HEAD INJURY

BY
SHILPA S
CRITICAL CARE
NURSING
 INTRODUCTION
• It includes any injury or trauma to the scalp,
skull, or brain.
• A serious form of head injury is Traumatic
Brain Injury (TBI).
• Males are five times more prone to TBI than
females.
• In India about 1.6 million sustain TBI and seek
medical aid and out of these 10% die.
 DEFINITION
• Any degree of injury to the head ranging from
scalp laceration to LOC to focal neurological
deficits.

OR
• Traumatic brain injury (TBI) is a non-congenital
insult to the brain from an external mechanical
force, possibly leading to permanent or
temporary impairment of cognitive, physical, and
psychosocial functions, with an associated
diminished or altered state of consciousness.
 ETIOLOGY

Motor vehicle accidents

Falls

Assaults

Sports-related injuries

Fire-related injuries
 RISK FACTORS:
• Colour blindness
• Alcohol addiction
• Youngsters
• Vertigo
• Males (about 1.5 times as likely as females to sustain a
brain injury)
• Young children or teenagers (especially infants to 4-
year-olds and 15–19-year-olds)
• Certain military personnel (for example, paratroopers)
• African Americans (who have the highest death rate
from brain injury)
MECHANISM AND PATHOPHYSIOLOGY
• Head injuries are caused by a sudden force to the head.
The results are complex. Three mechanisms contribute to
head trauma:

• Acceleration: An acceleration injury occurs when the

immobile head is struck by a moving object.
• Deceleration: If the head is moving and hits an immobile
object, a deceleration injury occurs.
• Deformation: It refers to injuries in which the force results
in deformation and disruption of the integrity of the
impacted body part (e.g. skull fracture).
• In an acceleration-deceleration injury, a moving object hits
the immobile head, and then the head hits an immobile
object. These injuries are also associated with rotation
injury, where the brain is twisted within the skull.
Acceleration Deceleration

Coup injury
Contrecoup injury
 Brain suffers traumatic injury

Brain swelling or bleeding

Increases intracranial volume

Pressure on blood vessels within the brain causes blood

flow to the brain to slow

Cerebral hypoxia and ischemia occur

ICP continues to rise, Brain may herniated

Cerebral blood flow ceases

 CLASSIFICATION
• According to glass gow coma scale
1. Mild (GCS 13-15 with loss of consciousness
to 15 min)
2. Moderate(GCS 9-10 with loss of
consciousness for up to 6 hr)
3. Severe (GCS 3-8 with loss of consiousness
greater than 6hr)
TYPES
 TYPES

TYPES OF
HEAD
INJURY

SCALP SKULL MINOR HEAD MAJOR HEAD

LACERATIONS FRACTURE TRAUMA TRAUMA
 LACERATIONS

Easily recognized
– The most minor type of head trauma
– Scalp is highly vascular  profuse bleeding
– Major complication is infection
 SKULL FRACTURES
• LINEAR
 break in the continuity of bone without
alteration of relationship of parts
 cause- Low velocity injuries
• DEPRESSED
 Inward indentation of skull
 cause- powerful blow
• COMMINUTED
 multiple linear fractures with fragmentation
of bones into pieces

• COMPOUND
 Depressed skull fractures and scalp
laceration communicating intracranial cavity
COMPOUND FRACTURE
 ACCORDING TO LOCATION

• Frontal fracture
• Temporal fracture
• Parietal fracture
• Posterior fossa fracture
• Orbital fracture
• Basilar skull fracture
 FRONTAL BONE FRACTURE
• Type of traumatic brain injury that affects the
frontal lobe, which is responsible for various
higher-level cognitive functions.
• Cognitive changes (e.g. memory loss, difficulty
with planning)
• Behavioral changes (e.g. impulsivity, apathy) -
• Motor changes (e.g. weakness, tremors) -
• Language changes (e.g. difficulty with speech) -
• Personality changes
 TEMPORAL BONE FRACTURE
• Boggy temporal muscle because
extravasation of blood
• Oval shaped bruise behind the ear in mastoid
region (battle sign)
• Otorrhoea
 PARIETAL BONE FRACTURE

