1


I have nothing to disclose
I have no conflict of interest
2
Objectives
Identify Common Mechanisms for Brain
Injury
 Describe Pathophysiology of Brain Injury
 Describe Nursing Assessment and
Interventions for Brain Injury Patient

3
4
1.7 million annually
 50,000+ deaths per year
 At least 125,000 are left with permanent
disabilities
 Approximately 715/100,000 ED visits per
year are related to brain injuries

5
At Risk Populations:
› Males 15-24
› Infants
› Young Children
› Elderly
6

Risks:
› Alcohol use
› Substance Abuse
› Anticoagulants
› Not using safety restraints or using incorrectly
› No bike helmets or other safety equipment
7

Causes of Injury
› Motor vehicle crashes
› Falls
› Sports
› Assault
› Firearms
8

Mechanisms of Injury
› Open Head Injury
› Closed Head Injury
› Deceleration Injury (Diffuse Axonal Injury)
› Chemical or Toxic
› Hypoxia
› Tumors
› Infection
› Stroke
9

Caused by penetrating wounds
10
Scalp Wounds are highly vascular
 Bleeding could lead to shock, esp in
children
 If no skull fracture treat with direct
pressure and dressings to the wound
 Unstable skull fractures apply dressings
but no direct pressure

11

Skull Fractures
› Linear
› Depressed
› Basilar
12

Linear
› Nondisplaced fracture of the skull
› May be indicative
of brain injury under
fracture line
› Signs
 Headache
 Decreased Level
of Consciousness
13

Depressed
› Extends below the surface
of the skull and can
cause compression
of brain tissue
Signs:
Headache
Decreased Level of
Consciousness
Palpable depression of skull
14

Basilar
› Fracture that involves any of the five bones
in the base of the skull
› Associated with brain injury, dura laceration
and cranial nerve damage
› Signs




Headache
Altered Level of Consciousness
Facial Nerve Palsy
CSF otorrhea or rhinorrhea
15

Raccoon Eyes
* Orbital Fractures
Battle’s Sign
* Auditory canal
fracture
16




Any skull fracture causing a laceration into the
dura has the potential for Cerebrospinal Fluid
(CSF) leaks from the ear (otorrhea) or nose
(rhinorrhea)
CSF is clear, odorless fluid
Leaking of Spinal fluid can lead to meningitis or
encephalitis
Infected CSF may be cloudy with blood
17
Delivery of oxygen and nutrients to the
brain is dependent on adequate
cerebral perfusion pressure and
autoregulatory mechanisms in the brain
 Any alterations in any of these systems
can damage the brain

18
Cerebral Perfusion Pressure: Mean Arterial
Pressure - Intracranial Pressure
(CPP= MAP-ICP)
› CPP needs to be maintained >60mmHg to
allow for adequate cerebral perfusion
› Increasing the blood pressure with
medications may be necessary to increase
the CPP
19
Intracranial Pressure is comprised of
three volumes within the skull – Brain,
Cerebrospinal fluid, and Blood Volume
 Body can compensate for loss of blood
volume and low blood pressure for a
short time before the ICP will increase
 Normal ICP is 10
 ICP above 20 is concerning

20

Early Signs
› Headache
› Nausea and Vomiting
› Altered Level of Consciousness
› Restlessness
› Lethargy
› Amnesia
› Confusion
21

Late Signs
› Changes in Pupil response
› Unresponsive to verbal or tactile stimuli
› Posturing
› Changes in Respiratory pattern
› Cushing’s Response – Very late sign
 Increased SBP with wide pulse pressure
 Bradycardia
 Decreased respiratory effort
22
Blunt trauma to the head
 No penetrating trauma
 Diffuse damage to the brain
 Several forces of injury

› Shearing
› Tensile
› Compressive
› Coup-contrecoup
23
24

Minor: GCS 13-15
› Risk of deterioration depends on clinical
presentation

Moderate: GCS 9-13
› High potential for deterioration to severe
head trauma in first 48 hours

Severe: GCS <8
› Coma, abnormal pupil response, posturing
25
Traumatic injury effecting the away the
brain functions temporarily
 Direct blow to the head, fall or any injury
that shakes the head
 Mild: No loss of consciousness
 Classic: Temporary loss of consciousness
and neurologic dysfunction

26

Signs
› Possible loss of consciousness
› Headache
› Confusion
› Memory Loss
› Dizziness
› Nausea and Vomiting
› Fatigue
27

Diagnosis
› Health History
ex. Sports Injury
› CT
› MRI
› Neuropsychological Tests – Memory, Emotions
Treatment
› Rest
› Pain Medicine
› Avoiding Strenuous activities and contact sports
28
Seen days to months after injury
 Signs

