definition, causes, signs and symptoms, diagnosis, management

1. 10/8/2016
Mr. Mahesh Chand
M.Sc. Nursing
B.V.D.U. College of Nursing, Sangli
HEAD INJURY

2. Introduction
2
 Trauma is the third most common cause of death.
 Head injury contributes significantly to the outcome in over half of
trauma-related deaths.
 It is the most common cause of death in young adults (age 15–24
years)
 Males > females.
 Account for 3.4% of all presentations
 incidence = 450 cases /100 000/ year.
 About 4 million people experience head injury annually.
 around 500 000 children with head injury attend hospital every year
and head injury admissions account for nearly 10% of all pediatric
hospital admissions.
 Head injury associated with traumatic brain injury (TBI) occurs with
an incidence of 20–40 cases per 100 000 population per year.
 Road traffic accidents (RTAs) are the most common cause of TBI
followed by falls and assaults.

5. Head Injury
 A head injury is any trauma to the scalp, skull,
or brain. The injury may be only a minor bump
on the skull or a serious brain injury.

6. Major Types of Head Injuries?
 Hematoma : A hematoma is a collection, or
clotting, of blood outside the blood vessels. It can be
very serious if a hematoma occurs in the brain. The
clotting can cause pressure to build inside your skull,
which can cause you to lose consciousness.

7.  Hemorrhage : A hemorrhage is uncontrolled
bleeding. There can be bleeding in the space around
your brain, which is a subarachnoid hemorrhage, or
bleeding within your brain tissue, which is an
intracerebral hemorrhage.
Subarachnoid bleeds often cause headaches and
vomiting. The severity of intracerebral hemorrhages
depends on how much bleeding there is, but over
time any amount of blood can cause pressure to
build.

8.  Concussion : A concussion is a brain injury that
occurs when your brain bounces against the hard
walls of your skull. Generally speaking, the loss of
function associated with concussions is temporary.
However, repeated concussions can eventually lead
to permanent damage.

9.  Edema: Any brain injury can lead to edema, or
swelling. Many injuries cause swelling of the
surrounding tissues, but it’s more serious when it
occurs in your brain. Your skull can’t stretch to
accommodate the swelling, which leads to a buildup
of pressure in your brain. This can cause your brain
to press against your skull.

10.  Skull Fracture: Unlike most bones in your body, your
skull doesn’t have bone marrow. This makes the
skull very strong and difficult to break. A broken
skull is unable to absorb the impact, making it more
likely that there will also be damage to your brain.

11.  Diffuse Axonal Injury: A diffuse axonal injury, or
sheer injury, is an injury to the brain that doesn’t
cause bleeding but does damage your brain cells.
Though it isn’t as outwardly visible as other forms of
brain injury, diffuse axonal injury is one of the most
dangerous types of head injuries and can lead to
permanent brain damage and even death.

12. Causes of Head Injury
 In general, head injuries can be divided into two categories
based on what causes them. They can either be head injuries
due to blows to the head or head injuries due to shaking.
 Head injuries caused by shaking are most common in infants
and small children, but they can occur any time you
experience violent shaking.
 Head injuries caused by a blow to the head are usually
associated with:
 motor vehicle accidents
 falls
 physical assaults
 sports-related accidents
 In most cases, your skull will protect your brain from serious
harm.

19. Diagnostic Evaluation
 X-ray
 Cervical Spine X-rays.
 You must see from 1 – 7 to see that they have no injury.
 PET
 Transcranial Doppler studies.
 Looking for vasospasm
 CT scan: standard modality
 Glasgow coma Scale (GCS).
 MRI
 Bleeding from the ear or nose in cases of suspected CSF
leak -"halo" or "ring" sign , when dabbed on a tissue paper
 CSF leak - analyzing the glucose level and by measuring
tau-transferrin.

20. Preventive Measures
Health Promotion.
 Prevent car and motorcycle accidents
 To Wear safety helmets
 Preventative measures include safer roads, barriers to
prevent falls, and gun control legislation.
 In addition, bicycle and motorcycle helmets, seatbelts,
airbags, and soft surfaces on playgrounds are effective.
 25-30% of head injuries in infants are the result of an
abuse - healthcare professionals need to be trained in
safeguarding and to raise concerns without delay.

