sskeleton0

Head Injury
 Head Injury
• Head injuries refer to injuries that occur
to the scalp, skull, brain, and underlying
tissue and blood vessels in the head.

• Traumatic brain injuries occur as a result

of
– Motor vehicle crashes,
– Violence,
– Falls
– Penetrating trauma.
 Head Injury
Head injury may produce

• Disturbance in the level of consciousness

• Changing in the cognitive abilities
• Changing physical functioning
• Changing behavioral and emotional
functioning.
 Mechanisms of injury
Primary injury

• Is a result of the initial injury. The

damage resulting from mechanical forces
directly applied to the cells and the tissue
of the initial traumatic event.

• Primary injury includes contusion,

laceration or hemorrhage.
 Primary injury
• It occur at the time of original insult
• Irreversible cellular injury as a direct result of the
injury
• Direct damage done to brain parenchyma and
associated with vascular injuries
• Brain tissue can be lacerated, punctured or bruised
by broken bones or foreign bodies
• Damage is already done and irreversible
 Secondary injury
• Damage that occurs after the initial insult (ongoing
injury processes)
• Damage to cells that are not initially injured
• Occurs hours to weeks after injury as a result of
Intracranial hemorrhage
Cerebral edema
Increased ICP
End result is increased intracranial pressure
(ICP) and/or herniation
Mass effect and subsequent elevated ICP and
mechanical shifting leading to herniation
 Secondary injury
• Intra cranial causes- Intra cranial
hypertension, Cerebral hematoma/edema,
Hydrocephalus, Seizures, Cerebral vasospasm,
Infection

• Systemic- Hypotension, Hypoxemia,

Hyperthermia, Hyponatremia,
Hypo/hyperglycemia
 Signs and symptoms of head
injury

• Mild head injury

• Moderate head injury

• Severe head injury

 Traumatic brain injury

Severity GCS LOC PTA

Mild 13–15 <20 min-1 hr <24 hr
Moderate 9–12 1 – 24 hrs. > 24 hrs.
- <7days
Severe 3–8 >24 hrs. >7 days

GCS = Glasgow Coma Scale

LOC = Loss of consciousness
PTA = Posttraumatic amnesia
 Mild head injury
• A person with a mild head injury may remain conscious.
• A person with a mild head injury may experience
– Loss of consciousness for few seconds or minutes (less
than 30 minutes)
– Headache
– Mental confusion
– Dizziness
– Double vision, blurred vision, or tired eyes
– Fatigue or lethargy
– Behavioral or mood changes
– Trouble with memory, concentration, attention, or
thinking
– Symptoms remain the same or get better; worsening
symtptoms indicate a more severe injury.
• Glasgow Coma Score (GCS): 13-15
• No abnormality on CT scan.
 Moderate head injury
The person may experience one or more of
the following:
• Loss of consciousness for more than 30 minutes,
but less than 24 hours
• Persistent, or worsening headache
• Repeated vomiting or nausea
• Confusion, restlessness
• Convulsions or seizures (single event immediately
after the injury)
• Large scalp bruises, hematoma or laceration.
• GCS Score of 9-12
• May have abnormality on CT scan
 Severe head injury
The person may experience one or more of
the following:
• Unconsciousness for more than 24 hours
• Amnesia for more than 24 hours
• CSF leak from nose or ears
• Localized neurological signs
• Unequal pupils size
• Weakness in a limb
• Convulsions or seizures (more than single
event immediately after the injury)
• May have a cerebral contusion, laceration, or
intracranial hematoma.
• Glasgow Coma Score (GCS): 3-8
 Classifications of head injury

The damage from head injuries can be

• Focal (confined to one area)

• Diffuse (involving the entire brain)

 Focal injuries
Scalp injuries
• Occurs as a result of excessive force
applied to the scalp.
• It may include abrasion or laceration to
the skin.
• These injuries cause profuse amount of
bleeding due to high vascularity of the
scalp.
 Focal injuries
Skull fractures
• Skull fractures occur when the bone of
the skull breaks.

• Skull fracture may be compound

(occurring with an open wound) or
displaced (closed fracture in which the
edges of the fracture no longer meet).
 Focal injuries
Depressed skull fractures
• Fractures in which a piece
of the broken bone is
pressed into the brain
tissue.
• This is usually felt as a
depression on palpitation.
• Depressed skull fractures
often require surgical
elevation of the bone.
 Focal injuries
Linear skull fracture
• Appears as a thin line
radiographically, and
there is no bone
displacement.

