Traumatic Head Injury

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Traumatic Head Injury

• Paula Ponder MSN, RN, CEN
• (Relates to Chapter 63 Management of Patients
  with Neurologic Trauma in the textbook)

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Learning Objectives

• Differentiate head injuries according to
  mechanism of injury and clinical signs and
  symptoms
• Identify diagnostic testing, and treatment
  options
• Describe the nursing management of patients with
  head injury
• Discuss the need for injury prevention

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Head Injury

• Any trauma to the
• Scalp
• Skull
• Brain
• Head trauma includes an alteration in
  consciousness, no matter how brief

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Head Injury

• Causes
• Motor vehicle accidents
• Account for ½ of all traumatic brain injury in
  the US
• Falls
• Assaults
• Firearm-related injuries
• Sports-related injuries
• Recreational accidents
• Highest risk group is ages 15-24, males 2x as
  likely as women

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• Advise drivers to obey traffic laws, and to avoid
  speeding or driving when under the influence of
  drugs or alcohol.
• Advise all drivers and passengers to wear seat
  belts and shoulder harnesses. Children younger
  than 12 years of age should be restrained in an
  age/size-appropriate system in the back seat.
• Caution passengers against riding in the back of
  pickup trucks.
• Advise motorcyclists, scooter riders, bicyclists,
  skateboarders, and roller skaters to wear
  helmets.
• Promote educational programs that are directed
  toward violence and suicide prevention in the
  community.
• Provide water safety instruction.
• Teach patients steps that can be taken to prevent
  falls, particularly in the elderly.
• Advise athletes to use protective devices.
  Recommend that coaches be educated in proper
  coaching techniques.
• Advise owners of firearms to keep them locked in
  a secure area where children cannot access them.

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Head Injury

• High potential for poor outcome
• Deaths occur at three points in time after injury
• Immediately after the injury
• From the injury itself
• Within 2 hours after injury
• From a progressive injury or internal injury
• 3 Weeks after injury
• MODS

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• Primary injury
• Contusion, puncture, ect.
• Only the stuff that happens at the injury, the
  stuff that happens right then and there
• Secondary Injury
• Happens afterward
• IICP, inadequate oxygenation

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Head InjuryTypes of Head Injuries

• Scalp lacerations
• Can bleed profusely
• Skull fractures
• Linear or depressed
• Linear is from a low velocity injury
• Simple, comminuted, or compound
• Simple with or without fragments is low velocity
• Comminuted is a direct blow, high momentum
  impact. The bone is fragmented into many pieces.
• Compound fracture is a severe head injury.
  Usually a depressed skull fracture with scalp
  laceration with a communicating pathway into the
  intracranial cavity
• Closed or open

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• Frontal fracture
• May see air in the forehead tissue, CSF coming
  out of their nose
• Orbital fracture
• Raccoon eyes, may have optic nerve injury
• Parietal fracture
• Battle signs, facial paralysis
• Basilar fracture
• CSF out ears, nose, battle signs, trouble hearing
  or tinnitus, facial paralysis, conjugate gaze,
  vertigo. There is a tear in the dura so there is
  an open pathway. B/c of where the break/tear is
  you wouldnt put an NG tube in, its an open
  pathway from your nose/ear to your brain!! Might
  give them meningitis

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Head InjuryTypes of Head Injuries

• Minor head trauma
• Concussion
• Temporary loss of neurological functioning with
  no apparent structural damage! May or may not
  have loss of consciousness
• May have amnesia
• Mild and Classic
• Mild may lead to a period of reported or
  observed confusion, memory lapse, possible loss
  of consciousness, can include a seizure, HA,
  dizziness
• Classic does result in a loss of consciousness,
  usually less than 6 hours. Always accompanied by
  some degree of post injury amnesia! No apparent
  structural damage on either one of these guys
• Major head trauma
• Contusion
• Moderate to severe head injury, bruise. Impact of
  the brain against the skull. Loss of
  consciousness (associated with stupor and
  confusion).
• Lacerations
• Involve actual tearing of the brain tissue, not
  just the dura.

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Head Injury

• Diffuse axonal injury (DAI)
• Widespread axonal damage occurring after a mild,
  moderate, or severe TBI
• Process takes approximately 12 to 24 hours
• Damage occurs around
• Axons in subcortical white matter of the cerebral
  hemispheres
• Basal ganglia
• Thalamus
• Brainstem
• Associated with prolonged coma, poorest prognosis
  of any other brain injury we have. Usually come
  in in a coma already, they are posturing, global
  cerebral edema, diagnosis is made with CT or MRI.
  Shearing type thing, as the brain shears there
  are little tears. Then injury stops and settles
  back down, doesnt look like an injury on the
  initial scan, but as time passes you being to see
  these little blood spots. Usually in white matter
  associated with acceleration and deceleration
  injury. Coup/ContreCoup injury. Responsible for
  most cases of post traumatic dementia, also in
  conjunction with hypoxic ischemic injury. Most
  common cause of persistent vegetative state.
  Slight movements are usually reflexes, but not
  always.

