Presentation Package on HEAD INJURY.pptx

Management of Head Injury

1. HEAD INJURY BY KUMODE STEPHEN ONIMISI

2. H ead Injury It is an external mechanical injury to the scalp, skull and/or the brain which can lead to impaired cognitive or psychosocial/psychomotor functions or alterations in consciousness. A head injury is any form of trauma that injures the scalp, skull or brain. It is used interchangeably with traumatic brain injury [TBI]

3. INCIDENCE Almost 10 million head injury occurs annually in the united states About 4-7million cases is recorded annually in Nigeria. About 20% of which are serious enough to cause brain damage Head injury occurs twice as many in males ,under 35yrs[usually vehicle/motor cycle collision account are the chief cause of death].[Brindles L.M,Elizabeth B.2012]

4. types of Head Injury Head injury is broadly classified into external and internal injury. Other classifications; Scalp Skull brain

5. Scalp injuries include; Abrasions ; a wound consisting of superficial damage to the skin, not deeper than the epidermis. It may just be a scrape. Lacerations ; irregular tear-like wound cause by blunt trauma Avulsion ; forcibly detachement of a body structures from it normal point of insertion.

6. Skull – it may be open or close, depressed or undisplaced Injury to the anterior skull base will cause; Subconjuctival haemorrhage Raccon’s eye (panda’s eye) - a peri - orbital ecchymosis that occurs at a time of head injury in which there is bilateral haemorrhage as a result of tearing of the meninges causing the venous sinuses to bleed into the arachnoid villi i.e blood seeps from the skull into the soft tissues around the eye.

7. Basal skull injury will cause Csf rhinorrhea Csf otorrhea Battle’s sign ( HALO sign) Possible damage to internal carotid artery High risk of infection or meningitis

8. Brain Primary brain injury – injury occuring immediately at the point of impact to the brain. It may be ; Concussion; a type of TBI cause by a blow to the head that jars and shakes the brain inside the skull Contussion ; 2. Secondary brain injury; refers to changes that occur over a period of time (from hours to days) after a primary brain injury.

9. Causes of secondary brain injury Hypotension Hypoxia Hypercapnia Pyrexia Siezures Hypoglycaemia Hypo/hyperthermia Metabolic disturbances

10. Classification of head injury By severity ( GCS) By pathology Diffuse injury – injury that occurs over a wide area Focal injury – injury located in a small specific area 3. By mechanism of trauma Blunt Penetrating injury

11. Classification by mechanism of injury -blunt [closed] head injury -penetrating [open] head injury-high & low velocity.

12. Causes of head injury Motor vehicle accidents Fire arms related injuries Falls Assaults Sport related injuries Recreational accident Pathological conditions – cva , neoplasm

13. pathophysiology The Brain receives 20% of cardiac output Brain oxygen consumption is 3.5ml/100g/min and relies on blood glucose for 90% of it’s energy requirements. Autoregulation ; Autoregulation could be defined as the inherent ability of the brain to maintain a fairly steady cerebral blood flow in the presence of wide variations in systemic blood pressure, in order to ensure adequate cerebral perfusion and maintain the viability of the brain for optimal neuronal function Cerebral blood flow - 55ml/100gm/min, brain cannot maintain this function if MAP is (less than 50 or greater than 150mmHg)

14. Morbidity and mortality of head injury results from Raised intracranial pressure(ICP) Focal brain ischaemia

15. Increased ICP When there is an impact either by RTA, blow, fall etc , injury may or may not occur immediately, it may involve the lobes or the entire brain. During this impact, the brain crashes back and forth inside the skull causing bruises, bleeding and nerve fibers tearing depending on the severity of the impact. Inflammatory processes takes place in response to the injury, vasodilatation occurs, as a result, extra fluid and nutrients accumulates causing further brain swelling thus increasing the ICP.

