Download - 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