DEBREBERHAN UNIVERSITY

AWHSC
HEAD INJURY SEMINAR
Sugical Nursing Students

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Outline
 Antomy overview
 Head injury
 Pathophysiology
 Types
 Diagnostic criteria
 pharmacological management
 Nursing assessment and
 Nursing management
 Reference

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Scalp
The scalp is composed of soft tissue layers that
cover the cranium.
It has 5 layers :
Skin
Connective Tissue,
 Aponeurosis,
 Loose Areolar
Connective Tissue and
Periosteum

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Skull
Skull: The skull is a collection of bones which
encase the brain and give form to the head and
face

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Skull cont…
The eight cranial bones are the bones
surrounding the brain.
paired bones
parietal bones (2),
 temporal bones (2),
Unpaired bones
frontal bone
 occipital bone,
sphenoid bone,and
ethmoid bone.

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Meningeal Layers:
 The three meninges that cover the brain and

spinal cord are:

1. Dura mater
2. Arachnoid mater
3. Piamater.
 Space above the dura mater epidural
layer
 Space below the dura mater
subdural layer
 Arachnoid surgical nursing students leptomeninges 6
Brain Tissue:
 Occupies 80% of the cranial vault.
 Composed of neurons and glial cells.
 Neurons are the functional units of brain.
 Neurons transmit sensory and motor impulses to
and from the PNS and CNS.
 The glial cells are the support structure to the
neurons.
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Cont’d
Intravascular Component:
 The brain must maintain a constant flow of blood
 Arterial blood flow to the brain  20% of the CO.
 Normal cerebral blood flow is 750 ml/min.
 Normal ICP level is 5-15mmHg
 Normal CPP level is 60-70mmHg
 CPP = MAP-ICP
 Two pairs of major arteries that supply the brain:

i. Right and left carotid arteries

ii. Right and left vertebral arteries.

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Cerebrospinal Fluid (CSF):
 Produced by ependymal cells on the choroid
plexus in the lateral ventricles.
 Approximately 250 –500cc’s are produced per day.
 CSF bathes the entire brain and spinal cord.

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HEAD INJURIES
 Any trauma that leads to injury of the scalp,
skull or brain.
 It is one of the most common causes for
attending emergency departments.
 The injuries can range from a minor bump on
the skull to severe brain injury

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Cont…
Causes:
 Road traffic accident – 80%
 Falls
 Assaults
 Injuries at work place, during sport, or at
home

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Cont…
Risk Factors
 People at highest risk for TBI are those in the
15- to 19-year age group.
 Males 2 times likely as females
 Colour blindness
 Alcohol addiction
 Vertigo
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Cont…
Forms of Head Injuries Can be:

1. Scalp injuries

2. Skull injury

3. Brain injuries

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Cont…
Head injuries include
3. Brain injuries
1. Scalp injuries
 Cerebral concussion
 Laceration
 Cerebral contusion
2. Skull injury  Cerebral Laceration
Simple Linear #  Intracranial hematomas
Depressed skull #  Cerebral swelling
Basal skull
(Brain edema

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Cont…
1. Scalp Injury
 Generally classified as a minor injury.
 Trauma may result in an abrasion, contusion, laceration,

or hematoma beneath the layers of tissue of the scalp

(subgaleal hematoma).
E.g., Subgaleal hematomas (hematomas below the outer

covering of the skull) usually absorb on their own and do

not require any specific treatment.
 Scalp wounds are potential portals of entry for organisms
that cause intracranial infections. Therefore, the area
should be irrigated before the laceration is sutured

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Cont…
2. Skull Injuries
 Is a break in the continuity of the eight bones that
form the skull
 If the force of the impact is excessive, damage to

the underlying structures

 Skull fractures are classified as

1. Linear,

2. Comminuted,

3. Depressed, or Basilar

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Cont…
Forms of skull injury

I . Simple Linear Fracture

 A linear skull fracture is a break in a
cranial bone resembling a thin line,
without splintering, depression, or
distortion of bone
 Are usually fairly straight and involve no
displacement of the bone
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Cont…
ii. Depressed skull fracture
 Usually resulting from blunt force
trauma.
 Broken bones are displaced inward.
 A high risk of increased pressure on the
brain, or a hemorrhage to the brain