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Head Injury
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Head Injury

• Diffuse axonal injury (DAI)
• Clinical signs
• Decreased LOC
• Increased ICP
• Decerebration or decortication (posturing)
• Global cerebral edema

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Head Injury

• Epidural hematoma
• Results from bleeding between the dura and the
  inner surface of the skull
• Neurologic emergency!!!
• Venous or arterial origin
• 99.9 a tear in the middle meningial arterial
  artery, the source of bleeding is arterial
• Presents with head injury with breif period of
  unconsciousness followed by a lucid period where
  consciousness is regained. The lucid period may
  or may not be there, but if they were out, came
  back, and went out again you KNOW its an
  epidural hematoma

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Head Injury

• Epidural hematoma
• Classic signs include
• Initial period of unconsciousness
• Brief lucid interval followed by decrease in LOC
• Headache
• Nausea, vomiting
• Focal findings

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Head Injury

• Subdural hematoma
• Occurs from bleeding between the dura mater and
  arachnoid layer of the meningeal covering of the
  brain
• Most common source is the veins that drain the
  brain surface into the sagittal sinus
• Since its venous its a slower bleed, but still
  an emergency!
• Bleed from the small bridging veins that connect
  the surface of the cortex to the dural sinuses

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Head Injury

• 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

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Head Injury

• Subdural hematoma
• Acute subdural hematoma
• Signs within 48 hours of the injury
• Similar signs and symptoms to brain tissue
  compression in increased ICP
• Drowsy, confused, HA
• Patient appears drowsy and confused
• Ipsilateral pupil dilates and becomes fixed
• Dilates on the side of the bleed and stays
  dilated
• Associated with high mortality b/c of the severe
  secondary injuries that are associated with it.
  Often uncontrolled rise in ICP
• Caused by crash, moment of impact stuff, hit in
  the head with a baseball

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Head Injury

• Subdural hematoma
• Subacute subdural hematoma
• Occurs within 2 to 14 days of the injury
• After initial bleeding, subdural hematoma may
  appear to enlarge over time
• Slow as shit bleed, it takes 2 14 days to start
  causing problems. Or from small acute subdural
  that they thought had stopped, but a little bit
  of increased ICP re-pops the shiz

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Head Injury

• Subdural hematoma
• Chronic subdural hematoma
• Develops over weeks or months after a seemingly
  minor head injury
• Peak incidence in sixth and seventh decades of
  life

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Head Injury

• Subdural hematoma
• Chronic subdural hematoma
• Presenting complaint often focal symptoms, not
  signs of increased ICP
• Delay in diagnosis in older adults because
  symptoms mimic those of vascular disease and
  dementia
• Usually older people because there is more space
  in their heads for swelling or what not, plus as
  they age their brain atrophies, may be on
  coumadin, tend to fall more

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Head Injury

• Intracerebral Hematoma
• Occurs from bleeding within the parenchyma
• Usually occurs within the frontal and temporal
  lobes
• Size and location of hematoma determine patient
  outcome
• Most of the time from a bullet (missile injury),
  stabbing,

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Head Injury

• Subarachnoid Hematoma
• Bleeding into the subarachnoid space
• Most common causes are subarachnoid aneurysm,
  head trauma, or hypertension
• Mean age is 50, super bad, people die all the
  time Mortality is high, maybe because there is
  usually something else going on in their body
  that is messed up that lead them to having the
  berry aneurysm and bleed in the first place

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Intracerebral and Subarachnoid Hematoma
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Berry aneurysm
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Berry aneurysm
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Subarachnoid Bleed

• Symptoms
• Worst HA of their life
• Photosensitive
• Nausea
• Dont put these guys out in the lobby because you
  think they have a migrane. They may have a
  subarachnoid bleed
• Vasospasm in the head narrowing of the lumen of
  a vessel, serious complication of subarachnoid
  bleed, leading cause of mortality of people who
  didnt initially die with the subarachnoid bleed.
  Usually 3-14 days after initial hemorrhage. S/S
  reflect the area of the brain involved, worse HA,
  decreased LOC, confusion, new focal deficit. Med
  is Nimotop, also triple H therapy (hypervolemia,
  induced arterial HTN, and hemodilute them)

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Head InjuryDiagnostic Studies and Collaborative
Care

• CT scan
• Best diagnostic test to determine craniocerebral
  trauma
• MRI
• PET
• Transcranial Doppler studies
• Looking for vasospasm
• Cervical spine x-ray
• You must see from 1 7 to see that they have no
  injury
• Glasgow Coma Scale (GCS)

