- 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
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