Adult Medical-Surgical Adult Medical-Surgical Nursing Nursing

Neurology Module: Neurology Module:

Head InjuryHead Injury

Head Injury: Classification Head Injury: Classification

Scalp traumaScalp traumaSkull Fracture: Skull Fracture: Linear: simple fractureLinear: simple fractureComminuted: fragmented boneComminuted: fragmented boneDepressed: dislocated piece of bone Depressed: dislocated piece of bone pressing into brain tissue pressing into brain tissue Basilar (basal/base of skull): the paranasal Basilar (basal/base of skull): the paranasal sinus of frontal bone or the temporal bone sinus of frontal bone or the temporal bone (allows drainage of blood/ CSF) (allows drainage of blood/ CSF)

Brain Trauma: ClassificationBrain Trauma: Classification

Coup/ contre-coup: force causes trauma to Coup/ contre-coup: force causes trauma to proximal and distal area of brainproximal and distal area of brainConcussion: temporary loss of Concussion: temporary loss of consciousness but no structural damage consciousness but no structural damage Contusion: bruising of brain tissue. May Contusion: bruising of brain tissue. May have surface brain haemorrhage, oedema have surface brain haemorrhage, oedema (Prolonged LOC, shock, slow recovery)(Prolonged LOC, shock, slow recovery)Diffuse axonal injury: widespread damage Diffuse axonal injury: widespread damage to neurons/ cerebral oedema (Coma)to neurons/ cerebral oedema (Coma)

Brain Haemorrhage: ClassificationBrain Haemorrhage: Classification

EpiduralEpidural

Sub-duralSub-dural

Intra-cerebralIntra-cerebral

Sub-arachnoidSub-arachnoid

Epidural HaemorrhageEpidural Haemorrhage

ArterialArterialBetween the skull bone and dura mater, Between the skull bone and dura mater, usually under temporal boneusually under temporal boneEmergencyEmergency as quickly ↑ pressure on brain as quickly ↑ pressure on brainTypically LOC, then lucid period Typically LOC, then lucid period (compensation to control ICP) until rapid (compensation to control ICP) until rapid increase in ICP and deteriorationincrease in ICP and deteriorationRequires urgent evacuation via burrhole/ Requires urgent evacuation via burrhole/ craniotomy: drain left in situ initiallycraniotomy: drain left in situ initially

Physiological Compensation for Physiological Compensation for Raised ICPRaised ICP

The body attempts to control a rise in The body attempts to control a rise in intra-cranial pressure through:intra-cranial pressure through:

Rapid reabsorption of cerebro-spinal fluidRapid reabsorption of cerebro-spinal fluid

Reduced secretion of CSFReduced secretion of CSF

Cerebral vasoconstriction to reduce Cerebral vasoconstriction to reduce intravascular volume of cerebral vesselsintravascular volume of cerebral vessels

→ → reduced pressure of space-occupation reduced pressure of space-occupation in cranium (and ↓ damage to brain tissue) in cranium (and ↓ damage to brain tissue)

Subdural HaematomaSubdural Haematoma

Usually venous: collection of blood Usually venous: collection of blood between dura mater and brain tissue between dura mater and brain tissue (arachnoid)(arachnoid)Related to coagulopathies, ruptured Related to coagulopathies, ruptured aneurysm as well as head injuryaneurysm as well as head injuryAcuteAcute, , sub-acutesub-acute: related to a major head : related to a major head injury (contusion or laceration)injury (contusion or laceration)ChronicChronic: minor head injury, mostly in the : minor head injury, mostly in the elderly, gradually thick fluid → ossificationelderly, gradually thick fluid → ossification

Subdural Haematoma:Subdural Haematoma:Clinical ManifestationsClinical Manifestations

LOCLOCPupil changesPupil changesHemiparesisHemiparesis→ → Coma, with ↑ BP and pulse pressure, Coma, with ↑ BP and pulse pressure, bradycardia, slow respirationsbradycardia, slow respirationsChronicChronic subduralsubdural: slow development: : slow development: fluctuating headache, paralysis, focal fluctuating headache, paralysis, focal seizures, mental deterioration, personality seizures, mental deterioration, personality changes (symptoms appear over time)changes (symptoms appear over time)

Subdural Haematoma: TreatmentSubdural Haematoma: Treatment

Surgical evacuation through burrholes or Surgical evacuation through burrholes or craniotomy if too largecraniotomy if too large

Intra-cerebral HaematomaIntra-cerebral Haematoma

Bleeding into the brain tissueBleeding into the brain tissue

Occurs with force over a small area: bullet Occurs with force over a small area: bullet or missile injury or stab woundor missile injury or stab wound

May be inaccessible and difficult to May be inaccessible and difficult to evacuateevacuate

Management involves maintaining ICP Management involves maintaining ICP and stabilising BP: support and and stabilising BP: support and maintenance until absorbedmaintenance until absorbed

Sub-arachnoid HaemorrhageSub-arachnoid Haemorrhage

Haemorrhage, not a haematomaHaemorrhage, not a haematoma

This is a bleed into the CSF (may be This is a bleed into the CSF (may be ruptured aneurysm or vascular anomaly as ruptured aneurysm or vascular anomaly as well as trauma)well as trauma)

Blood in CSF blocks flow → Blood in CSF blocks flow → hydrocephalus and ↑ ICPhydrocephalus and ↑ ICP

Compression of brain tissue or brain Compression of brain tissue or brain ischaemia and infarct from ischaemia and infarct from vasospasmvasospasm

Sub-arachnoid Haemorrhage:Sub-arachnoid Haemorrhage:Clinical ManifestationsClinical Manifestations

Sudden, severe headacheSudden, severe headacheLoss of consciousness (LOC)Loss of consciousness (LOC)Neck rigidity and pain (meningeal irritation)Neck rigidity and pain (meningeal irritation)Visual loss, diploplia, ptosisVisual loss, diploplia, ptosisTinnitus, dizziness, hemiparesisTinnitus, dizziness, hemiparesisIf slight may seal itselfIf slight may seal itselfComa and death if severeComa and death if severe50% mortality rate50% mortality rate

Sub-arachnoid Haemorrhage: Sub-arachnoid Haemorrhage: TreatmentTreatment

Early repair of damaged vessel (ablation Early repair of damaged vessel (ablation therapy to seal) if possible therapy to seal) if possible Support and maintenance otherwise:Support and maintenance otherwise:Prevention of complication of vasospasm Prevention of complication of vasospasm by calcium channel blockerby calcium channel blockerPrevention of seizures (Epanutin)Prevention of seizures (Epanutin)Early dissolving of clot (tPA) to reduce risk Early dissolving of clot (tPA) to reduce risk of secondary haem: IV volume expandersof secondary haem: IV volume expandersVentriculostomy/ VP shunt if hydrocephalus Ventriculostomy/ VP shunt if hydrocephalus

Head Injury: Head Injury: Nursing ConsiderationsNursing Considerations

ICU: ↑ head of bed ICU: ↑ head of bed Monitor and maintain ICPMonitor and maintain ICPGlasgow Coma Scale: level of Glasgow Coma Scale: level of consciousnessconsciousnessMonitor and maintain vital signs, fluid Monitor and maintain vital signs, fluid balancebalanceCare of the unconscious patientCare of the unconscious patientMaintain sterility of dressings and drainsMaintain sterility of dressings and drainsMedications as orderedMedications as ordered