• No treatment is
required for most
linear skull fractures.
 Focal injuries
Basal skull facture
• A fracture which involves the base or floor of
the skull.
• Features indicating skull base fracture
involve:
– Raccoon eyes: a ring like sign of bruising
around the eyes.
– Battle sign: Bruising behind the ear.
– CSF Otorrhea: CSF drainage from the ear.
– CSF Rhinorrhea: CSF drainage from the
nose.
CSF Otorrhea

Battle sign Raccoon eyes

 Focal injuries
• For a patient with basal skull fracture, the
placement of nasogastric tube and
nasotracheal intubation should be avoided.
Placement of an orogastric tube or orotracheal
intubation is a better option for these patients.

• A concern with basal skull fracture is the

possibility of infection. Hence, a broad-
spectrum antibiotic should be given and also
a Tetanus injection should be administered.
 Focal injuries
Hemorrhage
• Epidural hematoma
Bleeding between the skull and dura mater.
• Subdural hematoma
Bleeding between dura mater and the surface of
the brain.
Subarachnoid hematoma
• Blood in the space under the arachnoid
membrane.
Intracerebral hematoma
• Blood clots located within the brain tissue itself.
 Epidural hematoma
• Blood connect in the epidural space between the
skull and the dura
• Result from skull fracture
• Momentary loss of consciousness
• Signs of elevation of ICP
Subdural hematoma
• Collection of blood between dura and the brain
• Causes include trauma and rupture of aneurysm
 Subarachnoid
hemorrhage
• Accumulation of blood
throughout the
subarachnoid space
• Signs and symptoms
include headache,
reduced level of
consciousness, nuchal
rigidity (stiff neck, often
accompanied by pain
when trying to bend the
neck forward.) and
hemiplegia
 Intra cerebral hemorrhage

• Bleeding into the substance of the

brain
• Seen in injuries when force is exerted
to the head over a small area
• Also result from rupture of aneurysm,
vascular anomalies, intra cranial
tumors and complications of
anticoagulant therapy
• Signs and symptoms of neurologic
deficits and headache
 Focal injuries
Cerebral contusion
• A focal injury that occurs as a result of
laceration of the microvessles.
• It is a bruise of the brain tissue.
• A contusion causes bleeding and
swelling inside of the brain around the
area where the head was struck.
 Diffuse brain injuries
Concussion

• A concussion is defined as any alteration in mental status

resulting from trauma that may or may not involve a loss of
consciousness.
• A temporary loss of consciousness may occur immediately
following the trauma due to the shock waves from the blow.
• It is often followed by rapid and compete recovery
(reversible within minutes to hours).
• A concussion is associated with a variety of symptoms such
as:
– Dizziness
– Confusion
– Headache
– Visual disturbance
– Nausea and vomiting
 Neurological sequalae of brain injury
Cranial Nerves:
•Anosmia: Loss of smell.
•Vision Impairment: Includes blindness and visual field
defects.
•Diplopia/Strabismus: Double vision or misalignment of the
eyes.
•Hearing & Balance Disturbance: Hearing loss or issues
with equilibrium.
Motor Disorders:
•Paralysis (Mono-, Hemi-, Quadriplegia): Loss of muscle
function in one limb, one side, or all four limbs.
•Ataxia: Lack of voluntary coordination of muscle
movements.
•Dyspraxia: Impaired motor skill development and
coordination.
Sensory, Autonomic, Endocrine,
and Nerve Disorders
• Sensory Disorders:
• Anaesthesia: Loss of sensation.
• Abnormal Sensations: Tingling,
numbness, or burning feelings.
• Pain Syndromes: Chronic or neuropathic
pain.
 Autonomic Dysfunction:

• Bladder/Bowel Issues: Incontinence or

retention.
• Cardiovascular Problems: Blood pressure
irregularities.
• Respiratory Issues: Breathing difficulties.
• Gut Dysfunction: Digestive problems.
• Sexual Function Alterations: Impairments
in sexual health.
 Endocrine Dysfunction:

• Pituitary Dysfunction: Hormonal

imbalances due to pituitary gland issues.
• Neurological Injuries:
• Spinal Cord Injury: Damage affecting
motor, sensory, and autonomic functions.
• Peripheral Nerve Injury: Damage leading
to weakness, numbness, or pain.
 Diagnosis of head injury

• A brief initial history taking

• Physical examination
Priority of assessment and care includes
– Airway status
– Breathing status
– Circulation status
– Neurological examination
 Neurological examination
• Level of consciousness
• Cognitive function (ask about the person, place
and time)
• Glasgow Coma Score (eye opening, verbal
response & motor response):
– 13-15 is classified as mild head injury
– 9-12 is classified as moderate head injury
– 3-8 is classified as severe head injury
• A screening neurological examination to include
pupil size, symmetry & reactivity.
• Assess CSF drainage from the ear or the nose
• Assess other body systems.
 Radiological assessment

