PTP&M004 PTM of Central Nervous System trauma and disease Medical Journal

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:0004 Revision: 01 Page: 1 of 56

MANAGEMENT OF CENTRAL NERVOUS SYSTEM
TRAUMA AND DISEASE
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MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASE

SPEC. BY: Abdulrehman S. Mulla

DATE: 03/21/2009

REVISION HISTORY

REV. DESCRIPTION CN No. BY DATE
01 Initial Release PT0001 ASM 03/24/2009

Medicine: It’s a noble profession, it serves humanity.
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TRAUMA AND DISEASE

TABLE OF CONTENTS PAGE

1.0 NERVOUS SYSTEM DISEASES: ............................................................................................................................................................. 3
1.1 THE CENTRAL NERVOUS SYSTEM:...................................................................................................................................... 3
1.1.1 BRAIN: ...................................................................................................................................................................... 4
1.1.2 THE SPINAL CORD:................................................................................................................................................. 7
2.0 SPINAL CORD TRAUMA: ....................................................................................................................................................................... 11
2.1 DEFINITION: ........................................................................................................................................................................... 11
2.2 CAUSES:................................................................................................................................................................................. 11
2.2 SYMPTOMS:........................................................................................................................................................................... 13
2.3 CERVICAL (NEAR THE NECK) INJURIES: ........................................................................................................................... 14
2.4 THORACIC (CHEST-LEVEL) INJURIES: ............................................................................................................................... 15
2.5 LUMBAR SACRAL SHOWN IN PICT:17 (LOWER-BACK) INJURIES ................................................................... 16
2.6 PHYSICAL THERAPY FOR SPINAL CORD INJURY:............................................................................................................ 19
2.6.1 RESPIRATORY CARE: .......................................................................................................................................... 19
2.7 RANGE OF MOTION: ............................................................................................................................................................. 21
2.7.1 INCREASED STRENGTH: ..................................................................................................................................... 22
2,8 MUSCLE STRENGTHENING: ................................................................................................................................................ 22
2.9 COORDINATION AND BALANCE EXERCISES: ................................................................................................................... 23
2.9.1 AMBULATION EXERCISES: .................................................................................................................................. 24
2.9.2 GENERAL CONDITIONING EXERCISES:............................................................................................................. 25
2.11 TRANSFERS: ......................................................................................................................................................... 27
3.0 HEAD INJURY:........................................................................................................................................................................................ 29
3.1 PATHOPHYSIOLOGY: ........................................................................................................................................... 30
3.1.1 HEAD INJURY: ....................................................................................................................................................... 30
3.1.2 BRAIN INJURIES:................................................................................................................................................... 31
3.2 INTRACRANIAL PRESSURE (ICP):....................................................................................................................................... 33
3.2.2 PROGRESSIVE LEVELS OF INTRACRANIAL PRESSURE: ................................................................................ 35
3.2.3 ANOXIC BRAIN INJURY: ....................................................................................................................................... 38
4.0. SPECIFIC TYPES OF HEAD INJURY: ................................................................................................................................................... 39
4.1 SCALP WOUNDS: .................................................................................................................................................................. 39
4.2 SKULL INJURIES:................................................................................................................................................................... 40
4.2.1 SIGNS/SYMPTOMS OF SKULL INJURIES:........................................................................................................... 40
4.2.2 TREATMENT FOR SKULL FRACTURE:................................................................................................................ 41
5-0 GENERAL ASSESSMENT OF HEAD TRAUMA:.................................................................................................................................... 43
5.1 RESPIRATION: ...................................................................................................................................................................... 43
5.2 BLOOD PRESSURE: .............................................................................................................................................................. 44
5.3 PULSE: .................................................................................................................................................................. 44
5.4 GENERAL EXAMINATION: .................................................................................................................................................... 44
5.5 SPECIAL CONSIDERATIONS. BE AWARE THAT: ............................................................................................................... 45
5.6 NEUROLOGICAL EXAMINATION: ......................................................................................................................................... 45
6.0 JUDGING LEVEL OF SEVERITY OF HEAD INJURY: ........................................................................................................................... 46
7.0 LEVELS OF HEAD INJURY: .................................................................................................................................................................. 46
7.1 THE GLASGOW COMA SCALE: ............................................................................................................................................ 46
7.3 POINTS ASSIGNED RESPONSES ON THE GLASGOW COMA SCALE: ........................................................................... 47
7.3.1 EYE OPENING: ...................................................................................................................................................... 47
7.3.2 VERBAL RESPONSE: ............................................................................................................................................ 47
7.3.3 MOTOR RESPONSE:............................................................................................................................................. 47
7.3.4 MEANING OF TOTAL POINTS ON GLASGOW COMA SCALE:........................................................................... 48
8.0 GENERAL MANAGEMENT OF HEAD TRAUMA: .................................................................................................................................. 49
8.1 PHYSICAL THERAPY:............................................................................................................................................................ 49
8.2 PARKINSON'S SPECIFIC PROGRAMMING: ........................................................................................................................ 49
8.3 PHYSICAL THERAPY FOR PARKINSON'S ADDRESSES: .................................................................................................. 50
8.4 PHYSICAL THERAPY FOR INDIVIDUALS WITH PARKINSON’S DISEASE: ....................................................................... 50
8.4.2 CURRENT APPROACHES TO EXERCISE IN PD:................................................................................................ 52
8.5 VESTIBULAR THERAPY: ....................................................................................................................................................... 54
9.0 PREVENTION STRATEGIES: ................................................................................................................................................................ 56
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1.0 NERVOUS SYSTEM DISEASES:

