Head injury

11December 10, 2016December 10, 2016 Dr.D.Y.Patil CON,PuneDr.D.Y.Patil CON,Pune
Presented by:- Ganesh patidar

DEFINITIONDEFINITION
Head injury is the disruption of normal brainHead injury is the disruption of normal brain
function due to trauma related injury resultingfunction due to trauma related injury resulting
in compromised neurologic function resultingin compromised neurologic function resulting
in focal or diffuse symptoms.in focal or diffuse symptoms.

Cont…Cont…
In simpler terms, it refers to any injury to theIn simpler terms, it refers to any injury to the
scalp, skull {cranium or facial bones} orscalp, skull {cranium or facial bones} or
brainbrain

ANATOMY OF THE BRAINANATOMY OF THE BRAIN
THE BRAIN DEVIDE INTO THREE MAIN REGION:-THE BRAIN DEVIDE INTO THREE MAIN REGION:-
TheThe FOREBRAINFOREBRAIN (OR PROSENCEPHALON(OR PROSENCEPHALON)) is made up of ouris made up of our
incredible cerebrum, thalamus, hypothalamus and pineal gland.incredible cerebrum, thalamus, hypothalamus and pineal gland.
Subdivision-Subdivision-
a. Telencephalon(cerebrum)- made up of two cerebral hemispheresa. Telencephalon(cerebrum)- made up of two cerebral hemispheres
and the median part in front of the intraventricular foramenand the median part in front of the intraventricular foramen
b. Diencephalon (thalamencephalon), hidden by cerebrum .consistb. Diencephalon (thalamencephalon), hidden by cerebrum .consist
of-of-
A. ThalamusA. Thalamus
B. HypothalamusB. Hypothalamus
C. Metathalamus including the medial and lateral geniculate bodiesC. Metathalamus including the medial and lateral geniculate bodies
D. Epithalamus, including the pineal bodyD. Epithalamus, including the pineal body
E. SubthalamusE. Subthalamus

Cont….Cont….
TheThe MIDBRAINMIDBRAIN (OR MESENCEPHALON(OR MESENCEPHALON),), located near thelocated near the
very center of the brain between the interbrain and the hindbrain,very center of the brain between the interbrain and the hindbrain,
is composed of a portion of the brainstem.is composed of a portion of the brainstem.
TheThe HINDBRAINHINDBRAIN (OR RHOMBENCEPHALON) consists of(OR RHOMBENCEPHALON) consists of
the remaining brainstem as well as our cerebellum and ponsthe remaining brainstem as well as our cerebellum and pons
AND Medulla oblongata.AND Medulla oblongata.

PHYSIOLOGY OF THE BRAINPHYSIOLOGY OF THE BRAIN
MetabolismMetabolism
SensorySensory
Motor ControlMotor Control
HomeostasisHomeostasis
SleepSleep

TYPES OF HEADTYPES OF HEAD
INJURYINJURY
December 10, 2016December 10, 2016 77Dr.D.Y.Patil CON,PuneDr.D.Y.Patil CON,Pune

PRIMARY INJURY
It results from the physical stress ( force)It results from the physical stress ( force)
within the brain tissue caused by open orwithin the brain tissue caused by open or
closed trauma.closed trauma. initial damage to the brain thatinitial damage to the brain that
results from the traumatic event.results from the traumatic event.

OPEN HEAD INJURYOPEN HEAD INJURY

OPEN HEAD INJURY
Occurs when an object penetrates the skull,Occurs when an object penetrates the skull,
enters the brain, and damages the soft brainenters the brain, and damages the soft brain
tissue in its path (penetrating injury), or whentissue in its path (penetrating injury), or when
blunt trauma to the head is so severe that itblunt trauma to the head is so severe that it
opens the scalp, skull, and dura to expose theopens the scalp, skull, and dura to expose the
brain.brain.

Cont…Cont…
It occurs when there is fracture of theIt occurs when there is fracture of the
skullskull
oror
the skull is pierced by a penetratingthe skull is pierced by a penetrating
object.object.

THE TYPES OF FRACTURETHE TYPES OF FRACTURE
ASSOCIATED WITH ARE:ASSOCIATED WITH ARE:
Linear fractureLinear fracture
A simple fracture is a break in the continuityA simple fracture is a break in the continuity
of the brain.of the brain.
it is simple, clean break in which theit is simple, clean break in which the
impacted area of bone bends inward ,impacted area of bone bends inward ,
whereas the area around it bends outward.whereas the area around it bends outward.
OrOr
It is a fracture through entire thickness ofIt is a fracture through entire thickness of
bone that runs in straight linear pattern.bone that runs in straight linear pattern.

