Head 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
Types of Brain Injury
Types of Head Injury Scalp injury : minor injury resulting in laceration, abrasion & hematoma Skull injury : may occur with or without damage to brain. Brain injury
Head Injuries Closed or blunt: blunt object damages the brain and its coverings without actually perforating the skull or dura. Penetrating: when the skull and brain are directly lacerated by an object such as a bullet, or piece of bone. Coup-Contrecoup Injuries : same blow causes injury on opposite sides of the brain.
Skull Fractures Linear Skull Fracture: is a break in the continuity of the bone, appear as thin lines on X-ray. Depressed Skull Fracture - The broken piece of skull bone is pressed towards or embedded in the brain. Comminuted and Compound Skull Fracture - The scalp is cut and the skull is splintered, multiple fractures. Basilar Skull Fracture The skull fracture is located at the base of the skull and may include the opening at the base of the skull
Some Signs of SkullFractures – CSF or fluid draining from ear (“halo” sign) – Blood behind tympanic membrane – Raccoon Eyes: periorbital ecchymoses – Battles Sign: bruise over mastiod process – Cranial nerve and inner ear damage
Battles’ sign Often occurs in fractures at base of skull (posterior cranial fossa). Large "black and blue mark" looking areas below the ear, on the jaw and neck. It may include damage to the nerve for hearing. CSF Otorrhea: cerebral spinal fluid may leak out of the
Raccoon Eyes The skull fracture produces "black and blue" mark looking areas around the eyes. CSF Rhinorrhea: cerebral spinal fluid may leak into the sinuses and out of nose.
Traumatic Brain Injury
Traumatic brain injury (TBI) isAn insult to the brain, caused by an external physical force, that may produce physical, intellectual, emotional, social and vocational changes. Major causes of TBI motor vehicle accidents, falls, acts of violence, sports & recreational injuries, blows to head, child abuse (shaken baby syndrome).
Mechanisms of BrainInjury Acceleration injury occurs when the immobile head is struck by a moving object. Deformation injury : the force results in deformation and disruption of the impacted part, (skull fracture)
Mechanisms Cont’d Deceleration injury : head is moving and hits an immobile object (car accident-hitting steering wheel) Acceleration-deceleration injury : moving object hits immobile head and then head hits immobile object. Associated with rotation injury where brain is twisted in the skull (whiplash).
Injuries Blunt Penetrating Coup- Contrecoup
Types of Brain Injury Concussion: is a head trauma that may or may not result in loss of consciousness (for 5 minutes or less) and retrograde amnesia. Contusion: is a severe injury in which the brain is bruised resulting in swollen brain tissue, areas of hemorrhage, infarction, necrosis, edema. Results in loss of consciousness and symptoms of shock.
Concussion May experience only dizziness and feel “dazed”. Retrograde amnesia Treatment involves observing patient for headache, dizziness, lethargy, irritability and anxiety. Client should resume normal activities slowly and the following should be watched for: difficulty in awakening or speaking, confusion, severe headache, vomiting or weakness on one side of the body. May or may not show up on CAT scan. Blood clot can occasionally occur causing death Months to years to heal
Contusion Depends on which areas of the brain damaged – cerebral hemispheres, brain stem (RAS) Can cause diffuse axonal type injury resulting in permanent or temporary damage If widespread injury, abnormal eye movement and motor function, increased intracranial pressure and herniation - poor outcome. May have residual damage, seizures
Contusion resulting innecrosis
Diffuse Axonal Injury:severe widespread injury to axons in the cerebral hemispheres, corpus collosum and brain stem.
Diffuse Axonal Injury Extensive tearing of nerve tissue throughout the brain causing the release of chemicals, causing additional injury. Immediate coma, decerebrate & decorticate posturing, and global edema The tearing of the nerve tissue disrupts the brain’s regular communication and chemical processes producing temporary or permanent widespread brain damage, coma, or death. A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.
IntracranialHemorrhage Intracranial hematomas are collections of blood that develop within the cranial vault. Three kinds: epidural, subdural & intracerebral
Types of CerebralHemorrhage
Meninges Epidural Scalp Hematoma: mostly arterial Skull (blood collects Dura matter b/t the skull & Arachnoid the dura mater of the brain) Pia Brain tissue grey white
Subdural hemorrhage - usuallyScalp venous (bloodSkull collects b/t theDura matter dura & the arachnoid mater). May be classified as acute, subacute or chronic.