Diseases of the central and peripheral nervous system. This includes disorders of the brain, spinal
cord, cranial nerves, peripheral nerves, nerve roots, autonomic nervous system, neuromuscular
junction, and muscle.

1.1 THE CENTRAL NERVOUS SYSTEM:

Pict:1

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The Central Nervous System (CNS) is exactly what the name implies. It is the quot;absolutequot; central -
nervous - system. All of the other nerves that feed off the central - nervous - system are peripheral
nerves. These peripheral nerves are part of the peripheral nervous system (PNS). For the purpose of
this site, I have separated the Central Nervous System from the Peripheral Nervous System.

The Central Nervous System is composed of the Brain and Spinal cord, along with their nerves and
end organs (the end of nerves) that control voluntary and involuntary acts. In other words, those
physical body processes that you do on your own (moving your arm) and those you do without having
to tell your body to do it (like breathing).

The parts of the brain governing consciousness and mental activities are; parts of the brain, spinal
cord, and their sensory and motor nerve fibres controlling skeletal muscles; and end organs of the
body wall. Your CNS is the Master Control Centre, the CEO, the Commander in Chief, the Big Kuhuna,
The Master Communicator and the Grand Pooh-Bah all rolled into one!

1.1.1 BRAIN:
The brain is a large soft mass of nerve tissue that is contained inside a vault of bone called the
cranium. It is the cranial portion of the CNS. The brain is also called the quot;encephalon.quot; The
brain is composed of neurons (nerve cells) and neuralgia (supporting nerve cells). The brain
consists of gray and white matter. The gray matter is nervous tissues of a grayish color that
forms an quot;Hquot; shaped structure and is surrounded by white matter.

Pict:2
The human brain has more than 10 billion nerve cells and over 50 billion other cells and now weighs on
an average of 3 1/8 pounds, where it used to weigh less than 3 pounds. The brain monitors and
regulates your unconscious bodily functions like breathing and heart rate, and coordinates most of your
voluntary movement. It is also the area of consciousness, thought and creativity!

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Different areas of your brain perform different functions:
 Receive messages from sense organs  Interpreting images from the eye
 Controls balance and muscle coordination  Thoughts and creativity
 In charge of speech and reading  Basis of perception
 In charge of feeling emotion  Initiates activity in the glands and muscles
 Basic motor skills  Is the seat of consciousness, memory, reason and judgment
 Figuring complex calculations  Regulates circulation and respiration

Pict:3

The central nervous system, gives rise to the peripheral nervous system as shown in Pict:4 (the nerves
on the periphery of the body). The autonomic nervous system (ANS) is under control of central nervous
system and is also part of the peripheral nervous system, although these nerves stay within the body
and effect organs and soft tissues and do not leave to effect appendages (arms and legs). The
autonomic nervous system (ANS) is quot;automaticquot; and in control of involuntary bodily functions and it is
divided into two parts: The sympathetic and parasympathetic nervous system. It regulates the function
of glands, the adrenal medulla, smooth muscle tissue, organs and the heart.

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Pict:4 Pict:5

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1.1.2 THE SPINAL CORD:

The spinal cord is an ovoid column of nervous tissue that averages about 44 cm in length
when it is flattened out. The spinal cord extends from the medulla oblongata in the brain stem
to the 2nd lumbar vertebra in the spinal canal.