DEPRESSED FRACTURE
Here the bone is pressed inward into the brainHere the bone is pressed inward into the brain
tissue to at least the thickness of the skull.tissue to at least the thickness of the skull.

OPEN FRACTUREOPEN FRACTURE
The scalp is lacerated, creating a directThe scalp is lacerated, creating a direct
opening to the brain tissueopening to the brain tissue

BASILAR SKULL FRACTUREBASILAR SKULL FRACTURE
It is a unique fractureIt is a unique fracture
It occurs at the base of the skull, usually alongIt occurs at the base of the skull, usually along
the paranasal sinus and results in CSF leakthe paranasal sinus and results in CSF leak
from the nose or ears.from the nose or ears.

CLOSED HEAD INJURYCLOSED HEAD INJURY

Cont....
Occurs when the head accelerates and thenOccurs when the head accelerates and then
rapidly decelerates or collides with anotherrapidly decelerates or collides with another
object (eg, a wall or dashboard of a car) andobject (eg, a wall or dashboard of a car) and
brain tissue is damaged, but there is nobrain tissue is damaged, but there is no
opening through the skull and dura.opening through the skull and dura.
It is the result of blunt trauma, the integrity ofIt is the result of blunt trauma, the integrity of
the skull is not violatedthe skull is not violated

CONCUSSIONS
It is a transient interruption in brain activity itIt is a transient interruption in brain activity it
is characterised by a brief loss ofis characterised by a brief loss of
consciousness.consciousness. after head injury is aafter head injury is a
temporary loss of neurologic function with notemporary loss of neurologic function with no
apparent structural damage. A concussionapparent structural damage. A concussion
generally involves a period ofgenerally involves a period of
unconsciousness lasting from a few secondsunconsciousness lasting from a few seconds
to a few minutes.to a few minutes.

CONTUSIONSCONTUSIONS
It is a more severe injury inIt is a more severe injury in
which the brain is bruised,which the brain is bruised,
with possible surfacewith possible surface
hemorrhage. The patient ishemorrhage. The patient is
unconscious for more than aunconscious for more than a
few seconds or minutes.few seconds or minutes.
Clinical signs and symptomsClinical signs and symptoms
depend on the size of thedepend on the size of the
contusion and the amount ofcontusion and the amount of
associated cerebral edema.associated cerebral edema.December 10, 2016December 10, 2016 2424Dr.D.Y.Patil CON,PuneDr.D.Y.Patil CON,Pune

LACERATION
It causes actualIt causes actual
tearing of thetearing of the
cortical surfacecortical surface
vessels, whichvessels, which
may lead tomay lead to
secondarysecondary
haemorrhage.haemorrhage.

DIFFUSE AXONAL INJURYDIFFUSE AXONAL INJURY
Diffuse axonal injuryDiffuse axonal injury
involves widespread damageinvolves widespread damage
to axons in the cerebralto axons in the cerebral
hemispheres, corpushemispheres, corpus
callosum, and brain stem. Itcallosum, and brain stem. It
can be seen in mild,can be seen in mild,
moderate, or severe headmoderate, or severe head
trauma and results in axonaltrauma and results in axonal
swelling and disconnection.swelling and disconnection.

SECONDARY INJURIES
Secondary brain injury includeSecondary brain injury include
any neurologic damage thatany neurologic damage that
occurs after the initial injuryoccurs after the initial injury ..

The most frequently occurring responseThe most frequently occurring response
is the development of:is the development of:

INCREASED INTRACRANIALINCREASED INTRACRANIAL
PRESSUREPRESSURE

HAEMORRHAGE
HAEMORRHAGES areHAEMORRHAGES are
caused by vascular damagecaused by vascular damage
from the shearing force of thefrom the shearing force of the
traumatrauma

EPIDURAL HEMATOMA
 After a head injury, blood mayAfter a head injury, blood may
collect in the epiduralcollect in the epidural
(extradural) space between the(extradural) space between the
skull and the dura. This canskull and the dura. This can
result from a skull fracture thatresult from a skull fracture that
causes a rupture or laceration ofcauses a rupture or laceration of
the middle meningeal artery, thethe middle meningeal artery, the
artery that runs between the duraartery that runs between the dura
and the skull inferior to a thinand the skull inferior to a thin
portion of temporal bone.portion of temporal bone.
Hemorrhage from this arteryHemorrhage from this artery
causes rapid pressure on thecauses rapid pressure on the
brain.brain.

