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January lNursing2018CriticalCare l27Prolonged, elevated ICP leads to increased mortality for trauma patients. Decompressive craniec-tomies involve removal of part of the skull and opening the under-lying dura mater to relieve pres-sure, thereby lowering the ICP.14Most frequently, a decom-pressive craniectomy will be performed on patients with acute subdural hematoma. A large, randomized, controlled study to determine the effect of decompressive craniotomies for severe and refractory intracra-nial hypertension revealed that patients who had surgery had a lower mortality but higher rates of being in a persistent vegeta-tive state or of having lasting severe disability (defined as being dependent on others for care or are dependent on others for tasks outside the home).14Bifrontal decompressive crani-ectomies are not recommended in patients with severe TBI with diffuse brain injury because they were not shown to improve long-term outcomes in these patients.8Nursing considerationsPatients with TBI should be fed or have basal caloric replacement via enteral nutrition by day 5 postinjury to decrease mortality.8Transgastric jejunal feeding via a feeding tube (placed distal to the stomach into the jejunum) is also recommended to reduce the inci-dence of ventilator-associated pneumonia (VAP) from aspiration of gastric contents.8In addition, an early tracheostomy is recom-mended to reduce the total num-ber of ventilation days, thereby reducing exposure and risk of VAP.8All hospitalized patients must be carefully considered for venous thromboembolism prophylaxis. It can be particularly challenging to administer anticoagulation to patients with intracranial hemor-rhages, as the timing and dosing of the anticoagulation is impera-tive (as to not extend their hem-orrhage and cause further injury). Current recommendations are to use graduated compression stock-ings or intermittent pneumatic compression along with pharma-cologic prophylaxis if the brain injury is stable and the benefit outweighs risk.8Patients with TBI can suffer from posttraumatic seizures, espe-cially within the first 7 days fol-lowing their injury. While these seizures do not lead to increased mortality, they can be dangerous. Currently, phenytoin is recom-mended for the first 7 days of care postinjury to decrease the incidence of these seizures.8ConclusionResearch into the outcomes of patients with TBI is ongoing. One meta-analysis of 57 different studies looking at patients with mild TBI found that they had a higher lifelong risk postinjury of developing Alzheimer disease, Parkinson disease, mild cognitive impairment, depression, mixed affective disorders, and bipolar disorder; patients with more than one TBI had even higher odds of developing these disorders.
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- Winter '16
- Nursing, Traumatic brain injury