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Head injury

Head injury, types, management, clinical features, Nursing management

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Head injury

  2. 2. Any degree of traumatic brain injury ranging from scalp laceration to LOC to focal neurological deficits Head Injury
  3. 3. Head injuries are among the most common types of trauma encountered in emergency departments (EDs). Many patients with severe brain injuries die before reaching a hospital, with almost 90% of prehospital trauma-related deaths involving brain injury.
  4. 4. About 75% of patients with brain injuries who receive medical attention can be categorized as having minor injuries, 15% as moderate, and 10% as severe. Most recent United States data estimate 1,700,000 traumatic brain injuries (TBIs) annually, including 275,000 hospitalizations and 52,000 deaths.
  5. 5. Head Injury Causes • Motor vehicle accidents • Falls • Assaults • Sports-related injuries • Firearm-related injuries
  6. 6. 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
  7. 7. Head Injury TYPES: • Scalp laceration • Skull Fractures • Minor Head Trauma Concussion and post- concussion syndrome • Major Head Trauma: Cerebral contusion Laceration
  8. 8. Intracranial Perfusion Cranial volume fixed 80% = Cerebrum, cerebellum & brainstem 12% = Blood vessels & blood 8% = CSF Increase in size of one component diminishes size of another Inability to adjust = increased ICP
  9. 9. Head Injury Scalp lacerations • The most minor type of head trauma • Scalp is highly vascular - profuse bleeding • Major complication is infection
  10. 10. Head Injury Skull fractures : • Linear Skull Fracture • Depressed Skull Fracture • Diastatic Skull Fracture • Basal Skull Fracture • Compound Skull Fracture • Compound elevated Skull Fracture • Growing Skull Fracture • Coup & Countercoup
  11. 11. Head Injury • Skull fractures Location of fracture alters the presentation of the manifestations • Facial paralysis • Conjugate deviation of gaze • Battle’s sign, Raccoon eyes
  12. 12. Basilar Skull Fracture Battle’s sign Raccoon eyes
  13. 13. Basal Skull fractures • CSF leak (extravasation) into ear (Otorrhea) or nose (Rhinorrhea) • High risk infection or meningitis • ―HALO Sign ‖ on clothes or linen • Possible injury to Internal carotid artery • Permanent CSF leaks possible “HALO Sign ” Head Injury
  14. 14. Investigations • X-ray • CT scan: standard modality • MRI • Bleeding from the ear or nose in cases of suspected CSF leak -"halo" or "ring" sign , when dabbed on a tissue paper • CSF leak - analyzing the glucose level and by measuring tau-transferrin.
  15. 15. Management Pre-hospital care: • Patients with severe head injuries should be assumed to have a cervical spine (C-spine) injury and immobilized with cervical collar until clinical and radiographic studies can prove otherwise • 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 Definitive Rx: • Measures to reduce ICP • Supportive management • Surgery
  16. 16. Head Injury Minor head trauma Concussion : head injury with a temporary loss of brain function concussion can cause a variety of physical, cognitive , and emotional symptoms. Cause: Sudden acceleration and deceleration injury e.g.: Car accident, sports injury, bicycle accident etc.
  17. 17. Head Injury Types of Head Injuries Concussion Presentation: Physical-headache, LOC, Amnesia, s/s of ↑ ICP(Cushing’s triad) , convulsions Cognitive : confusion, irritability, behavioral changes
  18. 18. Head Injury Minor head trauma • Post-concussion syndrome • 2 weeks to 2 months • Persistent headache • Lethargy • Personality and behavior changes
  19. 19. Head Injury Major head trauma • Includes cerebral contusions and lacerations • Both injuries represent severe trauma to the brain
  20. 20. Head Injury Major head trauma Contusion The bruising of brain tissue within a focal area that maintains the integrity of the pia mater and arachnoid layers associated with multiple micro- hemorrhages, small vessel bleed into brain tissue Lacerations Involve actual tearing of the brain tissue Intracerebral hemorrhage is generally associated with cerebral laceration
  21. 21. Cerebral Contusion Cerebral Laceration Head Injury
  22. 22. Head Injury Pathophysiology Diffuse axonal injury (DAI) • Widespread axonal damage occurring after a mild, moderate, or severe TBI • Seen in half the cases of head injury • Process takes approximately 12-24 hours
  23. 23. Head Injury Pathophysiology Diffuse axonal injury (DAI) Clinical signs: • Level of Consciousness • ICP Decerebration or decortication Global cerebral edema 90% regain consciousness from severe DAI