All of the nerves in your arms, legs and trunk originate from the spinal cord. The spinal cord
is the center of reflexive action. When you are stimulated in any way, shape or form, there is
a reflex arc that goes from the peripheral nerve to the spinal cord, up to the brain and back
down to relay the action. That's some pretty quick service from your CNS as shown in Pict:6.
Especially when you just about drop something and catch it quickly or if you are Andy
Roddick hitting a150 mph tennis ball at the 2004 Davis Cup.

Pict:6

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Pict:6

The spinal cord is housed in a vertebral (bony) vault for its own protection. The spinal cord
travels down through a hole in each vertebrae. If you were to see the spinal cord in a cross-
section, you would notice that it does not fill the vertebral space in the vertebral column, it is
surrounded by other tissue (pia mater as shown in Pict:9), cerebrospinal fluid (CSF as shown
in Pict:8), another tissue (arachnoid mater as shown in Pict:9), and still another tissue (dura
mater as shown in Pict:9). The three types of mater are called the meninges. The meninges
also surround the brain. Hence the word quot;meningitisquot; when there is an inflammation of the
meninges or membranes of the spinal cord or brain.

Pict:8

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Pict:9

Cerebrospinal fluid (CSF) when normal contains 50 - 75 mg of sugar per 100 ml. The sugar
content is lower than that of blood. The CSF is a water cushion protecting the brain and
spinal cord from physical impact.

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The quot;Hquot; shape from the gray matter inside the white matter in the brain is carried through the
spinal cord as well because they are attached to one another. The anterior quot;hornquot; of the quot;Hquot;
is composed of motor cells from the fibers that make up the motor portions of the peripheral
nerves as shown in Pict:10. The sensory neurons as shown in Pict:11 enter the posterior
quot;hornquot; of the quot;H.quot; Incidentally, the quot;Hquot; does not mean quot;hornquot; although the quot;Hquot; formation does
represent the anterior and posterior sides at which the nerves enter.

Pict:10

Sensory Neurons carry impulses away from the spinal cord and brain to muscles or glands

Pict:11
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2.0 SPINAL CORD TRAUMA:

2.1 DEFINITION:
Spinal cord trauma (Spinal cord injury; Compression of spinal cord) is damage to the spinal
cord. It may result from direct injury to the cord itself or indirectly from damage to surrounding
bones, tissues, or blood vessels.

2.2 CAUSES:
Spinal cord trauma can be caused by any number of injuries to the spine. They can result from
motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial
accidents, gunshot wounds, assault, and other causes.

A minor injury can cause spinal cord trauma if the spine is weakened (such as from rheumatoid
arthritis or osteoporosis) or if the spinal canal shown in Pict:12 protecting the spinal cord has
become too narrow (spinal stenosis shown in Pict:13) due to the normal aging process.

Pict:13

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Direct injury, such as cuts, can occur to the spinal cord, particularly if the bones or the
disks have been damaged. Fragments of bone (for example, from broken vertebrae, which are
the spine bones) or fragments of metal (such as from a traffic accident) can cut or damage the
spinal cord.
Direct damage can also occur if the spinal cord is pulled, pressed sideways, or
compressed. This may occur if the head, neck, or back are twisted abnormally during an
accident or injury.
Bleeding, fluid accumulation, and swelling can occur inside the spinal cord or outside the
spinal cord (but within the spinal canal). The accumulation of blood or fluid can compress the
spinal cord and damage it.
Most spinal cord trauma happens to young, healthy individuals. Men ages 15-35 are most
commonly affected. The death rate tends to be higher in young children with spinal injuries.
Risk factors include participating in risky physical activities, not wearing protective gear
during work or play, or diving into shallow water.
Older people with weakened spines (from osteoporosis) may be more likely to have a
spinal cord injury. Patients who have other medical problems that make them prone to falling
from weakness or clumsiness (from stroke, for example) may also be more susceptible.

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2.2 SYMPTOMS:

Symptoms vary somewhat depending on the location of the injury. Spinal cord injury causes
weakness and sensory loss at and below the point of the injury. The severity of symptoms
depends on whether the entire cord is severely injured (complete) or only partially injured
(incomplete).

The spinal cord doesn't go below the 1st lumbar vertebra, so injuries at and below this level do
not cause spinal cord injury. However, they may cause quot;cauda equina syndromequot; injury to the
nerve roots in this area, shown in Pict:14.

