Injuries
Injuries
Learning Objective: Examine injuries that impact the nervous system, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
Injuries are common reasons for neurologic conditions. The CDC estimates 1.5 million Americans sustain a traumatic brain injury (TBI) each year. Besides TBI, spinal cord injuries and peripheral neuropathy cause injuries to the nervous system.
Traumatic Brain Injury
Learning Objective: Discuss traumatic brain injury, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
Traumatic brain injury (TBI) is an acquired brain injury. TBIs can occur as a result of falls, motor vehicle accidents, violence (e.g., shaken baby syndrome, gunshot wounds), sports injuries, and service in military combat zones. A concussion is a mild form of a TBI and is the most common type of sports injury. A contusion is bruising or swelling of the brain that occurs when small cerebral blood vessels bleed into brain tissue.
TBI can occur as a result of a violent jolt or blow to the head or body or when something pierces the skull (e.g., a bullet) and injures the brain tissue. Symptoms of TBI may not appear for weeks after the injury. TBI can be mild, moderate, severe, or life threatening, depending on the brain damage.
• Mild TBI symptoms include headache, neck pain, nausea, ringing in the ear, dizziness, lightheadedness, blurred vision, tiredness, dazed feeling, mood changes, and trouble concentrating or remembering. Children experience irritability and changes in eating.
• Moderate or severe TBI symptoms are similar. The headache is constant and gets worse. The person may experience repeated vomiting, seizures, inability to awaken, dilation of one or both pupils, slurred speech, agitation, loss of coordination, and weakness in the extremities. Children may also be inconsolable and refuse to eat.
For severe injuries, emergency personnel will use the Glasgow Coma Scale to assess the patient. In the hospital, imaging tests (CT and MRI), along with intracranial pressure monitoring, will be done. In the ambulatory care facility, the provider will obtain information on the injury and perform physical and neurologic examinations. CT or MRI may be ordered to check for skull fractures. For mild TBIs, treatment consists of rest and OTC analgesics. For moderate to severe TBIs, medications are given to reduce the brain swelling and prevent more damage. Surgery may be done to remove hematomas, repair skull fractures, stop bleeding in the brain, and relieve pressure (by removing a portion of the skull). Various rehabilitation specialists may be involved during the recovery phase.
Shaken Baby Syndrome
Shaken baby syndrome (SBS) is the leading cause of child abuse deaths. There are more than 1300 cases a year in the United States, and about a quarter of the children die. SBS occurs when a child is violently shaken, or the head strikes against a hard surface (e.g., wall, counter, floor). Crying is the leading trigger for the violence that leads to SBS, and most babies are less than 6 months old when it occurs.
Signs and symptoms of SBS include lethargy, extreme irritability, bruises, rigidity, difficulty breathing, bulging fontanels, inability to focus the eyes or track movement, unequal pupil size, seizures, and poor feeding.
About 80% of the children who survive SBS have lifelong disabilities, including blindness, seizures, hearing loss, developmental delays (e.g., speech, learning, memory, attention), cerebral palsy, and severe mental retardation.
According to the National Center on Shaken Baby Syndrome (www.dontshake.org), the Period of PURPLE Crying program is an evidence-based shaken baby syndrome prevention program that helps caregivers understand crying in infants and helps to prevent SBS. The letters in PURPLE describe important information for parents and caregivers.
Peak of crying: Crying may increase weekly until 2 months of age.
Unexpected: The child may cry off and on, though the parent/caregiver may not know why.
Resists soothing: The child may not stop crying regardless of what the parent/caregiver does.
Painlike face: The facial appearance may indicate that the child is in pain, though that may not be the situation.
Long lasting: The child can cry more than 5 hours a day.
Evening: Crying may increase in the late afternoon or evening.
Spinal Cord Injury
Learning Objective: Discuss spinal cord injury, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
Spinal cord injuries occur when a blow, gunshot, or stabbing fractures or dislocates the vertebrae, and the bone pieces cut into the cord or press on the nerves. This is a medical emergency. Common causes include motor vehicle accidents, falls, acts of violence, alcohol, and diseases. Spinal cord injuries can fall into the following categories:
• Complete: No signals can be sent below the level of the injury, and the person is paralyzed below the injury.
• Incomplete: Some signals can be sent below the injury, and thus the person has some movement and sensation below the injury.
Initially, the person may experience extreme back or neck pain, bowel or bladder incontinence, difficulty breathing, and paralysis.
• Quadriplegia (or tetraplegia): The spinal cord injury affects the arms, hands, trunk, legs, and pelvic organs (e.g., bowel, bladder, and sexual functions).
• Paraplegia: The spinal cord injury affects some or all of the trunk, legs, and pelvic organs.
The emergency providers will perform physical and neurologic examinations. Imaging studies (x-ray, myelogram, MRI, and CT) will be done. Treatments include surgery, traction, corticosteroids, and rehabilitation (e.g., physical and occupational therapies).
Peripheral Neuropathy
Learning Objective: Discuss peripheral neuropathy, including the signs, symptoms, etiology, diagnostic procedures, and treatments.
Peripheral neuropathy occurs as a result of damage to the peripheral nervous system. More than 100 types of peripheral neuropathy have been identified, each with its own symptoms. Diabetic neuropathy is one of the most common forms.
The cause of peripheral neuropathy may be inherited, acquired, or unknown (called idiopathic). Acquired peripheral neuropathy can be caused by the following:
• Physical injury: Related to trauma (accidents, sports-related activities, surgical procedures, and falls) or stress from repetitive activities.
• Diseases: Related to metabolic and endocrine diseases (e.g., diabetes mellitus), small vessel disease (e.g., vasculitis), autoimmune diseases (e.g., lupus, rheumatoid arthritis), kidney disorders, cancer, and infections (Lyme disease).
• Exposure to toxins: Includes medications, environmental and industrial toxins, and heavy alcohol consumption.
Signs and symptoms include tingling and numbness, paresthesia, weakness, increased sensitivity to stimuli, burning pain, muscle wasting, paralysis, and organ dysfunction. With diabetic neuropathy, pain and numbness are felt in both legs, with gradual progression up the legs. Eventually, the person may feel pain and numbness in the fingers, hands, and arms.
The provider will do physical and neurologic examinations. Additional tests will be done, including nerve conduction velocity (NCV), electromyography (EMG), MRI, and nerve and skin biopsies. Treatment addresses the underlying causes and symptom management. Medications such as antidepressants, anticonvulsants, antiarrhythmics, narcotics, and nonsteroidal anti-inflammatory drugs (NSAIDs) may ease the neuropathic pain.
22.7
Critical Thinking Application
Nancy’s last patient of the day has severe neuropathy in both her hands and feet. The patient states that she can’t feel much with her hands. After rooming the patient, Nancy thinks about her own life and what it might be like if she could not feel much in her hands and feet. How might that affect a person’s life? What complications might occur?