Head injury/Traumatic Brain

Injury
Objectives
 Definition
 Mechanism of injury
 Types of head injuries
 Investigations
 Clinical features
 Management of different types of head
injuries
 Complications
Head injury
 Broad term that that describes a vast
array of injuries that occur to the scalp,
skull, brain, and underlying tissue and
blood vessels in the head.
Incidence
 mortality almost 50%
 highest group 15 - 24 years
 males > females 3:1
Mechanisms of injury
Mechanisms of injury
 Acceleration
– when immobile head is struck by a moving
object

 Deceleration
– head is moving & hits an immobile object
Mechanisms of injury
 Acceleration - deceleration
– moving object hits the immobile head &
then the head hits an immobile object

 Deformation
– results in disruption of integrity of skull
Causes

 Road traffic accidents

 Falls
 Penetrating injuries such as

gunshots
 Assaults
 May be sports related, for

example, rugby
Other categorizations of head
injury
 Blunt

 Penetrating

 Coup/contrecoup
Risk factors
 Alcohol

 No seat belt

 No helmet
Main problems
 CEREBRAL EDEMA

INCREASED ICP


from cerebral edema + expanding lesions

(hematoma)
 Types of brain injuries
B rain injuries

Focal injuries Diffuse injuries

Contusion Laceration Hemorrhage Concussion Diffuse Axonal

Epidural hematoma Subdural hematoma Intracerebral Subarachnoid hemorrhage

Types of head injuries
 Scalp

 Skull

 Brain
Scalp injuries
 abrasion
– scraping away
 contusion
– bruise
 laceration
– wound or tear, may bleed profusely
Scalp injuries
 TREATMENT

skull films
abrasion = none
ice
suturing
Skull fractures
 Types
– Linear
– Comminuted
– Depressed
– Basal
Linear fractures
 simple fracture
– crack in skull
– 70‑80% of skull fractures

 treatment
– bedrest
– neuro check
Comminuted fracture
 fragmentation of bone into many pieces
or multiple fracture lines
Depressed skull fracture

inward depression of the bone



fragments to at least the thickness of

the skull

 hair, dust, & debris may be found

 dura may or may not be torn

Depressed skull fracture
 Treatment = surgery & debride
– craniectomy (depressed or comminuted)
– cranioplasty
• insertion of bone or artificial graft
• may be done immediately or postponed for 3‑6
months (if cerebral edema present)

 DEXAMETHASONE (decadron)
Basal skull fracture = Base of
skull
 may be linear, comminuted, or
depressed
 can be more serious
 CSF can leak through nose/ear =
rhinorrhea/otorrhea
Basal skull fracture
 increased risk of meningitis

 appearance of blood encircled by

yellowish stain on dressing or bed linen
– "halo 'sign = blood encircled by CSF
Basal Skull Fracture
Anterior fossa fracture
 fracture of the Paranasal sinus
– rhinorrhea
– subconjunctival hemorrhage
– periorbital ecchymosis (raccoon's eyes)
Basal skull
fracture
Anterior
Fossa
Fracture
Basal skull fracture
Middle fossa fracture
 associated with fracture of temporal
petrous bone; involves the middle ear
– otorrhea
– hemotympanum
– conductive hearing loss
Middle fossa fracture
 may have signs of vestibular
dysfunction = vertigo, nausea,
nystagmus
 facial nerve palsy (bell's palsy) ‑‑
appears 5‑7 days after injury
 ecchymosis over mastoid bone =
"Battle's" sign ‑‑ does not develop for
24‑36 hours
Basal Skull Fracture
Middle Fossa fracture
With skull fractures if dura torn
 ? prophylactic antibiotics

 most leaks resolve spontaneously

within 7‑10 days

 to aid resolution of leak LP’s BID to

remove 30cc CSF
If Dura torn
 lumbar catheter for continual drainage

 craniotomy to repair tear surgically

Brain injuries
Focal brain injuries

cerebral contusion
bruising of the surface of the brain;
hemorrhagic area present
+
cerebral laceration
actual tearing of cortical surface of brain
(may be found with contusion)
Focal brain injuries
 Can cause cerebral edema with
increased ICP

