HEAD INJURY OR TRAUMA

1. Head Trauma
Head Trauma

3. INTRODUCTION
 Trauma involving the central
nervous system can be life
threatening. Even if not life-
threatening, brain and spinal cord
injury may result in major physical
and psychological dysfunction
and can alter the patient’s life
completely.

4. DEFINITION
Head injury refers to
any injury to the scalp,
skull or the brain

5. INCIDENCE
Groups at highest risk for
traumatic brain injury are
persons age 15 to 24 years
and males, who suffer
traumatic brain injury at a rate
almost twice that of females.

6. ETIOLOGY
Motor vehicle accidents
Assaults
Falls
Accidents
Sports related injuries

7. CLASSIFICATION

8. CLASSIFICATION ACCORDING TO
MECHANISMS OF INJURY
CLOSED INJURY
OPEN
INJURY(PENERATING
INJURY)
DIFFUSE INJURY
COUNTER COUP

9. CLOSED INJURY
It refers to the injury in which
there is no break in the tissue
(scalp and skull) that separates
the intra cranial cavity from
external environment.
Eg: sub dural hematoma.

10. OPEN INJURY
It occurs when an object
penetrates the skull,
enters the brain and
damages the soft brain
tissues.

11. DIFFUSE INJURY
It occurs when a blow is
received that does not result
in fracture but causes the
brain to move enough to
shear or tear some of the
veins going from the cortical
surface of the brain to the
skull.

12. COUNTER COUP
Injury caused due to
rebound of the cranial
contents may result in an
area of injury opposite to
the point of impact.

14. CLASSIFICATION
ACCORDING TO LOCATION

15. Scalp injuries
It is considered as minor head injury
Abrasion (brush wound)
Laceration- it is an external
head trauma which is
relatively small wound and
can bleed significantly.

18. Skull injuries
LINEAR
DEPRESSED
SIMPLE
COMMINUTED
COMPOUND

19. LINEAR
Break in continuity of
bone without alteration
of relationship of
parts.

20. DEPRESSED
Inward
indentation of
skull.

21. SIMPLE
Linear or
depressed skull
fractures without
fragmentation

22. COMMINUTED
Multiple linear
fracture with
fragmentation of
bone into many
pieces.

23. COMPOUND
Depressed skull fracture
and scalp laceration with
communicating pathway
to intracranial cavity.

24. BRAIN INJURY

25. BRAIN INJURY
CONCUSSION
CONTUSION
DIFFUSE AXONAL INJURY
INTRACRANIAL
HEMORRHAGE

26. CONCUSSION
A TEMPORARY LOSS OF
NEUROLOGIC FUCTIONS
WITH NO APPARENT
STRUCTURAL DAMAGE
TO THE BRAIN.

27. CONTUSION
IT IS A SEVERE INJURY IN
WHICH THE BRAIN IS
BRUISED, WITH
POSSIBLE SURFACE
HEMORRHAGE.

28. DIFFUSE AXONAL INJURY
IT INVOLVES
WIDESPREAD DAMAGE
TO AXONS IN THE
CEREBRAL HEMISPHERE,
CORPUS CALLOSUM AND
BRAIN STEM.

29. Intra cranial hemorrhage
IT IS DIVIDED INTO:
Epidural hematoma
Subdural hematoma
Intracerebral
hematoma

30. EPIDURAL HEMATOMA
BLOOD MAY COLLECT
IN THE EPIDURAL
SPACE BETWEEN THE
SKULL AND THE DURA
.

31. SUBDURAL HEMATOMA
IT IS A COLLECTION
OF BLOOD
BETWEEN THE
DURA AND THE
BRAIN.

32. INTRA CEREBRAL
HEMORRHAGE
IT IS BLEEDING INTO THE
SUBSTANCE OF THE BRAIN.
IT IS COMMONLY SEEN IN
HEAD INJURIES WHEN
FORCE IS EXERTED TO THE
HEAD OVER A SMALL AREA.
Eg: BULLET WOUND.