• Deafness
• CSF otorrhoea
• Bulging of tympanic membrane by blood or
CSF
• Facial paralysis
 ORBITAL FRACTURE

• Periorbital ecchymosis(RACCOON EYES)

• Optic nerve injury
 BASILAR SKULL FRACTURE

• serious head injury that occurs when there is a

fracture to the bones of the skull base.
• Otorrhoea, rhinorrhoea
• Bulging of tympanic membrane
• Battle’s sign
• Facial paralysis
• Tinnittis , vertigo
 MINOR HEAD TRAUMA
• CONCUSSION
A sudden transient
mechanical head injury with
disruption of neuronal activity
and a change in the LOC.
It occurs when the brain
suddenly shifts inside the skull
and knocks against the skull
bony surface.
Typical Signs:-
* Brief disruption of LOC
* Concussion can lost from a few over 3 minutes or less than
5 minutes.
* Retrograde amnesia
* Headache
 Post-concussive syndrome
Timing: 2 weeks to 2 months
c /o
• Persistent headache
• fatigue
• Personality changes
• Short attention span
• Decreased short-term memory
• sleep disturbances
• depression, personality disorders
 MAJOR HEAD TRAUMA

CONTUSION

• It is the bruising of the brain tissue within

focal area
• It is usually associated with a closed head
injury
COUP-CONTRE-COUP IS OFTEN NOTED
• In this type of injury contusion occur both at
the site of direct impact of the brain on the
skull( coup) and at the a secondary area of
damage on the opposite side away from injury
( contrecoup) leading to multiple contusion
areas
• LACERATIONS
It involve actual tearing of brain tissue and
often occur in association with depressed ,open
fractures and penetrating injuries

• Intracerebral hemorrhage commonly

associated
 TYPES OF BRAIN INJURIES

DIFFUSE FOCAL

• Contusion
• Concussion
• Lacerations
• Diffuse Axonal Injury
 DIFFUSE AXONAL INJURY

Severe widespread
injury to axons in
the cerebral
hemispheres,
corpus collosum,
and brain stem.
Clinical signs:
–  LOC immediately
–  ICP
– Decerebration or decortication.
– Cognitive impairment, spasticity .
– 90% pts with severe DAI will be vegetative.
– CT  usually normal
COMPLICATIONS
 EPIDURAL HEMATOMA
• An epidural hematoma results from bleeding
the dura and the inner surface of the skull.
• An epidural hematoma is a neurologic
emergency and is usually associated with a
linear fracture crossing a major artery in the
dura, causing a tear.
• Classic signs of an epidural hematoma include
an initial period of unconsciousness,
headache, nausea and vomiting.
• Blow to the temporal, parietal bone
• Commonly bleeding by arterial origin-
breakage to middle meningeal artery
• Venous- dural venous sinus
• A rapid Open craniotomy for evacuation of the
congealed clot and hemostasis is indicated for
EDH
• Prevention of cerebral herniation can
dramatically improve outcome
• On head CT the clot
is bright, biconvex
shaped clot and has
a well-defined border
that usually respects
cranial suture lines
 SUBDURAL HEMATOMA
• It occurs from bleeding between the dura mater and
the arachnoid layer of the meninges.
• It usually results from injury to the brain tissue and
its blood vessels.
• Types
1. Acute subdural hematoma
2. Sub acute subdural hematoma
3. Chronic subdural hematoma
ACUTE SUBDURAL HEMATOMA

• An acute subdural hematoma manifests within

24 to 48 hours of injury.
• Commonly related to acceleration-
deceleration injury
• Clinical manifestations as same as elevated ICP
On head CT scan,
the clot is bright or
mixed-density,
crescent-shaped
(lunate), may have a
less distinct border
 SUBACUTE SUBDURAL HEMATOMA

• Usually occurs within 2-14 days of the injury

• The alteration in mental status as hematoma
develops
• Progression depends on the size and location
of hematoma
 CHRONIC SUBDURAL HEMATOMA