 S&S R/T anatomic area involved

 CT scan to identify contusions

 Treatment = increased ICP

Focal brain injuries
 possible rehabilitation

 management of postinjury problems =

seizures
Types of diffuse brain injuries
 concussion

 diffuse axonal injury

Concussion
 means to shake violently
S&S
 immediate unconsciousness (seconds,
minutes, hours)
 momentary loss of reflexes
 momentary (few seconds) respiratory
arrest
Concussion
 possible amnesia

 headache, drowsiness, confusion,

dizziness, irritability, giddiness, visual
disturbances (seeing stars), gait
disturbances
Diffuse axonal injury

widespread damage to axons in the white

matter in the hemispheres
R/T
high speed acceleration ‑ deceleration
associated with MVA's
Diffuse axonal injury

S&S
immediate coma

decerebration & an initially low ICP

94% die or remain in chronic vegetative

state = long term care
Hematomas
Epidural hematoma
 also called extradural hematoma

 bleeding into the potential space

between the skull & dura mater

 2% of all types of head injury

 85% also have a skull fracture
Epidural hematoma
Epidural hematoma

DX = CT scan

seen most often in children & young

people because the dura is less firmly
attached to bone
Epidural hematoma

S&S
momentary unconsciousness followed by
a lucid period (few hours to 1‑2 days);
longer if venous bleed involved
then
decreased LOC
other S&S = HA, seizures
Epidural hematoma

Treatment = surgery
Burr holes to evacuate clot & ligate
bleeding vessels
Burr holes
 Jackson -
Pratt drain in
Burr hole
 Subdural hematoma
 bleeding between dura mater &
arachnoid layer of the meninges

 causes direct pressure on the brain

 10 ‑15 % of head injuries develop

subdural
hematomas
Subdural hematoma
Subdural
hematoma
 Subdural hematoma
 Diagnosis = CT scan

 S&S

 3 categories based on interval between

injury & appearance of s&s
 Categories of subdural hematoma
 A) ACUTE = within 48 hrs

 B) SUBACUTE = 2 days ‑ 2 weeks

 C) CHRONIC = 2 weeks to several

months
 Subdural hematoma
 associated with cerebral contusion &
laceration
 headache, drowsiness, slow

cerebration, confusion ‑‑ all worsen

 ipsilateral pupil dilates & fixed
 hemiparesis = late sign
 Subdural hematoma
 elderly pts. & chronic alcoholics prone
to subdurals ‑‑ r/t cerebral atrophy
 treatment
– small ones = medical tx
– large = surgery = burr holes
Intracerebral hematoma
 bleed into cortical substance

 2 ‑3% of head injuries

 R/T contusions ‑‑ tend to occur in frontal

& temporal lobes
Intracerebral hematoma

Diagnosis = CT scan
S&S
unconsciousness, decreased LOC, HA,
hemiplegia on contralateral side, dilated
pupil on side of clot
Treatment = mortality high
injury to blood vessels can cause
vasospasm
General head injury treatment

treat all head injured patients for possible

cervical fracture

immediately immobilize neck

patent airway but do not hyperextend

jaw thrust maneuver
General head injury treatment
 AIRWAY
 all unconscious head injured patients =
ETT to prevent aspiration
 NO CERVICAL HYPEREXTENSION
 clear nose & mouth of blood, mucus, &
drainage
General head injury treatment
 aspiration prior to admission possible
even with negative CXR
 limit suction < 15 seconds
 do not use nasal passage for suction
until basal skull fracture & dural tear
ruled out
 oxygen/ventilator
General head injury treatment
 vital signs

 assess pulses & capillary refill

 peripheral IV
General head injury treatment
 ECG monitoring

 if BP low ‑‑? occult bleeding in abdomen

 if BP high ‑‑R/T head injury ‑‑ ICP

protocol
General head injury treatment
 Labs
CBC, electrolytes, T&C, ABG's, drug
screen

