HEAD INJURY

 

OVERVIEW

·             Head injury is a broad classification that include the injury to the scalp, skull or brain.

·         A serious form of head injury is traumatic brain injury(TBI).  In India about 1.6 million sustain TBI & seek medical Aid & out of these 10% dies.

ETIOLOGY:-

•  Motor vehicle collisions & Fall
• Fire
• Assaults
• Sports related trauma
• Recreational injuries
• War related injury

TYPE OF HEAD INJURIES:-

1.       Scalp injury

2.       Skull fracture:-                                                                                            

Skull fracture is again  5 types, those are:-

a)      Linear skull fracture

b)      Depressed skull fracture

c)       Simple skull fracture

d)      Comminuted skull fracture

e)      Compound skull fracture

3.       Brain injury

a)      Concussion                                           

b)      Contusion    

                                             

c)       Diffuse axonal injury

d)      Intracranial hemorrhage

·         Epidural hematoma

·         Sub dural hematoma

·         Intra cerebral hematoma

1.       SCALP LACERATION:-

·         It is classified as minor head injury.

·         Scalp contain many blood vessels which has poor constricting ability so when there is scalp injury it bleed profusely which can be detected from out side.

·         The scalp trauma may results in an abrasion ( brush wound), contusion, laceration or hematoma beneath the layer of the tissue of the scalp( subgaleal hematoma)

·         Scalp injury may cause portal of entry of microorganisms which can cause intra cranial infection

·         So to reduce the risk of infection the wound should be irrigated to remove foreign materials then sutured.

·         It can be diagnosed by physical examination. Inspection, palpation.

2.       SKULL INJURY:-

·         It is the break in the continuity of the skull caused by forced trauma.

·         It may cause with or without brain trauma

·         It is classified by its type & location of the fracture, it is classified in to following types:-

a.       Linear fracture:- It is the break in the continuity of the bone.

b.      Depressed skull fracture:- It occur when the bone of the skull are forcefully displaced  downwards & embedded within the brain tissue.

c.       Simple skull fracture:- It is the linear or depressed skull fracture without fragmentation or communicating laceration

d.      Comminuted skull fracture:- Multiple linear fracture with fragmentation of bone in to many pieces.

e.      Compound skull fracture:- depressed skull fracture & scalp laceration with communicating pathway to intracranial cavity.

CLINICAL MANIFESTATION OF SKULL FRACTURE:-

Ø  FRONTAL FRACTURE:- Exposure to brain to contaminant through frontal air sinus

Air in the for head

CSF Rhinorrhea.

Pneumocranium ( air between cranium & dura meter)

Ø  ORBITAL FRACTURE:- Optic nerve injury, periorbital  ecchymosis

Ø  TEMPORAL FRACTURE:- Boggy temporal muscle because of extravasations of blood, Oval shaped bruise behind ear in mastoid region ( Battle’s Sign), CSF Otorrhea, middle meningial artery disruption

Ø  PARITAL FRACTURE:- Deafness, CSF otorrhea, bulging of tympanic membrane caused y blood or CSF, Facial paralysis, loss of taste, Battle’s Sign

Ø  POSTERIOR FOSSA FRACTURE:- Occipital bruiseing result in cortical blindness, visual field defect, rare appearance of ataxia.

Ø  BASILAR SKULL FRACTURE:- CSF otorrhea, bulging of tympanic membrane due to blood or CSF, Battle’s Sign, tinnitus or hearing difficulty, Rhinorrhea, facial paralysis & vertigo.

3.       BRAIN INJURY:-

·         Open brain injury occur when object penetrate the skull, enter the brain & damage the soft brain tissue.

·         Close ( blunt) brain injury occur when head acceleration & rapidly deceleration or collides with another objects (e.g with a wall or dash board of car) it cause brain tissue damage but there is no opening through the skull or durameter. The brain injury is classified in to following types:-

a.       CONCUSSION

b.      CONTUSION

c.       DIFFUSE AXONAL INJURY

d.      INTRACRANIAL HEMORRHAGE

o   Epidural hematoma

o   Subdural Hematoma

o   Intracerebral hemorrhage & hematoma

a.       CONCUSSION:- It is the minor diffuse head injury  where there is no apparent structural damage to the brain but there is disruption of neural activity & change in LOC.