  24. 24. Intracranial Hemorrhage • Extra- axial hemorrhage Epidural hematoma Subdural hematoma- Acute Chronic Subarachnoid hemorrhage • Intra-axial hemorrhage • Intra-parenchymal hemorrhage • Intra-ventricular hemorrhage
  25. 25. Epidural and Subdural Hematomas Epidural Hematoma Subdural Hematoma
  26. 26. 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) - Middle meningeal artery Frontal - anterior ethmoidal artery Occipital - transverse or sigmoid sinuses Vertex - superior sagittal sinus Bridging veins Symptoms Lucid interval followed by unconsciousness Gradually increasing headache and confusion CT appearance Biconvex lens- limited by suture lines Crescent shaped- crosses suture lines
  27. 27. Subarachnoid Hemorrhage Causes: • Rupture of Berry aneurism(MCC) • Trauma (fracture at the base of the skull leading to internal carotid aneurysm) • Amyloid angiopathy • Blood dyscrasias • Vasculitis Clinical Features: • Explosive or thunderclap headache, ―worst headache of my life‖, • Nausea and vomiting, decreased LOC or coma. • Signs of meningeal irritation
  28. 28. Intracerebral Hemorrhage (ICH) Intracranial hemorrhage is hemorrhage that occurs within the brain tissue itself; an intra-axial hemorrhage. Two main types: • Intraparencymal hemorrahge- ICH extending into brain parenchyma; MCC- HTNsive vasculopathy • Intra-ventricular hemorrhage- ICH extending into ventricles; MCC –trauma Causes: Hypertensive vasculopathy(70-80%) Ruptured AVM Trauma Blood dyscrasias
  29. 29. Intracerebral Hemorrhage (ICH) Clinical presentation: Rapidly progressive severe headache, building over several minutes, often accompanied by focal neurological deficits, nausea and vomiting, decreased level of consciousness. S/S depend site of hemorrhage: Basal ganglia/internal capsule - hemiparesis, dysphasia Cerebellum - ataxia, vertigo Pons - cranial nerve deficits, coma Cerebral cortex- hemiparesis, hemi-sensory loss, hemi-anopsia, dysphasia
  30. 30. Complications • Neurological deficits or death • Seizures • Obstructive Hydrocephalus • Spasticity • Urinary complications • Aspiration pneumonia • Cushing’s ulcer • Neuropathic pain • Deep venous thrombosis • Pulmonary emboli • Cerebral herniation
  31. 31. Glasgow Coma Scale Suspect severe brain injury GCS <9 32 *Decorticate posturing to pain **Decerebrate posturing to pain
  32. 32. Diagnostic Studies CT scan – A GCS score less than 15 after blunt head trauma warrants a patient with no intoxicating consideration of an urgent CT scan.
  33. 33. CT findings Epidural Hematoma Subdural Hematoma
  34. 34. CT findings Subarachnoid hemorrhage Intracerebral hematoma
  35. 35. Diagnostic Studies • MRI – superior for demonstrating the size of an acute subdural hematoma. • Cerebral angiogram if hemorrhage is confirmed (not necessary in case of classic hypertensive hemorrhage) • Cervical spine X-ray • EEG • Lumbar Puncture
  36. 36. Management 1) Supportive Measures: • Endotracheal intubation for patients with decreased level of consciousness and poor airway protection. • Cautiously lower blood pressure to a MAP less than 130 mm Hg, but avoid excessive hypotension.[10] • Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan. • Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain perfusion without exacerbating brain edema • Avoid hyperthermia. • Facilitate transfer to the operating room or ICU.
  37. 37. Management 2) Decrease cerebral edema: • Modest passive hyperventilation to reduce PaCO2 • Mannitol, 0.5-1.0 gm/kg slow iv push • Furosemide 5-20 mg iv • Elevate head 20-30 degrees, avoid any neck vein compression • Sedate and paralyze if necessary with morphine and vecuronium (struggling, coughing etc will elevate intracranial pressure)
  38. 38. Management 3) Surgical Evacuation of hematoma: 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 Exception : In Subdural hematoma with GCS=15- hematoma >10mm ,or >5mm midline shift ---- requires Surgical decompression SAH: when a cerebral aneurysm is identified on angiography, clipping and coiling is done to prevent re-bleed
  39. 39. Management Surgical Decompression contd.. Types: • Burr-hole • Craniotomy- bone flap is temporarily removed from the skull to access the brain • Craniectomy – in which the skull flap is not immediately replaced, allowing the brain to swell, thus reducing intracranial pressure • Cranioplasty - surgical repair of a defect or deformity of a skull.
  40. 40. Initial management of the patient with traumatic brain injury (treatment option).
  41. 41. Initial management of the patient with traumatic brain injury (treatment option). Contd….
