Head Injury Flashcards
A lot of individuals die from head injuries, what are the 3 points in time that death can occur with a head injury?
- immediately after the injury (majority)
- within 2 hour after the injury progression of bleeding or injurt
- 3 weeks after the injury. multi-system failure
what are the 3 complications of skull fractures ?
infections - open wounds
hematomas - bleeding
tissue damage - swelling
its important to note that the location of the skull fracture will end up determining what ?
clinical manifestations that appear
there are multiple type of skull fractures. I am going to provide the name of the type and I want you to describe to me what each of it means.
linear - cause by low velocity injury
simple - low to moderate impact
depressed - powerful blow
comminuted - high momentum impact
compound - severe injury
open or closed
break in bone without displacement
( crack in the bone, a line )
without fragments, break in skin or disruption of sinus cavity
depression or inward indentation of skull
(dent in your head)
multiple fracture and scalp laceration with pathway to brain
open fractures involve scalp laceration or sinus cavity integrity
what are the 4 signs that we will see in a skull fracture ?
battle sign
raccoon eyes
blood behind the eardrum
(hemotampadn)
halo sign
what is a battle sign?
bruising behind the ear, bruising of the mastoid process
what is the raccoon eyes sign?
bleeding to the head and causes bilateral black eyes
(broken nose is very common)
blood from the head pulls it down to the eyes
what is hemotampadn?
blood behind the eardrums
( looking into ear and seeing blood behind the eardrum )
what is happening with halo sign ?
leaking of cerebral spinal fluid
- usually from your ears or your nose which is bad
how do you test for the halo sign that its csf? (2)
glucose and it looks like a halo sign
( it looks like a halo )
why do we care that a patient is having leakage of cerebral spinal fluid ?
infection and horrible headache
( csf protects your brain and spinal cord )
fracture location
tell me what you’d find
front - brain exposed through frontal sinus, csf leak, air between cranium and dura matter (pneumocranium )
orbital - optical nerve injury
temporal - csf leak, arterial disruption, epidural hematoma
parietal - csf or brain leak, facial paralysis, loss of taste
basilar - base of skull fracture, csf or brain leak, facial paralysis, tinnitus, or healing problems, rhinorrhea, vertigo
posterior fossa - deafness, csf or brain otorrhea, facial paralysis, loss of taste
subs emphysema in forehead
raccoon eyes
battle sign, boggy temporal muscle
battle sign, building tm from blood or csf
battle sign, conjugate deviation of gaze, bulging tm from blood or csf
battle sign, building tm from blood or csf
head trauma can be either
diffuse or focal (localized ) injury
what does it mean ?
which one do you think is worst?
diffuse
- damage to the brain is not limited to one location
focal (localized)
- damage is localized to one part of the brain
Diffuse worst
what do you think a concussion is, a diffuse or a focal injury and why ?
diffuse, because its a sudden blow to the head
( disruption in neural activity, possible disruption in loc, headache, short durtation )
sometimes patients who have concussions can have something called retrograde amnesia, what does this mean ?
you can remember things that happen yesterday and even earlier before that concussion, but can’t remember like 20minutes before leading up to the actual accident that made you have that concussion
concussion usually have a short duration of unconscious and the symptoms are respected to the side of the head you actually got hit on, and treatment is usually pretty well, however it can result in something called post-concussion syndrome, meaning what?
persistent headache, lethargy
personality and behavior changes
shorten attention span, decreased short-term memory
changes in intellectual ability
how long can post concussion syndrome last?
2 weeks to 2 months post injury
its important to note that a post concussion, the symptoms of the original concussion has resolved, however you have what ?
personality changes, short attention spam, decreased short term memory, persistent headache
post concussion syndrome is not normal however what ?
it can be expected to happen
what is diffuse axonal injury ?
results from brain movement due to injury-tissue shearing causes tears in axons resulting in cellular death.
can be caused by functional changes after trauma resulting in swelling
what are some clinical manifestation of diffuse axonal injury ? (3)
decreased loc, increased icp, global cerebral edema
what is the posturing that we can see in a patient who received an diffuse axonal injury ?
decorticate or decerebrate posturing
patients may also get something called a focal- lacerations which is what ?
tearing of brain tissue
( only a piece of the brain is lacerated )
focal-lacerations our main concern is what?
