head injury

Rijo george
Asso.Professor
AKG College of Nursing
head injury
 Introduction

Every minute there is an accident and in

India every 8 minutes there is a death

Nearly 1.5 to 2 million persons are

injured and 2 lakhs die every year in
India
 Definition
Traumatic brain injury can be
defined as an insult to the brain that
is capable of producing physical,
intellectual, emotional, social and
vocational changes………….
Structures involved in head injury
 Etiology
• Road traffic accidents :- 60%
• Falls :- 20 -25%
• Assault/ violence :- 10 - 15%
• Sports related injury
• Recreational accident

Alcohol involvement is known to be

present among 10 – 20 % of TBI at the time of
injury
 TYPES OF HEAD INJURY

• SCALP

• SKULL

• BRAIN

• FOCAL

• DIFFUSE AXONAL INJURY

1.SCALP
• Abration
• Concussion
• Laceration

2.SKULL
• Simple
• Compound
• Linear
• Basilar
• Depressed
• Communated
• 3.BRAIN
• Contusion
• Blunt injury
• Accelarated
• Decelarated
• Coup
• Counter coup
4.FOCAL
• Epidural hematoma
• Subdural hematoma
• Intra cerebral hematoma

• 5.DIFFUSE AXONAL INJURY

• Mild
• Moderate
• Severe
 Types of scalp injuries
1.Abrasion :  a wound consisting of superficial
damage to the skin
 2.CONCUSSION

• Concussion is a type of traumatic brain

injury,caused by a bump, blow to the head
or by a hit to the body

• that causes the head and brain to move

rapidly back and front
Break in scalp integrity, and bruise may occur
into subcutaneous layer
 3.Laceration
• Common, bleeds profusely due to poor
vasoconstriction ability
 SKULL FRACTURE
• Skull fractures frequently occur in head
trauma
 Types of skull fractures
• Simple (closed)
• Compound (open)
• Linear
• Basilar
• Depressed
• Comminuted
 1.Simple (closed)

Where the skin has not broken

Surrounding tissues are not damaged

2.Compound (open)
-Skin and tissues are broken
-Brain is exposed
 3.Linear skull fracture :
Break in continuity of bone without
alteration of relationship or part
 3.Basilar skull fracture
Associated with Dural tear
 4.Depressed skull fracture
(Crushed portion of skull, with depression towards the
brain)
 5.Comminuted fracture
• Occurs from multiple linear fractures with a
depression at the site of impact
 Traumatic brain injury (TBI)
• It  is a sudden injury that causes
damage to the brain.
1.Contusion : it is a bruising of the brain
tissue with in a focal area. It is usually
associated with close head injury
• A contusion may contain areas of
hemorrhage, infraction, necrosis and
edema.
 Types of brain injuries
2.Blunt injuries : Occur from blunt forces
• 3.Acceleration injury: Injuries occur when a
moving object(basket ball) strikes an
individual head.

• 4.Deceleration injury : Injuries result when an

individual head strike an immovable object
such as dashboard of a car or wall

• 5.Coup injury: usually cerebral injury ,the

cerebral injury is sustained directly below the
site of impact

• 6.Countercoup injury: cerebral injury is

sustained in the region or pole opposite the
site of impact
• 7.Penetrating injuries : Includes head wounds
made by foreign bodies ( knifes, bullets) or by
bone fragments from a skull fracture

• Gunshot wounds are the most lethal and carry a

mortality rate of more than 90%.
COMPLICATIONS OF HEAD
INJURY
 1.Epidural hematoma
1–2%
Occurs due to fracture of temporal
bone and laceration of middle
meningeal artery
Following injury there is brief loss
of consciousness with lucid interval
Compensation for expanding
hematoma occurs during lucid
interval
Later there will be restlessness,
respiratory difficulty,confusion and
coma
Considered as an extreme
emergency
 2.Subdural hematoma
• Onset: 2 weeks to several
months following injury
• Causes: trauma, rupture of
aneurysm,coagulopathy
• Types :
 acute(24 to 48 hrs)
 Subacute(2days to 2
weeks)
 chronic(3 weeks to
months)