› Headache
› Dizzy
› Irritable
› Insomnia
› Anxiety or Depression
› Trouble paying attention
29
Blunt head trauma
 Skull is moving in one direction
(acceleration) and stops abruptly
(deceleration) causing the brain be
jarred inside the skull
 During the jarring the axons are
stretched and torn resulting in neuron
death and diffuse brain damage

30
Brainstem may be involved leading to
coma
 Severe injury carries high morbidity and
mortality rates

31

Signs
› Immediate Unconsciousness lasting hours to
›
›
›
›
›
months
Increased ICP
Posturing
Hypertension
Hyperthermia
Sweating
32

Diagnosis
› History of trauma
› CT
› MRI
Treatment
Attempt to control the increased ICP
33
34
Bruised brain tissue
 Blunt head trauma
 Capillary bleeding into brain tissue
 Most frequently seen in frontal or
temporal lobes
 Swelling and bleeding peak at 18-36
hours

35

Symptoms
› Altered level of consciousness
› Posturing
› Changes in Speech, Motor or Behavior
› Signs of Increased ICP
36
37

3 Types:
› Epidural
› Subdural
› Intracerebral
38

Epidural
› Collection of blood
between the skull and
dura
* Blood is usually arterial
* Bleeds rapidly
**Requires immediate
Surgical intervention
39

Epidural
› Classic Sign: Trauma → Transient loss of
›
›
›
›
›
consciousness → Lucid Period → Rapid
Neurologic Decline
Severe Headache
Sleepy and Dizzy
Contralateral Hemiparesis or Hemiplegia
Posturing
Unilateral fixed and dialated pupil
40

Subdural
› Venous pooling
in subarachnoid
space
Bleeds slowly
Seen with direct injury to the brain and diffuse
axonal injuries
41

Subdural
› High risk patients are those on
anticoagulants and the elderly
› Acute: Symptoms appear within 48 hours of
injury
› Chronic: Symptoms may not be seen for
days to weeks after the injury
42

Intracerebral
› Bleed deep in brain
tissue
Usually in Frontal and
Temporal lobes
43

Intracerebral
Symptoms
Progressive decline in LOC
Increased ICP
Abnormal Pupils
Contralateral Hemiplegia
44
Concurrent Injuries

Primary Injury
› Direct injury to the brain
 Ex. Skull Fracture or Epidural Hematoma

Secondary Injury
› Pathophysiologic changes related to the
primary injury
 Compound initial damage and reduce the
ability of compensatory mechanisms
 Ex. Hypotension, Increased ICP
45
Concurrent Injuries
Common concurrent injuries are cervical
spine injuries and facial injuries.
 However depending on the type of
trauma concurrent injuries could involve
any or all other body systems

46
Patient History
Loss of consciousness? How Long?
 Complaints?
 Impact to the Head?
 Amnesia?
 Headaches? Nausea? Vomiting?
 Drugs or Alcohol?
 History of brain injury or seizures?

47
Nursing Assessment
Airway
 Respiratory Effort – Rate, Depth
 Pupil response
 Posturing
 Examine face for bleeding and bruising
 Look for drainage from ears or nose
 Palpate head for tenderness or
deformities

48
Pupils
Both dilated

Nonreactive: brainstem

Reactive: often reversible
Anisocoria
Unilaterally dilated
Eyelid closure
• Slow: cranial nerve III
• Fluttering: often hysteria

Reactive: ICP increasing

Nonreactive (altered LOC):
increased ICP

Nonreactive (normal LOC): not
from head injury
Head Trauma - 49
49
Extremity Posturing
Decorticate
• Arms flexed
and legs extended
Decerebrate
• Arms extended
and legs extended
Head Trauma - 50
50
51
Nursing Assessment

Diagnostic Tests
› CT
› Skull X-Rays
› MRI
› ABGs
› Coags
› Tox Screen
52
Nursing
Maintain a patent airway
 Administer oxygen
 Assist with RSI if necessary
 Keep pulse ox SaO2 > 90
 2 large bore IVs
 NG tube
 Foley?

53
Nursing
Consider placement of an ICP
monitoring device
 Medications

› Mannitol
› Sedation and Paralytics
› Anti-seizure meds
› Antibiotics
› Tetanus
54
Nursing
If ears and/or nose are leaking CSF do
NOT pack
 Apply direct pressure to bleeding
wounds, unless they are over an unstable
skull fracture

55
Ongoing Assessment
Level of consciousness
 Pupil changes
 Vital signs
 Signs of increased ICP
 Urine output
 Pain

56
Ocular, Maxillofacial and
Neck Trauma
57
Objectives
Identify Mechanisms of Ocular,
Maxillofacial and Neck Injury
 Describe Pathophysiology of Ocular,
Maxillofacial and Neck Injury
 Describe Nursing Assessment and
Interventions for the Patient

58
Ocular, Maxillofacial and
Neck Injuries

Mechanisms of Injury
›
›
›
›
Blunt trauma
Penetrating
Blast
Chemical
Usual Concurrent injuries
Head injury
Cervical Spine injury
Thoracic Injury
59

