Head Injury - Types, management and pathophysiology

Head Injury Adult Health Nursing -II

1. HEAD INJURY

2. INTRODUCTION Trauma is the third most common cause of death. Head injury contributes over the half of the trauma related deaths. Most common cause of death in adults. RTA s are one most common cause of head injuries

3. DEFINITION Head injury is the trauma to the scalp, skull or brain. The injury may be a minor bump on the skull or serious brain injury. A head injury is any injury that results in trauma to the skull or brain. The terms traumatic brain injury and head injury are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.

4. ETIOLOGY Motor Vehicle Crashes- 44% Falls - 26% Other/Unknown - 13% Non-Firearm Assaults - 9% Firearms - 8%

5. CLASSIFICATION

6. I. SCALP LACERATIONS Easily recognized Minor type of head injury Scalp is highly vascular, hence bleeding will be very high Infection will be the major complication

7. II.SKULL FRACTURES LINEAR Break in continuity of bone without alteration of relationship of parts Cause- low velocity injuries DEPRESSED Inward indentation of skull The cause will be a powerful blow © 2020, Lead College. All rights reserved

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9. II.SKULL FRACTURES COMMINUTED Multiple linear fractures with fragmentation of bones into pieces COMPOUND Depressed skull fractures and scalp lacerations communicating intracranial cavity © 2020, Lead College. All rights reserved

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11. ACCORDING TO LOCATION © 2020, Lead College. All rights reserved Frontal Temporal Parietal Posterior fossa Orbital Basilar skull

12. TEMPORAL FRACTURE Boggy temporal muscle due to extravasation of blood Oval shaped bruise behind the ear over the mastoid process – BATTLES SIGN Otorrhea

13. PARIETAL BONE FRACTURE Deafness CSF otorrhea Bulging of tympanic membrane by blood or CSF Facial paralysis

14. II.SKULL FRACTURES BASILAR FRACTURE Peri-orbital fracture(RACOONS EYES) Optic nerve injury. © 2020, Lead College. All rights reserved ORBITAL FRACTURE Otorrhea, rhinorrhea Bulging tympanic membrane Battles sign Facial paralysis Tinnitus , vertigo

15. TEST FOR CSF LEAKAGE Check for the presence of glucose strip. Dextrose strip method If blood is present the test becomes unreliable then go for 2 nd method HALOS SIGN: allow leaking fluid to drip on a towel Observe the drainage Within few minutes the blood coalesces into center and a yellowish ring encircles the blood.

16. III.MINOR HEAD TRAUMA CONCUSSION: A sudden transient mechanical head injury with disruption of neuronal activity and a change in LOC. It occurs when the brain suddenly shifts inside the skull and knocks against the skulls bony surface. May last from few moments to an unconscious state for over 3min Amnesia regarding event Headache

17. IV.MAJOR HEAD TRAUMA 1. CONTUSION: It is the bruising of the brain tissue within a focal area. Usually associated with closed head injury. Coup counter coup is often noted: contusion is often noted at the site of direct impact of the brain on the skull (COUP) and at the secondary area of damage on the opposite side of the injury(COUNTERCOUP) leading to multiple contusion areas

18. IV.MAJOR HEAD TRAUMA HEMORRHAGE: EXTRA-AXIAL HEMORRAGE: Epidural hemorrhage Subarachnoid hemorrhage Subdural hemorrhage Acute Chronic INTRA-AXIAL HEMORRHAGE: Intra parenchymal hemorrhage Intra ventricular hemorrhage

19. TYPES OF HEMORRHAGE-EPIDURAL Common type of Neurologic emergency Bleeding between duramater and inner surface of skull Blow to temporal and parietal bones Injury to middle meningeal artery Initially unconscious and then awakens and has a lucid interval followed by decreased LOC, Headache nausea and vomiting. On CT clot is biconvex and well defined boarder and usually respects cranial suture lines Open craniotomy and evacuation of the clot is advised Prevention of cerebral herniation will improve the outcome

20. TYPES OF HEMORRHAGE-subdural Bleeding between duramater and arachnoid membrane. Open craniotomy and evacuation of clot and decompression is indicated. Types: Acute SDH- Subacute Chronic

21. SUB DURAL HEMORRHAGE TYPES ACUTE SDH SUB ACUTE SDH CHRONIC 24-48hrs after severe head trauma 2-14 days after injury Over weeks or months after minor head injury Acceleration-deceleration injuries Progression depends on size and location of hematoma Peak incidence in 50-60 years of age Clinical features are similar to that of increases ICP, ipsilateral pupil dilation Altered mental status Progressive alteration in LOC

22. SUB ARACHNOID HEMORRHAGE Bleeding occurs between arachnoid hemorrhage and pia mater. Causes : Rupture of berry aneurysm Trauma (IC aneurysm formed due to basilar skull fracture) Clinical features –Explosive headache (worst headache of life), signs of meningeal irritation

23. INTRACEREBRAL HEMORRHAGE Intra axial hemorrhage occurs within the brain itself. INTRAPARENCHYMAL : ICH extending into brain parenchyma INTRA VENTRICULAR HEMORRHAGE : ICH extending into ventricles. Clinical features: rapidly progressive headache, nausea, vomiting, decreased level of consciousness.

24. DIAGNOSTIC TESTS 1. HISTORY COLLECTION: Mechanism of injury Loss of consciousness Level of consciousness at scene and at transfer Evidence of seizures History of vomiting Medications Pre existing medical conditions

25. PHYSICAL EXAMINATION Glasgow coma scale Pupil size and response Signs of skull fracture: racoons, battles,halo sign,hemotympanium . Full neurological examination: reflexes, power

26. CT SCAN AND MRI An urgent CT if age is >65 , coagulopathy (warfarin) and antegrade amnesia. MRI is more sensitive than CT Cervical spine X ray indicated when detect cervical injury Transcranial doppler to allow to measure CBF.

27. MANAGEMENT Best managed in NICU Position with head up to 30 degrees See to that Cervical immobilization collar doesnot obstruct venous return from the head AIRWAY AND VENTILATION: risk of aspiration and maintain normocapnia.

28. MANAGEMENT CIRCULATION AND CPP: Hypotension and hypoxia as major cause of SBI Systolic BP<90mmHg worst outcome in traumatic coma CPP should be maintained at >65mm Hg in severe head injuries.

29. MANAGEMENT CONTROL OF ICP: Position of head up to 30 degrees Avoid venous obstruction Sedation with or without muscle relaxant Normocapnia Diuretics : frusemide , mannitol Seizure control Normothermia barbiturates

30. MANAGEMENT MEDICATIONS: Osmotic diuretics: mannitol 25%, (1. 5 to 2g/kg infused over 30-60 min) Anticonvulscents:phenytoin-10-15mg/ kg,IV /PO,Q6-8 Phenibarbitol - reduce BMR and reduce ICP

31. SURGICAL MANAGEMENT