• Treatment : Burr holes and

evacuation of hematoma
 3.Intra cerebral hematoma
• Caused by
penetrating
injuries ,deep
depressed fractures,
aneurysm
rupture,tumors,vascul
ar anomalies

• Develops deep within

cerebral hemispheres
Comparison
 Diffuse axonal injury
• Results from wide
spread rotational forces
causing damage
throughout the brain

• Mortality rate 33%

• Characterized by loss
of consciousness,
abnormal posturing,
increased ICP and
coma
 DIFFUSE AXONAL INJURY

1.Mild-coma within 6-24 hrs

2.Moderete-coma within 4 hrs

3.Severe-coma+brain death
 INCREDED ICP
•  normally 7–15 mmHg
 Pathophysiology

Primary head injury Secondary head injury

1. Concussion 1. Brain edema
2. Contusion 2. Increased ICP
3. Laceration 3. Ischemia
4. Penetration of 4. Infarction
foreign objects 5. Irreversible brain
5. Hemorrhage damage
6. Brain death
Pathophysiology
Head trauma

Neuronal damage

Vasoconstriction and vasospasm

Increased ICP

Cerebral ischemia

Cerebral edema

Altered sensorium,
progressive neurologic deficit
MANIFESTATIONS OF SKULL FRACTURE

It is Characterized by,
Raccoon eye : periorbital echymosis and
conjunctival hemorrhage
 CSF Otorrhoea:
CSF leakage through ears
 CSF Rhiorrhoea
CSF leakage through nose
 Battle sign
Battle sign: Echymosis over mastoid
 Clinical features
Motor deficits
Cognitive deficits
Changes in vital signs
Pupillary abnormalities
Cranial nerve deficits
Sensory alterations
Seizures
Head ache and vomiting
 Clinical features of severe head
injury
Paresis or plegia Hypertension
Abnormal postures Bleeding and swelling
Absence of reflexes or at the site of injury
abnormal reflexes Pupillary abnormalities
Altered sensorium Neurologic deficits
Confusion Convulsions
Drowsiness Severe head ache
Restlessness Neck stiffness
Respiratory Vomiting
irregularities
Bradycardia
 Diagnosis
• X -ray of skull and cervical spine ( AP and
lateral view)
• CT scan
• MRI
• X – ray chest
• Blood test
• Neurologic examination
Assessment of patient with head
injury
Immobilize the patient
Assess the ABC
Level of consciousness using GCS
Head: palpate skull for any fracture, hematoma
and laceration
Pupillary changes
Ear ,nose ,throat, neck
Cardiac and respiratory changes
Abnormal postures
 Three components of GCS
Best eye response (E)

Best verbal response(V)

Best motor response(M)

 Best eye response
Response Score

Spontaneous 4

To call 3

To pain 2

No response 1
 Best verbal response
Response Score
Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

No response 1
 Best motor response
Response Score
Obeys commands 6

Localizes pain 5

Withdraws from pain 4

Abnormal flexion 3

Abnormal extension 2

No response 1
Classification of head injury according
to GCS
TYPE DURATION OF GCS
UNCONSCIOUSNESS

Minor Less than 30 minutes 13 - 15

Moderate More than 30 minutes 9 - 12

but less than 6 hours

Severe More than 6 hours 8 or less

 First aid of head injury
For mild injury
No specific treatment
Assess ABC
Immobilize the patient
Assess for the signs of head injury
Close observation for concerning symptoms
for 24 hours
No aspirin ( Risk of bleeding)
 Get medical help if……
Becomes drowsy
Develops severe head ache or neck stiffness
Loss of consciousness at any time
Behaves abnormally
Shift to hospital and stabilize spine during
transportation
Check ABC and give CPR if necessary
 Head injury – Don’t’s
Don’t wash a wound which is deep and
bleeding
Don’t remove any object sticking out of the
wound
Don’t move the patient unless absolutely
necessary
Don’t remove the helmet if suspecting
serious injury
Don’t drink alcohol within 48 hours of any type
of head injury
 Management of head injury
Aim
Preserving brain homeostasis
Preventing secondary injury
Medical management of severe head
injury
On the scene
Rescue efforts
Neurologic assessment
Immobilize the patient and rapid
transportation
Initial resuscitation
 Maintenance of airway and
breathing
Immobilize the patient
Place an airway
Suctioning
Start oxygen
Intubation and ventilation
Tracheostomy
Continuous monitoring
 Maintain circulatory status
A) Maintain BP and cerebral perfusion pressure
(CPP)
Systolic BP not less than 90 mm of Hg
CPP not less than 70 mm of Hg
Recent studies shows that a single episode of
hypotension is associated with a doubling of mortality in
patients with traumatic brain injury
B) Rule out any internal bleeding
C) Arrest any external hemorrhage to prevent
blood loss
 Maintain circulatory status
Isotonic fluids are appropriate for fluid
resuscitation(NS,RL)