  42. 42. Assessment parameters for the patient with a head injury include (A) eye opening and responsiveness, (B) vital signs
  43. 43. Assessment parameters for the patient with a head injury: (C, D) motor response reflected in hand strength or response to painful stimulus.
  44. 44. NURSING MANAGEMENT: • Ineffective Cerebral tissue perfusion related to increased ICP and decreased CPP • Fluid volume deficit related to decrease LOC and hormonal dysfunction. • Risk for injury related to decreased level of consciousness. • Knowledge deficit regarding the treatment modalities and current situation.
  45. 45. • Ineffective thermoregulation related to damage to hypothalamic centres. • Risk for Impaired skin integrity related to compromised circulation shifting of fluid from intra vascular to interstitial space. • Anxiety related to outcome of diseases as evidenced by poor concentration on work, isolation from others, rude behaviour
  46. 46. Nursing Process: The Care of the Patient with Brain Injury—Assessment • Health history with focus upon the immediate injury, time, cause, and the direction and force of the blow • Baseline assessment • LOC—Glasgow Coma Scale • Frequent and ongoing neurologic assessment • Multisystem assessment 51
  47. 47. Nursing Process: The Care of the Patient with Brain Injury—Diagnoses  Ineffective airway clearance and impaired gas exchange  Ineffective cerebral perfusion  Deficient fluid volume  Imbalanced nutrition  Risk for injury  Risk for imbalanced body temperature  Risk for impaired skin integrity  Disturbed thought patterns  Disturbed sleep pattern  Interrupted family process  Deficient knowledge 52
  48. 48. Collaborative Problems/Potential Complications • Decreased cerebral perfusion • Cerebral edema and herniation • Impaired oxygenation and ventilation • Impaired fluid, electrolyte, and nutritional balance • Risk of posttraumatic seizures 53
  49. 49. Nursing Process: The Care of the Patient with Brain Injury—Planning  Major goals may include Maintenance of patent airway, Adequate cerebral perfusion pressure (CPP), Fluid and electrolyte balance, Adequate nutritional status, Prevention of secondary injury, Maintenance of normal temperature, Maintenance of skin integrity, Improvement of cognitive function, Prevention of sleep deprivation, Effective family coping, Increased knowledge about rehabilitation process, and Absence of complications. 54
  50. 50. Interventions • Ongoing assessment and monitoring is vital • Maintenance of airway –Positioning to facilitate drainage of oral secretions with HOB usually elevated 30° to decrease venous pressure –Suctioning with caution –Prevention of aspiration and respiratory insufficiency –Monitor ABGs, ventilation, and mechanical ventilation –Monitor for pulmonary complications, potential ARDS 55
  51. 51. Interventions • I&O and daily weights • Monitor blood and urine electrolytes osmolality and blood glucose • Measures to promote adequate nutrition • Strategies to prevent injury –Assessment of oxygenation –Assessment of bladder and urinary output –Assessment for constriction due to dressings and casts –Pad side-rails –Mittens to prevent self-injury; avoid restraints 56
  52. 52. Interventions • Strategies to prevent injury –Reduce environmental stimuli –Adequate lighting to reduce visual hallucinations –Measures to minimize disruption of sleep-wake cycles –Skin care –Measures to prevent infection • Maintaining body temperature –Maintain appropriate environmental temperature –Use of coverings—sheets, blankets to patient needs –Administration of acetaminophen for fever –Cooling blankets or cool baths; avoid shivering 57
  53. 53. Interventions • Support of cognitive function • Support of family –Provide and reinforce information –Measures to promote effective coping –Setting of realistic, well-defined, short-term goals –Referral for counseling –Support groups • Patient and family teaching 58
  54. 54. Promotion of Effective Breathing and Airway Clearance • Monitor carefully to detect potential respiratory failure –Pulse oximetry and ABGs –Lung sounds • Early and vigorous pulmonary care to prevent and remove secretions • Suctioning with caution • Breathing exercises • Assisted coughing • Humidification and hydration 59
  55. 55. Improving Mobility • Maintain proper body alignment • Turn only if spine is stable and as indicated by physician • Monitor blood pressure with position changes • PROM at least four times a day • Use neck brace or collar, as prescribed, when patient is mobilized • Move gradually to erect position 60
  56. 56. 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
  57. 57. • 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.
  58. 58. 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.
  59. 59. Preventive Measures Health Promotion • Prevent car and motorcycle accidents • To wear safety helmets
  60. 60. Cognitive Rehabilitation Therapy Physical Therapy Speech Therapy Mental Rehabilitation Physical Exercise Occupational Therapy Rehabilitation
  61. 61. Rehabilitation Ambulatory and Home Care • Nutrition • Bowel and bladder management • Spasticity • Dysphagia • Seizure disorders • Family participation and education