Pict:14

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2.3 CERVICAL (NEAR THE NECK) INJURIES:

When spinal cord injuries occur near the neck shown in Pict:15, symptoms can affect both the
arms and the legs:

 Breathing difficulties (from paralysis of the breathing muscles)
 Loss of normal bowel and bladder control (may include constipation, incontinence,
bladder spasms)
 Numbness
 Sensory changes
 Spasticity (increased muscle tone)
 Pain
 Weakness, paralysis

Pict:15

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2.4 THORACIC (CHEST-LEVEL) INJURIES:

When spinal injuries occur at chest level, symptoms can affect the legs:

Breathing difficulties (from paralysis of the breathing muscles)
Loss of normal bowel and bladder control shown in Pict:16 (may include constipation,
incontinence, bladder spasms)
Numbness
Sensory changes
Spasticity (increased muscle tone)
Pain
Weakness, paralysis

Injuries to the cervical or high-thoracic spinal cord may also result in blood pressure problems,
abnormal sweating, and trouble maintaining normal body temperature.

Pict:16

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2.5 LUMBAR SACRAL SHOWN IN PICT:17 (LOWER-BACK) INJURIES

When spinal injuries occur at the lower-back level, varying dgrees of symptoms can affect the
legs:

PICT:17

 Loss of normal bowel and bladder control (may include constipation, incontinence,
bladder spasms)
 Numbness
 Pain
 Sensory changes
 Spasticity (increased muscle tone)
 Weakness and paralysis

The following tests may be ordered:

 A CT scan or MRI of the spine may show the location and extent of the damage and
reveal problems such as blood clots (hematomas shown in Pict:18).
 Myelogram (an x-ray of the spine after injection of dye shown in Pict:19) may be
necessary in rare cases.
 Somatosensory shown in Pict:20 evoked potential (SSEP) testing or magnetic
stimulation may show if nerve signals can pass through the spinal cord.
 Spine x-rays shown in Pict:21 may show fracture or damage to the bones of the spine.

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Pict:18

Pict:19

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Pict:20

Pict:21

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2.6 PHYSICAL THERAPY FOR SPINAL CORD INJURY:

Physical therapists are involved in many aspects of patient care following a spinal cord injury.
The major areas are as follows:
 Respiratory Care
 Range of Motion
 Muscle Strengthening
 Balance
 Wheelchair Skills
 Transfers
 Skin Care

2.6.1 RESPIRATORY CARE:
When in the intensive care unit, physical therapists can help teach you how best to
breath and cough using many hands-on techniques. They will also suction the mucous
out of your lungs if necessary. A physical therapist's purpose with respiratory care is to
help you breathe easier and to decrease your chance of developing a lung infection
such as pneumonia.

Respiratory complications of spinal cord injury (SCI), including:
 Atelectasis
 Pneumonia
 Respiratory failure
 Pulmonary embolism
 Pleural effusion
 Sleep-disordered breathing

2.6.1.1 MANAGEMENT:

1. Prevention and treatment of atelectasis and pneumonia.
 Monitoring indicators
 Intubation (for intractable respiratory failure, demonstrable
aspiration, or high risk for aspiration plus respiratory compromise)
 Specific tests of pulmonary mechanics and ventilation
 Clearing the airway of secretions
 Diaphragm fluoroscopy
 Reexpansion of the affected lung tissue following successful
treatment (required for atelectasis or pneumonia)

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2. Mechanical ventilation.
 Recognizing role of surfactant production
 Positive-end expiratory pressure (PEEP)
 Monitoring for pulmonary embolism and pulmonary effusion
 Treatment of complications of short and long-term ventilation
 Evaluation of the need for long-term ventilation

3. Weaning from the ventilator.
 Progressive ventilator-free breathing (PVFB)
 Synchronized intermittent mandatory ventilation (SIMV)
 Partial weaning
4. Evaluation for electrophrenic respiration
5. Polysomnographic evaluation
6. Positive airway pressure therapy (if sleep disordered breathing is
diagnosed)
7. Evaluation for and prevention of dysphagia and aspiration
8. Tracheostomy (for patients who are aspirating)
9. Psychosocial assessment and treatment
 Monitoring of patient's post-injury feeling states
 Assessment of substance abuse
 Assessment of pain
 Establishment of advance directives
 Assistance and support of family caregivers
 Addressing of intimacy and sexuality issues (with the patient and
other appropriate parties)
 Establishment of an effective communication system.

2.6.1.2 DISCHARGE AND FOLLOW-UP:
1. Education of patient and caregivers
2. Evaluation and modification of patient's home
3. Provision of appropriate medical equipment and personnel resources
4. Transportation assistance
5. Evaluation of financial resources and available benefits
6. Determining the availability of transition and leisure resources
7. Vocational evaluation

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2.7 RANGE OF MOTION:

Physical therapists help to maintain or increase your joint range by stretching your muscles and
moving your joints. It is important to keep your joints mobile in order to increase your ability to
move and perform everyday functions. Range of motion can also help to decrease you pain.