16. The increase ICP pushes the brain to one side thus causing injury to parts of the brain that were not initially injured. Headache, nausea and vomiting, hyper/hypotension, decreased mental disability, disorientation to time place and person, bipolar, hypercapnia with increase pressure, part of the brain is squeezed across structures (foramen magnum herniation/ brain herniaion ) resulting in 3 cardinal signs ; hypertension, bradycardia and irregular breathing ( cushing triad),cardiac depression and loss of all brain stem reflexes

17. Focal brain ischaemia Monro Kelly principles; The intracranial compartment is a rigid encasement because of the limited space for expansion within the skull. it contain 3 incompressible tissues- brain, blood and cerebrospinal fluid. It states that, the volume of brain, blood and CSF remains constant. So an increase in the volume of any of the 3 would lead to a rise in intracranial pressure.

18. Estimated volumes: Brain volume 1300 to 1600ml Blood volume 100 to 150ml CSF volume 100 to 150ml Under normal circumstances , the 3 tissues exerts an intracranial pressure of 10mmHg or less. In premature infants, pressure could be as low as 2.5 mmHg

19. Focal brain ischaemia occurs as a result of decrease cerebral perfusion and pressure as a result of herniation of the arteries. This lead to loss of coordination, slurred speech, non reactive or dilated pupils or possibly blindness

20. Clinical manifestations Altered LOC Raised ICP CSF leakage ( otorrhoea or rhinorhea ) Persistent localized pain Depression Dizziness or balance problem Double or fuzzy vision Feeling foggy or gloggy (confusion) Feeling sluggish or tired

21. Headache Memory loss Nausea , vomiting Sensitivity to light or/and noise Sleep disturbance Complaining of head and neck pain (if conscious) Vomits repeatedly Difficult to console Change in breathing pattern (abnormal breathing)

22. Diagnostic investigations Computerized tomography scan Magnetic resonance imaging Skull x-ray Cervical spine x-ray Evoked potential studies Continuous cerebral blood flow studies Other investigations include ; ABG FBC E/U/CR Urinalysis PCV

23. Management Assessment Assess the LOC of the patient using GCS Pupillary response Assess the pattern of respiration Assess for possible signs of ICP( hypotension, hypercapnia ) Assess for indicators of spinal cord injury ( loss of motor and sensory functions, abnormal head tilt, tenderness along the spine) Carefully observe patient’s nose and ear for any csf leak Observe for seizures Monitor pts vital signs and urine output

24. Positioning Maintain 30 head up Turn head to one side to allow drainage of secretions Proper alignment of the head with the body Airway management Suctioning prn Oropharyngeal airway Intubate pt Tracheostomy Place pt on mechanical ventilator

25. Prevention of raise icp 30 head up Alignment of the head Temperature control – head cooling Administration of sodium thiopentone – reduce metabolic rate of the brain Administration ot diuretics – mannitol Pain relieve Nutrition and fluid maintenance Assess fluid status

26. Pass urinary catheter Hourly monitoring of urine output Strict monitoring of intake and output Observe for early signs of AKI Pass NGT for feeding, maintain 2 hourly feeding as ordered Prevention of infection Wound dressing Maintain aseptic technique change soiled linen and diaper Assess catheter tip for any suppurative sign Condom catheter more preferable

27. Maintenance of skin integrity Bed bathing Turning patient 2 hourly Application of sudo cream in pressure areas Medications

28. Surgical management Surgical Rx - Elevation of depressed fractures -Burr holes -Craniotomy - Decompressive craniectomy

29. Complications Cardiovascular disorders e.g dysrrhythmia . Altered consciousness e.g vegetative coma, Permanent neurological deficit. Mendelson syndrome Infection Seizures Raised intracranial pressure Respiratory failure Post traumatic seizure Memory loss

30. Hemiplegia Meningitis Cerebral abscess Cranial nerve injuries( 7,8,1,2,3,4,6) Headache Post concussion syndrome CSF leak .

31. Nursing diagnosis Ineffective Airway clearance related to excessive secretions evidenced by grunting respiration Deficient fluid volume related inability to take orals evidenced by reduced urine output (less than 0.5mls/Kg) and concentrated Hyperthermia related to altered thermoregulation evidenced by thermometer reading of 39.8 O C Ineffective Cerebral Tissue Perfusion related to raised intracranial pressure (ICP) evidenced by decreased level of consciousness (GCS OF 3/15)

32. 5. Imbalance Nutrition Less Than Body Requirement related to reduced calorie replacement evidenced by muscle wasting 6 . Risk for aspiration related to loss of consciousness and depressed cough and gag reflex