HEAD INJURY

PREPARED BY: ROZELLE MAE BIRADOR

HEAD INJURY - DEFINITION

• Any injury that results in trauma to the SCALP,

SKULL or BRAIN.

• TRAUMATIC BRAIN INJURY and HEAD

INJURY are often used interchangeably.

HEAD INJURY - TYPESOPEN HEAD INJURY:

There is penetration to the skull.CLOSED HEAD INJURY

There is NO penetration to the skull.

COUP-CONTRECOUP INJURIES

• Damage may occur directly under the site of impact (COUP), or it may occur on the side opposite the impact

(CONTRECOUP).

HEAD INJURY - MECHANISMS

PRIMARY INTRACRANIAL INJURY

• It is the initial neuronal damage that occurs

IMMEDIATELY as result of trauma.

SECONDARY INTRACRANIAL INJURY

• Secondary injuries are the result of the

neurophysiological and anatomic changes, which occur from MINUTES to DAYS after the original

trauma.

HEAD INJURY - MECHANISMS

PRIMARY INTRACRANIAL INJURY

• Cerebral Laceration• Cerebral Contusion• Epidural Hematoma• Subdural Hematoma

• Subarachnoid Hematoma• Intracerebral Hematoma• Diffuse Axonal Injury

SECONDARY INTRACRANIAL INJURY

• Edema

• Impaired Metabolism

• Altered Cerebral Blood Flow

• Free Radical Formation

• Excitotoxicity

SCALP INJURIES

LACERATIONS SUBGALEAL HEMATOMA

SKULL INJURIES

CT SCAN OT

SKULL INJURIES - BASILAR SKULL FRACTURE

RACCOON EYE

SKULL INJURIES - BASILAR SKULL FRACTURE

SKULL INJURIES - BASILAR SKULL FRACTURE

BATTLE’S SIGN

SKULL INJURIES - BASILAR SKULL FRACTURE

BLEEDING FROM THE EAR CANAL CSF LEAKAGE FROM THE EAR OR NOSE

Etiology and Pathophysiology

• Result from trauma, frequently seen after motor vehicle accidents.

SKULL INJURIES (Fractures)DEPRESSED FRACTURES/COMPOUND DEPRESSED FRACTURES- break that

results in fragments or bone penetrating the brain tissue

NON-DEPRESSED LINEAL FRACTURES- Linear: simple break in the bone

EPIDURAL HEMATOMA- hematoma forms between the dura and the skull; may result from a laceration of the middle meningeal artery

SCHEMATIC CT SCAN

SUBDURAL HEMATOMA- hematoma forms between the dura and arachnoid layers; generally follows venous damage

SCHEMATIC CT SCAN

SUBARACHNOID HEMATOMA

SCHEMATIC CT SCAN

INTRACEREBRAL HEMATOMA

SCHEMATIC CT SCAN

HEMATOMAS

CEREBRAL EDEMA

NORMAL CT SCAN CEREBRAL EDEMA

HEAD INJURY (DIFFUSE) - DIFFUSE AXONAL INJURY

HEAD INJURY (DIFFUSE) - CONCUSSION

• Temporary disruption of synaptic activity

• Brain injury that does not result in any evidence of

structural alteration.

• Return of consciousness moments or minutes

after impact.

• There may be brief confusion,

disorientation, headache, dizziness,

amnesia.

• CT scan is normal.

BRAIN CONTUSION- bruising of brain tissue, with slight bleeding of small cerebral vessels into surrounding tissues at site of impact

(coup) or opposite to site (contracoup) as a result of rebound reaction

SIGNSSubjective• Lethargy• Indifference to surroundings• Altered sensory function (e.g. visual or

auditory)

SIGNS

Objective:

A sign of ↑ICP (INTRACRANIAL PRESSURE)

CUSHING REFLEX

↑ Blood Pressure

↓ Pulse Rate

↓ Respiratory Rate

SIGNS

• Lack of orientation to time and place• Restlessness• Labored respirations• Positive Babinski sign (stroking bottom of the

foot causes dorsiflexion of the toes)• Decreased level of consciousness

SIGNS

• A UNILATERAL , FIXED DILATED PUPIL indicates neurologic deterioration

may be secondary to hypoxia, hypovolaemia or

hypoglycaemia, due to ↑ICP, and compression of

the 3rd Cranial Nerve (OCULOMOTOR NERVE).

DILATED PUPIL

SIGNS

SIGNS

DECORTICATE POSTURING• Arms Flexed

• Arms bent inward on the chest

• Hands clenched into fists• Legs Extended

• Feet turned Inward• Score of 3 in the Motor

section of the Glasgow Coma Scale

SIGNS

DECEREBRATE POSTURING• Head is arched back

• Arms Extended by the sides• Legs Extended

• Patient is rigid with the teeth clenched.