 Xray
cervical spine, chest, long bones, pelvis
General head injury treatment

CT


Immediate if patient unconscious & focal

signs are present

 head to toe exam for other injuries

 Glasgow Coma scoring

Detailed neurological exam
 LOC
 pupillary signs & responses
 eye movement
 oculovestibular & oculocephalic &

corneal reflexes & gag = brain stem fx

 motor responses
Head injury
 Peak swelling 72 hours after injury
Other measures

NG = (if no basal skull fx)

keep gastric pH @ 4‑5
Nutrition support

jejunal feedings by day 7

– patient in hypercatabolic state
as early as 24 - 48 hrs. after injury
140% of caloric requirements if not
paralyzed
100% if paralyzed
15% protein
Interdisciplinary rehabilitation
 rehabilitation team approach =
maintenance, prevention, restoration
 Rancho Los Amigos Scale(RLAS). a
medical scale used to assess cognitive and
behavioral functioning in individuals recovering from a
closed head injury, particularly a traumatic brain injury
(TBI). It describes the progression of recovery as
patients emerge from a coma or a state of limited
awareness.
 Physiotherapy for paresis/paralysis
Interdisciplinary rehabilitation
 Ocupation Therapy for Activity of Dairly
Living performance evaluation & deficits
 Speech therapy for communication;

feeding; swallowing
 Neuro‑opthamologist for visual deficits
 Neuropsychologist for cognitive deficits
Interdisciplinary rehabilitation
 Urologist for bowel/bladder problems

 Psychiatrist for behavioral problems

 National Head Injury Foundation

Intracranial hemorrhage
 Bleeding into the brain tissue or
subarachnoid space
– usually due to
• head injury
• aneurysms
Aneurysm
 Localized arterial wall dilation that
develops secondary to a weakness of
the arterial wall
– 90% congenital
– 80% occur in Circle of Willis
Cerebral
arteries
Circle of
Willis
Circle of Willis
Incidence of Subarachnoid
Hemorrhage(SAH
 18, 000 in U.S. annually
 20 - 40% die at initial bleed
 1/3 of survivors have residual changes
 females > males
 peaks in 50’s
Risk factors
 Hypertension

 Cocaine use

 Head trauma

 Congenital
SAH
 Specific signs & symptoms depends on:
– location of hemorrhage
– degree of increased ICP
Pathophysiology
 Bleeding commonly stopped by
formation of fibrin-platelet plug at point
of rupture & by tissue compression

 Within three weeks hemorrhage

undergoes re-absorption
Pathophysiology
 serious risk of recurrent rupture 7 - 10
days after original hemorrhage
 massive hemorrhage (30 - 50 ml)
– produces rapid filling of ventricular system
or
– produces a hematoma that distorts
subarachnoid space & brain tissue
Classification
 Saccular (Berry)

 Fusiform
Types of aneurysms
Complications
 Rebleeding

 Vasospasm

 Hydrocephalus
Complication - Rebleeding
 greatest cause of mortality
 peak = 24 hours and in 7 - 10 days
 treatment = clipping
 if no surgery = Antifibrinolytic agents
(Aminocaproic Acid = Amicar) to prevent
clot dissolution
– SE = vasospasm
Complication - Vasospasm
 narrowing of vessel lumen
 usually in vessel adjacent to ruptured
aneurysm
 may spread throughout all major
vessels @ base of brain
 produces symptoms of ischemia
– 30 - 50% after SAH
– 65% after surgery
Vasospasm treatment
 DRUG
– Nimodipine (nimotop)
• cerebroselective Calcium channel blocker
• 60 mg. Q 4 hour no later than 48 hours after
hemorrhage
• continue for 21 days
• monitor BP carefully
Vasospasm treatment
 DRUG
– Nicardipine (Cardene)
• alternative to Nimodipine
Vasospasm treatment

Intravascular volume expansion

+
Induced arterial hypertension

“Hypervolemic - hypertensive” therapy

Vasospasm treatment

“Hypervolemic - hypertensive” therapy

 increases volume & pressure

 forces blood through spastic vessels
 increases flow to ischemic areas
Vasospasm treatment

“Hypervolemic - hypertensive” therapy

 keep low Hct (40) & low viscosity

– albumin
– IV fluids
 keep CVP 10 mm Hg. (PCWP 18 - 20
Hg.)
Vasospasm treatment

“Hypervolemic - hypertensive” therapy

 keep SBP 150 or higher
– clipped = 200
– unclipped = 160
 drugs
– Dopamine, Dobutamine, Levarterenol,
Metaramine
Complication - Hydrocephalus
 caused by blood in subarachnoid space
– prevents adequate CSF circulation
 contributes to increased ICP
 teatment = shunt
– ventriculoperitoneal
– ventriculoatrial
Aneurysm clinical manifestations
 Most are asymptomatic until the time of
bleeding

 some are uncovered @ autopsy and

NEVER bleed

 warning signs in 49%

Clinical manifestations
 Headache
– “This is the worst headache of my life”

