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head trauma

head trauma

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State of Illinois
Trauma Nurse Specialist Program
HEAD TRAUMA
Connie J. Mattera M.S., R.N., TNS
Time allotment: 2 hours
OBJECTIVES:
Upon completion the participant will
1.
state the incidence, morbidity, and mortality often associated with head trauma.
2.
apply knowledge of anatomy and physiology of the CNS to anticipate the pathophysiology
existent in traumatic brain injuries.
3.
predict nervous system trauma based on mechanism of injury.
4.
distinguish between head injury and brain injury.
5.
differentiate primary from secondary injuries.
6.
distinguish between focal and diffuse injuries.
7.
list five immediate complications of head injury that will worsen the prognosis.
8.
explain the dynamics of cerebral blood flow and cerebral perfusion pressure.
9.
sequence the evolution of increased intracranial pressure.
10.
differentiate early from late signs of\u2191 ICP including herniation syndromes.
11.
explain the primary assessments to be performed on a head injured patient
12.
state the resuscitative priorities based on the BTF guidelines which focus on methods to establish
airway control, provide ventilatory assistance and perfusion support.
13.

sequence the steps in performing a neurological exam on a head injured patient with an
emphasis on the mental status assessment including GCS, cranial nerve exam, motor, sensory
and reflex exams.

14.
interpret assessment data to formulate appropriate nursing diagnoses associated with head and
brain injured patients.
15.
classify head injuries as mild, moderate, or severe according to assessment findings.
16.
describe appropriate nursing interventions for the management of head injured patients.
17.
describe methods by which nurses can appropriately participate in, and assist with, medical
management of head injured patients.
18.
state the radiological and laboratory tests that physicians typically order for head injured patients.
19.
explain the pathophysiology, patient presentation, and management priorities for the following
vault fractures: linear, comminuted, depressed, basilar.
20.
explain the pathophysiology, patient presentation, and management priorities for the following
focal injuries: epidural, subdural, and subarachnoid hemorrhages; cerebral contusion; intracranial
hemorrhage.
21.
explain the pathophysiology, patient presentation, and management priorities for the following
diffuse injuries: concussion and diffuse axonal injury.
22.
evaluate the effectiveness of emergency interventions and amend the care plan as indicated by
patient responses.
CJM: 6/07
State of Illinois
Trauma Nurse Specialist Program
HEAD TRAUMA
Connie J. Mattera M.S., R.N., TNS
I.
Epidemiology of head trauma
A.
Definitions
1.
A head injury is defined as external influences causing traumatic insult to the head
that may result in injury to soft tissue, bony structures and/or brain.
2.
Traumatic brain injury (TBI), as defined by the National Head Injury Foundation,

is "a traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes." It is classified as direct (primary) or indirect (secondary) injury to the tissue of the cerebrum, cerebellum, or brainstem. Brain injury affects who we are, the way we think, act, feel and move. It can change everything about us in a matter of seconds (Brain Injury Association of America, 2004).

B.
Incidence: Estimated at 200/100,000 population which translates to one every 21 seconds

or 1.6 million/year with 230,000-270,000 hospitalized. Of these, about 50,000 \u2013 52,000 die and another 70,000 \u2013 90,000 survive with disabilities (BTF, 2004, CDC, 2001). TBI is more than twice as likely in males as in females; with the highest incidence in people 15-24 years of age and 75 years and older. Children ages 5 and younger are also a high-risk group. An estimated 5.3 million Americans live with disabilities resulting from traumatic brain injury (Brain Injury Association (2004), NIH, 2002).

C.
Common etiologies
1.

Motor vehicle crashes (MVCs) are the most common cause of closed head injury followed by falls, which are seen more frequently in children and the elderly. Other etiologies: intentional battery, use of firearms, water or recreational or sport-related injuries, pedestrian impacts, or domestic violence.

