Head injury


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  • Subgaleal_hemorrhage Subgaleal hemorrhage or hematoma is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis. Causes Majority (90%) result from vac Cephalhematoma is a hemorrhage of blood between the skull and the periosteum of a newborn baby secondary to ru ...
  • Battles's Sign- Periauricular ecchymosis Periauricular - around the external ear Ecchymoisis - bleeding under the skin
  • Raccoon Eyes - Ecchymosis in the periorbital area, resulting from bleeding from a fracture site in the anterior portion of the skull base
  • Subdural hemorrhage is bleeding due to trauma that occurs between the outer and middle membranes (meninges) covering the brain. The outer membrane is called the dura, the middle is called the arachnoid, and the inner membrane is known as the pia mater. Subdural hemorrhage, therefore, is bleeding beneath (below) the dura and above the arachnoid. This type of hemorrhage can result from blunt head trauma as minimal as a mild bump.
  • Cerebral contusions are “brain bruises” which occur from acceleration and de-acceleration of the head. Head trauma can also produce microscopic changes that are scattered throughout the brain. This category of injury is called diffuse axonal injury (DAI) and refers to the microscopic severing of axons (fibers which allow brain neurons to communicate with each other). If enough axons are injured in this way, then the ability of nerve cells to integrate and function may be lost or greatly impaired
  • Craniotomy Craniectomy Cranioplasty Burr-hole
  • Head injury

    1. 1. Head Injury Zafar Iqbal Sr. LecturerJinnah College Of Nursing Karachi
    2. 2. Head Injury• Any trauma to the scalp, skull, or brain• Head trauma includes an alteration in consciousness no matter how brief
    3. 3. Head Injury• Causes – Motor vehicle accidents – Firearm-related injuries – Falls – Assaults – Sports-related injuries – Recreational accidents
    4. 4. Road Traffic Crashes
    5. 5. Sports injuries A&E(VMH)
    6. 6. Assaults(Sickle injuries) A&E(VMH)
    7. 7. MECHANISM• BLUNT INJURY  High Velocity  Low Velocity• PENETRATING INJURY  Gunshot  Sharp instruments
    8. 8. 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
    9. 9. Classification• By Nature of insult; penetrating or blunt.• Concomitant injuries; isolated head injury or multiple trauma.• Timing of the injury; Primary or Secondary.
    10. 10. 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.
    11. 11. Types of Head Injuries• Scalp lacerations – The most minor type of head trauma – Scalp is highly vascular → profuse bleeding – Major complication is infection Cephal Hematoma
    12. 12. Minor Head Trauma Manifestation– 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
    13. 13. Minor Head Trauma Manifestation– Postconcussion syndrome • 2 weeks to 2 months • Persistent headache • Lethargy • Personality and behavior changes
    14. 14. Types of Head Injuries• Skull fractures – Linear or depressed – Simple, comminuted, or compound – Closed or open – Direct & Indirect
    15. 15. Types of Head Injuries• Skull fractures – Location of fracture alters the presentation of the manifestations – Facial paralysis – Deviation of gaze – Battle’s sign
    16. 16. Types 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
    17. 17. Basilar : with/with out CSF leak with/with out seventh-nerve palsy Raccoon eyes Battle sign CSF rhinorrhea
    18. 18. INTRACRANIAL LESIONS• Focal : epidural hematoma subdural hematoma intracerebral hematoma
    19. 19. INTRACRANIAL LESIONSIntracerebral -in the brainEpidural Hematoma -betweenthe skull and the dura Subdural Hematoma -between the brain and the dura)
    20. 20. Manifestation of Major Head Trauma– Includes cerebral contusions and lacerations– Both injuries represent severe trauma to the brain
    21. 21. 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
    22. 22. Pathophysiology• Diffuse axonal injury (DAI) – Widespread axonal damage occurring after a mild, moderate, or severe TBI – Process takes approximately 12-24 hours
    23. 23. Pathophysiology• Diffuse axonal injury (DAI) – Clinical signs: ∀↓ LOC ∀↑ ICP • Decerebration or decortication • Global cerebral edema
    24. 24. Approach to a Patient With Head Injury• History• Initial Assessment  Primary Survey  Secondary Survey
    25. 25. 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)
    26. 26. Management of Traumatic Head Injury• Maximize oxygenation and ventilation• Support circulation / maximize cerebral perfusion pressure• Decrease intracranial pressure• Decrease cerebral metabolic rate
    27. 27. Nursing Management Nursing Assessment– GCS score– Neurologic status (GCS)– Presence of CSF leak
    28. 28. Nursing Management Nursing Diagnoses– Ineffective tissue perfusion– Hyperthermia– Acute pain– Anxiety– Impaired physical mobility
    29. 29. 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
    30. 30. Nursing Management PRIMARY SURVEYAirway maintenance with cervical spine protection
    31. 31. Nursing ManagementIntubation 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
    32. 32. Nursing Management Circulation• Maintain MAP >90mmhg- adequate• Hematocrit >30%• Cushing reflex
    33. 33. Conti…..• Isolated intracranial injuries do not cause hypotension• LOOK FOR THE CAUSE OF HYPOTENSION
    34. 34. Decreasing Intracranial PressureDiuretic TherapyOsmotic Diuretic Loop Diuretic• Mannitol (0.25-1 gm / kg) • Furosemide• Increases serum osmolarity • Decreased CSF formation• Vasoconstriction • Decreased systemic and (adenosine) / less effect if cerebral blood volume autoregulation is impaired (impairs sodium and water and if CPP is < 70 movement across blood• Initial increase in blood brain barrier) volume, BP and ICP • May have best affect in followed by decrease conjunction with mannitol• Questionable mechanism of lowering ICP
    35. 35. 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+++
    36. 36. Nursing Management Nursing implementationHealth Promotion • Prevent car and motorcycle accidents • Wear safety helmets
    37. 37. Nursing Management Nursing implementationAcute Intervention • Maintain cerebral perfusion and prevent secondary cerebral ischemia • Monitor for changes in neurologic status
    38. 38. Nursing Management Nursing implementationAmbulatory and Home Care • Nutrition • Bowel and bladder management • Spasticity • Dysphagia • Seizure disorders • Family participation and education
    39. 39. Nursing Management EvaluationExpected Outcomes • Maintain normal cerebral perfusion pressure • Achieve maximal cognitive, motor, and sensory function • Experience no infection, hyperthermia, or pain
    40. 40. 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 A&E(VMH) – After careful preparation of visitors, allow calm contact
    41. 41. Complications• Epidural hematoma – Results from bleeding between the dura and the inner surface of the skull – A neurologic emergency – Venous or arterial origin
    42. 42. Complications• Subdural hematoma – Occurs from bleeding between the dura mater and arachnoid layer of the meningeal covering of the brain
    43. 43. Complications• 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
    44. 44. Complications• 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
    45. 45. Complications• Subdural hematoma – Subacute subdural hematoma • Occurs within 2-14 days of the injury • Failure to regain consciousness may be an indicator
    46. 46. Complications• Subdural hematoma – Chronic subdural hematoma • Develops over weeks or months after a seemingly minor head injury
    47. 47. Surgical Management• Craniotomy• Craniectomy• Cranioplasty• Burr-hole