 Range of motion in joints is often impaired after injury, illness, or surgery. When range of
motion is lost, your physical therapist may use joint and soft tissue mobilization or
stretching exercises to restore more useful, full movement. See Pict:22 .

 Joint and soft tissue mobilization is a unique, hands-on technique that allows the physical
therapist to release restrictions around joints and throughout the soft tissue system. By
releasing these restrictions your physical therapist works to achieve your full potential
range of motion in an area of dysfunction.

 Stretching exercises help to restore length to soft tissue that has shortened and lost
elasticity. Your physical therapist may help you stretch specific areas and then teach you
a stretching program to continue at home. Physical therapists also teach stretching to
help prevent back problems and athletic injuries.

Pict:22

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2.7.1 INCREASED STRENGTH:

Movement depends on adequate muscle strength. Muscles may weaken from surgery,
injury, or simply from not being used. Physical therapists can help improve strength by
making muscles work harder through exercise and electrical stimulation.

 Exercise has benefits beyond increasing strength. An exercise program designed
by your physical therapist also improves coordination, endurance, and
circulation. Your physical therapist will develop a program to meet your abilities,
lifestyle, age, and specific goals for therapy.

 Electrical stimulation may be used when muscles are immobilized (such as when
a limb is casted after surgery) or when muscles are extremely weak. To exercise
these muscles, an electrical impulse is sent through the skin causing muscles to
contract automatically

2,8 MUSCLE STRENGTHENING:

Following a spinal cord injury, it is very important for you to increase your strength in all muscles
that you still have control over. These muscles will have to work much harder than they did before
the injury in order to compensate for lost movements. Physical therapists can teach you the
correct exercises to increase the strength of specific muscles without causing injuries.

Many forms of exercise increase muscle strength. All involve progressively increased resistance.
When a muscle is very weak, movement against gravity alone is sufficient. As muscle strength
increases, resistance is gradually increased by using stretchy bands or weights. In this way,
muscle size (mass) and strength are increased, and endurance improves.

Pict:23

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2.9 COORDINATION AND BALANCE EXERCISES:
These exercises can help people who have problems with coordination and balance, usually
because of a stroke or brain damage. Coordination exercises aim to help people do specific
tasks. The exercises involve repeating a meaningful movement that works more than one joint
and muscle, such as picking up an object or touching a body part. Balance exercises are initially
done using parallel bars, with a therapist standing right behind the person. The person shifts
weight between the right and left legs in a swaying motion. Once this exercise can be done
safely, weight can be shifted forward and backward. When these exercises are mastered, the
person can do them without parallel bars.

Pict:24

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TRAUMA AND DISEASE

2.9.1 AMBULATION EXERCISES:
Walking (ambulation)—independently or with assistance—may be the main goal of
rehabilitation. Before starting ambulation exercises, people must be able to balance while
standing. To improve balance, people usually hold onto parallel bars and shift weight
from side to side and from front to back. To keep them safe, the therapist stands in front
of or behind them. Some people need to improve a joint's range of motion or muscle
strength. Some people need an orthotic device such as a brace. See Pict:23

Pict:23

When people are ready for ambulation exercises, they may begin on parallel bars, then
progress to walking with mechanical aids, such as a walker, crutches, or a cane. Some
people need to wear an assistive belt, which the therapist uses to prevent them from
falling.

As soon as people can walk safely on a level surface, they may be taught how to step
over curbs or to climb stairs. When climbing up stairs, they are instructed to step up with
the unaffected leg first. To climb down stairs, they are instructed to step down with the
affected leg first. The phrase quot;good is up, bad is downquot; can help people remember.
Family members and caregivers who help people walk should learn how to support them
correctly.

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TRAUMA AND DISEASE

2.9.2 GENERAL CONDITIONING EXERCISES:

A combination of range-of-motion, muscle-strengthening, and ambulation exercises is
used to counter the effects of prolonged bed rest or immobilization. General conditioning
exercises help improve cardiovascular fitness (the ability of the heart, lungs, and blood
vessels to deliver oxygen to working muscles), as well as maintain flexibility and muscle
strength.

Pict: 24

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TRAUMA AND DISEASE

2.10 WHEELCHAIR SKILLS:

A large amount of people who have had a spinal cord injury will have to use a wheelchair at least
some of the time. Using a wheelchair allows you to get where you want to go as independently as
possible. In order to independently move your wheelchair, there are many skills that you have to
learn. These vary from simple skills such as maneuvering wheelchair safety to more complex
skills such as climbing curbs and ramps.