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Cont…
Indications for elevation
 Depression greater than the cranial thickness

 Intracranial hematoma

 Frontal sinus involvement

 Neurologic deficit

 Cosmetic reason

 Dural penetration

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Cont…
iii. Basal Skull Fracture
 A fracture of the base of the skull, typically
involving:
 Temporal Bone
 Occipital Bone
 Sphenoid Bone and/or
 Ethmoid Bone.

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Cont…
Assessment and Diagnostic Findings:

 Hx & P/E
 Skull X ray
 CT scan
 MRI

 Cerebral angiography

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 Clinical Manifestations:
 Battle sign (ecchymosis over
the mastoid process )
 Raccoon sign (Periorbital
edema & ecchymosis)
 CSF Otorrhea (leakage of
CSF from the ears )
 CSF Rhinorrhoea (leakage of
CSF from the Nose)
 Hemotympanum (blood
behind the tympanic
membrane)
 Dilated pupils & Asymmetrical
sluggish response
Cont…
Medical Management:
 Nondepressed skull fractures generally do not
require surgical treatment.
 Close observation of the patient is essential.
 Many depressed skull fractures are managed
conservatively;
⚫ Only contaminated or deforming fractures require
surgery
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Cont…
 The nasopharynx and the external ear should be
clean.
 Sterile cotton pad may be taped loosely under
the
nose or against the ear to collect the draining
fluid.
 Avoid sneezing, and blowing the nose.
 Elevated the head 30 degrees to reduce ICP.
 Persistent CSF rhinorrhea or otorrhea usually
requires surgical intervention (Closure of dura )
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Brain Injuries
 An injury to the brain that is severe enough to interfere
with normal functioning
 The most important consideration in any head injury.

Brain injury
Acquired brain
Congenital brain injury
injury
(After birth
(pre birth, during process)
birth)

Traumatic brain injury Non traumatic

(external physical force ) brain injury

Primary Brain Secondary Brain

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Injury Injury
Cont…
Acquired Brain Injury
I. Traumatic brain injury(TBI), caused by:
 A blow to the head or
 By the head being moved rapidly.

II. Non-traumatic brain injury

 The brain cells are damaged or killed by
Toxic substances
Lack of oxygen
Pressure
Direct infection or stroke
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1.Traumatic Brain Injuries
 Traumatic brain injury (TBI) is a non-degenerative, non-

congenital insult to the brain from an external

mechanical force, leading to
 Permanent or temporary impairment of cognitive, physical,

and psychosocial functions, with an associated diminished

or altered state of consciousness.
 The damage can be focal (confined to one area of the

brain) or diffuse (occurs in more than one area of the

brain).
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Classification of TBIs
 Damage to the brain from traumatic injury takes two

forms
 Primary injury: is the initial damage to the brain that

results from the traumatic event.

 This may include contusions, lacerations, and torn blood
vessels from impact, acceleration/deceleration, or foreign
object penetration
 Secondary injury: evolves over the ensuing hours and

days after the initial injury.

 Primarily due to brain swelling or ongoing bleeding

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Cont…
Based on mechanism :
1. Closed (blunt) brain injury:- occurs when the head
accelerates and then rapidly decelerates or collides with
another object (eg, a wall or dashboard of a car) and
 Brain tissue is damaged, but there is no opening through
the skull and dura.

2. Open(penetrating) brain injury:- occurs when an

object penetrates the skull, enters the brain, and
damages the soft brain tissue in its path (penetrating
injury), OR
 When blunt trauma to the head is so severe that it
opens the scalp, skull, and dura to expose the brain
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Cont…
 Based on severity: TBIs classified as

1) Mild,

2) Moderate, and

3) sever TBIs.

