traumatic-head-injury by xiangpeng


									Traumatic Head Injury

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

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

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

• High potential for poor outcome
• Deaths occur at three points in time after
  – 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
• 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
            Head Injury
       Types 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
• 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 wouldn’t put an NG
     tube in, it’s an open pathway from your nose/ear to
     your brain!! Might give them meningitis
                                                Head Injury
• Minor head trauma                        Types of Head Injuries
  – 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.
                        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, doesn’t 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.
Head Injury
            Head Injury
• Diffuse axonal injury (DAI)
  – Clinical signs
     • Decreased LOC
     • Increased ICP
     • Decerebration or decortication (posturing)
     • Global cerebral edema
               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 it’s an
  epidural hematoma
            Head Injury
• Epidural hematoma
  – Classic signs include
     • Initial period of unconsciousness
     • Brief lucid interval followed by decrease in LOC
     • Headache
     • Nausea, vomiting
     • Focal findings
             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 it’s venous it’s a slower bleed, but still an
     • Bleed from the small bridging veins that connect the
       surface of the cortex to the dural sinuses
            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
                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
             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
            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
               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
        – 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
           Head Injury
• Intracerebral Hematoma
  – Occurs from bleeding within the parenchyma
• Usually occurs within the frontal and temporal
• Size and location of hematoma determine
  patient outcome
  – Most of the time from a bullet (missile injury),
           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
Intracerebral and Subarachnoid Hematoma
Berry aneurysm
Berry aneurysm
              Subarachnoid Bleed
• Symptoms
   –   Worst HA of their life
   –   Photosensitive
   –   Nausea
   –   Don’t 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 didn’t 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
                          Head Injury
         Diagnostic Studies and Collaborative Care

• CT scan
   – Best diagnostic test to determine craniocerebral trauma
• 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)
                          Head Injury
           Diagnostic Studies and Collaborative Care

• Treatment principles
    – Prevent secondary injury in the brain
    – Timely diagnosis
    – Surgery if necessary
•   Craniotomy
•   Craniectomy
•   Cranioplasty
•   Burr-hole
           Head Injury
      Nursing Management
• Nursing assessment
  – Airway
     • Semi-Fowler’s positioning, really good oral care
  – Glasgow Coma Scale score
  – Neurologic status
  – Presence of CSF leak
• Collaborative problem: Increased ICP
  Eye opening response         Spontaneous                     4
                               To voice                        3
                               To pain                         2
                               None                            1
  Best verbal response         Oriented                        5
                               Confused                        4
                               Inappropriate words             3
                               Incomprehensible sounds         2
                               None                            1
  Best motor response          Obeys command                   6
                               Localizes pain                  5
                               Withdraws                       4
                               Flexion                         3
                               Extension                       2
                               None                            1
  Total                                                        3 to 15

13-15 minor brain injury   9-12 is moderate              <8 is severe
          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
           Head Injury
      Nursing 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
           Head Injury
      Nursing Management
• Nursing implementation
  – Ambulatory and home care
     • Nutrition, Bowel / bladder control
     • Seizure disorders, Personality changes
     • Family participation and education
        Pathologic reflexes
• Babinski’s sign
   – Stroke the bottom of the foot and the toes go up towards
     the nose means it’s 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 don’t let go
• Snout
   – When you touch their lip and they purse the lips, that’s
     pathological, meaning it’s bad
• We need to check noxious stimuli, meaning pinching
  their nail bed, sternum rub, pinching arm, BUT NO
  Oculocephalic Reflex
• “Doll’s Eye Movement”
• Normal Doll’s Eye (brainstem intact)
  – Eyes move opposite direction of head rotation (remain focused
    on what pt may be viewing)

• Abnormal Doll’s Eye (brainstem injury)
  – Eyes follow direction of head rotation
  – Poss. loss of gag & cough reflex

• Chart as normal or abnormal

Doll’s eyes
  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

    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
           Brain Death
• Brain death is defined as the irreversible loss
  of function of the brain, including the brain
• Brain death is a clinical diagnosis, and a repeat
  evaluation at least 6 hours later is
• Medical documentation should include cause
  and irreversibility of the condition
            Brain Death
•   Corneal reflex
•   Gag reflex
•   Apnea
•   Angiography
•   Consider an EEG

• Cardinal signs of brain death are coma,
  absence of brain stem function, apnea
            Life Gift
• 806-798-5568
• Organ Procurement Organization
  – OPO
              One donor can help 70 people
•   Bone
•   Skin
•   Tissue – ligaments, tendons
•   Veins
•   Heart valves
•   Eyes/corneas
                      One donor can save 8 lives!
•   Heart
•   Lung (can be single or double)
•   Liver
•   Kidneys (2)
•   Pancreas
•   Intestine
• Texas law: you are brain dead “when your
  doctor says you are brain dead”
  – Family doesn’t have the choice to leave a brain-dead
    pt on vent indefinitely
        Brain Death Testing
• Clinical exam
  – GCS 3
  – No brain stem reflexes
• Apnea test
  – Baseline ABG is obtained
  – Vent removed, supplemental O2 provided
               Brain Death Testing
• Cerebral Blood Flow
  – Scan assesses for entry of dye into brain
• Cerebral Arteriogram
  – 4 vessel study
  – Absolute determination
  – Artifact may cause false interpretation
  – Slow turnaround on results of study
              Donor Management
• “What’s good for the patient is good for the
  – Normal labs, ABGs, CXRs
  – Normal vital signs
  – Urine output 50-300 ml/hour
• Adequate oxygenation
                      How do You sign up?
• Register as a donor at
  – Centralized state registry
  – First person consent
  – Coordinators can search the registry with the pt’s
    information, speeding up the donation process
•   Maintain airway
•   Early diagnosis and treatment
•   Prevention of secondary injury
•   Maintain cerebral perfusion pressure

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