Acute & Subacute SubduralHematoma Usually result from brain or blood vessel laceration Symptomatic within 24 to 48 hours of injury Symptoms include loss or variable levels of consciousness, headache, irritability, increasing signs of increased ICP (increased BP, decreased pulse, slowing respiratory rates) Requires prompt treatment!
IntracerebralHematomaBleeding directlyinto the braintissue.
Diagnostic Tests CT or MRI: data on structural causes such as tumor or hemmorhage. -Metabolic – will be unremarkable LP: infection or bleeding (cloudy or bloody) EEG: structural or metabolic, seizure activity Lab tests: LFTs, kidney function, glucose levels, toxicology, ABGS
Diagnostic Tests for Abnormal Reflexes Oculocephalic reflex response – abnormal if eyes remain in fixed position when head turned Oculovestibular reflex response – absence of eye movement when water instilled in ear = brain death
* Level of consciousness is *the single most importantindicator of neurologicalfunction and change*
Medical Management Prompt recognition and treatment of hypoxia & acid-base disorders (why?) Control of increasing ICP resulting from increased cerebral edema and expanding hematoma Surgical treatment – Burr holes – Craniotomy
Post Head Injury Observe for 24 hrs Take to emergency if any of following:: – decreasing LOC (confusion, drowsy) – loss of consciousness/inability to wake – vomiting – convulsions – bleeding or drainage from ears/nose – weakness or loss of sensation in arm or leg – blurring of vision/slurring of speech – changes in pupil
Nursing Assessment: Brain Injury ABCDs Maintaining airway History if possible Determine LOC, ability to respond to verbal commands, reactions to tactile stimuli, status of reflexes. Glasgow Coma scale Fluid and electrolyte balance Monitoring/managing potential complications
The Glasgow Coma ScaleThe Glasgow Coma Scale (GCS) is a universally used neurological assessment tool to assess degree of consciousness impairment. CGS measures eye, verbal, and motor response. It is an excellent scale to measure arousal. It is less helpful related to content measurement. Know the difference b/ content & arousal
GLASGOW COMA SCALE SCORE (GCS)Eyes 1 Closed at all times 2 Opens to pain 3 Opens to voice command A score of 10 or less 4 Open spontaneously indicates a need forMotor 1 No response emergency 2 Extension (decerebrate) attention 3 Flexion posturing (decorticate) 15 (top score) 4 Flexion withdrawal 5 Localizes painful stimulus A score less than 7 6 Obeys commands is interpreted asVerbal 1 No response coma 2 Incomprehensible sounds 3 Inappropriate words 4 Disoriented and converses 5 Oriented and converses
Nursing Diagnoses – Altered Tissue Perfusion – Risk for Suffocation/Aspiration – Altered Oral Mucous Membranes – Risk for Impaired Skin Integrity – Risk for Contractures – Altered Nutrition: Less than Body Requirements – Fluid volume deficit – Risk for Injury – Altered family processes
Nursing management – Maintaining the airway – Protecting the patient – Fluid balance – Mouth care, skin and joint integrity – Corneal integrity – Thermoregulation
Emergency Care ABCs Airway maintenance, intubation with oxygenation (PO2 > 90mmHg), mild hyperventilation – avoid hypercapnia. Ensure adequate fluid however avoid lowering the blood osmolarity. Initial neuro assessment and Glasgow Coma Scale Etiology of the brain injury will dictate further evaluation & treatment
Emergency Care Cont’d osmotic diuretics (mannitol IV) steroids (controversial) vasoactive medication (100-150mmHg systolic) elevate HOB (30 degrees) sedate as needed (barbituates IV) drain CSF (keep ICP < 20) maintain fluid status (normal serum Na &
Nursing Management Cont’d Administer prescribed meds to reduce ICP: barbituates, mannitol analgesics, narcotics Maintain fluid balance with NaCl or RL solution Avoid noxious stimuli (explain) Maintain cerebral perfusion pressure >70mmHg Maintain normal body temperature – avoid hyperthermia
Osmotic Diuretic (Mannitol) Reduces cereberal edema by osmotic dehydration. Preferred b/c it is confined to extracellular space & does not normally cross an intact blood brain barrier. Carefully monitor vitals, CVP, B.P, intake & output, catheter patency, signs of fluid overload, eye response /acuity & electrolyte imbalance?? Why?? NOTE: If blood-brain barrier is damaged the medication enters the brain and increases swelling!!