Management of Patients

With Neurologic Trauma

Head injury
Advanced Adult Nursing
0301218

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Learning objectives

• 1- Recognize types of head injuries

• 2- identify the c/m , diagnostic procedures and medical management
of each type
• 3- understand and capture the necessary nursing interventions for
these injuries.

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 Head Injury
• Injury to the scalp, skull, or brain.

• A head injury may lead to conditions ranging from mild concussion to coma
and death; the most serious form is known as a traumatic brain injury (TBI).

• Causes of TBIs are :falls, motor vehicle crashes , being hit by objects,
assaults.

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Pathophysiology

• Any bleeding or swelling within the skull increases the volume

of contents within the skull and therefore causes increases (ICP)

• If the pressure increases enough, it can cause displacement of

the brain through the rigid structures of the skull.

• This causes restriction of blood flow to the brain, decreasing

oxygen delivery and waste removal.

• Cells within the brain become anoxic and cannot metabolize

properly, producing ischemia, infarction, irreversible brain
damage, and, eventually, brain death
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 1-Scalp Injury
• classified as a minor injury.

• Blood vessels constrict

poorly, the scalp bleeds
profusely when injured.

• Trauma may result in an

abrasion, contusion,
laceration, or hematoma

• A large avulsion may be

potentially life-threatening
and is a true emergency.
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Diagnostic Tests

• Physical examination: inspection and palpation.

• Scalp wounds are potential portals of entry for organisms

that cause intracranial infections. Therefore, the area is
irrigated before the laceration is sutured, to remove foreign
material and to reduce the risk for infection.

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2-Skull Fractures

• It is a break in the continuity

of the skull caused by
forceful trauma.

• Classified as simple,
comminuted, depressed, or
basilar.

• A fracture may be open,

indicating a scalp laceration
or tear in the dura (eg, from
a bullet), or closed.
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Clinical Manifestation
• Symptoms depend on the severity and the anatomic location of the underlying
brain injury.

• pain suggests that a fracture is present.

• Swelling ; therefore, an x-ray is needed.

• Basilar skull fractures produce hemorrhage from the nose, pharynx, or ears,
and blood may appear under the conjunctiva.

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• ecchymosis (bruising) over the mastoid (Battle’s sign),and around eyes
(Raccoon eyes).

• CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

• Meningeal infection can occur if organisms gain access to the cranial

contents via the nose, ear, or sinus through a tear in the dura.

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 Dx findings
• X-rays
• A physical examination of neurologic status
• (CT) scan
• (MRI)
• Cerebral angiography

Medical RX :
• Non depressed skull fractures do not require surgical treatment;
close observation.
• Depressed skull fractures usually require surgery with elevation
of the skull and debridement, usually within 24 hours of injury.

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Types of Brain injury

• Damage to the brain from traumatic injury takes two forms:

primary injury and secondary injury.

• Primary injury is the initial damage to the brain that

results from the traumatic event. This may include
contusions, lacerations, and torn blood vessels due to impact,
acceleration/deceleration, or foreign object penetration.

• Secondary injury evolves over the next hours and days

after the initial injury and results from inadequate delivery of
nutrients and oxygen to the cells

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 Traumatic Brain
Injury

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Types of Brain Injury

• 1- A concussion is a temporary loss of neurologic function

with no apparent structural damage.

• A concussion may or may not produce a brief loss of

consciousness.

• The mechanism of injury is usually blunt trauma from an

acceleration-deceleration force, a direct blow, or a blast
injury .

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Types of concussion

A- A mild concussion B- A classic concussion

• lead to a transient confusion, • is an injury that results in a loss

disorientation, or impaired of consciousness; lasts less than
consciousness. 6 hours.

• a memory lapse at the time of • accompanied by some degree of

injury and a loss of posttraumatic amnesia.
consciousness lasting less than
30 minutes.
• Diagnostic studies may show
no apparent structural sign of
• seizures, headache, dizziness, injury, but the duration of
irritability, fatigue, or poor unconsciousness is an indicator
concentration of the severity.
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2- Contusion

• a moderate to severe head injury, the brain is bruised and damaged

in a specific area because of severe acceleration-deceleration force
or blunt trauma.

Clinical Manifestation:
• loss of consciousness associated with stupor and confusion.

• tissue alteration and neurologic deficit without hematoma formation, and is

surrounded by edema.

• (hemorrhage and edema) peak after about 18 to 36 hours.

• Temporal lobe contusions carry a greater risk of swelling, rapid deterioration, and
brain herniation.
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 4- Diffuse Axonal Injury
• (DAI) results from widespread
shearing and rotational forces that
produce brain damage (axons)

• DAI is associated with prolonged

traumatic coma; it is more serious and
is associated with a poorer prognosis
than a focal lesion or ischemia.

• The patient experiences no lucid

interval, immediate coma, decorticate
and decerebrate posturing , and global
cerebral edema.