hemorrhages - its in the name, lacerations/ bleeding
most of the time in focal lacerations we try to go in and do a surgical repair, but what happens?
its so intense because of how deep, depressed and open fracture it is that its nearly impossible
what is a focal contusion?
bruising of brain tissue
typically with closed head injury
what are the clinical manifestations of focal- contusion?
hemorrhage
infarction
necrosis
edema
what is a coup-contrecoup injury ?
think of the picture
brain moves within skull due to high impact injury
injury at point of impact and opposite side
coup - primary impact
( first time hitting head forward )
contre-coup = secondary impact ( head hitting a second time in the back )
which one is worst and why?
coup or contrecoup?
contrecoup
- because this is two injuries now and usually symptoms are contrecoup
its important to ask question to figure out how the head injury happened, but what is the first priority though ?
airway, breathing, circulation!!!!
But remember its still helpful to aid with it
how can we see a focal contusion on the ct?
its rebleed in the brain “blossom”
focal-contusion can have focal and generalized manifestations, which examples are these??
two types of seizures pretty much ,dont look too into it, she doesn’t talk much on it
if a patient has any form of head injury, in which csf leakage, icp happens or bleeding, seizures are very common in happening, so we like to do what?
have seizure precautions in place
- rails up
- stand by
- anti-convulsants
what is an epidural hematoma?
medical emergency of bleeding between the dura and the inner surface of the skull
if we do not get rid of a epidural hematoma, they will die. it can be either what two types of hematoma?
venous or arterial
a venous epidural hematoma its going to be very what ?
a arterial epidural hematoma its going to be very what?
so which one is worst, so pretty much is saying which is going to be bleed out faster, the vein or the artery ?
slow
rapid
artery
what is the main clinical manifestation of epidural hematoma?
brief lucid interval followed by decrease in loc
like you wake up then you just slowly knock out
( headaches, nausea, vomiting , focal findings are common )
a epidural hematoma requires rapid evacuation of hematoma to prevent what?
herniation and death
what is a subdural hematoma ?
bleeding between the dura mater and the arachnoid layer
most common source of subdural hematoma is the what ____that drains the brain surface into the _____sinus
veins
sagittal sinus
acute subdural hematoma is within what time frame?
24-48 hours of the injury
subacute subdural hematoma is within what time frame ?
2-14 days of the injury
acute subdural hematoma clinical manfiestions are what ?
ipsilateral pupil dilated and fixed if severe
( one pupil dilated and fixed )
- decreased loc, headache, symptoms related to increase cranial pressure
what is the subacute subdural hematoma clinical manifestions?
slow change, may appear to enlarge over time
enlargement is caused by breakdown of hematoma causing increase in fluid
what is the Time frame of a chronic subdural hematoma?
weeks or months after injury
we normally see which type of patients have chornic subdural hematoma and why ?
older adults
- because they have brain atrophy which cause increase subdural space
Patients who have chronic subdural hematoma have increase risk for what?
misdiagnosis, symptoms difficult to diagnose
most of the time patients have what type of symptoms with chronic subdural hematoma and why ?
focal symptoms
typically a certain area of the brain is developing that hematoma and so its just causing that one area to produce symptoms
what is intracerebral hematoma ?
usually within frontal and temporal lobes
size and location of hematoma determine patient outcome
bleeding within the brain tissue
how do we diagnose a head injury ?
CT scan
MRI
EEG
blood glucose
glasgow coma scale
ICP level
what is the emergency treatment we are going to do for patient with head injuries ?
patent airway
stabilize cervical spine
oxygen
IV access
control external bleeding
its important to note that even when patients get a spinal cord or even head injury they can walk talk move all just fine, however its always important to what and why ?
stabilize cervical spine
- to prevent further injury and rule out that it isn’t a neck/head injury present
when do you think we should intubate a patient with a head injury?
when during the GCS or a reflex is not present
GCS less than 8 or if gag reflex is affected
additional emergency treatment notes
- remove patients clothing
- maintain patient warmth
- ongoing monitoring
- anticipate possible intubation
- assume neck injury
- administer fluid cautiously
why do you think we need to keep a patient warm?
cause shivering will increase metabolic needs
- calories and muscles and fat breakdown
collaborative care
- Treatment principles
- Prevent secondary injury
- Timely diagnosis
- Surgery if necessary
- Concussion and contusion
- Observation and management of ICP
if you have a depressed skull fracture you need what?
