This document discusses the care of patients with severe head injuries. It covers the physiology of head injuries, types of injuries including skull fractures and brain injuries, assessment using the Glasgow Coma Scale, and monitoring of vital signs and intracranial pressure. Special issues in management are addressed, such as oxygenation, blood pressure control, seizure prophylaxis, and prevention of secondary injuries. A multidisciplinary approach is needed with nursing playing a key role in patient safety, rehabilitation, and family support.

1. CARE OF HEAD INJURY
(Severe)

2. General care of Unconscious patient
ICU Bundles
Tracheostomy and care
Ventilatory Management

3. Head Injury
• Introduction
• Physiology/Pathology
• Assessment/Examination/monitoring
• Investigation
• Special Issues
• Conclusion

4. Introduction

5. Introduction: Problem Statement
High Incidence: Isolated/Poly trauma
Affects high percentage of young population
High mortality and morbidity
Long stay in ICU/Hospital
lifelong physical, emotional, cognitive, and social
disability

6. Classification of Head Injury
Scalp Injury
The scalp has many blood vessels, so any scalp injury may
bleed profusely. Control bleeding with direct pressure
Skull Injury
Skull injury includes fracture to cranium and the face.
Depressed fractures and Linear fractures are common. If severe
enough there can be injury to the brain
Brain Injury
Brain injury can be classified as direct or indirect. Direct injuries
to the brain can occur in open head injuries

7. Mechanism of Brain Injury
Primary Brain Injury
sustained at time of accident
contusion, damage to blood vessels, DAI
Secondary Brain Injury
due to decrease in oxygenation of brain as a result of
Ischemia/hypotension/hypoxia/cerebral oedema/raised
ICP/brain herniation

8. Grades of Head Injury
MILD: 13-15
MODERATE: 9-12
SEVERE: <8
Confounded by intoxication

9. Physiology/Pathology

10. Highly Vascular Structure
(20% of Cardiac output ie 750ml/min)
Lacks oxygen/glucose reserve
(Poorly Compensate)

11. Monro Kellie Hypothesis
RIGID SKULL: Tight Intracranial compartment
ICP (7-15mm Hg) depends on: Brain + Blood + Cerebro-
spinal fluid (CSF)
CPP = MAP -ICP

12. Intracranial Pressure (ICP)
TBI
Brain becomes edematous and stiffer
Decompensation
Cellular Death and edema
Brain swelling worsens and the cycle
repeats

13. Intracranial Pressure (ICP)

14. Raised ICP: Intracranial Hypertension
Associated with adverse outcome.
BRAIN
(Brain swelling, Surgery, Craniectomy)
Obstruction to CSF flow/ absorption
(CSF removal, EVD, VP shunt)

15. Obstructed Venous outflow
Venous sinus thrombosis
Neck region
(avoid central line in neck/ tight ETT bandages/
extreme neck rotation/ HOB elevation)
Thoracic causes
(Tension Pneumothorax/ high airway pressures/ high
level of PEEP/ Coughing/ Straining/Frequent suctioning)

16. Diagnosis

17. CT Scan
On admission, a patient with severe TBI
undergoes CT brain scanning
A follow-up scan is obtained (within the next 24
hours) as clinically indicated
(if the patient’s neurologic status deteriorates or
sudden rise in ICP occurs)

18. EDH

19. SDH

20. Contusion

21. Penetrating Injury

22. DAI

23. Assessment
Examination
&
Monitoring

24. A
B
C
D
E

25. Neck Immobilisation

26. 26
Basic monitoring
• Bedside Neuro Charting
– Level of consciousness: Glasgow Coma Scale
– Pupillary size, symmetry, and reaction to light (PEARL)
– Spontaneous movement/Muscle Tone/Posturing/Reflexes
– Respiratory Pattern
– Response to pain
• 3-lead-ECG
• NIBP/IBP
• Pulse oximetry
• Capnography (ventilated patients)
• ICP (in selected patients)

27. Local Examination: Racoon Eyes

28. Base of Skull

29. Any other clues
CSF Rhinorrhoea
CSF Otorrhoea

30. Battle’s Sign

31. Glasgow Coma Scale

32. Eye Opening

33. Verbal

34. Verbal Response

35. Verbal Response

36. Motor: M5 response

37. M4 response

38. M3 response

39. M2 response

40. Different Motor Response
BEST
RESPONSE

41. Pupillary Reaction

42. Management
of
Special Issues

43. Low oxygenation Saturation
Oxygenation
Ventilatory Support
Tracheostomy
Ventilation
Carbon dioxide (CO2) value should be
maintained in the low-normal range
(35-40 mmHg)
Nursing care includes continual monitoring for
hypoventilation and assisted secretion removal

44. Blood pressure and volume
management
Hypotension should be avoided
Multiple IV access or CVC placement
vasopressors
ICP monitoring

45. Osmotherapy
To remove excess fluid from brain tissue
Mannitol and Hypertonic saline can be used
Seizure prophylaxis
Increase the risk of nonepileptic seizures in TBI
Seizures increase metabolic activity and oxygen
demands, which may further compromise the damaged
brain

46. Anaesthetic, sedatives, and analgesic
agents
Short acting drugs like propofol and fentanyl are used.
Hypotension is avoided
Daily assessment of withdrawal of sedation
Written protocol/doses in ICU
Temperature management
Damaged brain is more susceptible to increased
temperature
Maintain normothermia/ aggresively treat
hyperthermia

47. Nutrition
NG tube or Orogastric tubes
Increased metabolic demands
Percutaneous gastrostomy tube may be used
Positioning
Head of the bed elevated at least 30 degrees
Neck in neutral position
Skin care and prevention of Bed sore

48. Venous thromboembolism
prophylaxis
Antiembolic stockings or pneumatic
compression devices (DVT pumps)
Low-molecular-weight heparin may be
given after risk of haemorrhage has passed
Stress Ulcer prophylaxis

49. Bowel and Bladder Care
Prevention of CAUTI/use of male cath
Osmotherapy, NG feeding and limited
mobility leads to constipation
A preventive bowel care regimen should be
used

50. Ensuring patient safety
If the patient becomes restless or agitated, investigate
the cause and take appropriate interventions
Discomfort resulting from pain, constipation, urinary
retention, feeling too hot or too cold, wrinkled bed
linens, body positioning, or pressure points caused by
splints
Try communicating with patient
If restraints are needed, they should be applied for the
shortest duration
Prevent Contractures

51. Rehabilitation and Family
Counselling
Long process and multidisciplinary approach
Start range of motion exercises and early out of bed
mobilization
Prepare family members for good days and bad days
Family members are key members for ongoing support
so involve them early
Provide emotional support to them

52. Conclusion

53. Conclusion
Advances in emergency and critical care have
considerably reduced the death rate from TBI
Providing prompt, state-of-the-art care may help
improve the odds that TBI patient will survive
and, perhaps, spare him a lifetime of severe
disability
Multidisciplinary team approach is needed for
patient care

54. Nurses have pivotal role in such
profoundly life-altering injury