• It develops over weeks or months after

seemingly minor head injury
• The peak incidence of chronic SDH is in 50-60
Years of age
• Clinical manifestations is progressive
alteration in LOC
 INTRACEREBRAL HEMATOMA
• It occurs from bleeding within the brain tissue in
approx 16% of head injuries.
• It usually occurs within the frontal and temporal
lobes, possibly from rupture of Intracerebral vessels
at the time of injury
• The size and location of the hematoma are key
determinants of the patient’s outcome..
 DIAGNOSTIC STUDIES

• History collection and physical examination

• CT SCAN
• MRI
• Positron emission tomography
• X-RAY
 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) - Bridging veins
Middle meningeal artery
Frontal - anterior ethmoidal artery
Occipital - transverse or sigmoid
sinuses
Vertex - superior sagittal sinus
Symptoms Lucid interval followed Gradually
by unconsciousness increasing headache and c
onfusion
CT appearance Biconvex lens- limited by suture Crescent shaped- crosses
lines suture lines
MANAGEMENT
• Severe head injury is best managed in a neuro
intensive care setting
• The patient should be positioned with the
head up 30 degree
• It is important to ensure that the cervical
immobilization collar does not obstruct venous
return from the head
 Initial Management

• A: Airway control including cervical spine

immobilisation with a stiff collar.
• B: Breathing
• C: Circulation
• D: Dysfunction or Disability
• E: External Examination
 Airway and ventilation

• Patient in traumatic coma is unable to protect

their airway and is at risk for aspiration
• Maintain a normocapnia
 Circulation and cerebral perfusion
pressure

• Hypotension and hypoxia as a major cause of

secondary brain injury.
• A systolic BP < 90 mmHg worse outcome in
traumatic coma
• Cerebral perfusion pressure should be
maintained at > 65 mmHg in severely head-
injured patients.
 Control of intracranial pressure

• Position head up 30º

• Avoid obstruction of venous drainage from head
• Sedation +/– muscle relaxant
• Normocapnia
• Diuretics: furosemide, mannitol
• Seizure control
• Normothermia
• Barbiturates
 MEDICATIONS

• Osmotic diuretics
• Anticonvulsants
• Barbiturates:- Pentobarbital
• Calcium Channel Blockers
 SURGICAL MANAGEMENT

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
 Types:

• Burr-hole-
opening into cranium with a drill

• Craniotomy-
bone flap is temporarily removed
from the skull to access the brain
• Craniectomy –
Excision into the cranium to cut away a
bone flap

• Cranioplasty -
surgical repair of a defect or deformity of
a skull
 NURSING MANAGEMENT

• Nursing assessment
ABC
GCS Score
Neurologic examination
Signs of elevated ICP
Signs of CSF leakage
 Nursing diagnosis

• Ineffective tissue perfusion (cerebral) related to

interruption of CBF associated with cerebral
hemorrhage and edema
• Acute pain (headache) related to trauma and
cerebral edema
• Hyperthermia related to increased metabolism,
and loss of cerebral integrative function
secondary to possible hypothalamus injury
• Impaired physical mobility related to
decreased LOC and treatment –imposed bed
rest
• Anxiety related to abrupt change in health
status, hospital environment and uncertain
future
• Risk for complication related cerebral edema
and hemorrhage
 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.
 REHABILITATION

Ambulatory and Home Care

• Nutrition
• Bowel and bladder management
• Seizure disorders
• Family participation and education
 Unconscious stages

• Stupor is a state of partial or near complete

unconsciousness in which the patient is
lethargic, immobile, and has a reduced
response to stimuli.
• Coma is a state in which the patient is totally
unconscious and cannot be aroused even with
strong stimuli.
 Persistent vegetative state
• It is a condition in which awake patients are
unconscious and unaware of their
surroundings and the cerebral cortex is not
functioning. A vegetative state can result from
diffuse injury to the cerebral hemispheres of
the brain without damage to the lower brain
and brainstem. The vegetative state is
considered permanent if it persists for 12
months after TBI