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
symptoms
• Identify diagnostic testing, and treatment
options
• 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
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Falls
Assaults
Firearm-related injuries
Sports-related injuries
Recreational accidents
Highest risk group is ages 15-24, males 2x as likely as
women
• 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
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
• 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
• Minor head trauma
Head Injury
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
emergency!
• 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
life
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
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,
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
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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
them)
Head Injury
Diagnostic 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)
Head Injury
Diagnostic Studies and Collaborative Care
• Treatment principles
– Prevent secondary injury in the brain
– Timely diagnosis
– Surgery if necessary
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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
Best verbal response
Best motor response
Spontaneous
4
To voice
3
To pain
2
None
1
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sounds
2
None
1
Obeys command
6
Localizes pain
5
Withdraws
4
Flexion
3
Extension
2
None
1
Total
13-15 minor brain injury
3 to 15
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
function
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
NIPPLES
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
•
http://medstat.med.utuh.edu
• Chart as normal or abnormal
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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
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Persistent Vegetative State
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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
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
Brain Death
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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
• www.lifegift.org
• Organ Procurement Organization
– OPO
Tissue
One donor can help 70 people
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Bone
Skin
Tissue – ligaments, tendons
Veins
Heart valves
Eyes/corneas
Organs
One donor can save 8 lives!
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Heart
Lung (can be single or double)
Liver
Kidneys (2)
Pancreas
Intestine
Background
• 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
• EEG
– Artifact may cause false interpretation
– Slow turnaround on results of study
Donor Management
• “What’s good for the patient is good for the
donor”
– 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 www.donatelifetexas.org
– Centralized state registry
– First person consent
– Coordinators can search the registry with the pt’s
information, speeding up the donation process
Summary
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Maintain airway
Early diagnosis and treatment
Prevention of secondary injury
Maintain cerebral perfusion pressure