1. SEVERE BRAIN/HEAD INJURY
INTRODUCTION:
This refers to injury to the brain, skull or both. Such injuries are sufficient magnitude to require
medical attention.
CAUSES
1. Acceleration and deceleration:
Brain is semi-solid so when subjected to trauma , if exposed to violent movement , a patient
suffers from concussion - temporary diffuse injury to brain
2. Skull distortion or head rotation
Responsible for serious head injury. The brain responds to force by grinding forward and
rotating or turning within compartment.
The rotational forces produces distortion of brain, tension and shearing of tissues- thus
cerebral contusion ( bruising).
PATHOPHYSIOLOGY CHANGES ASSOCIATED WITH SEVERE BRAIN INJURY
 Cerebral edema
 Increased intra-cranial pressure
 Hemorrhage
 Meningeal tear
 Metabolic disorder
 Temperature grossly elevated
 Contusion of certain cranial nerves
CEREBRAL EDEMA
Due to injury there develops increased cerebral blood flow, then pressure within capillaries and
venules…..then alteration of BBB which results of fluid into extracellular space-oedema. It
increases cerebral mass and thus causes ICP.

2. INCREASED INTRA-CRANIAL PRESSURE
Normal ICP average 10mmHg and rises when compensatory mechanisms are exhausted. Increased
ICP is as a result of cerebral edema or expanding lesion such as hematoma.
CLINICAL FEATURES OF INCREASED INTRA-CRANIAL PRESSURE
 Rising systolic BP
 Widening pulse pressure
 Bradycardia
 Respiratory irregularity due to pressure on medulla oblongata
 Pupil abnormality- fully dilated
 Papilloedema
 Visual disturbance
 Motor dysfunction
 Headache
 Vomiting
 Altered level of consciousness
 Altered temp
 Loss of brain stem reflex
MANAGEMENT OF INCREASED ICP
 Osmotic diuresis eg IV mannitol 0.25-1.0 gm kg/bd/wt daily
 IV dexamethasome 12-20 mgs 6 hourly, which is a corticosteroids that stabilizes cell
membrane and decreases oedema. The dose is reduced gradually to prevent adrenal
insufficiency.
 Lasix may be used to supplement
 Maintain normal temp
 If hyperthermia, expose
 If hypothermia warm gradually
 Quiet environment nursing
 Surgery maybe indicated to drain hematoma
 Avoid dehydration or overhydration
 Maintain head and neck stable
HAEMORRHAGE
Maybe epidural, subdural, intracerebral hematoma and sub-arachnoid bleeding. It contributes to
increased ICP and subsequent herniation of brain through foramen magnum. Haemorrhage from
basilar artery and carotid artery is always fatal

3. MENINGEAL TEAR MAY OCCUR CAUSING:
Otorrhea- leakage of CSF through ear
Rhinorrhea-leakage of CSF through nose
TEMP ELAVATION
This is because of injury to the hypothalamus
CONTUSION OF CERTAIN CRANIAL NERVES
Particilary olfactory, facial, auditory which shows dysfuntion
NURSING DIAGNOSES
 Altered cerebral tissue perfusion
 Risk of increased ICP
 Hyperthermia
 Pain
 Impaired physical mobility
 Risk of infection
DIAGNOSTIC PROCEDURES
1) History of trauma
2) Neurological examination and general physical examination e.g decreased level of
consciousness, leakage of CSF from ears and nose
3) X-ray of skull, CT, MRI
4) Blood Hb, grouping and matching
MANAGEMENT
1) Immobilize head and neck and lower limbs. Assume neck injury as well
2) Ensure clear airway and ventilate oxygen by nasal catheter. Anticipate need for
intubatrion
3) Maintain a quiet environment
4) Institute seizure precautions:
 Have padded side rails and keep them up
 Have a tongue depressor in a receiver on bed side
 Have sunction machine on bedside
 Have oxygen by bedside

4.  If seizures occur:
i. Stay with the patient , ensure clear airway
ii. Put patient on iv diazepam 10mgs initially then phentyon 300mgs in 4
divided doses daily IV till controlled, then through N/G tube , then orally as
condition allows for at least 2yrs to prevent post traumatic eplilepsy.
5) Prevent and manage infections:
To avoid meningitis and wound infection, a combination of 2 antibiotics:
Crystapen 2-4 mega units 6 hourly 7-10 days
Flagyl IV 500mgs (over 20 mins) 8 hourly
6) Management of increased gastric secretions:
This is due to stress. Will be reduced by antacids 4-6 hourly through N/G
7) Neurological assement:
 Level of consciousness
 Pupillary size, shape, and reaction
 Check for gang reflex-if none prone to aspiration pneumoniae
 Respiratory rate- rhythm and characteristics
 Blood pressure- hypotension may indicate occult bleeding and aggressive search
for bleeding must be done. Hypertension may indicate ICP
 Pulse and temperature
 Hyperthermia due to injury of hypothalamus
GENERAL CARE
If loss of corneal reflex, lubricate corneal 4 hourly and apply shield to prevent damage .
visual adequacy to be evaluated as soon as possible.
Encourage patient to wake up. Turn 2 hourly - side to back to side
Maintain body hygiene , start physiotherapy to prevent complications. Start assessing
functional problems e.g speech
Encourage patient to do as much of their own personal hygiene and dressing.
Encourage to express feelings
PREPARATION FOR DISCHARGE
Share health messages with family as patients needs are complex. Some may require
intensive home care
Plan arrange for follow up care- direct to community resources that offer support.