SUBDURAL HEMATOMA
 A subdural hematoma is aA subdural hematoma is a
collection of blood betweencollection of blood between
the dura and the brain, athe dura and the brain, a
space normally occupied byspace normally occupied by
a thin cushion of ﬂuid. Thea thin cushion of ﬂuid. The
most common cause ofmost common cause of
subdural hematoma issubdural hematoma is
trauma, but it may alsotrauma, but it may also
occur from coagulopathiesoccur from coagulopathies
or rupture of an aneurysm.or rupture of an aneurysm.

INTRA CEREBRAL HAEMORRHAGE
 Hematomas (collections ofHematomas (collections of
blood) that develop within theblood) that develop within the
cranial vault are the most seriouscranial vault are the most serious
brain injuries . A hematoma maybrain injuries . A hematoma may
be epidural (above the dura),be epidural (above the dura),
subdural (below the dura), orsubdural (below the dura), or
intracerebral (within the brain) .intracerebral (within the brain) .
Major symptoms are frequentlyMajor symptoms are frequently
delayed until the hematoma isdelayed until the hematoma is
large enough to cause distortionlarge enough to cause distortion
of the brain and increased ICP.of the brain and increased ICP.

Hematomas (collections of blood) thatHematomas (collections of blood) that
develop within the cranial vault are the mostdevelop within the cranial vault are the most
serious brain injuries . A hematoma may beserious brain injuries . A hematoma may be
epidural (above the dura), subdural (belowepidural (above the dura), subdural (below
the dura), or intracerebral (within thethe dura), or intracerebral (within the
brain) . Major symptoms are frequentlybrain) . Major symptoms are frequently
delayed until the hematoma is large enoughdelayed until the hematoma is large enough
to cause distortion of the brain and increasedto cause distortion of the brain and increased
ICP.ICP.
December 10, 2016December 10, 2016 Dr.D.Y.Patil CON,PuneDr.D.Y.Patil CON,Pune 3434

ETIOLOGY AND RISK
FACTOR

PATHOPHYSIOGYPATHOPHYSIOGY
Brain suffers traumatic injuryBrain suffers traumatic injury

Brain swelling / bleeding increase intracranial volumeBrain swelling / bleeding increase intracranial volume

Rigid cranium allows no room for expansion of contentsRigid cranium allows no room for expansion of contents
so intracranial pressure increaseso intracranial pressure increase

Pressure on blood vessels within the brain cause bloodPressure on blood vessels within the brain cause blood
flow to the brain slow.flow to the brain slow.


Cerebral hypoxia and ischemia occursCerebral hypoxia and ischemia occurs

Intracranial pressure continues to rise brainIntracranial pressure continues to rise brain
merge terminate.merge terminate.

Cerebral blood flow ceasesCerebral blood flow ceases
Brain InjuryBrain Injury

CLINICAL MANIFESTATIONS
1.1. Disturbance in conciousness: confusion to coma.Disturbance in conciousness: confusion to coma.
2.2. Headache, vertigoHeadache, vertigo
3.3. agitation, restlessnessagitation, restlessness
4.4. Respiratory irregularitiesRespiratory irregularities
5.5. Cognitive deficitsCognitive deficits
6.6. Pupillary abnormalitiesPupillary abnormalities
7.7. Sudden onset of neurological deficitSudden onset of neurological deficit
8.8. Coma and coma syndromeComa and coma syndrome
9.9. OttorheaOttorhea
10.10. rhinorhearhinorhea
11.11. Raccoon eyes, battle signRaccoon eyes, battle sign
12.12. Episodes of altered LOC, tachycardia, tachypnea, hyperthermiaEpisodes of altered LOC, tachycardia, tachypnea, hyperthermia
13.13. Abnormal bleeding to coagulpathyAbnormal bleeding to coagulpathy
14.14. Cardiac arrhythmiasCardiac arrhythmias

DIAGNOSTIC EVALUATION

CT SCAN
$ To identify and$ To identify and
localise lesions,localise lesions,
edema, bleedingedema, bleeding

