Head Injury

• A serious form of head injury is traumatic brain injury (TBI)

TRAUMATIC BRAIN INJURY (TBI) is an insult to the brain, possibly
leading to permanent or temporary impairment of cognitive, physical, and
psychosocial functions, with an altered state of consciousness.
Incidence
Groups at highest risk for traumatic brain injury
 Age between 15 to 24 years
 Males two to three times higher than in females
 Elderly (over 75)
Causes
o Motor vehicle accidents
o Firearm-related injuries
o Falls, Assaults
o Sports-related injuries
o Recreational injuries
o War related injuries
 Alcohol & drug abuse.
 Personal violence & assaults.
 Most are males younger than 30 years of age.
 Peak occurrence is during night, evening & weekends.
 Driving without seat belts.
Head Injury-Pathophysiology
All neurologic damage does not occur at the moment of impact-it is a process
Primary injury
 The primary injury is defined as the immediate cellular injury that
result from the initial trauma. Primary head injuries include the following
 Scalp lacerations
 Skull fractures
 Contusions
  Concussions
 Penetrating injuries
 Hematomas
Secondary injury
 Progressive Damage to cells that evolves over the minutes, hours, and
days following the primary injury.
 Secondary injuries include the following
➢ Cerebral edema
➢ Hypoxia
➢ Hypotension
➢ Seizure etc.
Sudden impact force to the head or inertial force with in the skull (skull is
rigid and not allow any expansion)