Pict: 25

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TRAUMA AND DISEASE

2.11 TRANSFERS:
Depending on where your injury is, most spinal cord injured patients can learn to get in and out of
their bed and wheelchair independently. Physical therapists help teach you the easiest way for
you to transfer and move around.
For many people (particularly those who have had a hip fracture, an amputation, or a stroke),
transfer training is a critical goal of rehabilitation. Being able to transfer safely and independently
from bed to chair, chair to toilet, or chair to a standing position is essential to remaining at home.
People who cannot transfer without help usually require 24-hour assistance. Caregivers may help
them transfer using special devices, such as a gait belt or harness. See: Pict 26

Pict 26
The techniques used in transfer training depend on the following:
 Whether people can bear weight on one or both legs
 Whether they can balance well
 Whether they are paralyzed on one side of the body
Assistive devices can sometimes help. For example, people who have difficulty standing from a
seated position may benefit from a seat-lifting chair or a chair with a raised seat. See: Pict 27
Pict 27

Tilt Table: see Pict 28 If people have been limited to strict bed rest for several weeks or have had
a spinal cord injury, they may get dizzy when they stand up (orthostatic hypotension—see Low
Blood Pressure: Orthostatic Hypotension). A tilt table may be used to help such people. This
procedure may retrain blood vessels to narrow (constrict) and widen (dilate) appropriately in
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TRAUMA AND DISEASE

response to changes in posture. People lie face up on a padded table with a footboard and are
held in place with a safety belt. The table is tilted very slowly, determined by how well people
tolerate it, until they are nearly upright. The slow change in posture enables the blood vessels to
regain the ability to constrict. How long the upright position is maintained depends on how well
people tolerate it, but it should not exceed 45 minutes. The tilt-table procedure is done once or
twice a day. Its effectiveness varies depending on the type and degree of disability.

Pict 28

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TRAUMA AND DISEASE

3.0 HEAD INJURY:
Few nonfatal injuries cause such devastating physical and psychological effects as trauma to the
central nervous system. In many cases, irreversible damage occurs regardless of the care the victim
receives. In a significant number of cases, however, the initial care administered determines the
ultimate outcome of the case. In fact, in such quot;treatablequot; patients, the emergency management is
frequently more important than all subsequent efforts. This statement should trigger in your mind the
importance of your role in the evaluation and initial care of these patients.

a. The most important initial indicator of the severity of a head injury is the patient's level of
consciousness. A competent observer should assess the patient's consciousness level as soon as
possible after the injury has occurred. A severe head injury may be defined as one that leaves the
patient unconscious for at least 6 hours. A patient who has an altered level of consciousness less
severe and for a shorter time period may have medical problems much later, problems caused by
the injury.) Therefore, a patient with any level of impaired consciousness after a head injury should
be treated as though he has a serious head injury. See Pict 29.

b. The majority of head injuries are mild and self-limiting. However, since severe head injuries can be
life-threatening, it is important to assess and treat a head injury correctly to prevent death or
disability from secondary brain damage.

Pict: 29

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TRAUMA AND DISEASE

3.1 PATHOPHYSIOLOGY:
Pathophysiology is the physiology of disordered function. When there is trauma to the central
nervous system in the form of a head injury, a variety of pathophysiological responses can
occur.

3.1.1 HEAD INJURY:
See: Pict:30 The words quot;head injuryquot; usually refer to an injury to the portion of the skull
(cranium) that encloses the brain, the overlying scalp, or the contents of the cranial
cavity (brain, cranial nerves, meninges, and associated blood vessels). This definition
focuses attention on that portion of the head that is at or above the level of the
eyebrows anteriorly, the zygomatic arches laterally, and an imaginary line between the
tips of the mastoid processes posteriorly. These are approximate external landmarks
for the skull base, which is the floor of the cranial cavity. Nevertheless, physical signs
of injury of the brain or of its soft tissue or bony coverings may also be detected in
adjacent structures of the head (eyes, ears, and nose) or even in portions of the body
that are remote from it.

Pict:30

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TRAUMA AND DISEASE

3.1.2 BRAIN INJURIES:
Most brain injuries occur due to movement of the brain inside the skull. The level of
damage to the brain depends on the speed the head was traveling and the head's
position just prior to contact.

Pict:30

3.1.3 RESPONSES TO BRAIN INJURY:.
The base of the skull is rough; therefore, movement over this area will cause various
degrees of injury to the brain or blood vessels. Possible responses to brain injury
include the following:

a. Initial response to a bruised brain is swelling. The swelling is caused by:

 Increased blood volume due to vasodilation and increased cerebral blood flow
to the injured areas.
 Buildup of extra blood volume putting pressure on the brain and decreasing
blood flow to the injured part.