33. PATHOPHYSIOLOGY

34. Brain suffers traumatic
injury
Brain swelling or bleeding
increases intra cranial volume
Rigid cranium allows no room for
expansion of contents so ICP
increases
Pressure on blood vessels within
the brain causes blood flow to the
brain to slow

35. ICP continues to raise.
Brian may herniate
Cerebral blood flow
ceases
Cerebral hypoxia and
ischemia occurs
Brain
Death

36. CLINICAL MANIFESTATIONS
SKULL FRACTURE
 PAIN
 CSF leakage (Rhinorrhea,otorrhea)
 Cranial nerve injuries
 Periorbital ecchymosis(Raccoon
eyes)
 Postauricular ecchymosis (Battle's
sign)

37. C/M Skull Fracture
Battle’s sign Raccoon eyes
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Head Trauma -

38. CONT..
 Halo Sign: A blood stain
surrounded by a yellowish stain. It
may seen on bed linens or the
head dressings and is highly
suggestive of a CSF leak. Bloody
CSF suggests a brain laceration
or contusion.

40. CLINICAL MANIFESTATIONS
OF BRAIN INJURY
 Altered level of consciousness
 Confusion
 Pupillary abnormalities
 Absent gag reflex
 Absent corneal reflex
 Sudden onset of neurologic
deficit

41. Cont..
Changes in vital signs
Vision and hearing
impairment
Sensory dysfunction
Headache
Vertigo
seizures

42. DIAGNOSIS
 PHYSICAL AND NEUROLOGICAL
ASSESSMENT (particularly GCS)
 X RAYS
 C. T
 M.R.I
 POSITRON EMISSION
TOMOGRAPHY
 LUMBAR PUNCTURE

43. MANAGEMENT
OF HEAD INJURY

44. PRE-HOSPITAL
MANAGEMENT
 It refers to the immediate
resuscitation ,stabilization
,immobilization of a patient at
the scene of injury and en route
to the hospital,improvements in
airway management,fluid
replacement,and immobilization
of the neck in case of cervical
fracture and safe transport by
land or air

45. Major goals in the care of severely
head injury clients
Prompt recognition and
treatment of hypoxia and acid
base disorders that can
contribute to cerebral edema
Controlling of increased ICP
Stabilization of other
conditions

46. ARRIVAL IN THE
EMERGENCY DEPT:
.Quick history of the injury
.Base line vital signs
.Stabilization and support of vital signs
.Cervical neck assessment
.Triage neurological examination
.Control of seizures if any
.ICP management
.LAB data on blood

47. AFTER STABILIZATION
 Additional information for history
 Ongoing assessment of neurological
and vital signs
 Comprehensive physical examinations
 Radiological data-CT scan,X-rays
 Tetanus vaccination
 Antibiotics
 Drainage of bladder and stomach

48. Medical management

49. MEDICAL MANAGEMENT
 CORTICOSTEROIDS EG: methyl
predinislone
 Osmotic diuretic eg: manitol
 Analgesics eg: morphine sulphate
 Anticonvulsants drugs eg: phenytoin
 Electrolytes Eg; magnesium sulphate
 Barbituates eg: phenobarbitone
 Calcium channel blockers Eg;
nimodipine

50. Surgical management
 Craniotomy
 Burr hole surgery- opening into
cranium to remove fluid and blood
beneath the dura.
 Shunt procedure is an alternative
pathway to redirect CSF.

51. Supportive measures
Ventilatory support
Seizure prevention
Fluid and electrolyte
maintenance
Nutritional support
Pain and anxiety management

52. Controlling ICP in Severely
Brain-Injured Patients
 Elevate the head of bed 30 degrees.
 • Maintain the patient’s head and
neck in neutral alignment (no
twisting).
 • Initiate measures to prevent the
Valsalva maneuver (eg, stool
softeners).
 Maintain normal body temperature.

