DEBREBERHAN UNIVERSITY
AWHSC
HEAD INJURY SEMINAR
Sugical Nursing Students
surgical nursing students
Outline
Antomy overview
Head injury
Pathophysiology
Types
Diagnostic criteria
Medical and surgical management
Nursing assessment and
Nursing management
Reference
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Scalp
The scalp is composed of soft tissue layers that
cover the cranium.
It has 5 layers :
Skin
Connective Tissue,
Aponeurosis,
Loose Areolar
Connective Tissue and
Periosteum
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Skull
Skull: The skull is a collection of bones which encase the
brain and give form to the head and face
The facial bones include 14 bones,
paired bones
maxilla,
palatine,
zygomatic,
nasal,
lacrimal, and
inferior nasal conchae bones.
unpaired bones
vomer and mandible bones
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Skull cont…
The eight cranial bones are the bones
surrounding the brain.
paired bones
parietal bones (2),
temporal bones (2),
Unpaired bones
frontal bone
occipital bone,
sphenoid bone,and
ethmoid bone.
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Cont…
The Brain
- lies within the cranial vault
- It has four main region:
Cerebrum
Diencephalon
Brain stem
Cerebellum
Based on embryonic dev’t ,
subdivided as:
o Forebrain (cerebrum and
diencephalons)
o Midbrain
o Hindbrain (cerebellum, pons,
and medulla).
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HEAD INJURIES
Any trauma that leads to injury of the scalp,
skull or brain.
It is one of the most common causes for
attending emergency departments.
The injuries can range from a minor bump on
the skull to severe brain injury
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Cont…
Causes:
Road traffic accident – 80%
Falls
Assaults
Injuries at work place, during sport, or at
home
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Cont…
Risk Factors
People at highest risk for TBI are those in the
15- to 19-year age group.
Males 2 times likely as females
Colour blindness
Alcohol addiction
Vertigo
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Cont…
Forms of Head Injuries Can be:
1. Scalp injuries
2. Skull injury
3. Brain injuries
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Cont…
Head injuries include
3. Brain injuries
1. Scalp injuries
Cerebral concussion
Laceration
Cerebral contusion
2. Skull injury Cerebral Laceration
Simple Linear # Intracranial hematomas
Depressed skull # Cerebral swelling
Basal skull
(Brain edema
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Cont…
1. Scalp Injury
Generally classified as a minor injury.
Trauma may result in an abrasion, contusion, laceration,
or hematoma beneath the layers of tissue of the scalp
(subgaleal hematoma).
E.g., Subgaleal hematomas (hematomas below the outer
covering of the skull) usually absorb on their own and do
not require any specific treatment.
Scalp wounds are potential portals of entry for organisms
that cause intracranial infections. Therefore, the area
should be irrigated before the laceration is sutured
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Cont…
2. Skull Injuries
Is a break in the continuity of the eight bones that
form the skull
If the force of the impact is excessive, damage to
the underlying structures
Skull fractures are classified as
1. Linear,
2. Comminuted,
3. Depressed, or Basilar
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Cont…
Forms of skull injury
I . Simple Linear Fracture
A linear skull fracture is a break in a
cranial bone resembling a thin line,
without splintering, depression, or
distortion of bone
Are usually fairly straight and involve no
displacement of the bone
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Cont…
ii. Depressed skull fracture
Usually resulting from blunt force
trauma.
Broken bones are displaced inward.
A high risk of increased pressure on the
brain, or a hemorrhage to the brain
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Cont…
Indications for elevation
Depression greater than the cranial thickness
Intracranial hematoma
Frontal sinus involvement
Neurologic deficit
Cosmetic reason
Dural penetration
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Cont…
iii. Basal Skull Fracture
A fracture of the base of the skull, typically
involving:
Temporal Bone
Occipital Bone
Sphenoid Bone and/or
Ethmoid Bone.
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Cont…
Clinical Manifestations
Basal skull fractures are suspected when;
An area of ecchymosis (bruising) may be seen
over the mastoid (Battle’s sign).
cerebrospinal fluid escapes from the;
ears (CSF otorrhea)
nose (CSF rhinorrhea).
A halo sign (a blood stain surrounded by a
yellowish stain) may be seen on bed linens
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Cont…
Assessment and Diagnostic Findings:
Hx & P/E
Skull X ray
CT scan
MRI
Cerebral angiography
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Cont…
Medical Management:
Nondepressed skull fractures generally do not
require surgical treatment.