Primary Injuries
› Injury to eyes, face and neck

Secondary Injuries
› Injury to the airway, bleeding, neurologic
trauma
60
Ocular Injuries

2.4 million ocular
injuries annually
61
Ocular Injuries

Symptoms
› Pain
› Blood in the eye
› Visual changes
› Bruising in and around the eye
› Increased intraocular pressure
› Edema
62
Ocular Injuries

Foreign Body
› Signs
 Excessive tearing, burning, feeling of
something in the eye
› Assess the upper lid and sclera
› Flush with normal saline away from the
unaffected eye
63
Ocular Injuries

Corneal Abrasion
› Caused by contacts,
foreign body
› Symptoms
 Pain, burning,
photophobia, tearing
› Irrigate and Patch
both eyes
64
Ocular Injuries

Hyphema
› Blood in the anterior
chamber
› Pain
› Diminished Vision
65
Ocular Injuries

Open Globe Injury
› Caused by Blunt or
penetrating trauma
› Injury causes
increased intraocular
pressure which leads
to ocular rupture
› Visual Impairment
› Restricted Ocular
Movement
66
Ocular Injuries






Blowout Fracture
Direct blow to the
eye
Pain
Extraocular
movement altered
Eye hemorrhage
Orbital bone
deformaity
67
Maxillofacial Trauma
Caused by car accidents, sports injury,
animal bites, violence, industrial
accidents
 Most are not life threatening
 Use spinal precautions
 Monitor for a patent airway
 Control bleeding

68
Maxillofacial Trauma





LeFort I
Fracture above the
level of the teeth
Lip laceration
Maxillary swelling
Fractured teeth
69
Maxillofacial Trauma




LeFort II
Involved the middle
of the face
Facial and nasal
edema
CSF rhinorrhea
70
Maxillofacial Trauma






LeFort III
Involves maxilla,
orbits and base of
the skull
Facial edema and
bruisiing
Diplopia
CSF rhinorrhea
Elongation of face
71
Maxillofacial Trauma







Mandibular Fracture
Pain
Facial Assymetry
Blunt Trauma
Edema
Ruptured Tympanic
membrane
Numb lower lip
72
Maxillofacial Trauma

Dental Injuries
› Seen with facial fractures
› Teeth may be aspirated and/or swallowed
› Contact dentist ASAP
› Do not rinse the tooth
› Place in fresh whole milk to preserve the
tooth
73
Neck Injury

Mechanism of Injury
› Blunt
 Can cause ruptures or tears to airway,
esophagus, neck vessels
› Penetrating
 Knives, gunshots, debris
 Could injure other body systems
74
Neck Injury

Symptoms
› Dyspnea or Tachypnea
› Airway obstruction
› Subcutaneous air in neck or face
› Hoarse voice
› Difficulty swallowing
› Impaled object sticking out of neck
75
Spinal Trauma
Caused by spine being forced beyond
its normal range of motion
 C-spine is most vulnerable to injury
 Head to windshield injuries, shallow dive,
blunt trauma to top of head
 Any spinal injury requires spinal
immobilization

76
Spinal Shock
Nervous system is unable to transmit
signals effecting the persons movement,
sensation and how well the body’s
systems function.
 Often the persons loss of movement and
sensation occur below the level of the
spinal cord injury
 Shock begins immediately after injury but
make take several hours to show
symptoms

77
Spinal Shock
Initial 8 hours after spinal cord injury are
the most important to preserve function
 Correct C-spine immobilization is critical
 High dose steroids may be given to
reduce the swelling
 Surgery may be required to realign the
spine
 Depending on area of injury respiratory,
GI, GU and motor function may be
impacted

78
Nursing History
Mechanism of Injury?
 Previous Health history
 Current medications
 Patient complaints
 Contact lens?

79
Nursing Assessment
Assess face for swelling, bruising,
bleeding
 Symmetry?
 Assess vision and visual deficits
 Pain
 Palpate neck, face and orbital area for
swelling and sub Q air
 Palpate trachea for deviation

Nursing Care – Ocular Injuries
Irrigation with isotonic solution
 Assess visual acuity
 Control swelling and pain with ice
 Pain medication
 Decrease lighting to prevent
photophobia
 Shield eye
 Stabilize impaled object
 Consult Ophthalmologist

Nursing Care –
Maxillofacial and Neck
Assess and maintain patent airway
 Oxygen
 Direct pressure to stop bleeding
 Two large bore IVs
 Pain Meds
 NG or OG tube – With Caution!
 Facial films
 CT


Caution Blind NG tube Placement in
facial fracture patients
Nursing Care
Airway
 Monitor respiratory status
 Pain
 Level of consciousness
 Monitor circulatory status
 Vital signs
 Bleeding wounds

QUESTIONS????