• Diagnosis is made by clinical signs in

conjunction with a CT or MRI scan.

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5- Intracranial Hemorrhage

• a rapidly developing hematoma,

even if small, may be fatal,
whereas a larger but slowly
developing one may allow
compensation for increases in
ICP.

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A-Epidural Hematoma:

• blood collect in epidural space • the patient’s condition

between the skull and the dura deteriorates rapidly to signs of
mater. herniation (usually
• result from a skull fracture deterioration of consciousness
Clinical Manifestation: and signs of focal neurologic
• a brief loss of consciousness deficits, such as dilation and
followed by a lucid interval in fixation of a pupil or paralysis
which the patient is awake and of an extremity).
conversant.

Treatment :
• agitated, and confused 
progresses to coma. consists of making openings
through the skull (burr holes or
craniotomy ) to decrease ICP
emergently, remove the clot, and
control the bleeding.
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 B- Subdural Hematoma
• is a collection of blood I. Acute subdural
• hematomas are associated with major
between the dura and the head injury involving contusion or
brain. laceration.

• symptoms develop over 24 to 48 hours.

• Causes: trauma, or Symptoms:

coagulopathies or • Changes in (LOC), pupillary signs, and

hemiparesis.
rupture of an aneurysm.
• Coma, Cushing triad*, are all signs of a
rapidly expanding mass requiring
• Acute, subacute, or immediate intervention.

chronic, depending on *Cushing triad : bradycardia, irregular

the size of the involved respirations, and widened pulse pressures, is the
body's response to increased intracranial pressure
vessel and the amount of (ICP)

bleeding. 20
11. Subacute subdural 111. Chronic Subdural Hematoma
hematomas: Can develop from minor head injuries and in the
elderly.
• are the result of less severe
contusions and head trauma. • The time between injury and onset of symptoms
lengthy (eg, 3 weeks to months), so the actual
injury may be forgotten.

• It may be mistaken for a stroke. The bleeding is

• C/M: appear between 48 less profuse, but compression of the intracranial
contents still occurs.
hours and 2 weeks after the
injury, and are similar to • The blood within the brain changes becoming
those of an acute subdural thicker and darker. In a few weeks, the clot
breaks down and has the color and consistency
hematoma. of motor oil. Then calcification of the clot takes
place.

Treatment (RX): Symptoms :

• Severe headache(come and go); personality
• Craniotomy changes; mental deterioration; and focal
• Control of ICP seizures.
• The patient may be labeled neurotic or
• Monitoring of respiratory psychotic if the cause is overlooked.
function. Treatment : burr holes, or a craniotomy
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C.Intracerebral Hemorrhage and Hematoma

Treatment:
Bleeding into the substance of the brain.
• Supportive care.
• control of ICP, by the following:
Causes: a. Elevating your head.
• Head injuries b. Draining cerebrospinal fluid to lower
• Hypertension pressure in your brain.
• Rupture of aneurysm c. Breathing support, like intubation and
• Vascular anomalies(AVM) mechanical ventilation.
d. Medications (like barbiturates) to decrease
• Intracranial tumors brain swelling.
• Bleeding disorders such as leukemia, e. Antiseizure medications to prevent seizures,
hemophilia… which can worsen ICP.
• Complications of anticoagulant
therapy • administration of fluids, electrolytes.
• and antihypertensive medications.
• Surgical intervention :craniotomy or
The onset insidious, beginning with the craniectomy
development of neurologic deficits but may not be possible because of the
followed by headache. inaccessible location of the bleeding or the
lack of a clearly circumscribed area of
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blood that can be removed.
Management of Brain Injury

• Assessment and diagnosis :

• physical and neurologic examinations.
• CT and MRI scans
• Suspect a cervical spine injury (head and neck maintained in
alignment with the axis of the body).
• A cervical collar

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Treatments
• Stabilization of cardiovascular and respiratory function to maintain
adequate cerebral perfusion.
•
• control of hemorrhage and hypovolemia
• ventilatory support.
•
• seizure prevention.

• fluid and electrolyte maintenance.

•
• nutritional support.
•
• NGT may be inserted, to reduced gastric motility (prevent
aspiration).
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Brain Death

• The three cardinal signs of brain death on clinical

examination are :
• Coma(GCS 3/15)
• absence of brain stem reflexes(corneal, gag reflexes)
• apnea.
• Flat EEG.

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Nursing process: Assessment

• Health history (injury incident-LOC)

• GCS
• pupillary response to light,
• corneal and gag reflexes,
• motor & sensory function.

