HEAD INJURIES

INCIDENCE
• 100,000 Deaths a year
• Can result from: Industry, MVC, Military accidents
• #1 cause of death from ages 0-35
• Babies – shaken baby syndrome
• 70% of MVC will result in some type of head injury
• 2nd highest incident in the elderly population: Fall or jeark of head
• 2/3 are < 30 years old

ETIOLOGY
• Results form penetration or impact of the cranial vault
• Damage caused by:
o Direct injury
o Secondary to compression, tension or shearing forces
 Due to movement of brain in vault
• Results in injury to the scalp, skull and/or brain tissue –  ICP
• DO NOT move client until spinal cord traumas is ruled out

PATHOPHYSIOLOGY
• Results from penetration or impact
• Damage can be caused either by the direct injury itself or secondary to compression, tension, or
shearing forces
o Note: Brain tissue does not rebuild itself; once it is dead it is gone
• Specific patho of each injury depends on
o Type of injury
o Resulting damage
• Remember head injury and spinal cord injury often occur together
o Risk for spinal cord injury before being moved
o ER do not move until cervical x-rays

CLASSIFICATION OF HEAD INJURIES

• Open Head Injury
o Break or penetration of dura, exposing the cranial vault to the environment
o In order to have an Open Head Injury you must have a Skull Fracture
o  risk for infection,  risk for edema
o Results from: Bullets, knives, bone fragments, or direct blows to the head

• Closed Head Injury – BLUNT TRAUMA

o Dura intact; caused by rapidly moving blunt object “blunt trauma”; ex: baseball bat, MVC.
o The worst type of injury because of risk for  ICP
 Coup
• Injury occurs at the point of impact
 Countercoup
• Injury occurs opposite point of impact (if injured on rt side will have rt sided weakness)
 Acceleration – Deceleration
• Caused by MV accidents
• Head moving back and forth several times
TYPES OF HEAD INJURIES
• SCALP INJURIES
o Result in profuse bleeding because scalp is very vascular and bleeds profusely.
o Abrasion (scrape), Contusion (bruising), Laceration (cut), Avulsion (torn off part of
scalp)
 Clean area shave only with ok by MD
 Irrigate with NS to clean glass, dirt, etc.
 Subgleal hematoma – knot on head

• SKULL FRACTURES
o Linear
 Simple break in continuity of bone
 Straight line break
 70% of skull fx
• Treatment: Neurological checks, NO treatment
o Comminuted
 Fragmentation bone broken into several pieces
 Surgery R/F brain injury
o Depressed
 Cracked skull with inward depression of bone fragment
• Simple
o Dura with scalp intact; not penetrated dura
• Compound
o Scalp injury;scalp is open; dura with open wound. Dura may or
may not be torn
o At risk for  ICP
o Basal Skull Fracture
 Hard to see on X-Ray
 Occurs at base of the skull
• Most protected – protects the brain stem

CLASSIC SIGNS
 Battle’s Sign – Bruising behind mastoid and raccoon eyes
 Rhinorrhea – CSF – Leak – will have glucose
 Otorrhea – CSF – Leak
• Glucose test determines post crainy leaking
• Halo Test
 Compensating for  ICP
 Increased Risk for Infection

NURSING IMPLICATIONS OF SKULL FRACTURES

• Observe for ICP and S/S of infection – Notify MD
• Don’t administer respiratory depressants – sedatives, barbiturates, or morphine
• Observe patient closely for first 24 hours
• Start IV if necessary but limit fluids to 1500-2000cc daily as ordered per MD
• Maintain accurate I&O records
 • Frequent Neuro and VS checks – at least Q2o
• Cleanse and assist with suturing scalp lacerations of present