Close observation of the patient is essential.
Many depressed skull fractures are managed
conservatively;
⚫ Only contaminated or deforming fractures require
surgery
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Cont…
The nasopharynx and the external ear should
be clean.
Sterile cotton pad may be taped loosely under
the nose or against the ear to collect the
draining fluid.
Avoid sneezing, and blowing the nose.
Elevated the head 30 degrees to reduce ICP.
Persistent CSF rhinorrhea or otorrhea usually
requires surgical intervention (Closure of
dura )
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Brain injury
Brain Injuries
Acquired brain
Congenital brain injury
Aninjury
injury to the brain that is severe enough to interfere
with normal functioning (After birth
(pre birth, during process)
The most important consideration in any head injury.
birth)
Traumatic brain injury Non traumatic
(external physical force ) brain injury
Primary Brain Secondary Brain
Injury Injury
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Cont…
Acquired Brain Injury
I. Traumatic brain injury(TBI), caused by:
A blow to the head or
By the head being moved rapidly.
II. Non-traumatic brain injury
The brain cells are damaged or killed by
Toxic substances
Lack of oxygen
Pressure
Direct infection or stroke
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1.Traumatic Brain Injuries
Traumatic brain injury (TBI) is a non-degenerative, non-
congenital insult to the brain from an external
mechanical force, leading to
Permanent or temporary impairment of cognitive, physical,
and psychosocial functions, with an associated diminished
or altered state of consciousness.
The damage can be focal (confined to one area of the
brain) or diffuse (occurs in more than one area of the
brain).
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Classification of TBIs
Damage to the brain from traumatic injury takes two
forms
Primary injury: is the initial damage to the brain that
results from the traumatic event.
This may include contusions, lacerations, and torn blood
vessels from impact, acceleration/deceleration, or foreign
object penetration
Secondary injury: evolves over the ensuing hours and
days after the initial injury.
Primarily due to brain swelling or ongoing bleeding
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Cont…
Based on mechanism :
1. Closed (blunt) brain injury:- occurs when the head
accelerates and then rapidly decelerates or collides with
another object (eg, a wall or dashboard of a car) and
Brain tissue is damaged, but there is no opening through
the skull and dura.
2. Open(penetrating) brain injury:- occurs when an
object penetrates the skull, enters the brain, and
damages the soft brain tissue in its path (penetrating
injury), OR
When blunt trauma to the head is so severe that it
opens the scalp, skull, and dura to expose the brain
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Cont…
Based on severity: TBIs classified as
1) Mild,
2) Moderate, and
3) sever TBIs.
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Cont…
MILD BRAIN MODERATE SEVERE BRAIN
INJURY BRAIN INJURY INJURY
•Unconsciousness
exceeding 24
•Unconsciousness
hours (coma)
•Brief, if any, loss up to 24 hours
•No sleep/wake
of consciousness •Signs of brain
cycle during loss
•Vomiting and trauma
of consciousness
Dizziness •Contusions or
(LOC)
•Lethargy bleeding
•Signs of injury
•Memory Loss •Signs of injury
appear on
on neuroimaging
neuroimaging
tests
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Cont…
Primary Brain injury
occurs at the moment of trauma:
1. Cerebral concussion
2. Cerebral contusion & lacerations
3. Intracranial hemorrhage
Secondary brain injury refers to the changes that evolve
over a period of hours to days after the primary brain injury.
It includes an entire series of steps or stages of cellular,
chemical, tissue, or blood vessel changes in the brain that
contribute to further destruction of brain tissue.
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1.Cerebral concussion
Also referred to as a mild TBI.
A temporary loss of neurologic function with no apparent
structural damage.
Temporary impairment of neurological function that heals
by itself within time period
A concussion generally involves a period of
unconsciousness lasting from a few seconds to a few
minutes
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Cont…
There are two types of concussion:
1. Mild, and
2. Classic.
Mild:- may lead to a period of transient confusion,
disorientation, or impaired consciousness.
Commonly, there is a memory lapse at the time of
injury and a loss of consciousness lasting less than
30 minutes.
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Cont…
A classic concussion:- is an injury that results in
a loss of consciousness usually lasts less than 6
hours.
Difficulty in awakening
Difficulty in speaking
Confusion
Severe headache
Vomiting
Weakness of one side of the body
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2. Cerebral Contusion & Laceration
Cerebral contusion is a more severe injury
in which the brain is bruised, with possible
surface hemorrhage
Signs and symptoms may include: change in
LOC, seizures, disorientation, headache,
vomiting
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Cont…
Assessment & Diagnosis
Definitive diagnosis is made by a CT/MRI scan
which shows small amounts of diffuse bleeding
with edema.