21. When Does a Head Injury Require Medical
Attention?
 Head injuries shouldn’t be taken lightly. See your doctor
right away if you think you have the symptoms of a
serious head injury.
 In particular, you should always call 911 or go to an
emergency room if you experience loss of consciousness,
confusion, or disorientation. Even if you don’t go to the
ER immediately after the accident, you should seek help
if you still have symptoms after a day or two.
 In the case of a potentially serious head injury, you
should always call 911. Motion can sometimes make a
head injury worse, and emergency medical personnel are
trained to move patients carefully without causing more
damage.

22. First Aid
 If severe head trauma occurs
 Keep the person still. Until medical help arrives, keep
the injured person lying down and quiet, with the head
and shoulders slightly elevated. Don't move the person
unless necessary, and avoid moving the person's neck. If
the person is wearing a helmet, don't remove it.
 Stop any bleeding. Apply firm pressure to the wound
with sterile gauze or a clean cloth. But don't apply direct
pressure to the wound if you suspect a skull fracture.
 Watch for changes in breathing and alertness. If
the person shows no signs of circulation — no breathing,
coughing or movement — begin CPR.

23. Emergency Management
1) Supportive Measures:
 Endotracheal intubation for patients with decreased level of
consciousness and poor airway protection.
 Cautiously lower blood pressure to a MAP less than 130 mm
Hg, but avoid excessive hypotension.[10]
 Rapidly stabilize vital signs, and simultaneously acquire
emergent CT scan.
 Maintain euvolemia, using normotonic rather than
hypotonic fluids, to maintain brain perfusion without
exacerbating brain edema
 Avoid hyperthermia.
 Facilitate transfer to the operating room or ICU.

24. 2) Decrease cerebral
edema:
 Modest passive hyperventilation to reduce PaCO2
 Mannitol, 0.5-1.0 gm/kg slow iv push
 Furosemide 5-20 mg iv
 Elevate head 20-30 degrees, avoid any neck vein
compression
 Sedate and paralyze if necessary with morphine and
vecuronium (struggling, coughing etc will elevate
intracranial pressure)

25. 3) Surgical Evacuation of
hematoma:
 No surgical intervention if collection <10ml
Indication of surgical decompression:
 The GCS score decreases by 2 or more points between the time
of injury and hospital evaluation
 The patient presents with fixed and dilated pupils
 The intracranial pressure (ICP) exceeds 20 mm Hg
Exception :
In Subdural hematoma with GCS=15- hematoma >10mm ,or
>5mm midline shift ---- requires Surgical decompression
SAH: when a cerebral aneurysm is identified on angiography,
clipping and coiling is done to prevent re-bleed

26. Intracranial pressure monitoring
There are 3 ways to monitor pressure in the skull (intracranial
pressure).
 INTRAVENTRICULAR CATHETER
 The intraventricular catheter is the most accurate
monitoring method.
 To insert an intraventricular catheter, a hole is
drilled through the skull. The catheter is inserted
through the brain into the lateral ventricle. This area
of the brain contains liquid (cerebrospinal fluid or
CSF) that protects the brain and spinal cord.
 The intraventricular catheter can also be used to
drain fluid out through the catheter.
 The catheter may be hard to get into place when the
intracranial pressure is high.

27.  SUBDURAL SCREW : This method is used if
monitoring needs to be done right away. A
hollow screw is inserted through a hole drilled in
the skull. It is placed through the membrane that
protects the brain and spinal cord (dura mater).
This allows the sensor to record from inside the
subdural space.
 EPIDURAL SENSOR: An epidural sensor is
inserted between the skull and dural tissue.
The epidural sensor is placed through a hole
drilled in the skull. This procedure is less
invasive than other methods, but it cannot
remove excess CSF.

28.  Lidocaine or another local anesthetic:
injected at the site where the cut will be made. You
will most likely get a sedative to help you relax.
 First the area is shaved and cleansed with antiseptic.
 After the area is dry, a surgical cut is made. The skin is
pulled back until the skull is seen.
 A drill is then used to cut through the bone.

29. Why the Test is Performed
 This test is most often done to measure intracranial
pressure. It may be done when there is a severe head injury
or brain/nervous system disease. It also may be done after
surgery to remove a tumor or fix damage to a blood vessel if
the surgeon is worried about brain swelling.
 High intracranial pressure can be treated by draining CSF
through the catheter. It can also be treated by changing the
ventilator settings for people who are on a respirator, or by
giving certain medicines through a vein (intravenously).

30. Normal Results
 Normally, the ICP ranges from 1 to 20 mm Hg.
 Talk to your health care provider about the meaning
of your specific test results.