53.  Administer O2 to maintain PaO2 > 90 mm
Hg.
 Maintain fluid balance with normal saline
solution.
 Avoid noxious stimuli (eg, excessive
suctioning, painful procedures).
 Administer sedation to reduce agitation.
 Maintain cerebral perfusion pressure > 70
mm Hg.

54. NURSING DIAGNOSES
 Altered cerebral tissue perfusion related
to increased ICP
 Ineffective breathing pattern rlt increased
ICP or brain stem injury
 Altered nutrition less than body
requirement rlt compromised
neurological function and stress of injury.

55.  Altered thought process rlt physiology of
injury
 Risk for injury rlt altered thought
process
 Ineffective family coping related to
unpredictability of out come.

56. Cont…
 Ineffective airway clearance related to
coma or bleeding into the air way
 altered cerebral tissue perfusion related to
hypotension ICH
 impaired physical mobility related to motor
sensory deficits

57.  Altered nutrition
 altered urinary elimination
 high risk for fluid volume deficit
 sleep pattern disturbance
 high risk for seizures
 high risk for infection
 altered thought process
 altered health maintenance

58. NURSING INTERVENTIONS
 MAINTAINING ADEQUATE
CEREBRAL PERFUSION
 MAINTAINING RESPIRATION
 MEETING NUTRITIONAL NEEDS
 PROMOTING COGNITIVE
FUNCTIONS
 PREVENTING INJURY
 STRENGTHENING FAMILY COPING

59. Discussion
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Head Trauma -

60. COMPLICATIONS
 EARLY COMPLICATIONS
 EDH
 SDH
 ICH
 INFECTIONS
 CAROTID ARTERY OCCLUSION
 ARDS

61. COMPLICATIONS
 LATE COMPLICATIONS
 SEVERE BRAIN DISFUNCTION
 BRAIN DEATH
 DEATH

62. PATIENT EDUCATION
 Review with family the signs of increased ICP
 Reinforce the ability pf cognitive , language
and physical functioning of the person with
brain injury and lengthy recovery period
 Teach family therapeutic use of touch and
music to calm the patient
 Provde them information regarding agencies
like BRAIN INJURY ASSOCIATION

63. Remember this can save your
HEAD

65. INTENSIVE CARE NURSING
MANAGEMENT-OBJECTIEVES
Objective-1
 Continuous assessment and monitoring
of neurological and other body systems
for early recognition and treatment of
problems and complications

66.  CONTROL OF INCREASED ICP
 Osmotic diuretics:-eg: Manitol
 cortico steroids-eg:Dexamethasone
 Elevation of head end to 30* angle
 Hyper ventilation
 Continuous CSF drainage
 Prevent increase of ICP
 Maintenance of normo-thermia

67. LAB INVESTIGATIONS
 Arterial blood gas analysis
 Hb ,hematocrit,WBC,DC,
 PT,
 Biochemistry-creatinine, Serum
electrolytes,
 BUN,calcium
 RBS
 Urine routine tests
 Culture and sensitivity

68. Objective 2
 Prevention of secondary brain
injury-
 Is by early recognition of problems and
complications.

69. Objective 3
 Administration of aggressive forms of
therapy-
 Barbiturate coma in ICU

70. PHARMACOLOGICAL
MANAGEMENT
 Anti –epileptics:- Phenytoin
 Osmotic diuretics:- Manitol
 Histamine antagonists: Cimetidine
 Anti-biotics
 Tetanus toxoid

71. Community and home care
 Observe for signs of post contusion
syndrome:- like
 Had ache ,lack of concentration
 Irritability,dizziness,insomnia
 Restlessness,anxiety,
 Easy fatigability,
 Alcohol intolerance

72.  Encourage family members to report
these symptoms
 Act as laison in home care services the
pt will need,while keeping in touch with
the patients primary care provider
 Provide necessary education to the
family members in
feeding,positioning,range of motion
exercises