head injury

D R . J A Y E S H P A T I D A R

HEAD INJURY

30/04/2015 www.drjayeshpatidar.blogspot.com

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INTRODUCTION

Head injury is a broad classification that includes injury to the scalp, skull, or brain.

Trauma involving the central nervous system can be lifethreatening.

brain and spinal cord injury may result in major physical and psychological dysfunction and can alter the patients life completely.


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INCIDENCE

In the United States. Approximately 1 million people receive treatment for head injuries every year.

Of these, 230,000 are hospitalized,

80,000 have permanent disabilities,

and 50,000 people die


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Damage to the brain from traumatic injury takes two forms:

primary injury and secondary injury.

Primary injury is the initial damage to the brain that results from the traumatic event.

Secondary injury

evolves over the ensuing hours and days after the initial injury and is due primarily to brain swelling or ongoing bleeding.


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SCALP INJURY

scalp trauma is generally classified as a minor head injury.

Because its many blood vessels constrict poorly, the scalp bleeds profusely when injured.


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SKULL FRACTURES

A skull fracture is a break in the continuity of the skull caused by forceful trauma. It may occur with or without damage to the brain. Skull fractures are classified as linear, comminuted, depressed, or basilar.


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Type of skull fracture

Linear- breakn in continuty of bone without alteration of relationshup of part.

Depressed- inward indention of skull

Simpal- without fragmentation or communication laceration.

Communicated- fragmentation of bone into many pieces.


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Clinical Manifestations

The symptoms, apart from those of the local injury, depend on the severity and the distribution of brain injury.

frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva.

(Battles sign)- An area of ecchymosis (bruising) may be

seen over the mastoid

A halo sign (a blood stain surrounded by a yellowish stain) and is highly suggestive of a CSF leak.


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Assessment and Diagnostic Findings

physical examination,

a computed tomography (CT) scan

the x-rays.

Magnetic resonance imaging (MRI)


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Management

Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the patient is essential.

Nursing personnel may observe the patient in the hospital,


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nasopharynx and the external ear should be kept clean.

a piece of sterile cotton is placed loosely in the ear, or a sterile

cotton pad may be taped loosely under the nose or against the ear

The head is elevated 30 degrees to reduce ICP


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Brain Injury

The most important consideration in any head injury is whethe or not the brain is injured.

Significant brain damage secondary to obstructed blood flow and decreased tissue perfusion. The brain cannot store oxygen and glucose to any significant degree.

brain damage and cell death occur when the blood supply is interrupted for even a few minutes


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Type

Closed (blunt) brain

brain tissue is damaged, but there is no opening through the skull and dura.

Open brain injury occurs when an object penetrates the skull, enters the brain, and damages the soft brain Tissue it opens the scalp, skull, and dura to expose the brain.


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Pathophysiology Brain suffers traumatic injury

Brain swelling or bleeding

increases intracranial volume

intracranial pressure increases

Pressure on blood vessels within the brain causes blood flow to the brain to slow

Cerebral hypoxia and ischemia occur

Intracranial pressure continues

to rise. Brain may herniate

Cerebral blood flow ceases


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Clinical Manifestations of Brain Injury

Altered level of consciousness

Confusion

Pupillary abnormalities (changes in shape, size, and response to light)

Sudden onset of neurologic deficits

Changes in vital signs (altered respiratory pattern, hypertension, bradycardia, tachycardia, hypothermia or hyperthermia)


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Vision and hearing impairment

Sensory dysfunction

Headache

Vertigo

Seizures


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Concussion

A cerebral concussion after head injury is a temporary loss of neurologic function with no apparent structural damage.

A concussion generally involves a period of unconsciousness lasting from a few seconds to a few minutes.


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Contusion

Cerebral contusion is a more severe injury in which the brain is bruised, with possible surface hemorrhage.

The patient is unconscious for more than a few seconds or minutes. Clinical signs and symptoms depend on the size of the contusion and the amount

of associated cerebral edema.