31. Risks
 Risks from the procedure may include:
 Bleeding
 Brain herniation or injury from the increased
pressure
 Damage to the brain tissue
 Inability to find the ventricle and place
 Infection
 Risks of general anesthesia

32. Nursing management in critical care
 The critical-care nurse needs to be alert to the
potential problems that may be encountered by the
brain-injured patient, who may be at risk of sudden
deterioration at any time. This inv
 Respiratory care Hypoxia after head injury is
common for a number of reasons: inadequate airway
clearanceolves taking an holistic view of the patient.

33.  Haemodynamic/fluid management The minimum
monitoring required for a critically head-injured patient
should include continuous arterial blood pressure
monitoring (rather than non-invasive methods in order
to enable measurement of CPP), core body temperature,
respiration rate and pattern and continuous ECG. These
patients may develop arrhythmias due to induced
hypothermia and/or electrolyte imbalances.
 ICP monitoring should be employed in head-injured
patients who are ventilated and paralysed where
neurological deterioration cannot be readily observed
clinically (Chitnavis and Polkey, 1998).

34.  Temperature control In head-injured patients with
hypoxia and ensuing ischaemia, the oxygen demand of
brain tissue escalates.
 There may also be damage to the temperature-regulating
centre in the hypothalamus, which may cause body
temperature to fluctuate (Wong, 2000).
 ECG monitoring and regular electrolyte observation is
essential.
 Blood glucose control Hyperglycaemia is known to
exacerbate cerebral lactic acidosis (Wong, 2000) and
consequently aggravates cerebral ischaemia in head injury.
Therefore glucose solutions should be avoided, and initially
hourly blood sugar monitoring/insulin infusion
implemented to keep blood glucose below 11mmol/L
(Hughes, 2000).

35.  Positioning : Elevation of the head from 15 to 30 degrees
was associated with a mean decrease in I
 Nutritional support Severe head injury is associated with a
hypermetabolic state with, in some cases, the metabolic rate
increasing by as much as 40 to 100% (Hinds and Watson,
1996). It is therefore important to begin feeding as early as
possible, preferably enterally. The feeding tube should always
be passed via the orogastric route in head-injured patients,
unless a basal skull fracture has been definitively ruled out
(Withington, 1997).CP in all patients.

36. Complications
 Amnesia: common, and may be retrograde and/or antegrade.
 Raised intracranial pressure, cerebral oedema.
 Cerebral herniation.
• Meningitis: following skull fracture, may occur weeks to years
later.
 CSF leak (test fluid for glucose or drop on filter paper to see
double halo):
 From the ear - possible fracture of petrous temporal bone, may
involve VII/VIIIth nerves, leak closes spontaneously, lower
risk of meningitis.
 From the nose - possible fracture of cribriform plate, may
originate from ear, anosmia, leak may require surgery, don't
blow nose or insert nasogastric tube.

37.  Skull fractures.
 Diffuse axonal injury
 Penetrating injuries
 Seizures
 Concussion
 Intracranial haemorrhage:
 Extradural
 Subdural
 Subarachnoid
 Intracerebral

38. Prognosis
 Head injury is the leading cause of death in people aged 1-40 years.
 Death rates are estimated at 0.2% of all patients who attend A&E.
 The annual incidence of disability in adults with head injuries admitted to
hospital is 100-150 per 100,000 population.
 Survival with moderate or severe disability has been reported as common
after mild (GCS 13-15) head injury (47% of patients) and is similar to that
after moderate (45%) or severe injury (48%). Moderate head injury was
defined as GCS score of 9-12 and severe as GCS ≤ 8. These figures are
higher than previous data and excluded patients under the age of 14 years,
where mild head injuries without sequelae are very common. Yet a follow-
up study 12-14 years after the initial head injury reported a similarly high
recurrence of disability (51%).

39. References
 Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-
pressure monitoring in traumatic brain injury. N Engl J Med.
2012:367:2471-81. PMID:
23234472 www.ncbi.nlm.nih.gov/pubmed/23234472.
 Rabinstein AA. Principles of neurointensive care. In: Daroff RB,
Fenichel GM, Jankovic J, Mazziotta JC, eds. Bradley's Neurology in
Clinical Practice. 6th ed. Philadelphia, PA: Elsevier Saunders;
2012:chap 45.
 Raboel PH, Bartek J Jr, Andresen M, Bellander BM, Romner B.
Intracranial pressure monitoring: invasive versus non-invasive
methods - a review. Critical Care Research and Practice. 2012.
PMID: 22720148 www.ncbi.nlm.nih.gov/pubmed/22720148.