HEAD INJURY

DR RAJESH T EAPEN

ATLAS HOSPITAL

RUWI

MUSCAT

Any degree of traumatic brain injury ranging from

scalp laceration to LOC to focal neurological

deficits

Head Injury

Head injuries are among the most common types of trauma

encountered in emergency departments (EDs).

Many patients with severe brain injuries die before reaching a

hospital, with almost 90% of prehospital trauma-related deaths

involving brain injury.

About 75% of patients with brain injuries who receive medical

attention can be categorized as having minor injuries, 15% as

moderate, and 10% as severe.

Most recent United States data estimate 1,700,000 traumatic

brain injuries (TBIs) annually, including 275,000

hospitalizations and 52,000 deaths.

Head Injury

Causes

• Motor vehicle accidents

• Falls

• Assaults

• Sports-related injuries

• Firearm-related injuries

Head Injury

High potential for poor

outcome

Deaths occur at three points

in time after injury:

•Immediately after the injury

•Within 2 hours after injury

•3 weeks after injury

Head Injury

TYPES:

• Scalp laceration

• Skull Fractures

• Minor Head Trauma

Concussion and post-

concussion syndrome

• Major Head Trauma:

Cerebral contusion

Laceration

Intracranial Perfusion

Cranial volume fixed80% = Cerebrum, cerebellum & brainstem

12% = Blood vessels & blood

8% = CSF

Increase in size of one component

diminishes size of another

Inability to adjust = increased ICP

Head Injury

Scalp lacerations

• The most minor type of head trauma

• Scalp is highly vascular - profuse

bleeding

• Major complication is infection

Head Injury

Skull fractures :

• Linear Skull Fracture

• Depressed Skull Fracture

• Diastatic Skull Fracture

• Basal Skull Fracture

• Compound Skull Fracture

• Compound elevated Skull

Fracture

• Growing Skull Fracture

• Coup & Countercoup

Head Injury

• Skull fractures

Location of fracture alters the presentation of

the manifestations

• Facial paralysis

• Conjugate deviation of gaze

• Battle’s sign, Raccoon eyes

Basilar Skull Fracture

Battle’s sign Raccoon eyes

Basal Skull fractures

• CSF leak (extravasation) into

ear (Otorrhea) or nose

(Rhinorrhea)

• High risk infection or

meningitis

• ―HALO Sign ‖ on clothes or

linen

• Possible injury to Internal

carotid artery

• Permanent CSF leaks

possible

“HALO Sign ”

Head Injury

Investigations

• X-ray

• CT scan: standard modality

• MRI

• Bleeding from the ear or nose in cases of

suspected CSF leak -"halo" or "ring" sign ,

when dabbed on a tissue paper

• CSF leak - analyzing the glucose level and

by measuring tau-transferrin.

Management

Pre-hospital care:

• Patients with severe head injuries should be

assumed to have a cervical spine (C-spine) injury

and immobilized with cervical collar until clinical and

radiographic studies can prove otherwise

• Minimize CSF leak

• Bed flat

• Never suction orally; never insert NG tube; caution

patient not to blow nose

• Place sterile gauze/cotton ball around area

Definitive Rx:

• Measures to reduce ICP

• Supportive management

• Surgery

Head Injury

Minor head trauma

Concussion : head injury with a temporary

loss of brain function concussion can

cause a variety of physical, cognitive , and

emotional symptoms.

Cause: Sudden acceleration and

deceleration injury e.g.: Car accident,

sports injury, bicycle accident etc.