2.
Children: 10% of TBI are due to MVCs, falls, recreational (bicycling-related), home
or birth injuries.
3.
Behaviors that increase the risk of sustaining head trauma
a.
Alcohol ingestion
b.
Use of mild-altering drugs
c.
Incorrect use or nonuse of restraint systems
d.
Nonuse of helmets
e.
Participating in team sports without protective equipment
D.
General categories of injury
1.
Head injuries can be classified according to
a.
Severity of the injury
b.
Anatomical classification
c.
Pathological classification
d.
Primary and secondary brain injury
2.
Blunt (closed) trauma: The person receives an impact to the head from an

outside force, but the skull and dura remain intact and brain tissue is not exposed to the environment. More common than penetrating. The structures of the head and face generally protect well against most blunt trauma. However, when the magnitude of forces exceeds the tensile strength of the structures, severe injury can occur. For example, the sinus cavities of the face are frequently injured with blunt facial trauma. The air-filled spaces collapse upon impact and help to dissipate energy forces. A person may have a closed head injury with mild to severe traumatic brain injury.

State of Illinois TNS Program
Head Trauma - page 2
3.
Penetrating (open) trauma: A penetrating injury produces an opening through the

skull into cranial contents exposing them to the environment, creating a risk for infection and other injuries. Often caused by missiles such as rifles, hand guns, or shotguns and less commonly by other penetrating implements like knives, ice picks, exes, etc. While not as common as blunt trauma, they are very disruptive due to energy forces that can project hair, skin, bone and debris into the brain and contaminate the region. If the projectile is traveling at a low rate of speed through the skull, it can ricochet within the skull and widen the area of damage. High velocity projectiles can produce significant trauma from shock waves. Sharp projectiles may be superficial because of the protection afforded by the skull, but may pierce through bone and meninges into the brain. A \u201cthrough and through\u201d injury occurs if an object goes through the skull, brain, and exits the skull. These will produce the effects of penetration injuries, plus additional shearing, stretching, and rupture of brain tissue (Brain Injury Assoc. of America, 2004).

E.
Mechanisms of injury: Brain injury is usually due to a combination of forces
1.
Acceleration: Stationary head is hit by a moving object as in car vs. pedestrian,
abuse or sports injury.
2.
Deceleration injury: Moving head hits a stationary object as in falls, abuse, sports

injuries and MVCs. Sudden deceleration may produce bony deformity or cause the brain to slide back and forth by \u00bd inch at 38 mph collision. The brain can move in a straight linear acceleration with no loss of consciousness but can be injured as it moves across the rough base of the skull. The initial impact and pressure wave may tear tissue and result in injury on the side of the impact (coup) and the side opposite the point of impact (contrecoup). When these forces are applied, shearing, tensile and compressive stresses may lead to fractures, hemorrhage, hematomas, and contusions.

3.
Acceleration/deceleration injury: Moving head hits a moving object
4.
Distraction injuries: Ex. hanging. If the head is suspended in a drop 18" taller than
the person; it causes a fatal blow to the CNS.
5.
Penetrating trauma
F.
Mortality rates
1.
0%:
Mild head injury
2.
7%:
Moderate head injury
3.
25%: Severe head injury (BTF, 2007)
4.

90%: GSW to head: Nearly 2/3 are classified as suicides. Firearms are the single largest cause of death from traumatic brain injury, causing 44% of TBI deaths (CDC, August 22, 2002).

5.

In the last 12 years, more people have died of traumatic brain injury (TBI) than in all the wars combined. It contributes significantly to the outcome in 40%-50% of all trauma deaths (Feliciano, 267).

6.
TBI is the leading single-organ cause of death related to trauma. Fifty percent of
deaths due to MVC involve head trauma (Bourg, 2007).
7.
The challenge of improving outcome rests on advances in prehospital
management, critical care and rehabilitation.
G.
Morbidity: Brain injury can result in memory loss, rapid mood swings, fatigue, intellectual

dullness, mental rigidity, personality changes, and physical disabilities. The terms mild moderate and severe traumatic brain injury are used to describe the level of initial injury in relation to the neurological severity caused to the brain. There may be no correlation between the initial Glasgow Coma Score and the initial level of brain injury and a person\u2019s short or long-term recovery or functional abilities (Brain Injury Assoc. of Am, 2003).

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