 Localized S & S depend on size &

location of aneurysm
Clinical manifestations
 Dysfunction of:
– CN II = optic = vision
– CN III = occulomotor = eye movements,
pupils size, accomodation
– CN V = trigeminal = eye movement,
sensations of head & face
Cranial nerves & ocular
movements
Clinical manifestations
 Hemiparesis/hemiplegia
 Vomiting
 Seizures
 Meningeal irritation
– stiff neck
– leg & back pain
 KEY FEATURES OF DISEASE  Classification of Cerebral Aneurysms

Grade Amount of Bleeding Neurologic Findings

I Minimal Neurologically intact

Slight headache
II Mild Minimal neurologic deficit, alert
Severe headache
Stiff neck
III Moderate Facial deficits
Drowsy, sleepy
Headache, stiff neck
IV Moderate to severe Hemiparesis
Increasing neurologic deficits
Stuporous, obtunded
V Severe Comatose
Decorticate or decerebrate posturing
Key Features of Disease: Classification of Cerebral Aneurysms
@ 1991 W. B. Saunders Company. Medical -Surgical Nursing: A Nursing Process Approach
Diagnostic studies
 Lumbar puncture
– done with caution due to increased
opening pressures (nl = 50 - 180 mm H2O)
– bloody CSF with Xanthochromia
(hemolyzed RBC’s)
 CT scan or MRI
– blood in subarachoid space, clots
– displaced structures
Diagnostic studies
 Cerebral arteriogram
– identifies aneurysm structure & location
– identifies vessels supplying aneurysm
– identifies local or general vasospasm
– outlines cerebral vascualture
• small < 15 mm
• large 15 -25 mm
• giant 25 - 50 mm
• super giant > 50 mm
Cerebral
arteriogram
Treatment
 Surgery
 Corticosteroids
 Anticonvulsants
– Phenytoin (Dilantin)
– Phenobarbital
 Antihypertensives
Treatment
 Antifibrinolytics/hemostatic agents
– Aminocaproic Acid (amicar) 24 -36 g IV Q
day for 3 weeks
 Analgesics/antipyretics
– Tylenol
– Tylenol with codeine
 Pituitary hormone
– Vasopressin (pitressin)
Treatment
 Stool softener
 Electromechanical
– ventilatory support
– hypothermia blanket
– EKG monitoring
– arterial BP monitoring
Supportive treatment
 Elevate HOB
 Subarachnoid precautions
– dim lights
– private room
– decease noise
– limit visitors
– NO Valsalva
Supportive treatment
 Seizure precautions
 Foley
 No restraints
Interventional radiology
 Balloon occlusion of aneurysm
 Balloon occlusion of parent vessel

 Percutaneous transfemoral approach

Surgery
 Craniotomy
 Microsurgery
 Controlled systemic hypotension during
the 5 - 10 minutes of the dissection of
the aneurysm
– bloodless field
– collapsed aneurysm
Surgery
 Berry (saccular ) = clip

 Fusiform = wrap with special gauze &

acrylic wrap
Aneurysm
surgery
Aneurysm “clipping”
Arteriovenous malformation
 Congenital
 Tangles of thin walled blood vessels
without intervening capillaries
 Some large others microscopic
AVM treatment
 Neuroradiologic procedures
– embolization
– laser
 Surgery
Neurosurgery
Cranioplasty
 replacement of part of cranium with a
plate
– metal (tantalum)
– nonmetallic material (methyl methacrylate)

 closure can be delayed for 6 months to

1 year
Surgical approaches
 SUPRATENTORIAL

 INFRATENTORIAL
Supratentorial
 above double fold of dura called
tentorium

 incision within hairline over involved

area
Surgical approaches
 Supratentorial
– cerebrum (cerebral hemispheres)
– approach used to get at:
• frontal lobe
• parietal lobe
• temporal lobe
• occipital lobe
Supratentorial
Infratentorial
 below tentorium

 suboccipital incision made with patient

in sitting position
Surgical approaches
 Infratentorial
– brain stem
• midbrain
• pons
• medulla
– cerebellum
Infratentorial
Cranial surgery

