Head injury

Head InjuryHead Injury

Zafar Iqbal

Sr. Lecturer

Jinnah College Of Nursing Karachi

Head InjuryHead Injury

• Any trauma to the scalp, skull, or brain

• Head trauma includes an alteration in consciousness no matter how brief

• Any trauma to the scalp, skull, or brain

• Head trauma includes an alteration in consciousness no matter how brief

Head InjuryHead Injury

• Causes

– Motor vehicle accidents

– Firearm-related injuries

– Falls

– Assaults

– Sports-related injuries

– Recreational accidents

• Causes

– Motor vehicle accidents

– Firearm-related injuries

– Falls

– Assaults

– Sports-related injuries

– Recreational accidents

Road Traffic CrashesRoad Traffic Crashes

A&E(VMH)

Sports injuries

A&E(VMH)

Assaults(Sickle injuries)

Assaults(Sickle injuries)

MECHANISMMECHANISM

• BLUNT INJURY

High Velocity

Low Velocity

• PENETRATING INJURY

Gunshot

Sharp instruments

• BLUNT INJURY

High Velocity

Low Velocity

• PENETRATING INJURY

Gunshot

Sharp instruments

Head InjuryHead 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

• 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

Classification

• By Nature of insult; penetrating or blunt.

• Concomitant injuries; isolated head injury or multiple trauma.

• Timing of the injury; Primary or Secondary.

Classification

• Primary injury is that occurring at the scene and is usually outside the control of the intensivist.

• Secondary injury is anything that occurs to augment the primary injury; the prevention of this is predominantly where intensive therapy is aimed.

Types of Head InjuriesTypes of Head Injuries

• Scalp lacerations– The most minor type of

head trauma

– Scalp is highly vascular profuse bleeding

– Major complication is infection

• Scalp lacerations– The most minor type of

head trauma

– Scalp is highly vascular profuse bleeding

– Major complication is infection

Cephal Hematoma

Minor Head TraumaManifestation

Minor Head TraumaManifestation

– Concussion• A sudden transient mechanical head injury

with disruption of neural activity and a change in LOC

• Brief disruption in LOC• Amnesia• Headache• Short duration

– Concussion• A sudden transient mechanical head injury

with disruption of neural activity and a change in LOC

• Brief disruption in LOC• Amnesia• Headache• Short duration

Minor Head TraumaManifestation

Minor Head TraumaManifestation

– Postconcussion syndrome

• 2 weeks to 2 months

• Persistent headache

• Lethargy

• Personality and behavior changes

– Postconcussion syndrome

• 2 weeks to 2 months

• Persistent headache

• Lethargy

• Personality and behavior changes

Types of Head InjuriesTypes of Head Injuries

• Skull fractures

– Linear or depressed

– Simple, comminuted, or compound

– Closed or open

– Direct & Indirect

• Skull fractures

– Linear or depressed

– Simple, comminuted, or compound

– Closed or open

– Direct & Indirect

Types of Head InjuriesTypes of Head Injuries

• Skull fractures

– Location of fracture alters the presentation of the manifestations

– Facial paralysis

– Deviation of gaze

– Battle’s sign

• Skull fractures

– Location of fracture alters the presentation of the manifestations

– Facial paralysis

– Deviation of gaze

– Battle’s sign

Types of Head InjuriesTypes of Head Injuries

• Basal Skull fractures– CSF leak (extravasation) into ear (Otorrhea) or

nose (Rhinorrhea)– High risk infection or meningitis– “HALO Sign (Battle Sign)” – Possible injury to Internal carotid artery– Permanent CSF leaks possible

• Basal Skull fractures– CSF leak (extravasation) into ear (Otorrhea) or

nose (Rhinorrhea)– High risk infection or meningitis– “HALO Sign (Battle Sign)” – Possible injury to Internal carotid artery– Permanent CSF leaks possible

Basilar : Basilar : with/with out CSF leak with/with out seventh-nerve palsy

Battle sign Raccoon eyes CSF rhinorrhea

INTRACRANIAL LESIONS

• Focal Focal : epidural hematoma

subdural hematoma

intracerebral hematoma

INTRACRANIAL LESIONS

Epidural Hematoma -between the skull and the dura

Subdural Hematoma -between the brain and the dura)

Intracerebral -in the brain

Manifestation of Major Head Trauma

Manifestation of Major Head Trauma

– Includes cerebral contusions and lacerations

– Both injuries represent severe trauma to the brain

– Includes cerebral contusions and lacerations

– Both injuries represent severe trauma to the brain

Manifestation of Major Head Trauma

Manifestation of Major Head Trauma

– Contusion (“brain bruises” )• bruising’ within the brain with relatively

localised cellular damage, haemorrhage and oedema or The bruising of brain tissue within a focal area that maintains the integrity of the pia mater and arachnoid layers