INJURIES TO THE BRAIN

• Concussion
o Least serious
o Temporary loss of neuro function with no structural brain damage
o Brief loss of consciousness but will recover and do ok
o TX: Monitor for changes in LOC
o Discharge Teaching: Head Injury Instruction Sheet
o Note: You don’t have to wake the patient just turn light on or touch
 Bring back to ER if:
• You can’t arouse them
• Sudden vomiting – Projectile
• Severe Nausea
• Headache Typically get worse and worse
• Weakness on one side of the body
• Confusion
• Vision Changes

• Contusions and Lacerations

o Bruising or part of the brain – Bleeding – not good
o Laceration is a cut – Profuse bleeding
o Loss of consciousness, Days, weeks, months, years
o If they survive the injury the blood will absorb itself with no residual brain damage
they should be OK.
o If the bleeding is bad enough they may die from ICP or have residual brain damage
o The longer a person stays unconscious the more severe the injury

• Difuse Axonal Injury

o Axons have been destroyed

TRAUMATIC INTRACRANIAL HEMORRHAGE

o EPIDURAL HEMATOMA
 Bleeding between the skull and dura matter. The most life-threatening of
intracranial hemorrhages as the bleeding is usually arterial. Usually results
from tear in wall of middle meningeal artery.
 50% mortality Rate
 Have to have surgery

SIGNS AND SYMPTOMS OF EPIDURAL HEMATOMA

 Loss of consciousness, followed by a few hours of lucidity, then coma
 Hemiplegia on opposite side from hematoma
 Pupillary changes
 o SUBDURAL HEMATOMA
 Collection of blood between dura matter and arachnoid membrane. Usually
venous in origin.
 Most common type of hematoma
 Can be chronic (gradual bleed over days to months) or acute (faster bleed of
24-72 hrs)

SIGNS AND SYMPTOMS OF EPIDURAL HEMATOMA

 Acute – presents as epidural
 Subacute - >48o
• 2 weeks S/S similar to acute
 Headache
 Altered LOC
 Hemiplegia on opposite side from hematoma
 Irritability
• Mental confusion
 Unequal pupils
 Convulsions
 Positive babinski response

o INTRACEREBRAL HEMATOMA
 Hematoma is not confined by meninges, therefore bleeding can be widely
dispersed.
 Causes more direct damage
 Difficult to evacuate surgically
• Too widespread

SIGNS AND SYMPTOMS OF INTRACEREBRAL HEMATOMA

 Headache
 Drowsiness
 Signs of ICP
 Hemiplegia on opposite side from bleeding
 Dizziness
 Vomiting

DIAGNOSIS
• Skull Films
• CAT Scan
• MRI

MEDICAL MANAGEMENT
• Surgical evacuation of heamtomas when possible
• Neurosurgical procedures for open head injuries
 • Control of  ICP – osmotic diuretics, steroids(not 1st line with head trauma), ventricular
drainage, hyperventilation, etc.

NURSING MANAGEMENT
• Immediate Care – Baseline Assessment
o Find cause; loss of LOC, how long
o 1st ABC’s, LOC, Cause
• Post acute Phase
o Maintenance of airway
o Prevention of aspiration
 Suctioning, never place unconscious pt on back; place on side
o Cardiovascular complications
 Hypovolemic shock with multi system injury, not from head trauma
o Cerebrospinal fluid fistulas
 Communicate between brain, environment
 CSF; sniffing, swallowing; do not suction; antibiotics
o Prevent straining
  ICP
o Maintenance of proper body temperature
  fever =  ICP
o Frequent assessments
 Need rest (nursing care IICP); 24-48o frequent assessments
o Nutrition
 IV, NG or oral
 Monitor I&O
o Restlessness – Disorientation
 1st :check airway, assess pain, 2nd: distended bladder 3rd : Waking up
o Seizures
 Occur years after trauma – Post traumatic epilepsy
o Stress ulcers
 Antacids
o Promotion of rest
 Must assess
o Rehabilitation techniques
 ROM, Prevent disuse syndrome
o Eye care
 Corneal reflexes absent
o Psychological
 Family and patient support