Hypertonic saline (HTS) also is used

If the patient is unresponsive to fluid

resuscitation ,nor epinephrine may be
used to increase Mean arterial presure
 Control of increased ICP
Osmotherapy
Mannitol
Hypertonic saline
Sedation and analgesia
Midazolam
Morphine
Control of seizure
Antiepileptics :Phenytoin 15 – 20 mg/Kg IV
( Loading dose 300 mg)

Antibiotics : Prophylatic use of antibiotics in patients

with skull injuries and hematomas

DVT prophylaxis : Heparin, stockings

Follow up CT scan
 Maintenance of nutritional
requirement
• Severe head injury leads to generalized hyper
metabolic and catabolic response

• Caloric requirement : 50 – 100% higher

• Enteral feed should be started as soon as

possible( usually 2nd day)

• Early enteral feeding has been associated with

preservation of GI mucosa integrity and reduces
hyper metabolic response
 Surgical management
Indications for immediate surgical intervention

– Large extra dural hematoma

– Sign of herniation
– Increase in size of hematoma on CT
– Foreign body: bullet,knife,penetrating wood piece
– Profuse CSF rhinorrhoea and otorrhoea not
controlled on concervative treatment
– Growing skull fracture
 Surgical procedures
• Surgical evacuation of hematomas
• Craniotomy
• Cranioplasty
• Ventriculostomy
Surgical management
 Nursing management
Ineffective breathing pattern
– Clear the upper airway
– Place oral airway
– Assess : respiratory rate, pattern, associated
injury,pupillary reaction,CSF leakage
– If airway patency is not maintained assist with
intubation
– If there facial fracture assist for tracheostomy
– Suction as needed( not more than 10 sec)
 Nursing management
• Altered cerebral tissue perfusion
– Administer IV fluids
– Maintain patent airway and adequate
ventilation
– Monitor for the signs of increased ICP
– Maintain normothermia
– Measures to reduce ICP
– Observe for any signs of respiratory distress
– Check CVP line
– Insert urinary catheter
 Nursing management
• Nutritional management
– Total fluid replacement in first 24 – 48 hours
should be through IV route
– Start early enteral feed(after 24 hours)
– Intake out put chart
– Monitor serum electrolytes
– Monitor for signs of diabetes insipidus
 Nursing management
– Meet the increased nutritional demand
– No NG feed if CSF rhinorrhoea

(WRONG METHOD) IDEAL METHOD)

 Nursing management
• Maintain normal skin integrity
– Position change
– Avoid dragging
– Correct body positioning
– Use comfort devices
• Trochanter role
• Air mattress
– Back care
 Nursing management
• Maintenance of corneal integrity
– Eye irrigation

– Artificial tears

– Cold compress

– Eye patch
 Nursing management
• Reduce risk for contracture
– Proper positioning

– Use splints
 Nursing management
• Altered bowel elimination
– Assess abdominal distention
– No. and consistency of stool
– Listen bowel sounds
– Stool softener
– Adequate fluid intake
– Dietary fibers
 Nursing management
Sensory / perceptual alterations
– Explain what you are going to do
– Use walky- talky
– Play tape recording of a familiar voice of a
family member or friend
– During this do not converse with other
members in the room
– Stroke patients arms or legs with fabrics of
various textures
THANK YOU
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