– Lacerations• Involve actual tearing of the brain tissue• Intracerebral hemorrhage is generally

associated with cerebral laceration

– Contusion (“brain bruises” )• bruising’ within the brain with relatively

localised cellular damage, haemorrhage and oedema or The bruising of brain tissue within a focal area that maintains the integrity of the pia mater and arachnoid layers

– Lacerations• Involve actual tearing of the brain tissue• Intracerebral hemorrhage is generally

associated with cerebral laceration

PathophysiologyPathophysiology

• Diffuse axonal injury (DAI)

– Widespread axonal damage occurring after a mild, moderate, or severe TBI

– Process takes approximately 12-24 hours

• Diffuse axonal injury (DAI)

– Widespread axonal damage occurring after a mild, moderate, or severe TBI

– Process takes approximately 12-24 hours

PathophysiologyPathophysiology

• Diffuse axonal injury (DAI)

– Clinical signs: LOC ICP

• Decerebration or decortication

• Global cerebral edema

• Diffuse axonal injury (DAI)

– Clinical signs: LOC ICP

• Decerebration or decortication

• Global cerebral edema

Approach to a Patient With Head

Injury• History

• Initial Assessment

Primary Survey

Secondary Survey

Diagnostic Studies and Collaborative Care

Diagnostic Studies and Collaborative Care

• CT scan considered the best diagnostic test to determine craniocerebral trauma

• MRI• Cervical spine x-ray• Glasgow Coma Scale (GCS)

• CT scan considered the best diagnostic test to determine craniocerebral trauma

• MRI• Cervical spine x-ray• Glasgow Coma Scale (GCS)

Management of Traumatic Head Injury

• Maximize oxygenation and ventilation

• Support circulation / maximize cerebral perfusion

pressure

• Decrease intracranial pressure

• Decrease cerebral metabolic rate

Nursing Management Nursing Assessment

Nursing Management Nursing Assessment

– GCS score

– Neurologic status (GCS)

– Presence of CSF leak

– GCS score

– Neurologic status (GCS)

– Presence of CSF leak

Nursing Management Nursing Diagnoses

Nursing Management Nursing Diagnoses

– Ineffective tissue perfusion

– Hyperthermia

– Acute pain

– Anxiety

– Impaired physical mobility

– Ineffective tissue perfusion

– Hyperthermia

– Acute pain

– Anxiety

– Impaired physical mobility

Nursing Management Planning

Nursing Management Planning

– Overall goals:• Maintain adequate cerebral perfusion• Remain normothermic• Be free from pain, discomfort, and

infection• Attain maximal cognitive, motor, and

sensory function

– Overall goals:• Maintain adequate cerebral perfusion• Remain normothermic• Be free from pain, discomfort, and

infection• Attain maximal cognitive, motor, and

sensory function

Nursing Management PRIMARY SURVEY

Airway maintenance with cervical spine protection

Nursing Management Intubation with Cervical inline stabilization• Breathing and ventilation : Intubation precautions

Pre-medicate with Lidocaine, 1mg/kg IV 2 minutes prior to attemptICP Spike

• Laryngoscopy produces an

Nursing Management Circulation

• Maintain MAP >90mmhg- adequate

• Hematocrit >30%

• Cushing reflex

Conti…..

• Isolated intracranial injuries do not cause hypotension

• LOOK FOR THE CAUSE OF HYPOTENSION

Diuretic Therapy

Osmotic Diuretic

• Mannitol (0.25-1 gm / kg) • Increases serum osmolarity• Vasoconstriction

(adenosine) / less effect if autoregulation is impaired and if CPP is < 70

• Initial increase in blood volume, BP and ICP followed by decrease

• Questionable mechanism of lowering ICP

Loop Diuretic

• Furosemide• Decreased CSF formation• Decreased systemic and

cerebral blood volume (impairs sodium and water movement across blood brain barrier)