Ø  The mechanism of injury is due to blunt trauma from an acceleration deceleration force . There are 3 grade of concussion, those are:-

·         GRADE 1:- Concussion has symptoms of transient  confusion, no loss of consciousness & duration of mental status abnormalities resolve in less then 15 min.

·         GRADE 2:- Concussion has symptom of transient confusion, no loss of consciousness but mental status abnormalities last more then 15 min.

·         GRADE 3:- There is loss of consciousness lasting from second to minute

Ø  There is no structural sign of injury but duration of mental status abnormalities is an indicator of grade of concussion.

Ø  Patient can discharge from the hospital once return to the baseline

Ø  Patient should be  monitored for level of consciousness, worsening headache, dizziness, seizure, abnormal pupillary response, vomiting irritability, numbness weakness in the arm or leg.

b.      CONTUSION:-

·         It is the moderate to severe head injury in which brain is bruised & damage in a specific area because of severe acceleration & deceleration force or blunt trauma.

·         Contusion are characterised by loss of consciousness associated with stupor & confusion & neurologic deficit without hematoma formation & hemorrhage in to the tissue that varies in size & surrounded by edema.

·         The effect of injury peak after about 18 to 36 hour

·         Patient outcome depends on the area & severity of the swelling.

C. DIFFUSE ANOXAL INJURY:-

Ø  It results from wide spread shearing & rotational force that produce damage through the brain to axons s in the cerebral hemisphere , corpus callosum & brain stem.

Ø  In this type of injury patient experience immediate coma, decorticate, decerebrate  posturing, global cerebral edema.

Ø  Diagnosis made by clinical sign in conjugation with a CT Scan & MRI scan.

D. INTRACRANIAL HEMORRHAGE:-

·         In this there is collection of blood in the brain in epidural (above the durameter), sub dural ( below the dura) or intracerebral ( within the brain).

·         Symptoms are delay until the hematoma is large enough to cause the distoration of brain & increase ICP.

·         Sign & symptoms of cerebral ischemia results from compression by hematoma, vital areas are affected & injured.

         Intracranial hemorrhage is three types, those are:-

i.                     Epidural hematoma

ii.                   Subdural hematoma

iii.                  Intracerebral hemorrhage & hematoma.

i.                     EPIDURAL HEMATOMA:-   It is the head injury and collection of blood in the epidural space between skull & durameter.

·         Bleeding & hematoma occur due to rupture of middle meningial artery( the artery that runs between dura & skull interfere to thin portion of temporal bone.

·         The sign & symptoms includes brief loss of consciousness followed by  a lucid interval  in which the patient is a wake & conversant.

·         In lucid interval compression for the expanding hematoma  takes place by rapid absorption of CSF & decrease intracranial volume to maintain ICP.

·         If compensation mechanism fail to maintain ICP the volume of the blood clot increase in the patient goes towards the COMA.

·         It may cause neurologic deficit & respiratory deficit within minute.

·         The treatment options are craniotomy, remove the clots & control bleeding.

·         Drain is inserted after creation of bore hole to prevent re accumulation of blood.

ii.                    SUBDURAL HEMATOMA:-

·         It is the collection of blood between the durameter & brain.

·         The cause of hematoma is trauma, rupture of aneurysm or rupture of small blood vessels that bridge the subdural space.

·         Acute & subdural hematoma sign & symptoms includes Loss Of Consciousness, increase BP, increase HR, decrease Resp, COMA.

·         Clinical manifestation appear between 48 hours to 2 wk after the injury.

·         Out come depends on managing ICP by immediate craniotomy & REMOVAL OF clot & maintain respiration.

·         Chronic subdural hematoma seen among older adult due to brain atrophy due to ageing process. Time between injury & symptoms are 3 wk to months.

·         The blood within the brain become thick & darker after a week clot break down & look like motor  oil, calcification or ossification of clot

·         The patient will have severe headache, personality changes, mental disorientation & focal seizure.

·         It can be treated by surgical evacuation of clot

iii.                  INTRACRANIAL HEMORRHAGE & HEMATOMA:-

·         It is the bleeding in the parenchyma of the brain.

·         The hemorrhage within the brain results from increased BP which cause rupture of blood vessel, vascular anomalies, intracranial tumour & bleeding disorder such as haemophilia or thrombocytopenia.

·         It can be treated with controlling ICP, careful administration of fluid & electrolyte, antihypertensive medications & craniotomy for removal of blood clot & control hemorrhage.

