HEAD INJURY

Is a broad classification that includes injury to the scalp, skull or brain. It is the most common cause of death from trauma in the United States. Approximately 1.4 million people receive treatment for head injuries every year. Of these, 235,000 are being hospitalized, 80,000 have permanent disabilities and 50,000 people die.

 Head injury - classified as either close or open (penetrating) Closed head injury -means you received a hard blow to the head from striking an object, but the object did not break the skull. Open, or penetrating- head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

 Subarachnoid hemorrhage - bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space. Subdural hematoma - collection of blood on the surface of the brain.

Brain suffers traumatic injury

Brain swelling or bleeding increases intracranial volume

Pressure in blood vessels within the brain causes blood flow to the brain to slow

Rigid cranium allows no room for expansion of contents so intracranial pressure increases

Cerebral hypoxia and ischemia occur

Intracranial pressure continues to rise. Brain may be herniated

Cerebral blood flow ceases

 CLINICAL MANIFESTATIONS: Local Injuries: Depends on the severity and distribution of brain injury. Persistent, localized pain usually suggest that a fracture is present Fractures in the cranial vault may or may not produce swelling in the region of fracture.

 FRACTURES OF THE BASE OF THE SKULL Tend to transverse the paranasal sinus of the frontal lobe of the middle ear located in the temporal lobe. Thus, they frequently produce HEMORRHAGE from the NOSE, PHARYNX, or EARS, and BLOOD may appear under the CONJUNCTIVA. An area of ECCHYMOSIS may be seen over the mastoid. Basal skull fractures; CSF otorrhea, CSF rhinorrhea, halo sign, Bloody CSF suggests a brain laceration

 ASSESSMENT AND DIAGNOSTIC FINDINGS: Physical examination CT scan Magnetic resonance imaging (MRI) Skull X-ray

MEDICAL MANAGEMENT Nondepressed skull fracture: generally do not require surgical treatment nursing personnel may observe the patient in the hospital, but if no underlying brain injury is present, the patient may be allowed to return home.

Depressed skull fractures:

usually require surgery before surgery, scalp is shaved and cleansed with copious amount of saline to remove debris Large defects can be repaired immediately with bone or artificial grafts if significant edema is present, repair of the defect may be delayed for 3-6 months penetrating wounds require surgical debridement to remove foreign bodies and to control hemorrhage IV antibiotic treatment is instituted immediately and blood component is administered if indicated

 Fractures of the base of the skull are serious because they are usually open involving paranasal sinuses and middle and external ear that results in CSF leakage. Nasopharynx and the external ear should be kept clean. a piece of sterile cotton is placed loosely in the ear patient who is conscious must be cautioned not to blow his or her nose. Head is elevated 30 degrees to reduced ICP and promote spontaneous closure of the leak

BRAIN INJURY the most important consideration in any head injury is whether the brain is injured minor injury can cause significant brain damage secondary to obstructed blood flow and decreased tissue perfusion because the cerebral cells need an uninterrupted blood supply to obtain these nutrients, irreversible brain damage and cell death occur if the blood supply is interrupted for even a few minutes

Closed (blunt) brain injury occurs when the head accelerates and then rapidly decelerates or collides with another object brain tissue is damaged but there is no opening through the skull and dura

Open brain injury occurs when an object penetrates the skull, enters the brain and damages the soft brain tissue in its path or when the blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain

TYPES OF BRAIN INJURY: 1. Concussion A temporary loss of neurologic function with no apparent structural damage. Also referred to as a mild traumatic brain injury Generally involves a period of unconsciousness lasting from a few seconds to a few minutes Dizziness and spots before the eyes ( seeing stars ) or can cause complete loss of consciousness for a time

 Frontal lobe is affected: bizarre irrational behavior Temporal lobe: temporary amnesia or disorientation When occurrence of the symptoms such as headache, dizziness, lethargy, irritability, and anxiety after injury is referred to as postconcussion syndrome. The patient is advised to resume normal activities slowly; the exact recovery time is not known.

Observe for the following signs and symptoms: Difficulty in awakening Difficulty in speaking Confusion Severe headache Vomiting Weakness of one side of the body Residual effects of concussion: Headache Lethargy Personality and behavior changes Attention deficits Difficulty with memory Disruption in work habits

2. Contusion A more severe injury than concussion Brain is bruised with possible surface hemorrhage The patient is unconscious for more than a few seconds or minutes.