Head Injury

Types of Head Injuries

Concussion

Presentation:

Physical-headache, LOC, Amnesia,

s/s of ↑ ICP(Cushing’s triad) , convulsions

Cognitive : confusion, irritability, behavioral

changes

Head Injury

Minor head trauma

• Post-concussion syndrome

• 2 weeks to 2 months

• Persistent headache

• Lethargy

• Personality and behavior changes

Head Injury

Major head trauma

• Includes cerebral contusions and lacerations

• Both injuries represent severe trauma to the

brain

Head Injury

Major head trauma

Contusion

The bruising of brain tissue within a focal area

that maintains the integrity of the pia mater and

arachnoid layers associated with multiple micro-

hemorrhages, small vessel bleed into brain

tissue

Lacerations

Involve actual tearing of the brain tissue

Intracerebral hemorrhage is generally

associated with cerebral laceration

Cerebral Contusion Cerebral Laceration

Head Injury

Head Injury

Pathophysiology

Diffuse axonal injury (DAI)• Widespread axonal damage occurring after a mild, moderate,

or severe TBI

• Seen in half the cases of head injury

• Process takes approximately 12-24 hours

Head Injury

Pathophysiology

Diffuse axonal injury (DAI)Clinical signs:

• Level of Consciousness

• ICP

Decerebration or decortication

Global cerebral edema

90% regain consciousness from severe DAI

Intracranial Hemorrhage

• Extra- axial hemorrhage

Epidural hematoma

Subdural hematoma-

Acute

Chronic

Subarachnoid hemorrhage

• Intra-axial hemorrhage

• Intra-parenchymal

hemorrhage

• Intra-ventricular hemorrhage

Epidural and Subdural Hematomas

Epidural Hematoma

Subdural Hematoma

Epidural and Subdural Hematomas

Hematoma type Epidural Subdural

Location Between the skull and the dura Between the dura and

the arachnoid

Involved vessel Temperoparietal (most likely) - Middle

meningeal artery

Frontal - anterior ethmoidal artery

Occipital - transverse or sigmoid

sinuses

Vertex - superior sagittal sinus

Bridging veins

Symptoms Lucid interval followed

by unconsciousness

Gradually

increasing headache and

confusion

CT appearance Biconvex lens- limited by suture lines Crescent shaped- crosses

suture lines

Subarachnoid Hemorrhage

Causes:

• Rupture of Berry aneurism(MCC)

• Trauma (fracture at the base of the skull

leading to internal carotid aneurysm)

• Amyloid angiopathy

• Blood dyscrasias

• Vasculitis

Clinical Features:

• Explosive or thunderclap headache, ―worst

headache of my life‖,

• Nausea and vomiting, decreased LOC or

coma.

• Signs of meningeal irritation

Intracerebral Hemorrhage (ICH)

Intracranial hemorrhage is hemorrhage that occurs

within the brain tissue itself; an intra-axial

hemorrhage.

Two main types:

• Intraparencymal hemorrahge- ICH extending into

brain parenchyma; MCC- HTNsive vasculopathy

• Intra-ventricular hemorrhage- ICH extending into

ventricles; MCC –trauma

Causes:

Hypertensive vasculopathy(70-80%)

Ruptured AVM

Trauma

Blood dyscrasias

Intracerebral Hemorrhage (ICH)

Clinical presentation: Rapidly progressive severe

headache, building over several minutes, often

accompanied by focal neurological deficits, nausea and

vomiting, decreased level of consciousness.

S/S depend site of hemorrhage:

Basal ganglia/internal capsule - hemiparesis,

dysphasia

Cerebellum - ataxia, vertigo

Pons - cranial nerve deficits, coma

Cerebral cortex- hemiparesis, hemi-sensory loss,

hemi-anopsia, dysphasia

Complications

• Neurological deficits or death

• Seizures

• Obstructive Hydrocephalus

• Spasticity

• Urinary complications

• Aspiration pneumonia

• Cushing’s ulcer

• Neuropathic pain

• Deep venous thrombosis

• Pulmonary emboli

• Cerebral herniation

Glasgow Coma Scale

Suspect severe brain injury GCS <9

32

*Decorticate posturing to pain

**Decerebrate posturing to pain

Diagnostic Studies

CT scan –

A GCS score less than 15 after blunt head

trauma warrants a patient with no intoxicating

consideration of an urgent CT scan.