SKULLAND CERVICAL SPINE
FILMS
To identify fracture,To identify fracture,
displacementdisplacement

NEUROPSYCHOLOGICAL
TESTS
During rehabilitationDuring rehabilitation
phase to determinephase to determine
cognitive deficitscognitive deficits

MRI
TO identify andTO identify and
diagnose DAIdiagnose DAI

CBC, COAGULATION profile,CBC, COAGULATION profile,
electrolyte levels, serum osmolarity,electrolyte levels, serum osmolarity,
ABG values and other laboratoryABG values and other laboratory
teststests
To monitor for complications and guideTo monitor for complications and guide
treatmenttreatment

COMPLICATIONS

COMPLICATIONS
INFECTIONSINFECTIONS
INCRESED ICPINCRESED ICP
HYDROCEPHALUSHYDROCEPHALUS
POST TRAUMATICPOST TRAUMATIC
SEIZURE DISORDERSEIZURE DISORDER
NEURO BEHAVIOURALNEURO BEHAVIOURAL
ALTERATIONALTERATION
DICDIC
LOSS OF CORNEALLOSS OF CORNEAL
REFLEXREFLEX
PERI ORBITAL EDEMAPERI ORBITAL EDEMA
LOSS OF SWALLOWINGLOSS OF SWALLOWING
REFLEXREFLEX
ALTERED CONSCIOUSALTERED CONSCIOUS
LEVELLEVEL
DEATHDEATH

IMMEDIATE
MANAGEMENT
CIRCULATIONCIRCULATION
AIRWAYAIRWAY
BREATHINGBREATHING
CHECK G.C.SCHECK G.C.S

MANAGEMENT OF :
INCREASED ICP
Elevate the head of bed 30 degrees.Elevate the head of bed 30 degrees.
Maintain the patient’s head and neck in neutral alignment (noMaintain the patient’s head and neck in neutral alignment (no
twisting).twisting).
Maintain normal body temperature.Maintain normal body temperature.
Administer O2 to maintain pao2 > 90 mm hg.Administer O2 to maintain pao2 > 90 mm hg.
Maintain ﬂuid balance with normal saline solution.Maintain ﬂuid balance with normal saline solution.
Avoid noxious stimuli (eg, excessive suctioning, painfulAvoid noxious stimuli (eg, excessive suctioning, painful
procedures).procedures).
Administer sedation to reduce agitation.Administer sedation to reduce agitation.
Maintain cerebral perfusion pressure > 70 mm hg.Maintain cerebral perfusion pressure > 70 mm hg.
Monitor the ICP.Monitor the ICP.
CEREBRAL EDEMACEREBRAL EDEMA

SUPPORTIVE CARE
Treatment includes ventilator support, seizureTreatment includes ventilator support, seizure
prevention, ﬂuid and electrolyte maintenance,prevention, ﬂuid and electrolyte maintenance,
nutritional support, and pain and anxietynutritional support, and pain and anxiety
managementmanagement

MEDICAL MANAGEMENT INCLUDES DRUG
THERAPY:
Glucocorticoides (dexena) - is given to reduce cerebral
edema.
Dopamine to maintain cerebral perfusion pressure
above 50 mmHg (if blood pressure is low and ICP is
elevated)
Serum Glucose concentration should be monitors
because of steroid may cause hyperglycemias.
 Osmotic diuretic –Mannitol is used to treat ICP
Mannitol is effective for control of raised ICP after severe
TBI. Effective doses range from 0.25 to 1 g/kg/body
weight.
 Antiepileptic agent is given to reduce convulsion.-
phynatoin sodium
Dynaper used as analgesic drug to reduce pain.