• Score of 2 in the Motor section of the Glasgow

Coma Scale

SYMPTOMS

• Confusion/Irritibility

• Drowsiness

• Dizziness

• Nausea & Vomiting

• Amnesia

• Speech/Swallowing Difficulty

• CSF Leakage

• Ear Bleeding

• Numbness/Paralysis

• Coma

SYMPTOMS

Therapeutic Interventions

• Control seizures with anticonvulsants• Mechanical ventilation; hyperventilation will

constrict cerebral vessels lowering ICP• Reduce cerebral edema with glucocorticoids and

loop diuretics; there is disagreement regarding their efficacy

• Maintain adequate fluid and electrolyte balance• Surgical intervention in cases of depressed skull

fractures or hematomas

NURSING CARE

Assessment1. Airway and breathing pattern• Neurologic status• Cranial Nerves• Muscle Tone• Muscle Power• Sensations• Walking Gait

3. Signs of increased intracranial pressure4. Circumstances of injury5. Presence of glucose in clear drainage from nose or ear, which indicates cerebrospinal fluid

DIAGNOSIS - PHYSICAL EXAMINATION

ABCDE• A = AIRWAY

• B = BREATHING

• C = CIRCULATION

• D = DISABILITY

• E = EXPOSURE

• GLASGOW COMA SCALE (GCS)

GLASGOW COMA SCALE

MINIMUM=3/15 MAXIMUM=15/15 INTUBATION <8/15

GLASGOW COMA SCALE (GCS)

SEVERITY SCORE

13-15

9-12

3-8

MILD

MODERATE

SEVERE

GLASGOW COMA SCALE (GCS)

SEVERITY LOSS OF CONSCIOUSNESS

0-30 mins

>30 mins to <24 hrs

>24 hrs

MILD

MODERATE

SEVERE

DIAGNOSIS - OTHERS

X-RAYS / MRI

ANGIOGRAPHY

EEG

TRANSCRANIAL DOPPLER

PLANNING/ IMPLEMENTATION

1. Observe for signs of increased intracranial pressure; institute neurologic assessments every 15 minutes for several hours, progressing to every hour and then every 4 hours.

2. Maintain airway by suctioning as necessary (coughing increases intracranial pressure); use an airway or endotracheal tube

3. Keep the client’s head slightly elevated to reduce venous pressure within the cranial cavity

4. Administer glucocorticoids and/ or diuretics if ordered

PLANNING/ IMPLEMENTATION5. Institute seizure precautions; administer anticonvulsants if

ordered

6. Monitor for fluid or electrolyte imbalances; diabetes insipidus or syndrome of inappropriate antidiuretic hormone may occur

7. If the client’s eyes remain open, protect the corneas with moistened pads, mineral oil, or ointment as ordered.

8. Support client’s nutritional needs; administer tube feedings or assist with small frequent meals

PLANNING/ IMPLEMENTATION

9. Position the client to prevent pressure areas from forming decubiti

10. Provide range-of motion exercise and splints to prevent contracture

11. Provide auditory and tactile stimulation

12. Assist client to avoid activities that increase ICP such as Vasalva’s maneuver, lifting, sneezing, and flexion of head

PLANNING/ IMPLEMENTATION

13. Utilize hypothermia as ordered to reduce temperature and metabolic demands

14. Recognize that confusion upon return of consciousness can be a defense against additional stress

15. Encourage client and family to participate in planning and care

16. Provide opportunity for expression of grief

TREATMENT - ACUTE STAGE (DISABILITY)

TREATMENT FOR ↑ICP

• IV Mannitol (Osmotic Diuretic)

• IV Furosemide

• Hyperventilation

TREATMENT - ACUTE STAGE (DISABILITY)

TREATMENT FOR ↑ICP

• If there are no counter-indications (hypovolaemia,

spine injury) place the patient in “Reverse-Trendelenburg”

position

REVERSE-TRENDELENBURG

TREATMENT - ACUTE STAGE (PARAMETERS)

MONITOR• Blood Pressure

• Heart Rate

• Respiratory Rate

• S02, Etc02

• ECG

BLOOD SAMPLES

• Serum Electrolytes

• Arterial Blood Gas

• Hyper/Hypoglycaemia

TREATMENT - ACUTE STAGE (SURGERY)

DECOMPRESSIVE CRANIOTOMY

Evaluation/ Outcomes

1. Maintains a patent airway2. Improves level of consciousness3. Remains free from injury4. Participate in decisions about administration of

care5. Maintains ideal body weight for age and frame6. Identifies new coping skills to deal with

changes in life-style