1. Head Injury
Zafar Iqbal
Sr. Lecturer
Jinnah College Of Nursing Karachi

2. Head Injury
• Any trauma to the scalp, skull, or brain
• Head trauma includes an alteration in
consciousness no matter how brief

3. Head Injury
• Causes
– Motor vehicle accidents
– Firearm-related injuries
– Falls
– Assaults
– Sports-related injuries
– Recreational accidents

4. Road Traffic Crashes

5. Sports injuries
A&E(VMH)

6. Assaults
(Sickle injuries)
A&E(VMH)

7. MECHANISM
• BLUNT INJURY
 High Velocity
 Low Velocity
• PENETRATING INJURY
 Gunshot
 Sharp instruments

8. Head Injury
• High potential for poor outcome
• Deaths occur at three points in time after
injury:
– Immediately after the injury
– Within 2 hours after injury
– 3 weeks after injury

9. Classification
• By Nature of insult; penetrating or blunt.
• Concomitant injuries; isolated head injury or
multiple trauma.
• Timing of the injury; Primary or Secondary.

10. Classification
• Primary injury is that occurring at the scene and is
usually outside the control of the intensivist.
• Secondary injury is anything that occurs to augment
the primary injury; the prevention of this is
predominantly where intensive therapy is aimed.

11. Types of Head Injuries
• Scalp lacerations
– The most minor type of
head trauma
– Scalp is highly
vascular → profuse
bleeding
– Major complication is
infection Cephal Hematoma

12. Minor Head Trauma
Manifestation
– Concussion
• A sudden transient mechanical head injury
with disruption of neural activity and a
change in LOC
• Brief disruption in LOC
• Amnesia
• Headache
• Short duration

13. Minor Head Trauma
Manifestation
– Postconcussion syndrome
• 2 weeks to 2 months
• Persistent headache
• Lethargy
• Personality and behavior changes

14. Types of Head Injuries
• Skull fractures
– Linear or depressed
– Simple,
comminuted, or
compound
– Closed or open
– Direct & Indirect

15. Types of Head Injuries
• Skull fractures
– Location of fracture alters the
presentation of the manifestations
– Facial paralysis
– Deviation of gaze
– Battle’s sign

16. Types of Head Injuries
• Basal Skull fractures
– CSF leak (extravasation) into ear (Otorrhea) or
nose (Rhinorrhea)
– High risk infection or meningitis
– “HALO Sign (Battle Sign)”
– Possible injury to Internal carotid artery
– Permanent CSF leaks possible

17. Basilar :
with/with out CSF leak
with/with out seventh-nerve palsy
Raccoon eyes
Battle sign CSF rhinorrhea

18. INTRACRANIAL LESIONS
• Focal : epidural hematoma
subdural hematoma
intracerebral hematoma

19. INTRACRANIAL LESIONS
Intracerebral -in the brain
Epidural Hematoma -between
the skull and the dura
Subdural Hematoma -between the brain and the dura)

20. Manifestation of Major Head
Trauma
– Includes cerebral contusions and
lacerations
– Both injuries represent severe trauma to
the brain

21. Manifestation of Major Head
Trauma
– Contusion (“brain bruises” )
• bruising’ within the brain with relatively
localised cellular damage, haemorrhage and
oedema or The bruising of brain tissue
within a focal area that maintains the
integrity of the pia mater and arachnoid
layers
– Lacerations
• Involve actual tearing of the brain tissue
• Intracerebral hemorrhage is generally
associated with cerebral laceration

22. Pathophysiology
• Diffuse axonal injury (DAI)
– Widespread axonal damage occurring
after a mild, moderate, or severe TBI
– Process takes approximately 12-24 hours

23. Pathophysiology
• Diffuse axonal injury (DAI)
– Clinical signs:
∀↓ LOC
∀↑ ICP
• Decerebration or decortication
• Global cerebral edema

24. Approach to a Patient With Head
Injury
• History
• Initial Assessment
 Primary Survey
 Secondary Survey

25. Diagnostic Studies and
Collaborative Care
• CT scan considered the best diagnostic test to
determine craniocerebral trauma
• MRI
• Cervical spine x-ray
• Glasgow Coma Scale (GCS)

26. Management of Traumatic Head
Injury
• Maximize oxygenation and ventilation
• Support circulation / maximize cerebral perfusion
pressure
• Decrease intracranial pressure
• Decrease cerebral metabolic rate

27. Nursing Management
Nursing Assessment
– GCS score
– Neurologic status (GCS)
– Presence of CSF leak

28. Nursing Management
Nursing Diagnoses
– Ineffective tissue perfusion
– Hyperthermia
– Acute pain
– Anxiety
– Impaired physical mobility

