1. Head Injury

2. Head Injury
Head injury is a broad classification that includes injury to the scalp, skull, or brain
Head trauma includes an alteration in consciousness no matter how brief

3. Death from head injury trauma occurs at three time points after injury
Immediately after injury – massive hemorrhage and shock
Within 2 hours after injury – internal bleeding
Approximately 3 weeks after injury – multisystem failure

4. Causes Motor vehicle accidents Firearm-related injuries Falls Assaults
Sports-related injuries

5. Pathophysiology
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

6. 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

7. Mechanisms of injury
Deformation – results from the direct or indirect transmission of energy to the skull
If the force is sufficient, the skull is deformed and fractured.
Acceleration – deceleration injuries – it occur when the accelerating skull, moving in a motor vehicle, suddenly decelerates when it hits an immobile object such as the steering wheel (coup – contracoup)

8. Rotational – distort the brain and can cause tension, stretching and diffuse shearing of brain tissues

9. Type of head injury
Based on location , force imposed, and the cause head injury is classified as total brain injury, cranial injury etc

10. Blunt Injury (closed injury)
Motor vehicle collisions
Assaults
Falls
Penetrating Injury (open)
Gunshot wounds
Stabbing
Explosions

11. Scalp lacerations
The most minor type of head trauma
Scalp is highly vascular with poor constrictive abilities  profuse bleeding
Major complication is infection

12. Craniocerebral trauma
Trauma must be extreme to fracture

13. Frontal fracture – CSF rhinorrhea
Orbital fracture – periorbital ecchymosis
Temporal fracturre – CSF otorrhea
Parietal fracture – deafness, CSF otorrhea, facial paralysis, loss of taste, battles sign
Posterior fossa fracture – cortical blindness and visual field defects
Basilar skull fracture – CSF otorrhea, battles sign, bulging of tympanic membrane, tinnitus, facial paralysis, vertigo

14. Simple, comminuted, or compound Closed or open
A skull fracture is a break in the continuity of skull caused by forceful trauma.
Linear or depressed
Simple, comminuted, or compound
Closed or open

15. Brain Injury Direct brain injury Immediate damage due to force
Indirect brain injury
Results from hypoxia or decreased perfusion
Response to primary injury
Develops over hours
Primary brain injury is immediate damage to brain tissue as direct result of injury force and is essentially fixed at time of injury.
Most primary injuries are from blunt trauma or from movement of brain inside skull.
In deceleration injuries, head strikes object such as windshield, causing sudden deceleration of skull. Brain continues to move forward, impacting first against skull in original direction of motion (“coup”) and then rebounding to hit (fourth collision) opposite side of inner surface of skull (“contracoup”).
Interior base of skull is rough, and movement of brain over this area may cause various degrees of injury to brain tissue or to blood vessels supporting brain.
Management of primary brain injury is best directed at prevention with such measures as better occupant restraint systems in autos, use of helmets in sports and cycling, firearms education, and so forth.
Head Trauma - 15 15

16. Direct Brain Injury Types
Coup
Injury at site of impact
Contrecoup
Injury on opposite side from impact
A coup injury occurs under the site of impact with an object, and a contrecoup injury occurs on the side opposite the area that was impacted.

18. Direct Brain Injury Categories
Focal
Occur at a specific location in brain
Contusion
Intracranial Hemorrhage
Epidural hematoma
Subdural hematoma
Intracerebral Hemorrhage
Diffuse – occurs at diffuse areas
Concussion
Diffuse Axonal Injury

19. Contusion 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

20. Concussion
it is characterized by an immediate and transient impairment of neurologic function induced by mechanical force.
An instant or delayed loss of consciousness may occur but patient usually recovers rapidly
A person who shows any alteration in consciousness after a blow to the head should closely observed

21. Post concussion syndrome
2 weeks to 2 months
Persistent headache
Lethargy, memory impairment
Personality and behavior changes

22. Process takes approximately 12-24 hours
Diffuse axonal injury (DAI)
Caused by rapid movement of the brain during which delicate axons are stretched and damaged.
This damage interferes with nervous transmission and can cause extensive diffuse deficits
Process takes approximately hours

23. Diffuse axonal injury (DAI)
Clinical signs:
LOC
 ICP
Changes of postures
cerebral edema

24. 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.
Shaken Baby Syndrome can cause seizures, lifelong disability, coma, and death.
Irritability, changes in eating patterns, tiredness, difficulty breathing, dilated pupils, seizures, and vomiting are signs of Shaken Baby Syndrome.

25. Levels of brain injury
Mild traumatic brain injury – less than 30 min. symptoms appear at the time of injury but many not develop for days or weeks
Moderate - causes unconsciousness lasting more than 30 minutes. Symptoms are longer lasting
Severe – more than 24 hours. Symptoms are similar to mild injury but more serious and longer lasting.