Treatment may include:
Supportive therapy
Hyperventilation
Osmotic diuretics
Barbiturates
Managing ICP or surgery
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3. INTRACRANIAL HEMATOMA
Hematomas(collections of blood) that develop
within the cranial vault.
Are the most serious brain injuries.
A hematoma may be in:
A. Epidural(above the dura),
B. Subdural (below the dura)or
C. Intracerebral (within the brain
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Cont…
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Management of Traumatic Brain Injury
Blood Pressure Management
hypotension (SBP <90 mmHg) is associated with
increased mortality in TBI
maintaining systolic blood pressures
>100 mmHg (ages 50–69 years), or
>110 mmHg (ages 15–49 years or >70 years)
may be considered to reduce mortality and improve
outcomes
aggrassive management with
fluids(crystalloids) or
vassopressor(eg.vassopressors)
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Cont...
On the other hand,
hypertension(>160mmhg) in TBI may have
implications for intracranial hematoma
expansion
antihypertensives(labetalol and nicardipine)
Decompressive Craniectomy for Severe
TBI Decompressive
craniectomy can be performed to relieve
intracranial pressure
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Increased ICP
Increased ICP from any cause decreases
cerebral perfusion, stimulates further
cerebral swelling (edema), and may shift
brain tissue, resulting in Herniation, and
frequently fatal event.
Clinical Manifestation
Signs of increasing ICP are:-
Change in level of consciousness (LOC)
Slowing of speech, lethargy
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Cont...
Early Signs
Delay in response to verbal suggestions.
Restlessness
Weakness or paralysis
Increased BP (wide pulse pressure)
Bradycardia with full bounding pulse
Cushing Triads
Bradepnea
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Cont...
Increased ICP is a true emergency and must
be treated promptly.
Immediate management:
Decreasing cerebral edema
Lowering the volume of CSF or
Decreasing cerebral blood volume while
maintaining cerebral perfusion
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Cont...
Ventilation
mechanical ventilationshould then be
adjusted to maintain adequate ventilation and
oxygenation
Temperature management
Fever increases ICP and cerebral metabolism,
which can cause tissue hypoxia.
Normothermia can be achieved with the use
of external (ice, thermal blankets, surface
cooling device) or pharmacological
(acetaminophen, ibuprofen)
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Cont...
Glucose level
Maintaining normoglycemia is essential for the
acutely injured brain to maintain its increased
metabolic demands
Sodium level
Correction of hyponatremia is necessary because
it can exacerbate brain edema.
Osmotherapy is the cornerstone of
pharmacological treatment for the control of IHT
The most common agents are mannitol and
hypertonic saline solutions (HSS)
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Nursing assessment
Initial Assessment
o Cervical Spine
In a patient suffering with head injury, always consider if
the cervical spine may have also been injured
o Airway
Any patient with a GCS of 8 or less is at risk of being
unable to maintain their own airway.
o Breathing
ensuring adequate ventilation (with a secure airway)
and oxygenation is particularly important following
head injury, limiting further brain damage from hypoxia
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Cont…
o Circulation
ensure adequate tissue perfusion to prevent
any further secondary ischaemic damage to the
brain
o Disability & Neurological
examination(GCS)
In all patients presenting with a head injury, an
accurate Glasgow Coma Scale must be
recorded on admission
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Nursing management
o Monitor blood pressure,
which is critical in head trauma patients because hypotension
results in decreased cerebral perfusion and, subsequently, brain
ischemia.
o Beware of the Cushing’s reflex
a response to increased intracranial pressure that results in
reduced heart rate and increased blood pressure..
o Check body temperature
regularly because patients with brain injuries may have difficulty
regulating their own temperature..
o Monitor level of awareness,
pupil size, and PLR regularly. Hypovolemic patients may initially
present with an overall decreased mental status.
When providing IV fluids to these patients, it is important to
regularly check their level of awareness and mentation.
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Reference
Brunner and Suddarth's Textbook of Medical-
Surgical Nursing, 10th Edition - Smeltzer,
Suzanne C.; Bare, Brenda G
https;//todaysveterinarypractice.com
Schwartz's Principles of Surgery(Textbook by
Seymour I. Schwartz,2019 edition)
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