Clinical signs and symptoms: Lie motionless Faint pulse Shallow respirations Cool, pale skin Involuntary evacuation of the bowels and bladder occurs. The patient may be aroused with effort but soon slips back into unconsciousness. Conversely, patients may recover consciousness but pass into a stage of cerebral irritability. Gradually, vital signs and other body functions return to normal, but full recovery can be delayed for months.

Diffuse Axonal Injury Diffuse Axonal injury involves widespread damage to axons in the cerebral hemispheres, corpus callosum and brain stem. It can be seen with mild, moderate or severe head trauma. The patient experiences no lucid intervals, immediate coma, decorticate and decerebrate posturing and global edema. Diagnosis is made by clinical symptoms in conjunction with CT or MRI scan. Recovery depends on the severity of the axonal injury.

Intracranial Hemorrhage Hematomas that develop within the cranial vault are the most serious brain injuries. A hematoma may be epidural, subdural or intracerebral. Major symptoms are frequently delayed until the hematoma is large enough to cause distortion of the brain and increased ICP. In general, a rapidly developing, even if small, may be fatal, whereas a larger butslowly developing one may allow compensation for increases in ICP.

 A. Epidural Hematoma - After a head injury, blood may collect in the epidural space between the skull and the dura. Hemmorhage from this artery causes rapid pressure on the brain. The symptoms are momentarily loss of consciousness followed by and interval of apparent recovery. Although the lucid interval is considered a classic characteristic of an epidural hematoma, no lucid interval has been reported in many patients with this lesion and therefore it should not be considered a critical defining.

B. Subdural hematoma - is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid. A subdural hemorrhage is more frequently venous in origin and is caused by the rupture of small vessels that bridge the subdural space. It can be acute, subacute or chronic.

Acute and Subacute Subdural Hematoma - It is associated with major head injuries involving contusion or laceration. Clinical symptoms develop over 24 to 48 hours. Signs and symptoms are change in LOC, pupillary signs and hemiparesis. Subacute subdural hematomas are the result of less severe contusions and head trauma. Clinical manifestations usually appear between 48 and 2 weeks after the injury. Signs and symptoms are the same with acute subdural hematoma.

b. Chronic Subdural Hematoma - can develop from seemingly minor head injuries and are seen most frequently in the elderly. The elderly are prone to this injury secondary to brain atrophy. The blood within the brain changes in character in 2 to 4 days, becoming thicker and darker. In a few weeks the clot breaks down and has the color of consistency of motor oil.

 . Intracerebral Hemmorhage - A bleeding into the substance of the brain It is commonly seen in head injuries when force is exerted to the head and over a small area. This may result from: Systemic hypertension Rupture of a vessel Vascular anomalies Intracranial tumors Bleeding disorders Complications of anticoagulant therapy

 Treatment consists of an openings through the skull to decrease ICP emergently, remove the clot and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding . A drain is usually inserted after creation of burr holes or a craniotomy to prevent accumulation of blood.

 Management includes supportive care, control ICP and careful administrations of fluids, electrolytes and antihypertensive medications. Surgical intervention of craniotomy or craniectomy permits the removal of the blood clot and hemorrhage.

 Medical Management Initial management The primary brain injuries sustained at the time of trauma cannot be reversed. In order to minimize secondary brain damage, the initial management of any patient with TBI is to prevent hypoxia, maintains an adequate BP and to recognize and treat surgically correctable intracranial lesions. In addition, other concomitant injuries should be recognized and stabilized.

 Nondepressed skull fractures generally do not require surgical treatment but require close observation of patient Depressed skull fractures maybe managed conservatively; contaminated or deforming fractures require surgery. Antibiotic treatment is instituted with blood component therapy, if indicated.

 Spinal Tap Introduction A spinal tap is a procedure performed when a doctor needs to look at the cerebrospinal fluid (also known as spinal fluid). Spinal tap is also referred to as a lumbar puncture, or LP.)

 Some of the reasons your doctor may want to do a spinal tap include the following: To look for infection To check to see if there is bleeding around the brain (subarachnoid hemorrhage) To look for causes of unexplained seizures To look for causes of headaches

 Cerebrospinal fluid is a liquid that bathes the brain and spinal cord. An adult has about 140 mL (just under 5 oz) of spinal fluid. Typically, an adult makes 30-100 mL of spinal fluid daily. Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms

 Typically a catheter is inserted into a large artery (such as the femoral artery) and threaded through the circulatory system to the carotid artery, where a contrast agent is injected. A series of radiographs is taken as the contrast agent spreads through the brain's arterial system, then a second series as it reaches the venous system.