CT findings

Epidural Hematoma Subdural Hematoma

CT findings

Subarachnoid hemorrhage Intracerebral hematoma

Diagnostic Studies

• MRI – superior for demonstrating the size of an acute

subdural hematoma.

• Cerebral angiogram if hemorrhage is confirmed (not

necessary in case of classic hypertensive hemorrhage)

• Cervical spine X-ray

• EEG

• Lumbar Puncture

Management

1) Supportive Measures:

• Endotracheal intubation for patients with

decreased level of consciousness and poor airway

protection.

• Cautiously lower blood pressure to a MAP less

than 130 mm Hg, but avoid excessive

hypotension.[10]

• Rapidly stabilize vital signs, and simultaneously

acquire emergent CT scan.

• Maintain euvolemia, using normotonic rather than

hypotonic fluids, to maintain brain perfusion

without exacerbating brain edema

• Avoid hyperthermia.

• Facilitate transfer to the operating room or ICU.

Management

2) Decrease cerebral edema:

• Modest passive hyperventilation to reduce

PaCO2

• Mannitol, 0.5-1.0 gm/kg slow iv push

• Furosemide 5-20 mg iv

• Elevate head 20-30 degrees, avoid any neck

vein compression

• Sedate and paralyze if necessary with

morphine and vecuronium (struggling, coughing

etc will elevate intracranial pressure)

Management

3) Surgical Evacuation of hematoma:No surgical intervention if collection <10ml

Indication of surgical decompression:

• The GCS score decreases by 2 or more points between the

time of injury and hospital evaluation

• The patient presents with fixed and dilated pupils

• The intracranial pressure (ICP) exceeds 20 mm Hg

Exception :

In Subdural hematoma with GCS=15- hematoma >10mm ,or

>5mm midline shift ---- requires Surgical decompression

SAH: when a cerebral aneurysm is identified on angiography,

clipping and coiling is done to prevent re-bleed

Management

Surgical Decompression contd..

Types:

• Burr-hole

• Craniotomy- bone flap is temporarily removed

from the skull to access the brain

• Craniectomy – in which the skull flap is not

immediately replaced, allowing the brain to

swell, thus reducing intracranial pressure

• Cranioplasty - surgical repair of a defect or

deformity of a skull.

Initial management of the patient with traumatic

brain injury (treatment option).

Initial management of the patient with traumatic brain

injury (treatment option). Contd….

Assessment parameters for the patient with a head

injury include (A) eye opening and responsiveness,

(B) vital signs

Assessment parameters for the patient with a head injury:

(C, D) motor response reflected in hand strength or

response to painful stimulus.

NURSING MANAGEMENT:

• Ineffective Cerebral tissue perfusion related

to increased ICP and decreased CPP

• Fluid volume deficit related to decrease LOC

and hormonal dysfunction.

• Risk for injury related to decreased level of

consciousness.

• Knowledge deficit regarding the treatment

modalities and current situation.

• Ineffective thermoregulation related to

damage to hypothalamic centres.

• Risk for Impaired skin integrity related to

compromised circulation shifting of fluid

from intra vascular to interstitial space.