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Cont,d

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Cont…
Primary Brain injury
occurs at the moment of trauma:

1. Cerebral concussion

2. Cerebral contusion & lacerations

3. Intracranial hemorrhage

Secondary brain injury refers to the changes that evolve

over a period of hours to days after the primary brain injury.

It includes an entire series of steps or stages of cellular,

chemical, tissue, or blood vessel changes in the brain that
contribute to further destruction of brain tissue.

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1.Cerebral concussion

Also referred to as a mild TBI.

 A temporary loss of neurologic function with no apparent
structural damage.

 Temporary impairment of neurological function that heals

by itself within time period

 A concussion generally involves a period of

unconsciousness lasting from a few seconds to a few
minutes
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Cont…
There are two types of concussion:

1. Mild, and

2. Classic.
Mild:- may lead to a period of transient confusion,
disorientation, or impaired consciousness.
 Commonly, there is a memory lapse at the time of injury
and a loss of consciousness lasting less than 30 minutes.
 Other signs and symptoms include seizures, headache,
dizziness, irritability, fatigue, or poor concentration
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Cont…
 A classic concussion:- is an injury that results in

a loss of consciousness usually lasts less than 6

hours.
 This loss of consciousness is always
accompanied by some degree of posttraumatic
amnesia.
 Treatment involves observing the patient for
symptoms of Post Concussion Syndrome
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Cont…
 Difficulty in awakening
 Difficulty in speaking
 Confusion
 Severe headache
 Vomiting
 Weakness of one side of the body

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2. Cerebral Contusion & Laceration
Cerebral contusion is a more severe injury
in which the brain is bruised, with possible
surface hemorrhage
Signs and symptoms may include: change in
LOC, seizures, disorientation, headache,
vomiting

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Cont…
Assessment & Diagnosis
 Definitive diagnosis is made by a CT/MRI scan
which shows small amounts of diffuse bleeding
with edema.
Treatment may include:
 Supportive therapy

 Hyperventilation

 Osmotic diuretics

 Barbiturates

 Managing ICP or surgery

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3. INTRACRANIAL HEMATOMA
 Hematomas(collections of blood) that develop
within the cranial vault.
 Are the most serious brain injuries.
 A hematoma may be in:

A. Epidural(above the dura),

B. Subdural (below the dura)or

C. Intracerebral (within the brain

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Cont…

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Cont…
A. Epidural Hematomas
 Due to collection of blood in the extradural space (above
the dura meningeal layer) between the skull, and the dura
 Symptoms may include one or all of the following:
 Ipsilateral pupil dilation
 Change in LOC
 Abnormal posturing
 Contralateral limb weakness
 Hemiparesis or hemiplegia

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Cont…
 Treatment consists of

Making openings through the skull (burr

holes) to decrease ICP emergently,
Remove the clot, and

Control the bleeding.

 A craniotomy may be required to remove

the clot and control the bleeding

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Cont…
B. SUBDURAL HEMATOMA
 Collection of blood between the dura, and the brain.
 It is usually venous in origin.
 Frequently caused by falls, motor vehicle crashes, and
violent shaking.

 They are classified based on the time symptoms occur:

A. Acute (24 – 48 Hours)
B. Sub Acute (2 Days To 2 Weeks) Or
C. Chronic (2 Weeks To 3 Months)
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Cont…
Assessment & Dx:

 CT scan will show a hematoma spreading diffusely

along the inner table of the skull.
 Treatment includes the evacuation of the clot and
control of bleeding.

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Cont…
C. INTRACEREBRAL HEMATOMAS
 Bleeding within the cerebral tissue.
 As small as 5 cc’s of blood can result in adverse
neurological manifestations.

