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.
 HEAD INJURY - TYPES
OPEN HEAD INJURY: CLOSED HEAD INJURY
There is penetration to the skull. There is NO penetration to the skull.
 COUP-CONTRECOUP INJURIES

• Damage may occur

directly under the site
of impact (COUP), or it
may occur on the side
opposite the impact
(CONTRECOUP).
 HEAD INJURY - MECHANISMS
SECONDARY INTRACRANIAL
PRIMARY INTRACRANIAL INJURY INJURY

• It is the initial neuronal • Secondary injuries are the

damage that occurs result of the
IMMEDIATELY as result of neurophysiological and
trauma. anatomic changes, which
occur from MINUTES to
DAYS after the original
trauma.
 HEAD INJURY - MECHANISMS
SECONDARY INTRACRANIAL
PRIMARY INTRACRANIAL INJURY INJURY

• Cerebral Laceration • Edema

• Cerebral Contusion
• Impaired Metabolism
• Epidural Hematoma
• Subdural Hematoma • Altered Cerebral Blood Flow
• Subarachnoid Hematoma
• Intracerebral Hematoma • Free Radical Formation
• Diffuse Axonal Injury
• Excitotoxicity
 SCALP INJURIES
LACERATIONS SUBGALEAL HEMATOMA
 SKULL INJURIES
CT SCAN OT
SKULL INJURIES - BASILAR SKULL
FRACTURE
RACCOON EYE
SKULL INJURIES - BASILAR SKULL
FRACTURE
SKULL INJURIES - BASILAR SKULL
FRACTURE
BATTLE’S SIGN
 SKULL INJURIES - BASILAR SKULL
FRACTURE
CSF LEAKAGE FROM THE EAR OR
BLEEDING FROM THE EAR CANAL NOSE
 Etiology and Pathophysiology

• Result from trauma, frequently seen after

motor vehicle accidents.
 SKULL INJURIES (Fractures)
NON-DEPRESSED LINEAL
DEPRESSED FRACTURES/COMPOUND FRACTURES- Linear: simple break
DEPRESSED FRACTURES- break that in the bone
results in fragments or bone
penetrating the brain tissue
 EPIDURAL HEMATOMA- hematoma forms
between the dura and the skull; may result from a laceration of
the middle meningeal artery

SCHEMATIC CT SCAN
SUBDURAL HEMATOMA- hematoma forms
between the dura and arachnoid layers; generally
follows venous damage
SCHEMATIC CT SCAN
SUBARACHNOID HEMATOMA
SCHEMATIC CT SCAN
INTRACEREBRAL HEMATOMA
SCHEMATIC CT SCAN
HEMATOMAS
 CEREBRAL EDEMA
NORMAL CT SCAN CEREBRAL EDEMA
HEAD INJURY (DIFFUSE) - DIFFUSE
AXONAL INJURY
 HEAD INJURY (DIFFUSE) -
CONCUSSION
• Temporary disruption of • There may be brief
synaptic activity confusion, disorientation,
headache, dizziness,
• Brain injury that does not amnesia.
result in any evidence of
structural alteration. • CT scan is normal.

• Return of consciousness
moments or minutes
after impact.
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
 SIGNS
Subjective
• Lethargy
• Indifference to surroundings
• Altered sensory function (e.g. visual or
auditory)
 SIGNS
CUSHING REFLEX
Objective:

↑ Blood Pressure
A sign of ↑ICP
(INTRACRANIAL PRESSURE)
↓ Pulse Rate

↓ Respiratory Rate
 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
 SIGNS
DILATED PUPIL
• 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).
SIGNS
 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
 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
 SYMPTOMS
• Confusion/Irritibility • Speech/Swallowing
Difficulty
• Drowsiness
• CSF Leakage
• Dizziness
• Ear Bleeding
• Nausea & Vomiting
• Numbness/Paralysis
• Amnesia
• Coma
SYMPTOMS
 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
 NURSING CARE
Assessment
1. Airway and breathing pattern
• Neurologic status
• Cranial Nerves
• Muscle Tone
• Muscle Power
• Sensations
• Walking Gait
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
DIAGNOSIS - PHYSICAL EXAMINATION

ABCDE
• A = AIRWAY

• B = BREATHING • GLASGOW COMA SCALE

(GCS)
• C = CIRCULATION

• D = DISABILITY

• E = EXPOSURE
 GLASGOW COMA SCALE
MINIMUM=3/15 MAXIMUM=15/15 INTUBATION <8/15
GLASGOW COMA SCALE (GCS)
SEVERITY SCORE

MILD 13-15

MODERATE 9-12

SEVERE 3-8
GLASGOW COMA SCALE (GCS)
SEVERITY LOSS OF CONSCIOUSNESS

MILD 0-30 mins

MODERATE >30 mins to <24 hrs

SEVERE >24 hrs

 DIAGNOSIS - OTHERS
TRANSCRANIAL DOPPLER

X-RAYS / MRI

ANGIOGRAPHY

EEG
 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

 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
 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
 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

 TREATMENT - ACUTE STAGE
(DISABILITY)
TREATMENT FOR ↑ICP

• IV Mannitol (Osmotic
Diuretic)

• IV Furosemide

• Hyperventilation
 TREATMENT - ACUTE STAGE
(DISABILITY)
TREATMENT FOR ↑ICP REVERSE-TRENDELENBURG

• If there are no counter-

indications (hypovolaemia,
spine injury) place the
patient in
“Reverse-Trendelenburg”
position
 TREATMENT - ACUTE STAGE
(PARAMETERS)
MONITOR BLOOD SAMPLES
• Blood Pressure
• Serum Electrolytes
• Heart Rate
• Arterial Blood Gas
• Respiratory Rate

• Hyper/Hypoglycaemia
• S02, Etc02

• ECG
TREATMENT - ACUTE STAGE
(SURGERY)
DECOMPRESSIVE CRANIOTOMY
 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