CT scanning

Magnetic Resonance Imaging (MRI)

Electroencephalogram (EEG)
When to Get Immediate Cervical
Spine Imaging:
• If the patient has neck pain or midline
tenderness AND any of the following:
1.Age 65+
2.Dangerous injury (e.g., fall >1m, diving,
high-speed crash, rollover, ejection,
recreational vehicle accident, bicycle crash)
3.Can’t turn neck 45° left or right
4.Urgent diagnosis needed (e.g., before
surgery)
 When Imaging May Not Be
Needed:
• Simple rear-end crash
• Sitting comfortably in the ER
• Walking after injury
• No midline tenderness
• Neck pain started later
 Computerized tomography
– Best for rapid diagnosis of location, type and extent
of injury
– Comparison with serial scans help detect absent or
compressed cisterns
– Dual diagnosis of head and spinal injury
– Repeated every 2- 3 days
– CT scanning is almost 100% sensitive and
specific for the identification of intracranial
complications.
 Criteria for immediate request for CT scan (Risk
Factors)

• Age 65 years or older.

• Coagulopathy (history of bleeding, clotting disorder,

current treatment with warfarin).

• Dangerous mechanism of injury (a pedestrian or cyclist

struck by a motor vehicle, an occupant ejected from a
motor vehicle or a fall from a height of greater than 1
m or five stairs).
 Nursing Diagnosis
• Ineffective airway clearance related to level of
consciousness and pooling of secretions
• Ineffective cerebral tissue perfusion related to
edema
• Fluid volume deficit related to excessive blood
loss
• Impaired physical mobility related to traumatic
brain injury
• Disturbed sensory perception related to
decreased level of consciousness
 Nursing Diagnosis
• Risk for injury related to seizure episodes
• Risk for aspiration related to decreased level
of consciousness
• Risk for seizure activity related to cerebral
irritation
• Risk for increased ICP related to cerebral
edema
 I) Initial management
1) Maintenance airway and ventilation
The priority of initial management of a patient
with head injury includes

• Airway
• Breathing
• Circulation
• Proper spine immobilization.
 I) Initial management
Adequate ventilation should be established as
followed:
• Airway management and supplemental
Oxygen should be initiated at the scene
of the injury or mechanical ventilation to
maintain normal arterial Oxygen level.

• Frequent arterial blood gases analysis

and correct the parameters accordingly.
 I) Initial management
• Initiate continuous Pulse Oximeter
monitoring.

• Position the patient in appropriate

position (lateral position for unconscious
patient).

• Suction secretions gently to maintain

patent airway.
 I) Initial management
2) Maintenance of cerebral perfusion

• Alteration of cerebral tissue perfusion is

due to increased intracranial pressure.

• To maximize cerebral tissue perfusion,

the intracranial pressure must be
maintained below 20mmHg
 I) Initial management
The following measures are used to control
increased Intracranial pressure.
1) Hyperventilation
• Oxygen mask
• Mechanical ventilation


PaCO2, which results in cerebral

vasoconstriction and leads to a decrease
in Intracranial Pressure.
 I) Initial management
2) Providing appropriate pharmacological
therapy
• Manitol and Furosemide as prescribed to
promote osmotic diuresis.
• Hypertonic saline and colloids
• Barbiturates
• Steroids to prevent cerebral edema.
• Anticonvulsants for early seizure activity
(seizures increase metabolic activity in the
brain and lead to  Intracranial Pressure).
• Analgesics for pain relief.
 Surgical management
• Decompressive craniectomy

• Burr hole or craniotomy

• Elevation of depressed skull bones

• cranioplasty
 I) Initial management
3) Maintain normothermia to decrease
metabolic demand of the brain
• Strong evidence that suggests hyperthermia worsens
neurological outcome
4) Proper position to facilitate venous
return: head of the bed at 30-degree angle.
5) Avoid stimuli (suctioning, painful
procedures)
6) Prevent bearing down (Constipation)
7) Frequent neurological assessment
 I) Initial management
3) Fluid resuscitation
Hypotension is the main cause of
hypovolemia in a patient with head
injury.

Hypotension  hypoperfusion  
cerebral blood flow  cerebral
ischemia, cerebral hypoxia and
hypercapnia.
 I) Initial management
Hypotension must be treated with fluids
resuscitation:
• Placing two large bore intravenous
catheters.
• Administering fluids or blood as ordered
to maintain normal Blood Pressure.
• Monitoring CVP .
• Keeping the patient warm.
• Placing a urinary catheter in order to
monitor the intake and out .
 II) Prevention of secondary injuries

The major factors associated with

secondary brain injury are:

• Hypoxia

• Hypotension

• Hypercapnia

• Cerebral ischemia secondary to 

Intracranial Pressure