This document defines and describes head injuries and their mechanisms and treatment. It begins by defining head injury and traumatic brain injury. It then describes different types of head injuries like open or closed injuries. It outlines primary and secondary brain injuries and different types of brain hematomas and edema that can occur. The document discusses signs, symptoms, assessments like the Glasgow Coma Scale, treatments like managing increased intracranial pressure, and expected outcomes for patients with head injuries.

2. HEAD INJURY - DEFINITION
• Any injury that results
in trauma to the SCALP,
SKULL or BRAIN.
• TRAUMATIC BRAIN
INJURY and HEAD
INJURY are often used
interchangeably.

3. HEAD INJURY - TYPES
OPEN HEAD INJURY:
There is penetration to the skull.
CLOSED HEAD INJURY
There is NO penetration to the skull.

4. COUP-CONTRECOUP INJURIES
• Damage may occur
directly under the site
of impact (COUP), or it
may occur on the side
opposite the impact
(CONTRECOUP).

5. HEAD INJURY - MECHANISMS
PRIMARY INTRACRANIAL INJURY
• It is the initial neuronal
damage that occurs
IMMEDIATELY as result of
trauma.
SECONDARY INTRACRANIAL
INJURY
• Secondary injuries are the
result of the
neurophysiological and
anatomic changes, which
occur from MINUTES to
DAYS after the original
trauma.

6. HEAD INJURY - MECHANISMS
PRIMARY INTRACRANIAL INJURY
• Cerebral Laceration
• Cerebral Contusion
• Epidural Hematoma
• Subdural Hematoma
• Subarachnoid Hematoma
• Intracerebral Hematoma
• Diffuse Axonal Injury
SECONDARY INTRACRANIAL
INJURY
• Edema
• Impaired Metabolism
• Altered Cerebral Blood Flow
• Free Radical Formation
• Excitotoxicity

7. SCALP INJURIES
LACERATIONS SUBGALEAL HEMATOMA

8. SKULL INJURIES
CT SCAN OT

9. SKULL INJURIES - BASILAR SKULL
FRACTURE
RACCOON EYE

10. SKULL INJURIES - BASILAR SKULL
FRACTURE

11. SKULL INJURIES - BASILAR SKULL
FRACTURE
BATTLE’S SIGN

12. SKULL INJURIES - BASILAR SKULL
FRACTURE
BLEEDING FROM THE EAR CANAL
CSF LEAKAGE FROM THE EAR OR
NOSE

13. Etiology and Pathophysiology
• Result from trauma, frequently seen after
motor vehicle accidents.

14. SKULL INJURIES (Fractures)
DEPRESSED FRACTURES/COMPOUND
DEPRESSED FRACTURES- break that
results in fragments or bone
penetrating the brain tissue
NON-DEPRESSED LINEAL
FRACTURES- Linear: simple break
in the bone

15. EPIDURAL HEMATOMA- hematoma forms
between the dura and the skull; may result from a laceration of
the middle meningeal artery
SCHEMATIC CT SCAN

16. SUBDURAL HEMATOMA- hematoma forms
between the dura and arachnoid layers; generally
follows venous damage
SCHEMATIC CT SCAN

17. SUBARACHNOID HEMATOMA
SCHEMATIC CT SCAN

18. INTRACEREBRAL HEMATOMA
SCHEMATIC CT SCAN

19. HEMATOMAS

20. CEREBRAL EDEMA
NORMAL CT SCAN CEREBRAL EDEMA

21. HEAD INJURY (DIFFUSE) - DIFFUSE
AXONAL INJURY

22. HEAD INJURY (DIFFUSE) -
CONCUSSION
• Temporary disruption of
synaptic activity
• Brain injury that does not
result in any evidence of
structural alteration.
• Return of consciousness
moments or minutes
after impact.
• There may be brief
confusion, disorientation,
headache, dizziness,
amnesia.
• CT scan is normal.

23. BRAIN CONTUSION- bruising of brain tissue, with
slight bleeding of small cerebral vessels into surrounding tissues
at site of impact (coup) or opposite to site (contracoup) as a
result of rebound reaction

24. SIGNS
Subjective
• Lethargy
• Indifference to surroundings
• Altered sensory function (e.g. visual or
auditory)

25. SIGNS
Objective:
A sign of ↑ICP
(INTRACRANIAL PRESSURE)
CUSHING REFLEX
↑ Blood Pressure
↓ Pulse Rate
↓ Respiratory Rate

26. SIGNS
• Lack of orientation to time and place
• Restlessness
• Labored respirations
• Positive Babinski sign (stroking bottom of the
foot causes dorsiflexion of the toes)
• Decreased level of consciousness

27. SIGNS
• A UNILATERAL , FIXED
DILATED PUPIL indicates
neurologic deterioration
may be secondary to
hypoxia, hypovolaemia or
hypoglycaemia, due to
↑ICP, and compression of
the 3rd Cranial Nerve
(OCULOMOTOR NERVE).
DILATED PUPIL

