Head Injury

DEFINITION
 Head injury is a morbid state, resulting from gross or
subtle structural changes in the scalp, skull, and/or the
contents of the skull, produced by mechanical forces.

 The blunt force may result in injury to the contents of

the skull, either alone or with a fracture of the skull.

 The extent and degree of an injury is not necessarily

proportional to the amount of force applied to the head.
 Head Injury

• Any trauma to the scalp, skull, or brain

• Head trauma includes an alteration in

consciousness no matter how brief
 Head Injury

• Causes
– Motor vehicle accidents
– Firearm-related injuries
– Falls
– Assaults
– Sports-related injuries
– Recreational accidents
 Head Injury

• High potential for poor outcome

• Deaths occur at three points in time after
injury:
– Immediately after the injury
– Within 2 hours after injury
– 3 weeks after injury
 Head Injury
Types of Head Injuries

• Scalp lacerations
– The most minor type of head trauma
– Scalp is highly vascular  profuse
bleeding
– Major complication is infection
 Head Injury
Types of Head Injuries

• Skull fractures
– Linear or depressed
– Simple, comminuted, or compound
– Closed or open
– Direct & Indirect
– Coup & Contrecoup
 Head Injury
Types of Head Injuries

• Skull fractures
– Location of fracture alters the
presentation of the manifestations
– Facial paralysis
– Conjugate deviation of gaze
– Battle’s sign
 Head Injury
Types of Head Injuries

• Basal Skull fractures

– CSF leak (extravasation) into ear (Otorrhea)
or nose (Rhinorrhea)
– High risk infection or meningitis
– “HALO Sign (Battle Sign)” on clothes of
linen
– Possible injury to Internal carotid artery
– Permanent CSF leaks possible
Battle’s Sign

Fig. 55-13
 Nursing Care of Skull
Fractures

• Minimize CSF leak

– Bed flat
– Never suction orally; never insert NG tube; never use Q-Tips
in nose/ears; caution patient not to blow nose

• Place sterile gauze/cotton ball around area

• Verify CSK leak:

– DEXTROSTIX: positive for glucose

• Monitor closely: Respiratory status+++

 Head Injury
Types of Head Injuries

• Minor head trauma

– Concussion
• A sudden transient mechanical head
injury with disruption of neural activity
and a change in LOC
• Brief disruption in LOC
• Amnesia
• Headache
• Short duration
 Head Injury
Types of Head Injuries

• Minor head trauma

– Postconcussion syndrome
• 2 weeks to 2 months
• Persistent headache
• Lethargy
• Personality and behavior changes
 Head Injury
Types of Head Injuries

• Major head trauma

– Includes cerebral contusions and
lacerations
– Both injuries represent severe trauma
to the brain
 Head Injury
Types of Head Injuries

• Major head trauma

– Contusion
• The bruising of brain tissue within a focal
area that maintains the integrity of the pia
mater and arachnoid layers
– Lacerations
• Involve actual tearing of the brain tissue
• Intracerebral hemorrhage is generally
associated with cerebral laceration
 Head Injury
Pathophysiology

• Diffuse axonal injury (DAI)

– Widespread axonal damage occurring
after a mild, moderate, or severe TBI
– Process takes approximately 12-24
hours
 Head Injury
Pathophysiology

• Diffuse axonal injury (DAI)

– Clinical signs:
•  LOC
•  ICP
• Decerebration or decortication
• Global cerebral edema
 Head Injury
Complications

• Epidural hematoma
– Results from bleeding between the
dura and the inner surface of the skull
– A neurologic emergency
– Venous or arterial origin
 Head Injury
Complications

• Subdural hematoma
– Occurs from bleeding between the
dura mater and arachnoid layer of the
meningeal covering of the brain
 Epidural and Subdural Hematomas

Epidural Hematoma

Subdural Hematoma

Fig. 55-15
 LACERATIONS OF SCALP
 If the scalp is lacerated by a blow, blood is driven out of the
vessels due to compression and considerable bleeding
occurs
 With further blows, blood is projected about the scene
 With repeated blows, blood is splattered over assailant