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Intracranial Hemorrhage

Hematomas (collections of blood) that develop within the cranial vault are the most serious brain injuries hematoma may be epidural (above the dura), subdural (below the dura), or intracerebral (within the brain)


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EPIDURAL HEMATOMA (EXTRADURAL HEMATOMA OR HEMORRHAGE)

After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

This can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery,

the artery that runs between the dura and the skull inferior to a thin portion of temporal bone.

Hemorrhage from this artery causes rapid pressure on the brain.


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SUBDURAL HEMATOMA

A subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid. The most common cause of subdural hematoma is trauma


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INTRACEREBRAL HEMORRHAGE AND

HEMATOMA

Intracerebral hemorrhage is bleeding into the substance of the brain.

It is commonly seen in head injuries when force is exerted to the head over a small area (bullet wounds; stab injury).

These hemorrhages within the brain may also result from systemic hypertension, which cause degeneration and rupture of a vessel;


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Diagnostic evaluation

Management of Brain Injuries

History

Initial physical and neurologic examinations.

CT and MRI

Positron emission tomography

(PET scan) this method of scanning examines brain function rather than structure.


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TREATMENT OF INCREASED INTRACRANIAL PRESSURE

As the damaged brain swells with edema or as blood collects within

the brain, a rise in ICP occurs

maintaining adequate cerebralnoxygenation.

Surgery is required for evacuation of blood clots,

dbridement and elevation of depressed fractures of the skull,

and suture of severe scalp lacerations.

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ICP is monitored closely; if increased, it is managed by

maintaining adequate oxygenation,

elevating the head of the bed,

maintaining normal blood volume


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SUPPORTIVE MEASURES

Treatment also includes ventilatory support, seizure prevention, fluid and electrolyte maintenance, nutritional support, and pain and anxiety management.

Protect the airway.


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Severity of Injury

Amount of brain tissue damage

measure severity

Duration of loss of consciousness

Initial score on Glasgow Coma Scale (GSC)


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Mild injury

0-20 minute loss of consciousness GCS = 13-15


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Moderate injury

20 minutes to 6 hours LOC GCS = 9-12


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Severe injury

> 6 hours LOC GCS = 3-8


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Diagnosis NURSING DIAGNOSES

Based on the assessment data, the patients major nursing diagnoses

may include the following: Ineffective airway clearance and impaired gas exchange

related to brain injury Ineffective cerebral tissue perfusion related to increased

ICP Deficient fluid volume related to decreased LOC and

hormonal dysfunction Imbalanced nutrition, less than body requirements,

related to metabolic changes, fluid restriction, and inadequate intake


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Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage

Risk for imbalanced (increased) body temperature related to damaged temperature-regulating mechanism

Potential for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, and immobility

Disturbed thought processes (deficits in intellectual function, communication, memory, information processing) related to brain injury


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Head and Spinal Cord Injury Prevention

The most effective treatment for brain and spinal cord injury is prevention. To decrease the incidence of these devastating and catastrophic injuries, the following steps should be taken:

Drivers should obey traffic laws, particularly not speeding or driving when under the influence of drugs or alcohol.

All drivers and passengers should wear seat belts and shoulder harnesses. Children under 12 should be restrained in an age/size-appropriate system in the back seat.

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Passengers should not ride in the back of pick-up trucks.

Motorcyclists, scooters, bicyclists, skateboarders, and roller skaters should wear helmets


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Educational programs should be directed toward violence and suicide prevention in the community.

Water safety instruction should be provided. Steps should be taken to prevent falls, particularly in the elderly.


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Athletes should use protective devices; coaches should be educated in proper coaching techniques.

Owners of firearms should keep them locked in a secure area where children cannot access them.


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head injury

Documents

secondary injury

primary injury

initial injury

traumatic injury

distribution of brain

local injury

introduction head injury

minor head injury