Head Injuries

HEAD INJURIES INCIDENCE • • • • •

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100,000 Deaths a year Can result from: Industry, MVC, Military accidents #1 cause of death from ages 0-35 Babies – shaken baby syndrome 70% of MVC will result in some type of head injury 2nd highest incident in the elderly population: Fall or jeark of head 2/3 are < 30 years old

ETIOLOGY • •

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Results form penetration or impact of the cranial vault Damage caused by: o Direct injury o Secondary to compression, tension or shearing forces  Due to movement of brain in vault Results in injury to the scalp, skull and/or brain tissue –  ICP DO NOT move client until spinal cord traumas is ruled out

PATHOPHYSIOLOGY •

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Results from penetration or impact Damage can be caused either by the direct injury itself or secondary to compression, tension, or shearing forces o Note: Brain tissue does not rebuild itself; once it is dead it is gone Specific patho of each injury depends on o Type of injury o Resulting damage Remember head injury and spinal cord injury often occur together o Risk for spinal cord injury before being moved o ER do not move until cervical x-rays

CLASSIFICATION OF HEAD INJURIES •

Open Head Injury Break or penetration of dura, exposing the cranial vault to the environment In order to have an Open Head Injury you must have a Skull Fracture o  risk for infection,  risk for edema o Results from: Bullets, knives, bone fragments, or direct blows to the head o o

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Closed Head Injury – BLUNT TRAUMA o Dura intact; caused by rapidly moving blunt object “blunt trauma”; ex: baseball bat, MVC. o The worst type of injury because of risk for  ICP   

Coup • Injury occurs at the point of impact Countercoup • Injury occurs opposite point of impact (if injured on rt side will have rt sided weakness) Acceleration – Deceleration

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Caused by MV accidents Head moving back and forth several times

TYPES OF HEAD INJURIES •

SCALP INJURIES o Result in profuse bleeding because scalp is very vascular and bleeds profusely. o Abrasion (scrape), Contusion (bruising), Laceration (cut), Avulsion (torn off part of scalp)  Clean area shave only with ok by MD  Irrigate with NS to clean glass, dirt, etc.  Subgleal hematoma – knot on head

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SKULL FRACTURES o Linear  Simple break in continuity of bone  Straight line break  70% of skull fx • Treatment: Neurological checks, NO treatment o Comminuted  Fragmentation bone broken into several pieces  Surgery R/F brain injury o Depressed  Cracked skull with inward depression of bone fragment • Simple o Dura with scalp intact; not penetrated dura • Compound o Scalp injury;scalp is open; dura with open wound. Dura may or may not be torn o At risk for  ICP o Basal Skull Fracture  Hard to see on X-Ray  Occurs at base of the skull • Most protected – protects the brain stem CLASSIC SIGNS  Battle’s Sign – Bruising behind mastoid and raccoon eyes  Rhinorrhea – CSF – Leak – will have glucose  Otorrhea – CSF – Leak • Glucose test determines post crainy leaking • Halo Test  Compensating for  ICP 

Increased Risk for Infection

NURSING IMPLICATIONS OF SKULL FRACTURES • • • • •

Observe for ICP and S/S of infection – Notify MD Don’t administer respiratory depressants – sedatives, barbiturates, or morphine Observe patient closely for first 24 hours Start IV if necessary but limit fluids to 1500-2000cc daily as ordered per MD Maintain accurate I&O records

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Frequent Neuro and VS checks – at least Q2o Cleanse and assist with suturing scalp lacerations of present

INJURIES TO THE BRAIN •

Concussion o Least serious o Temporary loss of neuro function with no structural brain damage o Brief loss of consciousness but will recover and do ok o TX: Monitor for changes in LOC o Discharge Teaching: Head Injury Instruction Sheet o Note: You don’t have to wake the patient just turn light on or touch  Bring back to ER if: • You can’t arouse them • Sudden vomiting – Projectile • Severe Nausea • Headache Typically get worse and worse • Weakness on one side of the body • Confusion • Vision Changes

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Contusions and Lacerations o Bruising or part of the brain – Bleeding – not good o Laceration is a cut – Profuse bleeding o Loss of consciousness, Days, weeks, months, years o If they survive the injury the blood will absorb itself with no residual brain damage they should be OK. o If the bleeding is bad enough they may die from ICP or have residual brain damage o The longer a person stays unconscious the more severe the injury

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Difuse Axonal Injury o Axons have been destroyed

TRAUMATIC INTRACRANIAL HEMORRHAGE o EPIDURAL HEMATOMA  Bleeding between the skull and dura matter. The most life-threatening of intracranial hemorrhages as the bleeding is usually arterial. Usually results from tear in wall of middle meningeal artery.  50% mortality Rate  Have to have surgery SIGNS AND SYMPTOMS OF EPIDURAL HEMATOMA  Loss of consciousness, followed by a few hours of lucidity, then coma  Hemiplegia on opposite side from hematoma  Pupillary changes

o SUBDURAL HEMATOMA  Collection of blood between dura matter and arachnoid membrane. Usually venous in origin.  Most common type of hematoma  Can be chronic (gradual bleed over days to months) or acute (faster bleed of 24-72 hrs) SIGNS AND SYMPTOMS OF EPIDURAL HEMATOMA  Acute – presents as epidural  Subacute - >48o • 2 weeks S/S similar to acute  Headache  Altered LOC  Hemiplegia on opposite side from hematoma  Irritability • Mental confusion  Unequal pupils  Convulsions  Positive babinski response o INTRACEREBRAL HEMATOMA  Hematoma is not confined by meninges, therefore bleeding can be widely dispersed.  Causes more direct damage  Difficult to evacuate surgically • Too widespread SIGNS AND SYMPTOMS OF INTRACEREBRAL HEMATOMA  Headache  Drowsiness  Signs of ICP  Hemiplegia on opposite side from bleeding  Dizziness  Vomiting

DIAGNOSIS • • •

Skull Films CAT Scan MRI

MEDICAL MANAGEMENT • •

Surgical evacuation of heamtomas when possible Neurosurgical procedures for open head injuries

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Control of  ICP – osmotic diuretics, steroids(not 1st line with head trauma), ventricular drainage, hyperventilation, etc.

NURSING MANAGEMENT • •

Immediate Care – Baseline Assessment o Find cause; loss of LOC, how long o 1st ABC’s, LOC, Cause Post acute Phase o Maintenance of airway o Prevention of aspiration  Suctioning, never place unconscious pt on back; place on side o Cardiovascular complications  Hypovolemic shock with multi system injury, not from head trauma o Cerebrospinal fluid fistulas  Communicate between brain, environment  CSF; sniffing, swallowing; do not suction; antibiotics o Prevent straining   ICP o Maintenance of proper body temperature   fever =  ICP o Frequent assessments  Need rest (nursing care IICP); 24-48o frequent assessments o Nutrition  IV, NG or oral  Monitor I&O o Restlessness – Disorientation  1st :check airway, assess pain, 2nd: distended bladder 3rd : Waking up o Seizures  Occur years after trauma – Post traumatic epilepsy o Stress ulcers  Antacids o Promotion of rest  Must assess o Rehabilitation techniques  ROM, Prevent disuse syndrome o Eye care  Corneal reflexes absent o Psychological  Family and patient support