 Flat surface or object causes ragged split (linear, stellate or

irregular)

 Temporal arteries spurt freely, as they are firmly bound

and unable to contract and a fatal blood loss can occur
LACERATION OF SCALP
 AVULSION OF SCALP
Involves large are of scalp

Occurs in :
- traffic accident
- hairs entangled in machinery
Avulsion of scalp
 INJURIES TO FACE

Bleeding is more in facial

wounds
 EYES
Blunt trauma on the eye causes
a) Permanent injury to :
- cornea
- iris
- lens
b) Vitreous hemorrhage
c) Detachment or rupture of retina
d) Traumatic cataract
 BLACK EYE
(PERIORBITAL
BRUISING)
It is caused by:
1.Direct blow in front of orbits, bruising lids.
2.Injury to the forehead, the blood tracking
down under the scalp.
3.Fracture in the anterior cranial fossa, the
blood leaking through cracked orbital plates.
Black Eye
NOSE
1. May be bitten or cut off due to sexual
jealousy or enemity.
2. A blow may cause nasal bleeding due to partial
detachment of mucous membrane

EARS
A blow may produce -
1.Rupture of the tympanum
2.Deafness
3.Labyrinth may injured
FACIAL BONES
A blow often fractures the nasal bone and also ethmoid bone
with radiating fractures into supraorbital plates, if the force is
severe.
A blow may fracture maxilla and malar bone.
Pulping of face may result from striking with a heavy stone.
The mandible is fractured by a blow from a fist, stick or by fall
from height.
A heavy blow on the jaws drives the condyles against the base of
skull producing a fissured fracture.

TEETH
A fall or a blow with a blunt weapon may cause fracture or
dislocation of teeth, with contusion or laceration on lips or
gums and bleeding from the sockets.
 Head Injury
Complications

• Subdural hematoma
– Usually venous in origin
– Much slower to develop into a mass
large enough to produce symptoms
– May be caused by an arterial
hemorrhage
 Head Injury
Complications

• Subdural hematoma
– Acute subdural hematoma
• High mortality
• Signs within 48 hours of the injury
• Associated with major trauma (Shearing
Forces)
• Patient appears drowsy and confused
• Pupils dilate and become fixed
 Head Injury
Complications

• Subdural hematoma
– Subacute subdural hematoma
• Occurs within 2-14 days of the
injury
• Failure to regain consciousness may
be an indicator
 Head Injury
Complications

• Subdural hematoma
– Chronic subdural hematoma
• Develops over weeks or months after
a seemingly minor head injury
 Head Injury
Diagnostic Studies and
Collaborative Care
• CT scan considered the best diagnostic test to
determine craniocerebral trauma
• MRI
• Cervical spine x-ray
• Glasgow Coma Scale (GCS)
• Craniotomy
• Craniectomy
• Cranioplasty
• Burr-hole
 Head Injury
Nursing Management
Nursing Assessment

– GCS score
– Neurologic status
– Presence of CSF leak
 Head Injury
Nursing Management
Nursing Diagnoses

– Ineffective tissue perfusion

– Hyperthermia
– Acute pain
– Anxiety
– Impaired physical mobility
 Head Injury
Nursing Management
Planning

– Overall goals:
• Maintain adequate cerebral perfusion
• Remain normothermic
• Be free from pain, discomfort, and
infection
• Attain maximal cognitive, motor, and
sensory function
 Head Injury
Nursing Management
Nursing implementation

Health Promotion
• Prevent car and motorcycle accidents
• Wear safety helmets
 Head Injury
Nursing Management
Nursing implementation

Acute Intervention
• Maintain cerebral perfusion and
prevent secondary cerebral ischemia
• Monitor for changes in neurologic
status
 Head Injury
Nursing Management
Nursing implementation

Ambulatory and Home Care

• Nutrition
• Bowel and bladder management
• Spasticity
• Dysphagia
• Seizure disorders
• Family participation and education
 Head Injury
Nursing Management
Evaluation

Expected Outcomes
• Maintain normal cerebral perfusion
pressure
• Achieve maximal cognitive, motor, and
sensory function
• Experience no infection, hyperthermia,
or pain