- Majority of head injury deaths occur immediately from direct trauma or from massive hemorrhage and shock.
– Acute head injury results from a trauma to the head, leading to brain injury or bleeding within the brain. Effects of injury may include edema and hypoxia.
– A head injury is classified by brain injury types: fracture, hemorrhage, or trauma.
– Hemorrhages are classified as epidural, subdural, intracerebral, or subarachnoid.
– Deaths occurring in a few hours are caused by progressive worsening of head injury or from internal bleeding.
– Usually signifies craniocerebral trauma
– Includes alteration in consciousness
– High potential for poor outcome
– Death at injury
– Death within 2 hours after injury
– Death 3 weeks after injury
– Scalp lacerations – scalp has many blood vessels and will bleed profusely.
– Skull fracture types
Skull Fracture Locations
– Orbital fracture
– Temporal fracture
– Parietal fracture
– Posterior fossa fracture
– Basilar skull fracture
– Occurs at base of the skull
– Watch for rhinorrhea and otorrhea (leakage CSF)
– Test fluid leaking from nose or ear for glucose.
Classification of head injury
• Primary brain injury:
Is the direct injury that occurs to the brain, include: concussion, contusion, hematoma
• Secondary brain injury:
Complicates the situation following a primary brain injury and is the result of hypoxia, hypotension, anemia, hypercarbia or infection.
- This injury results in the temporary failure of impulse conduction. The neurological deficit are reversible and generally mild.
– Patient may lose consciousness for a few seconds at the time of injury, but lasting effect are not common.
– Altered level of consciousness, confusion and disoriented.
- Is the result of injuries accompanied by bruising and generalized hemorrhage into brain tissue.
– Injury can be to the areas are prone to bleeding and swelling, they act as an intracranial expanding mass.
- Tearing of brain tissue
– Occurs with depressed skull fracture and penetrating injuries
– May have bleeding into the brain structures-intracerebral hemorrhage
– Very difficult to remove blood
- Comes from bleeding between dura and inner surface of the skull
– Tearing of an artery from a skull fracture, brisk bleeding and rapid accumulation in the epidural space
– Will be unconscious, then awake, and then deteriorate
– Headache, nausea and vomiting
– Needs surgical intervention to prevent brain herniation and death
- Usually bleeding is from veins, so bleeding is generally slower than epidurals
– CAN be from arteries and these require IMMEDIATE removal
– Bleeding in the subarachnoid space from the rupture of a traumatic aneurysm; altered LOC, headache and photophobia.
- Skull x-rays routine to r/o or identify fracture
– CT/MRI are best to determine trauma rapidly
- Bleeding to the ventricles; altered of LOC, cranial nerve dysfunction, motor changes.
- Bleeding into brain tissue, producing necrosis.
– Is a large hemorrhage into brain tissue that creates a mass lesion. This lesion can occur anywhere in the brain.
– Automobile accident
– Blunt trauma
– Penetrating trauma
- Decrease level of consciousness LOC
– Disorientation to time, place, or person
– Otorrhea, rhinorrhea (if CSF leak occurs).
– Unequal pupil size, loss of pupillary reaction.
Diagnostic Test Results
- CT scan shows hemorrhage, cerebral edema, or shift or midline structures.
– EEG may reveal seizure activity.
– ICP monitoring shows increase ICP.
– MRI shows hemorrhage, cerebral edema, or shift or midline structure.
– Skull x-ray may show skull fracture.
– Stabilize cervical spine
– Oxygen administration
– IV access (2 large bore catheters), LR or NS
– Control external bleeding with pressure
– Assess for rhinorrhea, otorrhea, scalp wounds
– Remove clothing
- Maintain patient warmth
– Monitor VS, LOC, O2 sats, cardiac rhythm, GCS, pupil size and reactivity
– Anticipate intubation if absent gag reflex
– Assume neck injury with head injury
– Administer fluids cautiously to prevent IICP
Medical (Nonsurgical) intervention
- The treatment of a patient with a head injury is the same as for a patient with increase ICP.
– The emphasis is on reducing ICP, maintaining the airway, provide oxygenation, maintaining cerebral perfusion and prevent secondary head injury.
- Acute hyperventilation decrease PaCo2, causing vasoconstriction of the cerebral arteries, reducing cerebral blood flow, decrease intracranial pressure.
– Using hyperventilation over a long period of time is contraindication and may not reduce ICP significantly.
– Physicians may utilize the technique by setting the ventilator at a rate that produces hyperventilation.
– PaCo2 is generally maintained at (30-35 mmHg)
- A variety of surgical procedures exist for head injury patient.
– For a patient with depressed skull fracture, elevation of the fracture may be needed, depending on the nature of the fracture.
– Surgical removal of an epidural, subdural or intracerebral hematoma may be perfomred to prevent a mass lesion from causing a shift in brain tissue or herniation.
Types of Cranial Surgery: Craniotomy
– Penetrating wounds to the skull and brain may necessitate a craniotomy, remove bone fragments and repair laceration
– Location varies
– Frontal, Parietal, Occipital, Temporal or
– Burr holes drilled, saw to remove bone flap
– Bone flap wired or sutured after surgery
– Drain may be placed to remove blood or fluid
Nursing Care: Pre-op
– What can be expected
– Hair will be shaved
– Client will be in ICU after surgery
Nursing Care: Post-op
- Prevent increased ICP.
– Maximum swelling occurs within 24-48 hours
– Frequent assessment of neuro status x 48 hrs.
– Monitor fluids, electrolytes, osmolality closely
– Detects changes in sodium regulation, onset of diabetes insipidus, severe hypovolemia
– Positioning varies depending on procedure
– Assess dressing, drainage, incision
– Care to prevent wound infection
Nursing Care: ambulatory and home
- Rehab potential depends on reason for surgery, post-op course of recovery, and client’s