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Head InjuryDiagnostic Studies and Collaborative
Care

• Treatment principles
• Prevent secondary injury in the brain
• Timely diagnosis
• Surgery if necessary
• Craniotomy
• Craniectomy
• Cranioplasty
• Burr-hole

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Head InjuryNursing Management

• Nursing assessment
• Airway
• Semi-Fowlers positioning, really good oral care
• Glasgow Coma Scale score
• Neurologic status
• Presence of CSF leak
• Collaborative problem Increased ICP

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13-15 minor brain injury 9-12 is moderate
lt8 is severe
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Head InjuryNursing Management

• Planning
• Overall goals
• Maintain adequate cerebral perfusion
• Remain normothermic
• Be free from pain, discomfort, and infection
• Attain maximal cognitive, motor, and sensory
  function

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Head InjuryNursing Management

• Nursing implementation
• Acute intervention
• Maintain cerebral perfusion
• Prevent secondary cerebral ischemia
• Monitor for changes in neurologic status
• Treatment of life-threatening conditions will
  initially take priority in nursing care

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Head InjuryNursing Management

• Nursing implementation
• Ambulatory and home care
• Nutrition, Bowel / bladder control
• Seizure disorders, Personality changes
• Family participation and education

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Pathologic reflexes

• Babinskis sign
• Stroke the bottom of the foot and the toes go up
  towards the nose means its positive, but
  positive is bad!
• Kids is positive until 12 mo or if their bearing
  weight
• Grasp
• You put something in their hand nad they dont
  let go
• Snout
• When you touch their lip and they purse the lips,
  thats pathological, meaning its bad
• We need to check noxious stimuli, meaning
  pinching their nail bed, sternum rub, pinching
  arm, BUT NO NIPPLES

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Oculocephalic Reflex

• Dolls Eye Movement
• Normal Dolls Eye (brainstem intact)
• Eyes move opposite direction of head rotation
  (remain focused on what pt may be viewing)
• Abnormal Dolls Eye (brainstem injury)
• Eyes follow direction of head rotation
• Poss. loss of gag cough reflex
• http//medstat.med.utuh.edu
• Chart as normal or abnormal

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Dolls eyes
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Oculovestibular Reflex

• Cold Caloric Testing
• Intact brainstem
• Nystagmus, w/ eyes slowly move toward ear
  irrigated w/ cold water rapid movement away
• Severe brainstem damage
• Both eyes fixed midline position
• Inhibition of reflex
• Neuromuscular blockers
• Barbiturates

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Persistent Vegetative State

• absence of awareness of self
• inability to interact with others
• lack of language comprehension
• brain stem function to maintain life
• condition has continued for at least 1 month

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Brain Death

• Brain death is defined as the irreversible loss
  of function of the brain, including the brain
  stem
• Brain death is a clinical diagnosis, and a repeat
  evaluation at least 6 hours later is recommended
• Medical documentation should include cause and
  irreversibility of the condition

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Brain Death

• Corneal reflex
• Gag reflex
• Apnea
• Angiography
• Consider an EEG
• Cardinal signs of brain death are coma, absence
  of brain stem function, apnea

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Life Gift

• 806-798-5568
• www.lifegift.org
• Organ Procurement Organization
• OPO

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TissueOne donor can help 70 people

• Bone
• Skin
• Tissue ligaments, tendons
• Veins
• Heart valves
• Eyes/corneas

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OrgansOne donor can save 8 lives!

• Heart
• Lung (can be single or double)
• Liver
• Kidneys (2)
• Pancreas
• Intestine

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Background

• Texas law you are brain dead when your doctor
  says you are brain dead
• Family doesnt have the choice to leave a
  brain-dead pt on vent indefinitely

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Brain Death Testing

• Clinical exam
• GCS 3
• No brain stem reflexes
• Apnea test
• Baseline ABG is obtained
• Vent removed, supplemental O2 provided

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Brain Death Testing

• Cerebral Blood Flow
• Scan assesses for entry of dye into brain
• Cerebral Arteriogram
• 4 vessel study
• Absolute determination
• EEG
• Artifact may cause false interpretation
• Slow turnaround on results of study

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Donor Management

• Whats good for the patient is good for the
  donor
• Normal labs, ABGs, CXRs
• Normal vital signs
• Urine output 50-300 ml/hour
• Adequate oxygenation

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How do You sign up?

• Register as a donor at www.donatelifetexas.org
• Centralized state registry
• First person consent
• Coordinators can search the registry with the
  pts information, speeding up the donation process

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Summary

• Maintain airway
• Early diagnosis and treatment
• Prevention of secondary injury
• Maintain cerebral perfusion pressure

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