• May have best affect in conjunction with mannitol

Decreasing Intracranial PressureDecreasing Intracranial Pressure

Nursing Management of Skull Fractures

Nursing Management of Skull Fractures

• Minimize CSF leak– Bed flat– Never suction orally; never insert NG tube; never use Q-Tips

in nose/ears; caution patient not to blow nose

• Place sterile gauze/cotton ball around area

• Verify CSK leak: – DEXTROSTIX: positive for glucose

• Monitor closely: Respiratory status+++

• Minimize CSF leak– Bed flat– Never suction orally; never insert NG tube; never use Q-Tips

in nose/ears; caution patient not to blow nose

• Place sterile gauze/cotton ball around area

• Verify CSK leak: – DEXTROSTIX: positive for glucose

• Monitor closely: Respiratory status+++

Nursing Management Nursing implementationNursing Management

Nursing implementation

Health Promotion

• Prevent car and motorcycle accidents

• Wear safety helmets

Health Promotion

• Prevent car and motorcycle accidents

• Wear safety helmets

Nursing Management Nursing implementation

Nursing Management Nursing implementation

Acute Intervention

• Maintain cerebral perfusion and prevent secondary cerebral ischemia

• Monitor for changes in neurologic status

Acute Intervention

• Maintain cerebral perfusion and prevent secondary cerebral ischemia

• Monitor for changes in neurologic status

Nursing Management Nursing implementation

Nursing Management Nursing implementation

Ambulatory and Home Care

• Nutrition

• Bowel and bladder management

• Spasticity

• Dysphagia

• Seizure disorders

• Family participation and education

Ambulatory and Home Care

• Nutrition

• Bowel and bladder management

• Spasticity

• Dysphagia

• Seizure disorders

• Family participation and education

Nursing ManagementEvaluation

Nursing ManagementEvaluation

Expected Outcomes

• Maintain normal cerebral perfusion pressure

• Achieve maximal cognitive, motor, and sensory function

• Experience no infection, hyperthermia, or pain

Expected Outcomes

• Maintain normal cerebral perfusion pressure

• Achieve maximal cognitive, motor, and sensory function

• Experience no infection, hyperthermia, or pain

A&E(VMH)

Summary of Recommended Practices

• Decrease intracranial pressure – Evacuate mass occupying hemorrhages – Consider draining CSF with ventriculostomy when possible– Hyperosmolar therapy, +/- diuresis (cautious use to avoid

hypovolemia and decreased BP)– Mid-line neck, elevated head of bead (some research supports

elevation not > 30 degrees)– Treat pain and agitation - consider pre-medication for nursing

activities, +/- neuromuscular blockade (only when needed)– Careful monitoring of ICP during nursing care, cluster nursing

activities and limit handling when possible– Suction only as needed, limit passes, pre-oxygenate / +/- pre-

hyperventilate (PaCo2 not < 30) / use lidocaine IV or IT when possible

– After careful preparation of visitors, allow calm contact

ComplicationsComplications

• Epidural hematoma

– Results from bleeding between the dura and the inner surface of the skull

– A neurologic emergency

– Venous or arterial origin

• Epidural hematoma

– Results from bleeding between the dura and the inner surface of the skull

– A neurologic emergency

– Venous or arterial origin

ComplicationsComplications

• Subdural hematoma

– Occurs from bleeding between the dura mater and arachnoid layer of the meningeal covering of the brain

• Subdural hematoma

– Occurs from bleeding between the dura mater and arachnoid layer of the meningeal covering of the brain

ComplicationsComplications

• Subdural hematoma

– Usually venous in origin

– Much slower to develop into a mass large enough to produce symptoms

– May be caused by an arterial hemorrhage

• Subdural hematoma

– Usually venous in origin

– Much slower to develop into a mass large enough to produce symptoms

– May be caused by an arterial hemorrhage

ComplicationsComplications

• Subdural hematoma– Acute subdural hematoma

• High mortality• Signs within 48 hours of the injury• Associated with major trauma (Shearing

Forces)• Patient appears drowsy and confused• Pupils dilate and become fixed

• Subdural hematoma– Acute subdural hematoma

• High mortality• Signs within 48 hours of the injury• Associated with major trauma (Shearing

Forces)• Patient appears drowsy and confused• Pupils dilate and become fixed

ComplicationsComplications

• Subdural hematoma

– Subacute subdural hematoma

• Occurs within 2-14 days of the injury

• Failure to regain consciousness may be an indicator

• Subdural hematoma

– Subacute subdural hematoma

• Occurs within 2-14 days of the injury

• Failure to regain consciousness may be an indicator

ComplicationsComplications

• Subdural hematoma

– Chronic subdural hematoma

• Develops over weeks or months after a seemingly minor head injury

• Subdural hematoma

– Chronic subdural hematoma

• Develops over weeks or months after a seemingly minor head injury

Surgical Management Surgical Management

• Craniotomy

• Craniectomy

• Cranioplasty

• Burr-hole

• Craniotomy

• Craniectomy

• Cranioplasty

• Burr-hole