Disruption of blood vessels and rapid brain tissue displacement

Bleeding or swelling with in the skull increases the volume of contents

with in a fixed size

Increase ICP

Downward or lateral displacement of the brain through or against the

rigid structures of the skull

Restriction of blood flow to the brain

Cell in the brain become anoxic

Ischemia and infarction

 Irreversible brain damage

Brain death
Mechanisms of injury
 ACCELERATION - Acceleration injury is the term used to describe a
moving object hitting a stationary head. An example of this type of injury
is a patient who is hit in the head with a baseball bat.
 DECELERATION - A deceleration injury occurs when the head is in
motion and strikes a stationary surface. This type of injury is seen in
patients who trip and fall, hitting their head on furniture or the floor.
 Acceleration–deceleration injuries – A combination of acceleration-
deceleration injury occurs when the stationary head is hit by a mobile
object and the head then strikes a stationary surface.
 A soccer player who sustains a blow to the head and then hits the ground
with his head can sustain an acceleration-deceleration injury.
 Rotational – distort the brain and can cause tension, stretching and
diffuse shearing of brain tissues
Types of head injury
Based on
 severity,
 mechanism of injury,
 area involved force imposed
 brain injury.
CLASSIFICATION
[Link] TO SEVERITY
MILD - GCS13-15
➢ post traumatic amnesia < hour, Loss of consciousness < 30 minutes
MODERATE - GCS 9-12
➢ post traumatic amnesia > 1 hour, Loss of consciousness 30 minutes – 24
hours.
SEVERE - GCS 3-8
➢ post traumatic amnesia > 1 day, Loss of consciousness >24 hours
[Link] TO MECHANISM OF INJURY
➢ BLUNT TRAUMA : These are injuries in which the skin remains intact
and there is no penetration of the dura by a foreign object.
➢ occurs when the head strikes an immobile object.
 PENETRATING TRAUMA : injuries include those made by foreign
bodies (e.g ,knives or bullets ) or those made by bone fragments
from a skull fracture.
COUP & COUNTRE COUP
Damage from coup-contrecoup injury occurs when the brain moves inside
the skull due to high-energy or high-impact injury mechanisms .
 Coup
◦ Injury at site of impact
 Contrecoup
◦ Injury on opposite side from impact
[Link] TO AREA INVOLVED
 Abrasion: The top layer of the scalp is scraped away, this is a minor
injury that may cause slight bleeding. The area is cleaned and possibly
dressed, and no other treatment is required.
➢ LACERATIONS : minor type of head trauma. Scalp is highly
vascular with poor constrictive abilities → profuse bleeding
➢ Major complication is infection and blood loss
❖ Contusion
The scalp is bruised with possible effusion of blood into the
subcutaneous layer without a break in the integrity of the skin.
A scalp contusion may benefit from the application of ice initially to
prevent hematoma formation.
X- ray may be ordered to rule out a skull fracture,
❖ Subgaleal hematoma
Hematoma in the subgaleal layer of the scalp.
It will usually absorb on its own.
SKULL FRACTURE:
➢ are often caused by a force sufficient to fracture the skull & cause
brain injury.
1. LINEAR SKULL FRACTURE: fracture appear as thin lines radio
graphically & do not require treatment. They are important only if
there is significant underlying brain damage.
[Link] SKULL FRACTURE: occur in bones over base
of the frontal & temporal lobes. These are not observable on plain
radiographs but may be manifested as ecchymosis around the eyes
or behind the ears.
3. DEPRESSED SKULL FRACTURE : occurs when the bones of the skull
are forcefully displaced downward. It may be palpated & are seen radio
graphically.
 4. simple fracture – where the skull fractures without damaging the skin
  [Link] fracture – occurs from multiple linear fractures with a
depression at the site of impact.
 6. Compound fracture – also known as open fracture, it occurs when the
skin is broken and the bone emerges
BRAIN INJURIES
▪ Direct injuries
▪ Indirect injuries
▪ OPEN INJURIES : are those that penetrate the skull.
▪ CLOSED INJURIES: are from blunt trauma & bruised areas in brain
tissue.
Diffuse (generalized) injury
 In a diffuse injury (concussion, diffuse axonal injury), damage to the
brain cannot be localized to one particular area.
Focal (localized) injury
 In a focal injury (contusion, hematoma), damage can be localized to a
specific area of the brain.
➢ CONCUSSIONS: A concussion is head trauma that may result in loss
of consciousness for 5 minutes or less & retrograde amnesia. There
is no break in the skull or dura & no visible damage on a CT or
MRI scan .
DIFFUSED AXONAL INJURIES: is the most severe form of head injury.
The injury involves the tissue of the entire brain & occurs at the
microscopic level.
MILD - loss of consciousness lasting 6 to 24 hours.
MODERATE - coma lasting less than 24 hours is the predominant clinical
feature, with incomplete recovery on awakening.
SEVERE - involves primary injury to the brain stem. The patient may
present with abnormal posturing & in coma, but there is no evidence of
cerebral edema or increased ICP
 CONTUSIONS: A contusion is a bruise (bleeding) on the brain. A
contusion can be the result from a direct impact to the head. It is
 characterized by the extravasation of blood into the brain. Contusion may
occur on the site of impact or on the opposite side
Shaken Baby Syndrome
Shaken Baby Syndrome is a violent criminal act that causes traumatic brain
injury. Shaken Baby Syndrome occurs when the perpetrator aggressively
shakes a baby or young child. The forceful motion causes the brain to be
injured.
 Blood vessels between the brain and skull rupture and bleed.
 The accumulation of blood causes the brain tissue to compress while the
injury causes the brain to swell. This damages the brain cells.
Signs & Symptoms
of Brain Injury
 Cushing’s Reflex
◦ Widened pulse pressure
◦ Bradycardia
◦ Irregular respirations
 Frontal fracture – CSF rhinorrhea
 Orbital fracture – periorbital ecchymosis
 Temporal fracture – CSF otorrhea
 Parietal fracture – deafness, CSF otorrhea, facial paralysis, loss of taste,
battles sign
 Posterior fossa fracture – cortical blindness and visual field defects
 Basal Skull Fracture Signs
◦ Battle’s Signs
 Retroauricular Ecchymosis
 Associated with fracture of
auditory canal and lower
areas of skull