NOTE: Since the edema builds over a period of 24 to 48 hours, early care and efforts
to decrease the vasodilation is important.

b. Carbon dioxide may build up, having a critical effect on cerebral vessels. This
buildup causes more vasodilation.

c. Hyperventilation may occur, causing a decrease in the carbon dioxide,
vasoconstriction, and better perfusion (passage of a fluid through the vessels of an
organ) for the brain.

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TRAUMA AND DISEASE

NOTE:
Hyperventilation -- a condition marked by fast, deep breathing, which tends to remove increased amounts of
carbon dioxide from the body and lower the partial pressure of the gas, causing buzzing in the ears, and
tingling of the lips and fingers. See picture 31

Pict. 31
d. Unconsciousness may occur due to injury to the cerebral cortex or the brain stem. See picture 32.

Pict. 32.

e. If there is increased intracranial pressure (ICP) and decreasing cerebral blood flow, no matter what
the cause, the level of consciousness is depressed.
f. The intracranial cavity is filled to capacity with contents that cannot be compressed
-- cerebral spinal fluid, intravascular blood, brain tissue water (interstitial fluid). If
the volume of one of the constituents of the intracranial cavity increases, a
32


TRAUMA AND DISEASE

reciprocal decrease in volume of one or both of the others must occur. Otherwise,
the result is an increase in intracranial pressure.

3.2 INTRACRANIAL PRESSURE (ICP):

Pict:33

NOTE: Intracranial pressure monitoring is performed by inserting a catheter
into the head with a sensing device to monitor the pressure around the
brain. An increase in intracranial pressure can cause a decrease in
blood flow to the brain causing brain damage.

33


TRAUMA AND DISEASE

3.2.1 CHANGES CAUSED BY INTRACRANIAL PRESSURE:

A patient with head injury may experience an alteration in his level of consciousness.
Other symptoms associated with a severe head injury may include convulsions,
delirium, coma, paralysis, and increased intracranial pressure, which will be discussed
here. The skull (a container that cannot expand) holds the brain, vascular tissue, and
cerebrospinal fluid. Any problem (trauma, edema, tumor, infection, or bleeding) which
adds to the contents of the skull will result in an increase in intracranial pressure in the
skull. That increased pressure sets off the changes listed below:

a. As the intracranial pressure increases, the blood vessels are squeezed from the
outside, restricting blood flow throughout the arteries.
b. As the brain notes a drop in blood pressure, the sympathetic defenses respond,
causing the blood pressure to increase.
c. Respiratory changes occur due to the chemoreceptors that sense changes in the
blood chemistry.
d. The vagus nerve is affected, causing the pulse to slow.
e. Cushing's response - Increased blood pressure characterized by slow pulse. This
is a clear but late sign of increased intracranial pressure.
f. As the intracranial pressure progresses, the level of consciousness is altered.
Eventually, unconsciousness occurs because the body's vital functions cannot
operate properly. Ultimately, there is brain death due to loss of adequate cerebral
perfusion (passage of fluid through the brain).
g. Once the brain's ability to compensate is exhausted, the areas of the brain shift,
causing herniation.

NOTE: Compression may be from above (central syndrome) or from the side (lateral
syndrome). The central syndrome progresses in a more orderly manner and causes
unconsciousness early.

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TRAUMA AND DISEASE

3.2.2 PROGRESSIVE LEVELS OF INTRACRANIAL PRESSURE:

Three progressive levels of intracranial pressure can be identified.

1. Progressive level one.
a. Involves cerebral cortex and upper brain stem.
b. Blood pressure rises, pulse slows.
c. Pupils appear small but are reactive.
d. Abnormal respiratory pattern noted (possibly Cheyne-Stokes).
e. Initially, patient will try to remove painful stimuli. Later, the patient withdraws from
pain.
f. As progression occurs, the pain will cause decorticate posturing (flexion of the
upper extremities with lower extremities becoming rigid and extended).
g. Still reversible.

Pict:34

35


TRAUMA AND DISEASE

2. Progressive level two.
a. Middle portion of the brain stem is involved.
b. Blood pressure increases.
c. Pulse slows.
d. Pupils become fixed at 3 to 5 mm and nonreactive or only sluggishly reactive
to light.
e. Abnormal respiratory pattern: fast, shallow panting (neurogenic
hyperventilation).