26. Signs & Symptoms of Brain Injury
Cushing’s Reflex
Increased BP
Bradycardia
Erratic respirations
Vomiting
Without nausea
Projectile
Body temperature changes
Changes in pupil reactivity
Abnormal posturing

27. Unconsciousness
Confusion and disorientation
Headache
Dizziness
Blurry vision
Ringing in the ears- tinnitus
Trouble speaking
Changes in emotions or sleep patterns

28. 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

29. Cushing ulcer 
It is a gastric ulcer produced by elevated intracranial pressure. It is also called von Rokitansky-Cushing syndrome. Apart from in the stomach, it may also develop in the proximal part of the duodenum and the distal esophagus.
In increased ICP vagal stimulation occures which leads to increased secretion of gastirc acid

30. 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

31. Battle’s sign Raccoon eyes
Basilar skull fracture indicated by any of following:
Bleeding from ear or nose
Clear or serosanguineous fluid running from nose or ear
Swelling and/or discoloration behind ear (Battle’s sign)
Swelling and discoloration around both eyes (raccoon eyes)
Battle’s sign can occur from immediately following injury to within 1–2 hours postinjury.
Raccoon eyes are a sign of anterior basilar skull fracture.
Through thin cribriform plate in upper nasal cavity and allow spinal fluid and/or blood to leak out.
Raccoon eyes with or without drainage from nose are an absolute contraindication to inserting a nasogastric tube or nasotracheal intubation.
Head Trauma - 31 31

32. CSF leak (extravasation) into ear (Otorrhea) or nose (Rhinorrhea)
“HALO Sign – a blood stain surrounded by a yellowish stain
High risk infection or meningitis

33. Diagnostic Studies Methods to test CSF leakage
Tes 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

34. 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

35. CT scan considered the best diagnostic test to determine craniocerebral trauma
MRI
Cervical spine x-ray
Glasgow Coma Scale (GCS)
Routine laboratory test (hemoglobin electrolytes, coagulation studies etc)

36. 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

37. Nursing Care of Skull Fractures
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

38. Immediate management
Intubation to protect the airway, undergo surgery to treat internal injuries or immobilization to prevent further injures
Ventilatory support

39. 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 – is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed

40. 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

43. Nursing management Emergency management In initial stage
Ensure patent airway
Stabilize cervical spine
Administer oxygen via nasal cannula or mask
Establish IV access with two large bore catheters to infuse NS
Control external bleeding with sterile pressure dressing
Assess for rhinorrhea, scalp wounds
Remove patients clothing's

44. Nursing assessment
The patient with head injury is always considered to have potential for development of increased ICP.
GCS
Neurological status
Leakage of CSF
Obtain cause of injury, time of injury, direction and force of blow, loss of consciousness

45. Overall goals:
Maintain adequate cerebral perfusion
Remain normothermic
Be free from pain, discomfort, and infection
Attain maximal cognitive, motor, and sensory function

46. 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

47. 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

48. Health Promotion
Prevent car and motorcycle accidents
Wear safety helmets

49. Nursing diagnosis Ineffective airway clearance r/d to hypoxia
Ineffective cerebral tissue perfusion r/d to decreased CPP
Deficient fluid volume related to disturbances of consciousness
Imbalanced nutrition less than body requirement r/d to metabolic changes
Risk for injury r/d to disorientation
Risk for imbalanced body temp r/d to damage to temp regulating mechanism

50. 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

51. Head Injury Complications
Epidural hematoma or extra dural hematoma
Results from bleeding between the dura and the inner surface of the skull
Bleeding in this area mainly caused by laceration of middle meningeal artery
This follows a basilar and temporal skull fractures

52. Subdural hematoma
Occurs from bleeding between the dura mater and arachnoid layer of the meningeal covering of the brain
Usually venous in origin and is due to rupture of small blood vessels that drain from the surface of the brain (bridging veins)

54. Epidural and Subdural Hematomas
Epidural Hematoma
Subdural Hematoma

55. Subdural hematoma (acute, subacute or chronic)
Acute subdural hematoma
High mortality
Signs within 48 hours of the injury
Associated with major trauma (Shearing Forces)
Patient appears drowsy and confused with headache
Pupils dilate and become fixed

56. Subacute subdural hematoma
Occurs within 2-14 days of the injury
Failure to regain consciousness may be an indicator

57. Chronic subdural hematoma
Develops over weeks or months after a minor head injury.
After two to 4 days of bleeding in the brain it will become thicker and darker and later calcification or clot takes place
Severe headache confusion and personality changes

58. Intra cerebral hematoma
Bleeding with in the parenchyma leads to intra ceretral 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