 NURSING INTERVENTIONS MONITOR FOR DECLINING NEUROLOGIC FUNCTION

LEVEL OF CONSCIOUSNESS Glasgow coma scale is used to assess LOC at regular intervals because changes in LOC precede all other changes in vital and neurologic signs. VITAL SIGNS monitored at frequent intervals to assess intracranial status.

 MOTOR FUNCTION is assessed frequently by observing spontaneous movements, asking the patient to raise and lower the extremities, and comparing the strength and equality of the upper and lower extremities at periodic intervals. OTHER NEUROLOGIC SIGNS The patient with a head injury may develop deficits such as anosmia (lack of sense of smell), eye movement abnormalities, aphasia, memory deficits, and post traumatic seizures or epilepsy.

 MAINTAINING THE AIRWAY Maintain the unconscious patient in a position that facilitates drainage of oral secretions, with the head of the bed elevated about 30 degrees to decrease intracranial venous pressure. Establish effective suctioning procedures. Guard against aspiration and respiratory insufficiency. Closely monitor arterial blood gas values. Monitor the patient who is receiving mechanical ventilation. Monitor for pulmonary complications such as Acute Respiratory Syndrome (ARDS) and Pneumonia.

 MONITORING FLUID AND ELECTROLYTE BALANCE Monitoring of serum electrolyte level. Serial studies of blood and urine electrolytes and osmolality are carried out because head injuries may be accompanied by disorders of sodium regulation. Monitor Intake and output.

 PROMOTING ADEQUATE NUTRITION

Early initiation of nutritional therapy has been shown to improve outcomes in patients with head injury. Parenteral nutrition via a central line or enteral feedings administered via a nasogastric or nasojejunal feeding tubes should be started within 48 hours after admission.

PREVENTING INJURY Patient is assessed to ensure that oxygenation is

adequate and bladder is not distended. Padded side rails are used or the patient s hand are wrapped in mitsto protect the patient from self-injury and dislodging of tubes. Opioids are avoided as means of controlling restlessness, because these medications depress respiration, constrict pupils and alter responsiveness.

 Environmental Stimuli are reduced by keeping the room quiet, limiting visitors, speaking calmly and providing frequent orientation information. Adequate lighting is provided to prevent visual hallucinations Efforts are made to minimize disruption of the patient s sleep/wake cycles MAINTAINING BODY TEMPERATURE Monitor the patient s temperature every 2-4 hours. Cooling blankets should be used with caution so as not to induce shivering which increases ICP.

MAINTAINING SKIN INTEGRITY

Assessing all body surfaces and documenting skin integrity every 8 hours. Turning and repositioning the patient every 2 hours. Providing skin care every 4 hours. Assisting the patient to get out of bed to a chair 3 times a day

IMPROVING COGNITIVE FUNCTIONING A nueropsychologist (specialist in evaluating and treating cognitive problems) plans a program and initiates therapy or counseling to help the patient reach maximal potential. Cognitive rehablilitation activities help the patient to devise new problem-solving strategies

PREVENTING SLEEP PATTERN DISTURBANCES Environmental noise is decreased. Room lights are dimmed Back rubs and other measures to increase comfort can assist in promoting sleep and rest

 MONITORING AND MANAGING POTENTIAL COMPLICATIONS

DECREASE CEREBRAL PERFUSION - Elevation of head and increase of IV fluid to decrease cerebral edema and increase venous outflow from the brain. Systematic hypotension which causes vasoconstriction and a significant decrease in CPP is treated with increase IV fluid. CEREBRAL EDEMA AND HERNIATION Cerebral edema is most common cause of increased ICP with head injury welling, peaking approximately 48 to 72 hours. IMPAIRED OXYGENATION AND VENTILATION Mechanical ventilation, endotracheal intubation.

 POST TRAUMATIC SEIZURES

Classified as immediate (within 24 hours after injury) early (within 1 to 7 days after injury) or late (more than 7 days). Seizure prophylaxis is given especially in the immediate and early phase of recovery because seizure increases ICP an decrease oxygenation. However, they medication can impair cognitive performance and can prolong the duration of rehabilitation.

 The nurse must assess the patient for risk

factors for developing seizure before given medication such as brain contusion with subdural hematoma, skull fracture, loss of consciousness or amnesia of 1 day or more and age.