 Microsurgery
Stereotaxis
 precisely localizing areas in brain

 stereotactic probe or electrode passed

to target area

 placement confirmed by CT scan

Stereotaxis
 done under local anesthesia

 used to:
– remove or biopsy deep, small subcortial
tumors that previously were inaccessible
by routine surgery
Uses for Stereotaxis
 ablate lesions in extrapyramidal
disorders causing rigidity & uncontrolled
movements
 aspirate cysts, abscesses, &
hematomas
 implant radioactive seeds
 interrupt pain fibers/centers
Laser
 narrow laser beam
 excellent for removing highly vascular
lesions due to ability to simultaneously
dissect, coagulate, & vaporize abnormal
tissue
 no bleeding into the field
Laser
 no trauma to surrounding tissue

 allows removal of tumors proximal to

delicate cerebral
Cryosurgery
 liquid nitrogen to produce temperatures
as low as -20 c

 destroy abnormal tissue by using cold

temperatures
Stereotactic radiosurgery
 can be performed with gamma knife,
which is actually not knife but a helmet
containing radioactive cobalt

 focus so precise on malignant tissue =

one treatment enough
Stereotactic radiosurgery
 surrounding tissue not harmed

 only a few facilities have this because of

its expense

 may take from 1 to 3 years lag time

before lesion is totally destroyed
Measures to preserve cerebral
function during surgery
 HYPOTENSION
– to control cerebral blood flow during repair
of aneurysm or AVM
• accomplished by:
– use of sitting position
– vasodilators (sodium nitroprusside = nipride)
– effects of anesthetics (halothane)
Measures to preserve cerebral
function during surgery
 HYPOTHERMIA
– reduces oxygen consumption of brain thus
decreasing chance of neuronal damage
– metabolic by-products also reduced
– accomplished by: hypothermia blanket
Measures to preserve cerebral
function during surgery
 HYPERVENTILATION
– to decrease ICP by decreasing CO2
• slows cerebral blood flow
• constricts cerebral vessels so increases venous
return
• reduces intracranial volume
– accomplished by: ETT & ventilator
Complications during surgery
 1)elevated ICP controlled by:
– hyperventilation
– osmotic diuretics
– dexamethasone (Decadron)

 2) seizure activity controlled by:

– phenytoin (Dilantin) (pre & post op)
Complications during surgery
 3) infection controlled by:
– aseptic techniques
– antibiotics
 4) venous air embolism
– potential problem when surgery in sitting
position
• having head higher than heart causes negative
pressure in cerebral veins & venous sinuses
Complications during surgery
 4) venous air embolism
– air in venous system goes to right heart
– patient monitored with doppler sensor to
detect air
– if air detected, surgeon identifies &
occludes entry site
– anesthesiologist aspirates air through the
central venous catheter
Complications during surgery
 4) venous air embolism
– patient vital signs are stabilized & surgery
continues
– if entry site of air cannot be identified,
surgery terminated & patient placed in
supine position immediately & monitored
for transient neurologic deficits
– air embolus can be fatal
Surgical approaches
 By Fossa
– Anterior fossa
• frontal lobe
– Middle fossa
• temporal lobe
• parietal lobe
• occipital lobe
– Posterior fossa
• brain stem & cerebellum
Surgical approaches
 Supratentorial

 Infratentorial
Preoperative care
 antiseptic shampoos to head
 no coughing, no enemas, no leg
exercises due to increased ICP
 teach relaxation techniques
 discuss tubes, monitors, & appliances
(ventilator)
Preoperative care
 hair not usually removed unless
absolutely necessary - show how to
cover with stockinet caps, scarves,
hats, or a hairpiece
 preop med based on specific pathology
& LOC
 NPO
Preoperative care
 preop corticosteroids (dexamethasone)
to control cerebral edema
 anesthesia light since the brain itself
has no pain receptors
 osmotic diuretic (mannitol) may be
given to aid in decreasing increased
ICP
Preoperative care
 antibiotics prescribed if organism
isolated or as prophylaxis, esp. if
ventriculostomy is anticipated

 drains (Jackson - Pratt for 24 - 48 hours)