PATHOPHYSIOLOGY:-

Brain damage from traumatic injury takes in two form.

1.       Primary injury:- It is the initial damage of brain that results from traumatic event which include contusion, laceration & turn blood vessel due to foreign body penetration.

2.       Secondary injury:- It seen hours to day after initial injury which results from inadequate delivery of nutrient & o2 to the cell.

This process include intracranial hemorrhage, cerebral edema, increase ICP, hypoxic brain damage & infection.

Monro-Kellie hypothesis explain the dynamic equilibrium content.

The cranial vault contains three main component brain, blood & cerebrospinal fluid.

Cranial vault is closed system & if one of the three component increase in volume the pressure will increase.

It can cause displacement of the brain through against the rigid structure of skull. Restriction of blood flow to the brain, decrease o2 delivery & waste removal. Cell become anoxic cannot metabolize properly, producing  ischemia, infraction, irreversible brain damage & brain death.

DIAGNOSIS:-

• History collection
• Physical examination:- Neurologic examination
• CT or MRI for detecting brain lesion
• Transcranial Doppler studies for measurement of CBF viscocity
• Cervical spine X-Ray studies to determine cervical spine trauma.
• PET Scan.

MANAGEMENT:-

1.       EMERGENCY MANAGEMENT:-

v  Ensure patient airway

v  Stabilize survical spine

v  Administer o2 via non rebreathable mask.

v  Established IV assess with two  large bore catheter to infuse NS & RL.

v  Intubate if GCS decrease 8

v  Control external bleeding with sterile pressure dressing.

v  Remove patient clothing.

2.       ONGOING MONITORING:-

v  Maintain patient warmth using blanket, warm IV fluid, warm humidified o2.

v  Monitor vital sign, LOC, o2 saturation, cardiac rhythm, GCS score, pupil size & reactivity

v  Anticipate need for intubation if gag reflex is impaired or absent

v  Assess for rhinorrhea, otorrhea, scalp wound.

v  Administer fluid cautiously to prevent fluid overload & increase ICP.

v  Maintain head & neck alignment with the axis of the body apply cervical collar till absence of spinal cord injury documented.

v  Avoid secondary brain injury which may occur due to edema, hypotension, respiratory depression lead to hypoxemia & electrolyte imbalance.

v  Surgery is required to evacuation of blood clot, debridement & elevation of depressed fracture of the skull & suture of severe scalp laceration.

v  ICP managed by adequate o2, elevating HOB maintain normal blood volume.

v  Placement of drain to remove excess CSF

v  Due to hypoxia seizure may occur so antiseizure medication should be provided.

v  Sedative benzodiazepine should be administered for agitated patient.

v  Administration of NG tube.

 NURSING MANAGEMENT:-

1.       History Collection:- Collect history of mechanism of injury such as vehicle collision, sports injury, industrial incident, assaults fall or use of anticoagulant medication.

Collect sign of brain injury such as headache, mood or behavioural changes, aphasia, dysphagia, impaired judgement, aggression, depression.

2.       Physical examination:-

v  Check GCS

v  Integumentary :- laceration, contusion, abrasion, hematoma, battle’s sign, periorbital edema, ecchymosis, otorrhea.

v  Respiratory:- rhinorrhea, impairment gag reflex, inability to maintain patient airway, irrigulay resp.

v  Cardiovascular:-  Cushing tried( systolic hypertension with widen pulse pressure, brady cardia with full & bounding pulse, irregular resp.

v  Gastrointestinal:- vomiting, projectile vomiting, bowel incontinence.

v  Urinary:- bladder incontinence.

v  Neurology:- altered level consciousness, seizure activity, pupil disfunction, cranial nerve deficit.

v  Skeletal system:- motor deficit, weakness, paralysis, spasticity, decorticate or decorticate posturing. Muscular rigidity, ataxia.

NURSING DIAGNOSIS:-

1.       Ineffective airway clearance & impaired gas exchange related to brain injury.

2.       Risk for ineffective cerebral tissue perfusion related to increase ICP, decrease CPP & possible seizure.

3.       Deficit fluid volume related to decreased LOC & hormonal dysfunction .

4.       Risk for injury related to seizure, disorientation restlessness or brain damage.

5.       Risk for imbalanced body temp related to damaged temperature regulating  mechanism in the brain.

6.       Risk for impaired sin integrity related to bed rest, Hemiparesis, hemiplagia, immobility.