◦
 ◦ Raccoon Eyes
 Bilateral Periorbital
Ecchymosis
 Associated with orbital
fractures
Battle’s sign
Raccoon eyes
 Unconsciousness
 Confusion and disorientation
 Headache
 Dizziness
 Blurry vision
 Ringing in the ears- tinnitus
 Trouble speaking
 Changes in emotions or sleep patterns
 Reduce mental status or Amnesia
 Retrograde
 Unable to recall events before injury
 Antegrade
 Unable to recall events after trauma
 “Repetitive Questioning”
◦ Altered orientation
◦ Alteration in personality
Hemiplegia, Weakness or Seizures
Cushing ulcer
 It is a gastric ulcer produced by elevated intracranial pressure
  In increased ICP vagal stimulation occurs which leads to increased
secretion of gastric acid
Diagnostic Studies
Methods to test CSF leakage
 Test tape or dextrostix (same as suger test)
Glucose is present in CSF . CSF gives a +ve reading for glucose. But if the
blood is present, it gives a unreliable
Halo or ring sign
Collect the fluid into a white pad. With In a few minutes the blood collects into
the center and encircles the blood if CSF present

 CT scan considered the best diagnostic test to determine cranio cerebral

trauma
 MRI
 Cervical spine x-ray
 Glasgow Coma Scale (GCS)
 Routine laboratory test (hemoglobin electrolytes, coagulation studies etc)
 Management
 Emergency management
Initial
 Ensure patent airway & Stabilize cervical spine.
 Administer O2 via non-rebreather mask.
 Establish IV access with two large-bore catheters to infuse normal saline
or lactated Ringer’s solution.
 Intubate if GCS score <8.
 Control external bleeding with sterile pressure dressing.
 Remove patient’s clothing.
Ongoing Monitoring
 Maintain patient warmth using blankets, warm IV fluids, overhead
warming lights, warm humidified O2.
 Monitor vital signs, level of consciousness, O2 saturation, cardiac
rhythm, GCS score, pupil size and reactivity.
 Anticipate need for intubation if gag reflex is impaired or absent.
 Assume neck injury with head injury.
 Assess for rhinorrhea, otorrhea, scalp wounds.
 Administer fluids cautiously to prevent fluid overload and increasing ICP.
 Management
Medical management
 Medications depends on the nature and severity of the injury
 Medications include drugs to reduce ICP, prevent seizures, and analgesics
 Antibiotics are administered to any patient with a penetrating injury
 Analgesics to control pain
Management of increased ICP
 Osmotic diuretics
 Corticosteroids
 Fluid restrictions
 Inotropic agents
  Oxygen administration
 Control fever
 Reduce metabolic demands ( use of barbiturates )
 Surgical management
If hematoma formation is there surgical intervention should be done
 Craniotomy - A craniotomy is a surgical operation in which a bone flap
is temporarily removed from the skull to access the brain.
The bone flap is then replaced using titanium plates and screws or another
form of fixation (wire, suture)
 Decompressive Craniectomy
 It is a neurosurgical procedure in which part of the skull is removed to
allow a swelling brain room to expand without being squeezed
 The section of bone removed, known as a bone flap, can be stored in the
patient's abdomen or thigh and resited back to complete the skull.
 Alternatively a synthetic material may be used to replace the removed
bone section
Methods provided for preserving and restoring cranial bone flaps.
 In one aspect, the method to preserve a cranial bone flap includes
cleaning a cranial bone flap, washing the cranial bone flap with a sterile
saline solution including gentamycin, followed by washing the bone with
a sterile saline solution including vancomycin.
 The cranial bone flap may be dried, wrapped, and packaged before being
stored in a freezer.
 The fixing method may include removing the preserved cranial bone flap
from a freezer and unwrapping the preserved cranial bone flap from any
wrappings.
 The preserved cranial bone flap may be washed with a sterile saline
solution including gentamycin and a sterile saline solution including
vancomycin.
 Cranioplasty - Cranioplasty is a surgical repair of a defect or deformity
of a skull.
  Burr-hole or trepanning - is a surgical intervention in which a hole
is drilled or scraped into the human skull, exposing the dura mater to
treat health problems related to intracranial diseases
 Burr holes are used to help relieve pressure on the brain when fluid, such
as blood, builds up and starts to compress brain tissue.
Nursing assessment
◦ Overall goals:
 Maintain adequate cerebral perfusion
 Remain normothermic
 Be free from pain, discomfort, and infection
 Attain maximal cognitive, motor, and sensory function