Pict:35

36


TRAUMA AND DISEASE

3. Progressive level three.
a. Pupils become fixed and dilated.
b. If only one quot;blownquot; pupil, it will be on the same side as the hematoma or
swelling. (Crossover of nerves occurs at about the lip level.)
c. Document which pupil dilates first.
d. Respiratory ataxia (erratic, no rhythm) or absent. No response to painful
stimuli.
e. Pulse is rapid and irregular.
f. Decreased blood pressure.

Pict:36

37


TRAUMA AND DISEASE

3.2.3 ANOXIC BRAIN INJURY:
Anoxic brain injury is injury to the brain from lack of oxygen (from cardiac arrest,
choking, or drowning). Spasms develop in small arteries if the brain goes without
oxygen for more than 4 to 6 minutes. Blood flow does not reach the cerebral cortex.
The level of brain damage is based on the length of anoxia (lack of oxygen). See
pict.37

Pict.37
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TRAUMA AND DISEASE

4.0. SPECIFIC TYPES OF HEAD INJURY:

4.1 SCALP WOUNDS:
The scalp has many blood vessels, a number of which are close to the surface. A scalp
laceration, therefore, may bleed profusely even though a major blood vessel has not been cut.
Initially, even a minor laceration may bleed a great deal. Normally, blood in the scalp clots
rapidly, and blood flow can be controlled easily. If necessary, bleeding can usually be
controlled by direct pressure; that is, by compressing the scalp between the fingertips and the
skull. It is important to control bleeding in both adults and children, but it is especially important
in children because they have a smaller volume of blood. See picture 38.

Pict: 38

39


TRAUMA AND DISEASE

4.2 SKULL INJURIES:
The skull is composed of the cranium and the face. Skull fractures are commonly fractures to
the cranium rather than the face.

Pict:39

4.2.1 SIGNS/SYMPTOMS OF SKULL INJURIES:
The most obvious signs of a skull fracture are visible bone fragments and bits of brain
tissue. The possibility of a skull fracture exists when any of the following less obvious
signs/symptoms are present:

a. Following an injury, the patient may be either unconscious or have an altered level
of consciousness.
b. The patient has sustained an injury that has caused a deep laceration or severe
bruises to the scalp or forehead.
c. There is severe pain or swelling at the site of a patient's head injury.
d. There is a deformity of the patient's skull; for example, a depression in the
cranium, a large swelling, or anything that looks unusual about the cranium's
shape.
e. The patient has a bruise or swelling behind the ear (Battle's sign - discoloration
behind the ear caused by a fracture in the base of the skull). This sign may appear
hours to days after the injury.
f. The pupils of the patient's eyes are unequal in size.

40


TRAUMA AND DISEASE

g. Tissue around or under both eyes of the patient are discolored (quot;black eye(s)quot; or
quot;raccoon eyesquot;). This discoloration may appear hours after the injury.

4.2.2 TREATMENT FOR SKULL FRACTURE:

4.2.2.1 FOLLOW THESE GENERAL PROCEDURES:
1. Assure/maintain an open airway.
2. Resuscitate, if necessary.
3. Keep the patient at rest; do not let him move around.
4. Control bleeding.
5. Monitor the patient's vital signs.
6. Dress and bandage any open wounds.
7. Try to keep a conscious patient alert by talking to him. Ask him
questions to force him to concentrate.

4.2.2.2 REMEMBER:

1. DO NOT put pressure on an obvious skull fracture.
2. DO NOT try to remove penetrating objects. Leave them in place and
transport the patient.

4.2.2.3 If the patient has no hematoma, infection, or cerebral spinal fluid leak,
a skull fracture presents no danger at this time.

4.2.2.4 CONCUSSION:
A concussion is a mild state of stupor or temporary unconsciousness caused
by a blow to the head. In this condition, there is no laceration or bleeding in
the brain. There is no significant injury to the brain itself.
1. Signs/symptoms of concussion. Signs and symptoms of a concussion
occur immediately. Included are the following:
a. Knowledge that the patient has received a blow to the head, has had
a temporary loss of consciousness, and memory loss are indications
of a concussion.
b. The most important indication of concussion is memory loss for the
exact moment of injury. This is a sign of brain dysfunction. The
patient may never remember the exact moment of injury. His brain
had not had time to record the moment in his memory. Sometimes,
the patient cannot remember events just preceding the moment of
injury, a condition called retrograde. Or, a patient may not be able to
remember events that happened just after the moment of injury, this
condition being called antigrade. Short time memory loss may cause
a patient to ask questions repeatedly about the moments
surrounding his injury.
c. The patient may become combative.
d. Not all patients who have a concussion lose consciousness. But
those who do may regain consciousness anywhere from a few
41

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