• Anxiety related to outcome of diseases as

evidenced by poor concentration on work,

isolation from others, rude behaviour

Nursing Process: The Care of the Patient

with Brain Injury—Assessment

• Health history with focus upon the immediate

injury, time, cause, and the direction and force of

the blow

• Baseline assessment

• LOC—Glasgow Coma Scale

• Frequent and ongoing neurologic assessment

• Multisystem assessment

51

Nursing Process: The Care of the Patient

with Brain Injury—Diagnoses

Ineffective airway clearance and impaired gas exchange

Ineffective cerebral perfusion

Deficient fluid volume

Imbalanced nutrition

Risk for injury

Risk for imbalanced body temperature

Risk for impaired skin integrity

Disturbed thought patterns

Disturbed sleep pattern

Interrupted family process

Deficient knowledge52

Collaborative Problems/Potential

Complications

• Decreased cerebral perfusion

• Cerebral edema and herniation

• Impaired oxygenation and ventilation

• Impaired fluid, electrolyte, and nutritional

balance

• Risk of posttraumatic seizures

53

Nursing Process: The Care of the Patient with

Brain Injury—Planning

Major goals may include

Maintenance of patent airway,

Adequate cerebral perfusion pressure (CPP),

Fluid and electrolyte balance,

Adequate nutritional status,

Prevention of secondary injury,

Maintenance of normal temperature,

Maintenance of skin integrity,

Improvement of cognitive function,

Prevention of sleep deprivation,

Effective family coping,

Increased knowledge about rehabilitation process, and

Absence of complications. 54

Interventions

• Ongoing assessment and monitoring is vital

• Maintenance of airway

–Positioning to facilitate drainage of oral secretions with

HOB usually elevated 30° to decrease venous

pressure

–Suctioning with caution

–Prevention of aspiration and respiratory insufficiency

–Monitor ABGs, ventilation, and mechanical ventilation

–Monitor for pulmonary complications, potential ARDS

55

Interventions

• I&O and daily weights

• Monitor blood and urine electrolytes

osmolality and blood glucose

• Measures to promote adequate nutrition

• Strategies to prevent injury–Assessment of oxygenation

–Assessment of bladder and urinary output

–Assessment for constriction due to dressings and casts

–Pad side-rails

–Mittens to prevent self-injury; avoid restraints

56

Interventions

• Strategies to prevent injury–Reduce environmental stimuli

–Adequate lighting to reduce visual hallucinations

–Measures to minimize disruption of sleep-wake cycles

–Skin care

–Measures to prevent infection

• Maintaining body temperature–Maintain appropriate environmental temperature

–Use of coverings—sheets, blankets to patient needs

–Administration of acetaminophen for fever

–Cooling blankets or cool baths; avoid shivering

57

Interventions

• Support of cognitive function

• Support of family–Provide and reinforce information

–Measures to promote effective coping

–Setting of realistic, well-defined, short-term goals

–Referral for counseling

–Support groups

• Patient and family teaching

58

Promotion of Effective Breathing and Airway

Clearance

• Monitor carefully to detect potential respiratory

failure

–Pulse oximetry and ABGs

–Lung sounds

• Early and vigorous pulmonary care to prevent

and remove secretions

• Suctioning with caution

• Breathing exercises

• Assisted coughing

• Humidification and hydration59

Improving Mobility

• Maintain proper body alignment

• Turn only if spine is stable and as indicated by

physician

• Monitor blood pressure with position changes

• PROM at least four times a day

• Use neck brace or collar, as prescribed, when

patient is mobilized

• Move gradually to erect position

60

DIET PLAN

Amino Acids

• Protein is used for the growth, repair and

maintenance of nearly every tissue in the

body and is composed of amino acids.

• Those with traumatic brain injuries

require 0.55 to 0.73 grams of protein per

pound of body weight

• Other Foods

A person living with a brain injury should

consume a rounded diet that is rich in fruits,

vegetables and whole grains.

Avoid saturated fat, hydrogenated fats and sodium

because they may increase your risk of suffering

a stroke.

CALORIE REQUIREMENTS

• The Glasgow Coma Scale is a tool used by

medical professionals to measure someone's

level of consciousness.

• Someone with a GCS of 4 to 5 needs 22.7 to

27.3 calories per pound of body weight per day.

• Someone with a GCS of 6 to 7 needs 18.2 to

22.7 calories.

• Those with less-severe injuries who have a GCS

of 8 to 12 require 13.6 to 16 calories.

Preventive Measures

Health Promotion

• Prevent car and motorcycle accidents

• To wear safety helmets

Cognitive Rehabilitation Therapy

Physical Therapy

Speech Therapy

Mental Rehabilitation

Physical Exercise

Occupational Therapy

Rehabilitation

Rehabilitation

Ambulatory and Home Care

• Nutrition

• Bowel and bladder management

• Spasticity

• Dysphagia

• Seizure disorders

• Family participation and education