28. SIGNS

29. SIGNS
DECORTICATE POSTURING
• Arms Flexed
• Arms bent inward on the
chest
• Hands clenched into fists
• Legs Extended
• Feet turned Inward
• Score of 3 in the Motor
section of the Glasgow
Coma Scale

30. SIGNS
DECEREBRATE POSTURING
• Head is arched back
• Arms Extended by the sides
• Legs Extended
• Patient is rigid with the
teeth clenched.
• Score of 2 in the Motor
section of the Glasgow
Coma Scale

31. SYMPTOMS
• Confusion/Irritibility
• Drowsiness
• Dizziness
• Nausea & Vomiting
• Amnesia
• Speech/Swallowing
Difficulty
• CSF Leakage
• Ear Bleeding
• Numbness/Paralysis
• Coma

32. SYMPTOMS

33. Therapeutic Interventions
• Control seizures with anticonvulsants
• Mechanical ventilation; hyperventilation will
constrict cerebral vessels lowering ICP
• Reduce cerebral edema with glucocorticoids and
loop diuretics; there is disagreement regarding
their efficacy
• Maintain adequate fluid and electrolyte balance
• Surgical intervention in cases of depressed skull
fractures or hematomas

34. NURSING CARE
Assessment
1. Airway and breathing pattern
• Neurologic status
• Cranial Nerves
• Muscle Tone
• Muscle Power
• Sensations
• Walking Gait

35. 3. Signs of increased intracranial pressure
4. Circumstances of injury
5. Presence of glucose in clear drainage from
nose or ear, which indicates cerebrospinal fluid

36. DIAGNOSIS - PHYSICAL EXAMINATION
ABCDE
• A = AIRWAY
• B = BREATHING
• C = CIRCULATION
• D = DISABILITY
• E = EXPOSURE
• GLASGOW COMA SCALE
(GCS)

37. GLASGOW COMA SCALE
MINIMUM=3/15 MAXIMUM=15/15 INTUBATION <8/15

38. GLASGOW COMA SCALE (GCS)
SEVERITY SCORE
13-15
9-12
3-8
MILD
MODERATE
SEVERE

39. GLASGOW COMA SCALE (GCS)
SEVERITY LOSS OF CONSCIOUSNESS
0-30 mins
>30 mins to <24 hrs
>24 hrs
MILD
MODERATE
SEVERE

40. DIAGNOSIS - OTHERS
X-RAYS / MRI
ANGIOGRAPHY
EEG
TRANSCRANIAL DOPPLER

41. PLANNING/ IMPLEMENTATION
1. Observe for signs of increased intracranial pressure;
institute neurologic assessments every 15 minutes for
several hours, progressing to every hour and then
every 4 hours.
2. Maintain airway by suctioning as necessary (coughing
increases intracranial pressure); use an airway or
endotracheal tube
3. Keep the client’s head slightly elevated to reduce
venous pressure within the cranial cavity
4. Administer glucocorticoids and/ or diuretics if ordered

42. PLANNING/ IMPLEMENTATION
5. Institute seizure precautions; administer anticonvulsants if
ordered
6. Monitor for fluid or electrolyte imbalances; diabetes
insipidus or syndrome of inappropriate antidiuretic
hormone may occur
7. If the client’s eyes remain open, protect the corneas with
moistened pads, mineral oil, or ointment as ordered.
8. Support client’s nutritional needs; administer tube
feedings or assist with small frequent meals

43. PLANNING/ IMPLEMENTATION
9. Position the client to prevent pressure areas from
forming decubiti
10. Provide range-of motion exercise and splints to
prevent contracture
11. Provide auditory and tactile stimulation
12. Assist client to avoid activities that increase ICP such
as Vasalva’s maneuver, lifting, sneezing, and flexion of
head

44. PLANNING/ IMPLEMENTATION
13. Utilize hypothermia as ordered to reduce
temperature and metabolic demands
14. Recognize that confusion upon return of
consciousness can be a defense against additional
stress
15. Encourage client and family to participate in planning
and care
16. Provide opportunity for expression of grief

45. TREATMENT - ACUTE STAGE
(DISABILITY)
TREATMENT FOR ↑ICP
• IV Mannitol (Osmotic
Diuretic)
• IV Furosemide
• Hyperventilation

46. TREATMENT - ACUTE STAGE
(DISABILITY)
TREATMENT FOR ↑ICP
• If there are no counter-
indications (hypovolaemia,
spine injury) place the
patient in
“Reverse-Trendelenburg”
position
REVERSE-TRENDELENBURG

47. TREATMENT - ACUTE STAGE
(PARAMETERS)
MONITOR
• Blood Pressure
• Heart Rate
• Respiratory Rate
• S02, Etc02
• ECG
BLOOD SAMPLES
• Serum Electrolytes
• Arterial Blood Gas
• Hyper/Hypoglycaemia

48. TREATMENT - ACUTE STAGE
(SURGERY)
DECOMPRESSIVE CRANIOTOMY

49. Evaluation/ Outcomes
1. Maintains a patent airway
2. Improves level of consciousness
3. Remains free from injury
4. Participate in decisions about administration of
care
5. Maintains ideal body weight for age and frame
6. Identifies new coping skills to deal with changes
in life-style