– could be entry site for infection
Preoperative care
 anticonvulsant

 careful neuro & cognitive assessment

performed and documented to use as
reference during surgery & immediately
postop
Postoperative care
 depends on specific problem
 must have following data:
– neurologic status & specific deficits
preoperatively
– other medial problems existing
preoperatively
– purpose of surgery
Postoperative care
 Needed data
– actual procedure used
– location of the area of involvement;
whether a bone flap was replaced & if a
large area was evacuated
– intraoperative problems
Postoperative nursing goals
 1) prevention & recognition of
complications;
 2) evaluation of patient's neurologic
status;
 3) prevention, recognition, & control of
increased ICP;
 4) supportive care;
 5) rehabilitation
Postoperative nursing care
 usually ICU
 hemodynamic monitoring
 many IV lines but keep fluid amount low
to prevent cerebral edema
 bed have alternating pressure mattress
 hypothermia blanket to rewarm patient
Postoperative nursing care
 IV meds immediately available for tx of:
– vasospasm
– increased ICP
– HTN
– hypotension
– infection
– seizures
– cardiac arrhythmias
Postoperative nursing care
 seizure precautions
 antiembolic stockings & a sequential
compression device
 ETT/ventilator/suction/oxygen
Postoperative nursing assessment
 document LOC (glasgow coma scale)
 pupillary signs
 ocular movement
 sensory function
 motor function
 vital signs
 compare baseline data to preoperative
& intraoperative data
Postoperative nursing assessment
 Neurological assessments q 15-30
minutes until stable (or more frequently
if unstable) = no time frame can be
placed on this process, can vary from 4
hours to days

 once patient is stable, assessments are

q 1 hour initially & then every 2-4 hours
Postoperative nursing assessment
 urine specimens to measure osmolality
& specific gravity
 blood for electrolytes, therapeutic drug
levels, & ABG’s
 cultures from sputum, urine, blood, &
wound sources if fever
Proper positioning
 Supratentorial approach
– HOB elevated to 30
– turn patient to either side unless a large
area of tissue removed;
– if removed, patient should not lie on
operated side
Proper positioning
 Infratentorial approach

– relatively flat with a very small pillow to

neck
– flat position prevents pressure on brain
stem
– can turn to either side but may not be
allowed by some surgeons to lie on back
Proper positioning
 Infratentorial approach
– can experience dizziness so remind patient
no sudden moves (dizziness due to edema
of CN VIII)
– maintain position for 1 week with very
gradual elevation to 30 if tolerated
Postoperative nursing assessment
 oral fluids
– (after 24 hours) post nausea
– if patient able to swallow (CN IX & X = gag
& swallow)
 watch for CSF leak
Postoperative nursing assessment
 inspect eyes q 2 hours for drying or
abrasions = blink & corneal may be
absent

 periorbital swelling (48 - 72 hours eye

may be swollen shut)
Nursing diagnosis
 Depends on the type of head injury,
procedure done and the condition of the
patient.
 Below are examples of preoperative
nursing diagnosis
Pre operative nursing management

 Ineffective cerebral tissue perfusion

related to cerebral edema.
 Risk for injury related to bleeding ,

infection and invasive procedure's.

 Anxiety related to the surgical

outcome.
Post operative management
 Altered breathing pattern related to the
effects of anesthesia on the brainstem
and accumulation of bronchial secretions.
 Risk for injury related to decreased level
of consciousness secondary to increased
intracranial pressure.
 Risk for infection related to invasive
procedure.
Assignment
 Students to formulate three priority
nursing diagnosis for a patient with
Fracture base of skull and manage
preoperatively and post operatively.
Reference
 Lewis, S.M., Dirkse, S.R., Heitkemper, M.M.,
& Bucher, L. (2023). Medical-Surgical
Nursing: Assessment and Management of
Clinical Problems (12th ed.). St. Louis:
Mosby.
 LeMone, P., Burke, K.M., & Bauldoff, G.
(2020). Medical-Surgical Nursing: Critical
Thinking in Client Care (8th ed.). Upper
Saddle River, NJ: Pearson/Prentice Hall.
Reference
 Head injury accessed 29/08/2022 John
Hopkins
https://www.hopkinsmedicine.org/health/co
nditions-and-diseases/head-injury