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by zacarias

Hey,


Last night I took care of a pt s/p CHI with tib/fib fx and humurus fracture. It's a terribly sad case but I have a question. This guy showed NO reaction to sternal or clavicle rub, but would frown and scrunch his face when I suctioned him or he coughed. His arms and neck would never move. So that mean his brain function is so bad he doesn't even posture? Why can he still scrunch his face?
His tib/fib wound is open all the way to muscle and it looks like bone, but the docs said they debrided down to muscle...they didn't mention bone. If you debride down to muscle, isn't that pretty much down to bone too? Just wondering why they didn't say that.
Anyway, I learned a lot last night but just wondering about the above things. Thanks.

Zach

[allantiques4me]

Re: Traumatic Brain Injury pt

TBI are so tragic .Ive worked on a specialty unit strictly with TBIs.Sometimes they do have very primitive movements and non purposeful movements and sounds.Some injuries to certain parts of the brain cause different posturing.

[Altra]

Re: Traumatic Brain Injury pt

Does the patient have a spinal cord injury? This could account for lack of movement. Agree w/previous poster regarding non-purposeful movement.

[zacarias]

Re: Traumatic Brain Injury pt

Thanks for the replies, I took care of this same patient today and he did scrunch his face with clavicular rub and sometimes with sternal rub. He always scrunches with turning head.

I still don't understand why he doesn't posture at all...

[MS._Jen_RN]

Re: Traumatic Brain Injury pt

I work with TBI (traumatic brain injury) patients all the time in acute care rehab. It is not uncommon for them to not "posture" after the the initial injury. Infact, if they continue to do so after medical intervention (often to relieve intracranial pressure) it is an ominous sign. Also, the patients will often be inconsistant in ther responses for some time. (ie responding to a stimulus a certian way) I've seen some miraculous recoveries from states of being that I didn't think possible. The most critical time period for recovery is for the first 3 months after the injury. Good recovery happens most rapidly if the patient is put into an agressive therepy program for PT, OT and Speach tx's. Alo the use on stimulants (ie ritalin, amatadine) has been proven to increase the rate of recover and possible the overall prognosis.
This field can be sad, but I love this population because of the great gains the patients can make.
Let this young man be a reminder to wear your seatbelt/helmet, drive slow and safe and don't drink and drive.
~Jen

[zacarias]

Re: Traumatic Brain Injury pt

Jen, thanks for your response. I was wondering. Is it possible for a person's brain and/or brainstem to be so compromised that they don't even exhibit decerebrate posturing? Or will they always at some point exhibit decerebrate posturing as long as the spinal cord is intact?

[MS._Jen_RN]

Re: Traumatic Brain Injury pt

I don't have experience with patients in the ER or ICU and I believe that this is where you would see most of the posturing that you are talking about. I've taken care of more than 50 severly brain injured patients and only seen one person in a true decerebrate posture. I don't know if those patients who are posturing just don't make it to me but I do know that a few of the patient's who I do recieve were posturing in the ER on arrival (per the ER notes). It's my general feeling that the sort of posturing that you are talking about happens mostly inthe acute phase immediatly following the injury.
~Jen

[GilaRN]

Re: Traumatic Brain Injury pt

In addition, posturing may not be seen in patients depending on the location of the injury.

Decorticate posturing is seen in lesions that damage the corticospinal tract and mesencephalic area. This causes motor impulses to be sent through the cervical spine causing the upper arm posturing. In addition, motor neurons lower in the spinal cord receive impulses that cause the leg posturing.

Decerebrate posturing indicates damage at the level of the brain stem. The transition from decorticate to decerebrate posturing is highly suggestive of uncal herniation.

With this knowledge lets say we have a patient with DAI who did not develop a structural lesion. Let us say the cerebrum was involved. This would be a very serious injury; however, posturing may not occur with this patient. In addition, let us say the patient did develop a large lesion that caused posturing. The lesion was removed, but massive damage was sustained to the upper brain areas with sparing of the stem. The lesion and pressure resolved so the patient may no longer posture, but he still sustained a serious injury.

[RNperdiem]

Re: Traumatic Brain Injury pt

Try to be in the room when Neuro does their exam. Observe what they do to elicit a response.

[zacarias]

Re: Traumatic Brain Injury pt

Thanks for the all the posts and follow ups. It's interesting that posturing doesn't occur all the time. This patient had massive cerebral and brain stem bleeds, so I figured he would posture when painfully stimulate but he didn't. Maybe it's wasn't all that dramatic as all that.

Also my charge said his forehead scrunching to painful stimuli was cerebella in nature. I don't get that, I would assume that's brainstem stuff.