Head Injury

CA 2

SITUATION
A 22 year old man is brought to the emergency room with an apparent head injury after being involved in a serious motor vehicle accident. He is unconscious on arrival and exhibits signs of increasing intracranial pressure. He is accompanied by his friends.

 Traumatic insult to the head that may result in any injury to the soft tissue bony structures and/or brain Traumatic brain injury (TBI) is a nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness.

What protects the brain?

SKULL 8 bones encase the brain protecting it ( frontal,temporal,parietal,occipital) fuse in childhood in junctions called sutures. MENINGES Fibrous connective tissue covering the brain the spinal cord providing protection, support and nourishment. Dura mater, arachnoid, pia mater.

 CSF Clear colorless fluid, 100-160 mls circulate b/w the subarachnoid space and the ventricles. Approx. 500mls produced per day, most is reabsord by the blood. Consider pressure on the brain , if not reabsorbed. Cushion and shock observer. BLOOD BRAIN BARRIER Blocks macromolecules and many compounds from dyes and medications from reaching the nuerons. Helps keep a stable env. For nuerons by regulating ion movements.

CLASSIFICATION OF HEAD INJURY

Based on the Severity GCS: Best predictor of neurological outcome Severity Minor15 Mild14-15 Moderate9-12 Severe3-8

Open head injury

Comminuted fracture

Depressed fracture

PATHOPHYSIOLOGY
Types of brain injuries include concussion, contussion, epidural hematoma,subdural hematoma, and skull fracture. Caused by blunt or penetrating injury Nuerologic deficits result from shearing of white matter, ischemia, and mass effect from hemorrhage, and cerebral edema of sourrounding brain tissue.

Racoon eyes, battle signs,

Subarchachnoid , subdural hemorrhage-shaken baby syndrome ,

Clinical Features
Altered consciousness, confusionto coma headache., vertigo Agitation, restlessness Pupillary abnormalities Respiratory irregularities Cognitive deficits Nuerologic deficits Persistive vegetative state or coma

Diagnotic evaluation
SKULL SPINE XRAY films to identify fracture displacement/ CT scan to identify and localize lesions, edema and bleeding CEREBRAL ANGIOGRAPHY- subarachnoid haemorrhage LUMBAR PUNCTURE subarachnoid haemorrhage, meningitis

ICP and brain herniation

The addition of mass lesion is compensated by displacement of CSF and venous blood out of cranial cavity.

As further expansion of mass occur quite small rise in volume result in large increase in ICP and Brain herniation can occur

NURSING ASSESSMENT
Monitor for signs of increased ICP altered LOC abnormal pupil response, vomitting , increased pulse pressure, bradycardia, hyperthermia. Observe CSF leakage Note for contusions about eyes and ears. Perform cranial nerve, motor, sensory and reflex assessmenr. Assess for behavior that warrants potential for injury to self or others.

NURSING DIAGNOSIS
Altered cerebral tissue perfussion related to increase ICP Ineffective breathing pattern related to increased ICP or brain stem injury Altered thought process related to physiology of injury. Altered nutrition less than body requirements related to compromised nuerologic functions and stress of injury.

NURSING MANAGEMENT
Position-head of the patient should be placed 30 degree up, it is the known as REVERSE TRENDELENBERG. Collar must not be too tight This is to avoid obstruction of venous drainage from the head.

 Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) should be constantly monitored. CPP should be maintained >65mm Hg in a severely head injured patient. So if the ICP is 20mm Hg the MAP should be >85mm Hg. If needed ionotropes can be used to support the CPP and the blood pressure.

A tunnelled parenchymal ICP monitor can be inserted through a twist drill burr hole

Cushing's triad
is the triad of widening pulse pressure (rising systolic, declining diastolic), change in respiratory pattern (irregular respirations), and bradycardia. It is sign of increased intracranial pressure, and it occurs as a result of the Cushing reflex.

MEASURES TO DECREASE THE ICP

Sedation with/without muscle relaxants Patient is sedated using Propofol or Midazolam. Muscle relaxants like Atracurium can be used. Diuretics- Frusemide and Mannitol can be used to decrease the cerebral swelling and raised ICP. Mannitol an osmotic diuretic is used mainly in subarachnoid haemorrhage.It is contraindicated in extradural haematoma.

 Turn patient every 2 hours and assist in coughing Assist patient in intubation and ventilatory assistance. Suction patient as needed but be sure to hyperventilate the patient before sunctioning to prevent hypoxia.

Seizure control Seizures will increase the brain metabolic rate and thereby increase the ICP. So prophylactic anticonvulsants can be used in the first week to decrease the incidence of seizures. Phenobarbitone 60mg Q8H or Phenytoin 100mg Q8H can be used. If the ICP cannot be controlled it can lead to status epilepticus. Here EEG burst suppression therapy with Lorazepam or Thiopentone may be used.

 Normothermia should be maintainedPyrexia may decrease the cerebral blood flow so this should be avoided. Active cooling may be used to decrease the metabolic rate. Maintaining fluid and electrolyte balanceSeverely brain injured people are susceptible to disturbances in sodium homeostasis like Diabetes insipidus and Syndrome of inappropriate antidiuretic hormone(SIADH).SIADH can lead to dilutional hyponatremia will in turn can precipitate seizures.

 IV fluids should be administered until nasogastric feeding can be commenced .If patient is conscious, oral feeding can be started . If the patient is in pain analgesics like Fentanyl or Codeine may be used. Pantoprazole 40mg iv OD may be given to avoid gastritis If fever occurs due to meningitis following basal skull fracture lumbar puncture should be done and empirical treatment for meningitis should be started. Any other source of infection should be ruled out Antimeningitic prophylactic regimen(CP 20lakh unit iv Q6h, Chloromycetin 500mg Q6h iv, Metronidazole 500 mg iv Q8h):Indications-Comminuted fractures, otorrhoea, rhinorrhoea, pneumocephalus

 Nasogastric tube feeding. Care of the eyes by padding. Urinary catheter for drainage of urine and to monitor the urine output. Urinary incontinence may occur in frontal lobe lesions. Change of position of the patient to avoid bed sores. Limb physiotherapy to prevent deep vein thrombosis. Chest physiotherapy to prevent respiratory infections. Care of the endotracheal tube.

Care of the unconscious patient

Repeat CT scan should be considered: If there is deterioration of the mental state of the patient. If there is a continued rise in the ICP. If there is a failure to improve over 24 hours .

 CRANIOTOMY Indications- mainly for brainlesions, traumatic brain injury Done under general anaesthesia Preceded by an CT scan Assessed by Glasgow Outcome Score(GOS)
Good Recovery Moderate disability Severe disability Persistent vegetative state Dead 5
4 3 2 1

Surgical management

EVALUATION
ICP and vital signs stable; alert nad responsive. Respiration -24 regular Tube feeding tolerated welll without residual Oriented to person place and time Less agitated; side rails maintaimed Rehabilitative state