 Most frequently caused by:

 Depressed skull fractures
 Penetrating injuries
 Complications of anticoagulant therapy
 Surgical intervention by craniotomy or brain
debridement permits removal of the blood clot and
control of hemorrhage
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Nursing assessment
Initial Assessment
o Cervical Spine
 In a patient suffering with head injury, always consider if
the cervical spine may have also been injured
o Airway
 Any patient with a GCS of 8 or less is at risk of being
unable to maintain their own airway.
o Breathing
 ensuring adequate ventilation (with a secure airway)
and oxygenation is particularly important following
head injury, limiting further brain damage from hypoxia

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Cont…
o Circulation
 ensure adequate tissue perfusion to prevent
any further secondary ischaemic damage to the
brain
o Disability & Neurological
examination(GCS)
 In all patients presenting with a head injury, an
accurate Glasgow Coma Scale must be
recorded on admission

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Management of ICP
• First-level measures start by placing the head in
neutral position (not flexed nor extended), aligned

with head of the bed raised to 30 degrees to

facilitate venous drainage.
• Agitation, anxiety, and pain significantly increase
blood pressure and ICP;

• Therefore, analgesia and sedation are essential for

the control of IHT.
• Use short-acting agents (remifentanyl/propofol)
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Cont’d
Osmotherapy is the cornerstone of pharmacological
treatment for the control of IHT.
Osmotic agents work by:

 Creating gradients causing fluid shift from the

interstitial space to the intravascular space, thus
increasing CBF and in turn causing a compensatory
vasoconstriction that lowers the ICP.
 The most common agents are mannitol and hypertonic

saline solutions (HSS)

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Cont’d
Mannitol :- is administered as bolus doses usually ranging from
0.25 to 1 g/kg.
• Increased serum osmolality and extraction of water from
the brain
• The maximal effects observed after 30 – 40 minutes, but ICP may
start to decline within minutes and the effect can last for several
hours.
• Mannitol requires monitoring of serum osmolality and intravascular
volume status. A serum osmolality >320 mOsm/L is associated
with higher risk of acute renal injury.
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Hypertonic saline solution
 HSS rapidly expands the intravascular space and can

improve cardiac output. It may have a greater and longer

effect (18–24 hours) on ICP than mannitol and may also
have a better effect on CPP.
 Administration practices vary but concentration of 3% -

24.3% should be infused into a central vein.

 Monitoring of serum sodium is necessary, and HSS
administration is generally stopped when hypernatremia
exceeds 155–160 mEq/L
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sadation
• Sedation lowers elevated ICP by decreasing cerebral
metabolism, causing a consequent reduction in CBF
 It may also ameliorate ventilator asynchrony and blunt

sympathetic responses of hypertension and tachycardia.

• Pentobarbital remains a RX option for elevated

ICP refractory to other therapies.
 A loading dose of 5 to 20 mg/kg is given as a bolus,

followed by 1 to 4 mg/kg per hr.

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Nutritional support

 Nutrition should begin early, as soon as the

patient is hemodynamically stable, and ideally

within 24-48 hours of injury
 Enteral nutrition is recommended over the use
of parenteral nutrition

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• The Guidelines for Surgical Management of severe TBI
recommended surgery in the following cases:
 Epidural lesion of more than 30 cc independent of the GCS

 Subdural mass of more than 10 mm thickness independent

of the GCS & Subdural mass lesion with midline deviation of
more than 5 mm
 Intracerebral mass lesion of more than 50 cc

• Suggested management: unilateral or bilateral

decompressive craniectomy
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Nursing management
o Monitor blood pressure,
 which is critical in head trauma patients because hypotension
results in decreased cerebral perfusion and, subsequently, brain
ischemia.
o Beware of the Cushing’s reflex
 a response to increased intracranial pressure that results in
reduced heart rate and increased blood pressure..
o Check body temperature
 regularly because patients with brain injuries may have difficulty
regulating their own temperature..
o Monitor level of awareness,
 pupil size, and PLR regularly. Hypovolemic patients may initially
present with an overall decreased mental status.
 When providing IV fluids to these patients, it is important to
regularly check their level of awareness and mentation.
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Reference
Brunner and Suddarth's Textbook of Medical-
Surgical Nursing, 10th Edition - Smeltzer,
Suzanne C.; Bare, Brenda G
https;//todaysveterinarypractice.com

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