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N.D: Ineffective airway clearance and impaired gas
exchange

Maintaining the Airway: • monitoring of electrolyte levels ,

• head of the bed elevated especially in osmotic diuretics
about 30 degree. (hypokalemia).
a. Hyponatremia due to shifts in
• Suctioning extracellular fluid, electrolytes, and
volume (dilutional).
b. Hyperglycemia, can cause an increase in
• Closely monitoring ABGs to extracellular fluid that lowers sodium.
c. Hypernatremia may also occur as a result
assess the adequacy of of sodium retention.
ventilation Receiving M.V
• A daily weights
• Monitoring Fluid and
Electrolyte Balance

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N.D: Ineffective cerebral tissue perfusion

• Monitoring Neurologic Function

• GCS
• Pupil size and reaction and shape.
• V/S
• MOTOR FUNCTION
• A unilaterally dilated and poorly
• Motor response to pain is assessed responding pupil may indicate a
by applying a central stimulus, developing hematoma, with
such as pinching the pectoralis subsequent pressure on the CN III .
major muscle, to determine the
patient’s best response.
• If both pupils become fixed and
• Peripheral stimulation may provide dilated, this indicates overwhelming
inaccurate assessment because it injury to the upper brain stem and is a
may result in a reflex movement poor prognostic sign.
rather than a voluntary motor
response.
• Monitor anosmia (lack of sense of
• (lack of motor response; extension
smell), aphasia, memory deficits, and
responses) are associated with a seizures.
poorer prognosis.
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N.D: Imbalanced nutrition, less than body
requirements,

Promoting Adequate Nutrition

• Head injury results increase
calorie consumption . Protein
demand increases (high protein
diet).

• Early initiation of nutritional

therapy (enteral or Parenteral )

• If CSF rhinorrhea occurs, an oral

feeding tube should be inserted
instead of a nasal tube.

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N.D: Risk for injury (self-directed and directed at others)

Preventing Injury: • Environmental stimuli are

reduced, limiting visitors,
• ensure that oxygenation is
speaking calmly, and providing
adequate frequent orientation information .
• ensure the bladder is not
distended.
• Adequate lighting to prevent
• Padded side rails or the visual hallucinations.
patient’s hands are wrapped . • minimize disruption of the
Restraints are avoided. patient’s sleep–wake cycles.
• floor-level bed. • The patient’s skin is lubricated
• Opioids are avoided because with oil or lotion .
they depress respiration, • If incontinence occurs, an
constrict the pupils, and alter external sheath catheter may be
responsiveness. used on a male patient.
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N.D: Risk for imbalanced N.D: Risk for impaired skin
body temperature integrity

Maintaining Body
Temperature: Maintaining Skin Integrity:
• Fever result of damage to the • Assessing and documenting skin
hypothalamus, cerebral irritation integrity every 8 hours
from hemorrhage, or infection. • Turning and repositioning the
• use acetaminophen and cooling patient every 2 hours
blankets. • Providing skin care every 4 hours
• Potential sites of infection are • Assisting the patient to get out of
cultured and antibiotics are bed to a chair three times a day
administered.

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Monitoring and Managing Potential
Complications
• Maintenance of adequate CPP* is important to prevent serious complications of head
injury.

• CPP = (MAP) -ICP. The normal CPP is 70 to 100 mm Hg. Adequate CPP is greater than
60 mm Hg.

• If CPP falls a vasodilation occurs, causing the volume of blood to increase inside the
brain, causing ICP to increase.

• A decrease in CPP impair cerebral perfusion and cause brain hypoxia and ischemia,
leading to permanent brain damage.

• Once the threshold CPP is reached, vasoconstriction of the cerebral blood vessels occurs,
causing ICP to decrease

*cerebral perfusion pressure

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Monitoring and Managing Potential
Complications
• Cushing’s triad: bradycardia, hypertension (widening of the pulse
pressure), and bradypnea  herniation of the brain stem and
occlusion of the cerebral blood flow occur
• Therapy is directed toward decreasing cerebral edema and increasing
venous outflow from the brain.
• Systemic hypotension, which causes vasoconstriction and a
significant decrease in CPP, is treated with increased IV fluids or
vasopressors.

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Cerebral Edema And Herniation.

• Cerebral edema is the most common cause of increased ICP, with the
swelling peaking approximately 48 to 72 hours after injury.

• Also herniation of the brain stem and resulting in irreversible brain

anoxia and brain death.

Posttraumatic Seizures.
• administering antiseizure medications because seizures may increase ICP
and decrease oxygenation
• antiseizure medications impair cognitive performance and can prolong
the duration of rehabilitation(not advised in late seizures).

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 Exercise
Q2: Which of the following
is NOT a high-risk factor
Q1: if your child had mild head for life-threatening injury
trauma and the doctor inform you in trauma?
to watch your child at home.
Which of these symptoms should A. GCS <13
give you cause for concern? B. Falls 2 m or more
A. Continuous vomiting C. Two or more proximal
B. Your child takes a nap but can be long-bone fractures
awakened easily D. Age <5 or >55
C. Your child is confused and not
acting normal
D. All except (B)

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