Cont….Cont….
USE OF BARBITURATES IN THE CONTROLUSE OF BARBITURATES IN THE CONTROL
OF INTRACRANIAL HYPERTENSIONOF INTRACRANIAL HYPERTENSION

SURGICAL MANAGEMENT

ELEVATION OF SKULL
FRACTURE
REPAIR OF C.S.F. LEAKS

Assessment – according to theAssessment – according to the
patient neurologic ststus , GCSpatient neurologic ststus , GCS
scale , an the type of injury,scale , an the type of injury,
severity of injuryseverity of injury
present history of the patient,present history of the patient,

NURSING DIAGNOSISNURSING DIAGNOSIS
 Altered cerebral tissue perfusion related to increasedAltered cerebral tissue perfusion related to increased
intracranial pressureintracranial pressure
Position patient to reduce ICPPosition patient to reduce ICP
Head in midline position to promote venous drainageHead in midline position to promote venous drainage
Elevate HOB 30 degreesElevate HOB 30 degrees
Avoid extreme rotation or flexion of neckAvoid extreme rotation or flexion of neck

Cont…..
Ineffective airway clearance and ventilation related to hypoxia
Assess the patency of airway.Assess the patency of airway.
Keep the unconscious patient in a position that facilitates drainage ofKeep the unconscious patient in a position that facilitates drainage of
the secretions with the head of the bed elevated to about 30 degreesthe secretions with the head of the bed elevated to about 30 degrees
to decrease intracranial venous pressure.to decrease intracranial venous pressure.
Establish effective suctioning procedures to facilitate drainage of theEstablish effective suctioning procedures to facilitate drainage of the
secretions.secretions.
Encourage deep breathing and coughing exercises.Encourage deep breathing and coughing exercises.
Monitor arterial blood gas values to determine adequate cerebralMonitor arterial blood gas values to determine adequate cerebral
blood flow.blood flow.
Monitor the patient who is receiving mechanical ventilationMonitor the patient who is receiving mechanical ventilation

Cont…..Cont…..
Fluid volume deficit related to disturbance of consciousness
and hormonal dysfunction
Assess the level of fluid volume deficit to obtain a baseline data.Assess the level of fluid volume deficit to obtain a baseline data.
Serum electrolytes should be monitored especially in patients withSerum electrolytes should be monitored especially in patients with
osmotic diuretics,osmotic diuretics,
blood and urine electrolytes and osmolality is carried out becauseblood and urine electrolytes and osmolality is carried out because
head injuries are accompanied by disorders of sodium regulation.head injuries are accompanied by disorders of sodium regulation.
Endocrine function is evaluated by monitoring the serumEndocrine function is evaluated by monitoring the serum
electrolytes, blood glucose values, and intake and output.electrolytes, blood glucose values, and intake and output.
Monitor intake and output of the patientMonitor intake and output of the patient

EVIDANCE BASED PRACTICESEVIDANCE BASED PRACTICES
Hyperthermia is a loss of thermoregulatory ability, which canHyperthermia is a loss of thermoregulatory ability, which can
occur with injury to the hypothalamus or in malignantoccur with injury to the hypothalamus or in malignant
hyperthermia.hyperthermia.
The management of fever in the head injured patient can beThe management of fever in the head injured patient can be
complex because the etiology of fever is not always clear.complex because the etiology of fever is not always clear.
Assessment of fever is first step of management. The nurseAssessment of fever is first step of management. The nurse
evaluate the diagnosis of the patient , the disease processesevaluate the diagnosis of the patient , the disease processes
that might be occurring in conjunction with the fever . and thethat might be occurring in conjunction with the fever . and the
pattern of fever patient can be experiencing.pattern of fever patient can be experiencing.
The literature suggests that fever can enhance the host defenseThe literature suggests that fever can enhance the host defense
by activating the body physiologic adaptive response, inby activating the body physiologic adaptive response, in
certain vulnerable population (neurologic, cardiac immunecertain vulnerable population (neurologic, cardiac immune
compromised and other clients.), evidence shows that fever iscompromised and other clients.), evidence shows that fever is
maladaptive and needs aggressive management.maladaptive and needs aggressive management.

Cont….Cont….
Cooling measure should be directed towardsCooling measure should be directed towards
increasing heat loss. Example of this includes placingincreasing heat loss. Example of this includes placing
ice packs at the groin or axilla or sponging withice packs at the groin or axilla or sponging with
alcohol and tepid water. it is important to observe thealcohol and tepid water. it is important to observe the
patient for shivering , which should be avoidedpatient for shivering , which should be avoided
because of the increase in metabolic activity and thebecause of the increase in metabolic activity and the
potential to increase rather than decrease the feverpotential to increase rather than decrease the fever
.cooling measures that allow evaporation may be.cooling measures that allow evaporation may be
more effective than the use of cooling blankets.more effective than the use of cooling blankets.

Head injury

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (18)

Recently uploaded

Recently uploaded (20)

Head injury

Editor's Notes