Care of Skull Fractures

 Monitor vitals
 Assess for slowing of pulse, increased systolic pressure.
 Respirations become rapid and blood pressure may decrease
 Monitor for rapid rise in temperature
 Keep temperature below 38 degree to avoid metabolic demands
 Tachycardia and hypotension are indicators of bleeding
 Assessing motor function
 Observe spontaneous movements
 Ask patient to raise and lower extremities
 Compare strength of hand grasp
 Assess responses to painful stimuli
 Determine ability to speak and quality of speech
Health Promotion
▪ Obey traffic rules
▪ Avoid driving when under the influence of alcohol or drug
 Wear helmets & seat belts
 Water safety instructions
 Prevent fall in elderly
 Protective devices for athlets
 Safe custody of firearms
NURSING DIAGNOSIS
 Ineffective cerebral tissue perfusion r/t increased icp.
 Ineffective breathing pattern r/t respiratory centre compression.
 Inefective airway clearance r/t presence of secretion.
 Risk for seizures r/t injury to brain tissue.
 Risk for imbalanced body temperature
R/t damage to temperature control centre.
 Risk for fluid volume deficit r/t use of diuretics.
 Pain r/t injuries.
 Imbalanced nutrition less than body requirement r/t inability to take food.
 Impaired skin integrity r/t injuries.
 Impaired physical mobility r/t brain injury.
 Self care deficit r/t altered level of consciousness.
Monitor for complications
 Cerebral edema
 Brain herniation
 Decreased cerebral perfusion
 Intra cranial Hemorrhage and hematoma formations
 Meningitis, wound infection
 Anosmia (nerve palsies) – lack of sense of smell
 Eye movement abnormalities
 Aphasia – language disorder
  Memory defects, post traumatic seizures
Complications
Epidural hematoma or extra dural hematoma
• It results from bleeding between the dura and the inner surface of the
skull. It is a neurologic emergency
• It is usually associated with a linear fracture crossing a major artery or
vein in the dura, causing a tear.
• In arterial hemorrhage, the hematoma develops rapidly
• Classic signs include initial period of unconsciousness at the scene, with a
brief interval followed by a decrease in LOC.
• Other manifestations - headache, nausea and vomiting.

Subdural hematoma
◦ Occurs from bleeding between the dura mater and arachnoid layer
of the meningeal covering of the brain
A subdural hematoma usually results from injury to the brain tissue and its
blood vessels.
Subdural hematomas may be acute, subacute, or chronic
Acute subdural hematoma
High mortality
It manifests within 24 to 48 hours of the injury. The size of the hematoma
determines the patient’s clinical presentation and prognosis
Signs within 48 hours of the injury
 Patient appears drowsy and confused with headache
 Decreasing LOC
 The ipsilateral pupil dilates and becomes fixed if ICP is
significantly elevated.
 Treatment – craniotomy and evacuation

Subacute subdural hematoma

It usually occurs within 2 to 14 days of the injury. After the initial
bleeding, a subdural hematoma may appear to enlarge over time as the
breakdown products of the blood draw fluid into the subdural space.
 Chronic subdural hematoma
It develops over weeks or months after a minor head injury. These are
more common in older adults because of a potentially larger subdural space as a
result of brain atrophy.
Chronic alcoholics are also prone to cerebral atrophy and subsequent
development of subdural hematoma because of an increased incidence of falls.
Intra cerebral hematoma
 Bleeding with in the parenchyma leads to intra cerebral hematoma
(bleeding into the substance of the brain).
 Because of rupture of intracerebral vessels at the time of injury.
 Symptoms are related to the specific area of the brain where clot forms
Signs and symptoms
 Headache
 Deteriorating consciousness progressing to deep coma
 Hemiplegia on the contralateral side
 Dilated pupil on the side of the clot
 As ICP increases, there is evidence of developing tentorial herniation
with accompanying changes in pupils, respirations, and other vital signs.