked. This does not mean that the role of the respiratory therapist is obsolete during this particular trauma. The respiratory staff will always work side by side with the nursing staff in care of a patient with a TBI. Monitoring of the oxygen in the blood would be a main concern for respiratory. Not to mention if a TBI patient is on a ventilator they would need a respiratory therapist monitoring that patient.

References

1. ^{Kakarla UK, Kim LJ, Chand SW, Theodore N, Spetzler RF (2008). “Safety and accuracy of bedside external ventricular drain placement”. Neurosurgery 63 (1 Suppl 1)}
2. ^{Crippen DW. 2011. “Head Trauma”.Emedicine.com}
3. ^{Davis DP, Kimbro TA, Vilke GM. The use of midazolan for prehospital rapid sequence intubation may be associated with dose-related increase in hypotension. Prehospital Emergency Care 2001; 5:163-168.}
4. ^{Lafferty KA. 2011 “Rapid Sequence Intubation” Emedicine.com}
5. ^{Tolias C, Sgouros S. 2003 “Initial Evaluation and Management of CNS Injury” Emedicine.com}
6. ^{Sharma A, (1999). Raised Intracranial Pressure and its Management. Vol 1 No 1}
7. ^{15 Facts About World Class Athletes. (2001) Retrieved from: http://strengthplanet.com}
8. ^{Arbour, R. 2011. “Intracranial Hyptertension Monitoring and Nursing Assessment” ccn.aacnjournals.org}
9. ^{Traumatic Brain Injuy (2011) The Journey Home. Retrieved from} http://www.traumaticbraininjuryatoz.org/
10. ^{Pilbeam SP, Cairo JM, (1998). Mechanical Ventilation Physiological and Clinical Applications. St Louis, MO: Mosby, Inc.}
11. ^{Wilkins RL, Stoller JK, Kacmarek R. (2003). Fundamentals of Respiratory Care. St. Louis, MO: Mosby, Inc.}

I Love Old People!!

I have always loved old people.  I love talking to them and hearing their stories.  Old people have a lot of knowledge that no book can ever teach you.  I have my mother, Emma Camille Gamble Harrison (aka Cammy) to thank for my love of old people. My mother is very traditional.  She believes in doing what's right, no matter how it affects her.  I don't always agree with her version of right, but at least I always know where she stands.  That must be why I can't stand wishy-washy people. My mother raised us to visit, write, or take care of the older people in our family until the end. I remember when I was very very young visiting my grandpa's mother, Clara Mae Kimball Gamble, aka Muzzy. I don't remember any interactions with Muzzy but she had a reputation for being kind of mean, but my mother visited her anyway and I took that example to heart.

My grandmother's mother, Georgia Emma Burelson Thompson/Hastings, aka Bamba, lived in California with her husband James <middle name> Hastings, aka Grandpa Jimmy. As a child my grandparents, Howard Ladd Gamble, aka Papa, and Mildred Cleo Thompson Gamble, aka Memo, and mom would pack me and my sister, Natalie Iva Harrison Wills, up in the motor home every summer and take a trip to California (and other places). I vividly remembering visiting Bamba many many times. My mother also wrote her a letter every week. She loved Bamba and was a diligent granddaughter. She name me after her, Georgette Pearl Harrison.

We also visited and cared for my Aunt Ivy Pearl <maiden name> Kimball/Alpert, aka Iva.  I was also named after Iva. Iva married into our family by way of my grandpa's favorite uncle, Delbert Kirkland Kimball.  Delbert died in the mid-1950s and Iva moved from Oklahoma to Arizona and in with my grandparents when my mom was very young. She and my mom became best buddies. I think Iva was the only person who my mom truly trusted. They told stories about the tricks they used to play on each other and the fun they had. One story was that they shared a bed with a trundle and my mom would set up the trundle in such a way that it would hit the floor when Iva climbed in it. It was a big laughing joke between them. They truly loved each other.

I didn't know Delbert, I knew Iva's second husband, Walter Alpert.  Walter was a strange man and he would sometimes make me mad, but I loved him. I have memories with him as young as 3. One time he took me to a playground and I crawled UNDER a moving merry-go-round, scared the bejeeziz out of Walter and he dragged me out and spanked me.  Pretty sure that's the only spanking I've had in my life and I'm pretty sure I deserved that one plus many more! Iva and Walter lived in a Trailer park near 27th Ave and Camelback in a horrible neighborhood, not because they were poor but because Walter was a stereotypical Jew. Lived more frugally than I have ever seen. When Walter died he left Iva over $300,000 in the bank. No investments built that money, he just saved every penny he could from his job as a mail carrier and whatever pension or social security they received (man I wish I had the self-disciplin!).

