Head Injury Flashcards
What is intracranial pressure?(ICP)
state of equilibrium and maintain a normal ICP of 10 to 20 mm Hg.
-pressure within the craniospinal compartment
- With disease or injury, ICP may increase
- ↑ ICP decreases cerebral perfusion, causes ischemia, cell death, and (further) edema
- Brain tissues may shift through the dura and result in herniation
- CO2 plays a role:
↓ CO2 = vasoconstriction
↑ CO2 = vasodilatation and ↑ ICP
How is LOC important when it comes to head injuries and increased ICP?
- Level of responsiveness and consciousness is the most important indicator of the patient’s condition
- LOC is a continuum from normal alertness and full cognition (consciousness) to coma
What is akinetic mutism?
unresponsiveness to the environment; the patient makes no movement or sound but sometimes opens eyes
What is persistent vegetative state?
patient is devoid of cognitive function but has sleep–wake cycles
What is locked-in syndrome?
patient is unable to move or respond except for eye movements owing to a lesion affecting the pons
What are early S&S of ICP?
- changes is LOC
-Restlessness, confusion, increasing drowsiness, increased respiratory effort, and purposeless movements - Pupillary changes
-Weakness in one extremity or one side - headache
What are late S&S of ICP?
-Projectile vomiting
-Further deterioration of LOC; stupor to coma
- Hemiplegia, decortication, decerebration, or flaccidity
- Respiratory pattern alterations including Cheyne-Stokes breathing and arrest
- Loss of brain stem reflexes: pupil, gag, corneal, and swallowing
What do we do when increased intracranial pressure happens?
- Detect the underlying cause of increased ICP
- MRI, CT, MRA, CT angiography
- Taking a careful history is important
- Ensure adequate oxygenation
- Drug therapy
- Hyperventilation therapy
- Nutritional therapy
- maintenance of patent airway
How do we assess eye signs and motor function for increased ICP?
Eye: perrla (pupils, equal, round, reactive to light, and accommodation)
motor function: observe spontaneous movements, hand strength, response to painful stimuli , speech
What are interventions for increased ICP?
- Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP
-
HOB elevation 30 degrees
-Frequent monitoring of respiratory status and lung sounds and measure to maintain a patent airway - Maintain a calm, quiet atmosphere and protect patient from stress
- Use strict aseptic technique for management of ICP monitoring system
- monitor fluid status
What is a head injury?
A broad classification that includes injury to the scalp, skull, or brain
-Head trauma includes an alteration in consciousness, no matter how brief.
What is the two types of a brain injury?
- closed brain injury (blunt trauma)
- open brain injury
What is a closed brain injury?
acceleration or deceleration injury occurs when the head accelerates then rapidly decelerates, damaging brain tissue
What is an open brain injury?
object penetrates the brain or trauma is so severe that the scalp and skull are opened
What is the three points in time after an injury where death can occur?
- primary injury: initial/immediate damage resulting from the traumatic event.
- within 2 hours after the injury
- secondary injury
What is secondary injury?
- Damage evolves after the initial insult
- 3 weeks after the injury
What is the cause and S&S of a secondary injury?
- Caused by cerebral edema, ischemia, or chemical changes associated with the trauma
- Includes a series of complications that lead to a poorer prognosis or even death
Symptoms: depend on the severity and location of injury, persistent, localized pain, stiff neck, nasal discharge, swelling, bruising, LOC
What is a scalp laceration?
- The most minor type of head trauma
- Scalp is highly vascular → profuse bleeding
—> Because tend to bleed heavily; scalp wounds are also portals for infection - Major complication is infection.
What is a skull fracture?
fracture in the skull
What is the S&S of a skull fracture?
- Usually have localized, persistent pain
- Facial paralysis
- Battle’s sign: ecchymosis behind the ear
- Conjugate deviation of gaze
- Rhinorrhea or otorrhea indicates that a fracture has traversed the dura.
halo sign: ring of csf leak around the blood stain from drainage
What are the 7 classified types of a skull fracture?
- linear
- depressed
- comminuted
- compound
- basilar
- closed (dura is not torn)
- open (dura is torn)
What is a linear fracture? Care?
Greatest number, Single crack in skull. Simple, clean break
care: bedrest, close observation of behaviours of brain injury
What is a depressed fracture?
- Bone pressed inward into brain tissue to at least the thickness of the skull
- Requires surgery to elevate bone and debride body fragments from underlying tissue
What is a comminuted fracture?
- Bone is fragmented into many pieces
- Requires craniectomy of fragments
What is a compound or perforated fracture?
- Depressed fracture with added problems of hemorrhage from scalp lacerations and an entry for intracranial infections
- Debris includes impact object, hair, dirt, and tissue
–> Surgically removed to decrease risk of abscess
What is a basal skull fracture?
- Involves base of skull
- Most often results from extension of linear fracture into base of skull
- Majority involve temporal bone (hearing) and frontal lobe
- Results in CSF leak through dural tear from nose or ear Will produce halo sign on bed linen
-Fractures of the base of the skull frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva, battles sign, serious infection - does not need surgery if dura repairs on its own
What is the medical management for a skull fracture?
- Non-depressed skull fractures do not require surgical treatment but require close observation
- Depressed skull fractures may be managed conservatively
- Contaminated or deforming fractures require surgery
- Antibiotic treatment and blood component therapy if indicated
When is surgery necessary for a skull fracture?