29. Nursing Management
Planning
– Overall goals:
• Maintain adequate cerebral perfusion
• Remain normothermic
• Be free from pain, discomfort, and
infection
• Attain maximal cognitive, motor, and
sensory function

30. Nursing Management
PRIMARY SURVEY
Airway maintenance with cervical spine protection

31. Nursing Management
Intubation with Cervical inline stabilization
• Breathing and ventilation : Intubation precautions
Pre-medicate with Lidocaine, 1mg/kg IV 2
minutes prior to attemptICP Spike
• Laryngoscopy produces an

32. Nursing Management
Circulation
• Maintain MAP >90mmhg- adequate
• Hematocrit >30%
• Cushing reflex

33. Conti…..
• Isolated intracranial injuries do not cause
hypotension
• LOOK FOR THE CAUSE OF HYPOTENSION

34. Decreasing Intracranial Pressure
Diuretic Therapy
Osmotic Diuretic Loop Diuretic
• Mannitol (0.25-1 gm / kg) • Furosemide
• Increases serum osmolarity • Decreased CSF formation
• Vasoconstriction • Decreased systemic and
(adenosine) / less effect if cerebral blood volume
autoregulation is impaired (impairs sodium and water
and if CPP is < 70 movement across blood
• Initial increase in blood brain barrier)
volume, BP and ICP • May have best affect in
followed by decrease conjunction with mannitol
• Questionable mechanism of
lowering ICP

35. Nursing Management of Skull
Fractures
• Minimize CSF leak
– Bed flat
– Never suction orally; never insert NG tube; never use Q-Tips
in nose/ears; caution patient not to blow nose
• Place sterile gauze/cotton ball around area
• Verify CSK leak:
– DEXTROSTIX: positive for glucose
• Monitor closely: Respiratory status+++

36. Nursing Management
Nursing implementation
Health Promotion
• Prevent car and motorcycle accidents
• Wear safety helmets

37. Nursing Management
Nursing implementation
Acute Intervention
• Maintain cerebral perfusion and prevent
secondary cerebral ischemia
• Monitor for changes in neurologic status

38. Nursing Management
Nursing implementation
Ambulatory and Home Care
• Nutrition
• Bowel and bladder management
• Spasticity
• Dysphagia
• Seizure disorders
• Family participation and education

39. Nursing Management
Evaluation
Expected Outcomes
• Maintain normal cerebral perfusion
pressure
• Achieve maximal cognitive, motor, and
sensory function
• Experience no infection, hyperthermia, or
pain

40. Summary of Recommended Practices
• Decrease intracranial pressure
– Evacuate mass occupying hemorrhages
– Consider draining CSF with ventriculostomy when possible
– Hyperosmolar therapy, +/- diuresis (cautious use to avoid
hypovolemia and decreased BP)
– Mid-line neck, elevated head of bead (some research supports
elevation not > 30 degrees)
– Treat pain and agitation - consider pre-medication for nursing
activities, +/- neuromuscular blockade (only when needed)
– Careful monitoring of ICP during nursing care, cluster nursing
activities and limit handling when possible
– Suction only as needed, limit passes, pre-oxygenate / +/- pre-
hyperventilate (PaCo2 not < 30) / use lidocaine IV or IT when
possible
A&E(VMH)
– After careful preparation of visitors, allow calm contact

41. Complications
• Epidural hematoma
– Results from bleeding between the dura
and the inner surface of the skull
– A neurologic emergency
– Venous or arterial origin

42. Complications
• Subdural hematoma
– Occurs from bleeding between the dura
mater and arachnoid layer of the
meningeal covering of the brain

43. Complications
• Subdural hematoma
– Usually venous in origin
– Much slower to develop into a mass large
enough to produce symptoms
– May be caused by an arterial hemorrhage

44. Complications
• Subdural hematoma
– Acute subdural hematoma
• High mortality
• Signs within 48 hours of the injury
• Associated with major trauma (Shearing
Forces)
• Patient appears drowsy and confused
• Pupils dilate and become fixed

45. Complications
• Subdural hematoma
– Subacute subdural hematoma
• Occurs within 2-14 days of the injury
• Failure to regain consciousness may be
an indicator

46. Complications
• Subdural hematoma
– Chronic subdural hematoma
• Develops over weeks or months after a
seemingly minor head injury

47. Surgical Management
• Craniotomy
• Craniectomy
• Cranioplasty
• Burr-hole