 I don't remember Iva doing anything but sitting in her chair, painting her fingernails, or going to eat with us at a buffet. She loved buffets. She was very overweight and it was hard for her to walk.  I spent quite a bit of time in hospitals because of Iva. We visited Iva and Walter at least once a week, and drove them around to doctors appointments and such. I had graduated high school when Walter passed away. We prepared ourselves to take care of Iva until her end however the most heartbreaking thing happened to us the weeks to follow after his funeral. Iva's family in Oklahoma, which had had nothing to do with her for years, showed up and managed to brain wash her into thinking that we were going to hurt her and they took back to Oklahoma. It hurt so much with her gone, and I can't even imagine what my mom went through when her best friend was taken from her.  We learned later that Iva's family had taken her money, put her in a home, and left her there to die. They never visited her. I don't understand why they didn't just come take her money and leave her with us. We didn't want her money, we wanted Iva.

After Iva our lives went on, but my love for old people lived on. I always managed to endear myself to an older person.  I had several restaurant jobs and inevitably the restaurant had one older hostess that I became fast friends with. I just love talking to these ladies and hearing about their lives.  It makes me sad that I didn't keep in touch with them after leaving these different jobs.  So at the age of 24, having two kids at the time, I went to work in the nurse's office at my mom's school because my husband had been out of work for a while. The nurse I worked with was a wonderful older lady and I really enjoyed my time with her.

I left the school to go work as a CNA in a care center a few months before the school year was out. The job was hard, and frustrating, and the only thing that kept me going were the residents, my old people. Several residents stick out in my mind. Strelsa had Alzheimer's and was a difficult patient. I did my best to talk to her and made her feel comfortable. She told me quite a bit about her early life and I discovered she liked music.  Showering her was always a hard task because she wouldn't cooperate but as soon as I started singing to her she was completely relaxed. I was so sad when she passed away. I still have her obituary somewhere and was saddened that the family didn't put much thought or creativity into it.  Another resident, Pam, was the funniest lady. She only had one leg due to her diabetes and she was heavy and quite difficult to move around and care for. But being able to have conversations with her is what made caring for her fun. I wish I had had more patients with my co-workers I could have stayed longer at that job. I've always struggled getting along with stupid, unmotivated people.

I left that job and went back to taking care of my babies. When I was 25 my grandpa, who had been struggling with old age for a while, had open heart surgery. After 3 weeks recovering at a hospital he was moved to a care center. We didn't know how long he'd have to be there and were just going day by day making the best decisions we could. I visited him on the third day he had been there, it was Valentines Day (which is an insignificant fact, but it sticks out in my mind). He left with me that day. He was miserable and uncomfortable not being home and more scared than I have ever seen him. He looked me in the eye and said 'please take me with you'. It meant rearranging my life so that he would have round the clock care, but I did it. There is no way I could have told that man no after everything he had done for me his entire life. So I gave up my profitable in home baby-sitting business, moved my oldest kids, Coraleigh Shreeve and Ethan Ladd Shreeve, in with my mother so they could continue going to school, and my youngest daughter, Georgia Pearl Shreeve, and I moved in with my grandparents. They lived in Morristown which was about an hour from town in a house they built in the middle of the desert. We were there for a month and it wasn't easy, but I got him so that my grandma would be able to take care of him.  He lived a couple more years after that. He died at home surrounded by family. It was a bittersweet time. I was so grateful his suffering had come to an end but my heart was broken because the man that I had loved the longest was gone. I miss him.

So now I'm 32 and I'm going to school for respiratory therapy and the past month I have been doing a clinical rotation at John C Lincoln North Mountain. A respiratory therapist doesn't spend much time with their patients but I'm enjoying the interactions with my old people. I love them and I think that is my calling in life.  I'm hoping I can find a job as a respiratory therapist working with old people. Respiratory therapists have some down time built into their schedules because they are on call their entire shift, meaning if someone needs a treatment we hop to give it to them even if we're on a break. I hope to be able to use my down time talking to my old people.

Bloggin Bloggin Bloggin

I swear I have positively good intentions of blogging regularly and then life gets in the way and I forget to log in here. Facebook is so easy to put a quick little blurb or picture on that I neglect the rest of the World Wide Web!

Today was the first day of my first clinical rotation. I'm spending 10 weeks at John C Lincoln North Mountain, two 12 hour day shifts on Monday and Tuesday. Today I met some really nice people and generally had a very tiring but enjoyable day. I got to give a bunch of treatments, and do some patient education, and learn about the routine of a respiratory therapist. I believe I am really going to enjoy doing this for a living and am going to spend a lot of time hoping and praying that I get a job when I graduate! It's really nice to know that I am not a dummy and that I have retained quite a bit of information from my classes!