- If necessary: scalp is shaved and cleansed with copious amounts of saline to remove debris.
- Fracture is exposed
- Skull fragments are elevated and the area is debrided.
- Immediate bone or artificial grafts
- Repair can be delayed 3 to 6 months if there is significant edema.
What is minor head trauma?
- concussion: A temporary loss of consciousness with no apparent structural damage, amnesia, headache
- post-concussion syndrome: persistent headache, lethargy, personality and behavioural changes. short term memory loss, changes in intellectual ability
- diffuse axonal injury: Widespread axonal damage following mild, moderate, or severe traumatic brain injury (TBI), decrease LOC; patient experiences immediate coma, increased ICP, Decortication, decerebration, Global cerebral edema
What is major head trauma?
- Includes cerebral contusions and lacerations
- Both injuries represent severe trauma to the brain.
What is a coup-countercoup injury?
coup: primary impact where brain strikes part of skull
contrecoup: secondary impact when brain strikes the skull in a second location
What is an intracranial hemorrhage?
- Hematomas that develop within the cranial vault are the most serious results of brain injury
- A hematoma may be epidural, subdural, or intracerebral depending on the location
- Interval between bleeding and appearance of symptoms may be minutes or weeks
- Its main effects are frequently delayed until the hematoma is large enough to cause distortion, increased ICP, and herniation of the brain
what are the three types of intracranial hemorrhage?
- subdural
- intracerebral
- epidural
What is an epidural hematoma?
- atrial bleed
Blood collects in the epidural space between the skull and dura mater
What are the signs of an epidural hematoma?
- Initial period of unconsciousness
- Brief lucid interval followed by decrease in LOC
- Headache
- Nausea, vomiting
- Focal findings
- positive babinski
- pt will deteriorate quickly when the is no possible side signs of compression (deterioration of LOC, IICP, Positive babinski)
What is the medical management for an epidural hematoma?
- Extreme emergency!!!
- Respiratory arrest may occur within minutes
- Burr holes are made to remove the clots, and the bleeding point is controlled
What is a subdural hematoma?
- venous bleeding, slower to develop
- Blood collects between the dura and the underlying brain (arachnoid)
- Creates direct pressure on brain
- Most common cause is trauma
- May be associated with various bleeding tendencies ie. Rupture of an aneurysm
What are the three types of subdural hematoma?
- acute
- subacute
- chronic
What is an acute subdural hematoma?
- (major head injury)-within 2 days
-Signs within 24 to 48 hours of the injury - Similar signs and symptoms to brain tissue compression in increased ICP
- Patient appears drowsy and confused.
- Ipsilateral pupil dilates and becomes fixed.
What is an subacute subdural hematoma?
- Occurs within 2 to 14 days of the injury
- After initial bleeding, subdural hematoma may appear to enlarge over time.
What is an chronic subdural hematoma?
- chronic (more than 2 weeks)
- Develops over weeks or months after a seemingly minor head injury
- Peak incidence in sixth and seventh decades of life
What are the symptoms of a subdural hematoma?
- Much slower to develop into a mass large enough to produce symptoms
- Nuchal rigidity (neck stiffness)
- Severe headache
- Decreased LOC
- Contralateral hemiparesis (stroke)
- Dilated pupil
What is the diagnostic studies for intracranial hemorrhage?
- CT scan: Best diagnostic test to determine craniocerebral trauma
- MRI
- PET
- Transcranial Doppler studies
- Cervical spine x-ray
- Glasgow Coma Scale (GCS)
** Bloody spinal fluid suggests brain laceration or contusion**
What is the nursing management for an intracranial hemorrhage?
- glasgow coma scale score
- neuro status
- presence of CSF leak
- health promotion
- monitor ICP, maintain body temperature and away
What are some supportive measures for an intracranial hemorrhage?
- Seizure precautions and prevention
- NG to manage reduced gastric motility and prevent aspiration
- Fluid and electrolyte maintenance
–> Monitor blood and urine electrolytes, osmolality, and blood glucose, Monitor I&O and daily weights - Pain and anxiety management
- Nutrition
–> Implement measures to promote adequate nutrition
What is decorticate posturing?
extension posturing (decerebrate rigidity)
What is decerebrate posturing?
Abnormal flexion (decorticare rigidity)
What is decerebrate posturing?
Abnormal flexion (decorticare rigidity)
What is a contusion?
- more severe injury with possible surface hemorrhage
- Usually associated with closed head injury
- Prognosis is dependent on amount of bleeding around the contusion site.
- Symptoms and recovery depend on the amount of damage and associated cerebral edema
- Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs
- Coup-contrecoup injury
What is a laceration?
- Involve actual tearing of the brain tissue
- Often occur in association with depressed and open fractures and penetrating injuries
- Intracerebral hemorrhage is generally associated with cerebral laceration.
- Surgical repair of laceration is impossible.
- Prognosis is poor with large intracerebral lacerations.
What are some interventions to prevent further injury in patients with intracerebral hematoma?
- Reduce environmental stimuli
- Use adequate lighting to reduce visual hallucinations
- Implement measures to minimize disruption of sleep–wake cycles
- Provide skin care
- Implement measures to prevent infection ie. Posey Mitt