surgery
if you have subdural or epidural hematoma you need to have what?
surgical evacuation
craniotomy
craniectomy
notes story
when a patient has hematoma, they might need to take a flap of your skull and put it into your abdomen, cause we need to put it back in and keep it sterile inside your body.
remember abdomen is huge, gets blood supply, you won’t lose it!
nursing assessment - subjective notes
Mechanism of injury
Medications-anticoagulants
Alcohol/drug use; risk-taking behaviors
Headache
Mood or behavioral changes
Mentation changes; impaired judgment
Aphasia, dysphasia
Fear, denial, anger, aggression, depression
nursing assessment objective notes
altered mental status
Lacerations, contusions, abrasions
Hematoma
Battle’s sign
Periorbital edema and ecchymosis
Otorrhea
Exposed brain
Rhinorrhea
Impaired gag reflex
Altered/irregular respirations
Cushing’s triad
Vomiting
Bowel and bladder incontinence
Uninhibited sexual expression
Altered LOC
Seizures
Pupil dysfunction
Cranial nerve deficits
Motor deficit
Palmar drift
Paralysis
Spasticity
Posturing
Rigidity or flaccidity
Ataxia
nursing diagnoses
Risk for ineffective cerebral tissue perfusion
Hyperthermia
Impaired physical mobility
Anxiety
Potential complication: increased ICP
nursing planning
Overall Goals
Cerebral oxygenation & perfusion
Normothermic
Control pain and discomfort
Free of infection
Adequate nutrition
Maximal cognitive, motor, and sensory function
Health Promotion notes
Prevent car and motorcycle accidents.
Wear safety helmets.
Use seat belts and child car seats.
Home safety to prevent falls
Acute Intervention
Maintain cerebral perfusion.
Prevent secondary cerebral ischemia.
Monitor for changes in neurologic status.
Patient and family teaching
Acute Intervention notes
Major focus of nursing care relates to increased ICP.
Eye problems
Eye drops, compresses, patch
Hyperthermia
Goal 36°to 37° C
Prevent shivering
we dont want patients to sneeze or blowing nose when having a head injury
and no ng tubes or suctioning why ?
because bleeding, pressure and infection are all high
Acute Intervention notes
Bowel/bladder interventions, skin care, ROM
Antiemetics - forceful vomit
Analgesics
Pre-op preparation, if needed
Ambulatory and Home Care
Acute rehabilitation
Motor and sensory deficits
Communication issues
Memory and intellectual functioning
Nutrition
Bowel and bladder management
Ambulatory and Home Care
Seizure disorders-likely to develop in first week, but can appear years later
Mental and emotional difficulties
Progressive recovery-6 months or more
Family participation and education
Expected Outcomes
Maintain normal cerebral perfusion pressure.
Achieve maximal cognitive, motor, and sensory function.
Experience no infection or hyperthermia.
Achieve pain control.
apparently patients with head injury become very what?
sexual
what medication can cause more bleeding if a patient is taking it ?
anti coagulants
vital meningitis most common causes are what?
enterovirus, arbovirus, HIV and HSV
how is viral meningitis spread?
direct contact with respiratory secretions
what are clinical moanifestaionts of vital meningitis?
headache, fever, photophobia and stiff neck
what is the diagnostic study to test for vital mengintis ?
test for csf
how do we treat meningitis ?
antibiotics after obtaining diagnostic sample but while awaiting test results
what is encephalitis ?
acute inflammation of the brain
what is encephalitis caused by ?
virus
( ticks or mosquitoes too )
what is cmv encephalitis caused by ?
progression of aids with patients with aids
what are clinical manifestations fo encephalitis?
when do they appear
fever, headache, nausea, vomiting
2-3 days
what are diagnosis studies for encephalitis ?
CT, MRI, PET, PCR TESTS FOR HSV, BLOOD TESTS
Mosquito control for prevention
Nursing management is symptomatic and supportive
Intensive care may be required
what 2 medications are we going to give for encephalitis ?
acyclovir ( Zovirax )
vidarabine (vira-a) for hsv infection
sometimes we may give what type of drugs to prevent or control seizures that can happen with encephalitis ?
anti-seizures drugs
rifampin is used for vital meningitis too
to try to prevent bacterial meningitis
- very very continuous
- vaccine against this too
