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Head Trauma and TBI

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Health And Illness I (NUR 275)

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Pennsylvania College of Health Sciences

Academic year: 2022/2023

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Head Trauma & TBI

 Head Injury o Head injury: any damage to the head as a result of trauma o Brain injury: an external force that can cause significant damage to the brain o Head injury does NOT always mean brain injury o Traumatic brain injury (TBI): injury that is the result of an external force  Causes & Risk Factors o Causes:  Falls  Motor vehicle accidents (MVA’s)  Sport and recreation  Assaults o Risk Factors:  Age  Infants & children 0- 4 yrs- physical abuse, shaken baby syndrome  Adolescents 15-19 yrs  Adults >65 years  Men> women o Elderly highest risk= falls; teens highest risk= MVA’s  Prevention o Prevention is the gold standard o Examples:  Airbags  Passive seat belts

 Not drinking and driving  Preventing falls at home  Not speeding  Not texting and driving  Pathophysiology o TBI leads to swelling or bleeding increasing ICP o Increased ICP leaves no room for expansion in the cranium allowing for more increased ICP o Pressure on the blood vessels decreases perfusion to the brain o Cerebral hypoxia and ischemia occur o ICP continues to increase leading to herniation o Cerebral blood flow decreases  Traumatic Injury

Primary Secondary  Direct contact to the head/brain during the instant of initial injury

 Occurs over hours to days as a result of the primary injury  Focal: localized to one area of the brain

 Inadequate delivery of nutrients and oxygen to the cells  Diffuse: global injury to the brain

 Injury Types o Scalp injuries  Very vascular which can result in a lot of bleeding  “Looks worse than it actually is”  Stop the bleed, clean up the wound, suture it up  High infection risk o Open head trauma: scalp laceration/tear in the dura, skull is opened (ex: bullet or ice pick)

 Ex: baseball bat hits the occipital lobe the contrecoup will be seen in the frontal lobe  Skull Fractures o Skull fracture: break in the continuity of the skull from forceful trauma o Linear: single fracture or crack in the bone  Normally let it heal on its own and treatment is pain management o Comminuted: splintered/shattered  Treatment is pain control and possible surgery o Depressed: bone fragments that become inwardly depressed into the brain tissue  Treatment is pain control and surgery o S/S: pain at the site, swelling, warmth/bruising/redness, facial weakness o ** An ongoing headache indicates there is a fracture**  Basal Skull Fracture o Basal skull fracture: fracture of the base of the skull o S/S:  Facial trauma  CSF leak from the ears or nose  Blood leaking from the ears/nose  Halo sign: take a sample of the draining fluid and put it on a white surface and will get

the halo sign; testing the CSF for glucose can help also determine if it is CSF  Battle sign: bruising behind the ear  Racoon eyes o Most occurs in the temporal lobe o NOTHING goes up the nose can cause intracranial tubing or placing the tube in the brain o *** Anytime you see CSF/blood from the ears/nose or racoon eyes or battle sign automatically think basilar*** o Assessment:  Halo sign testing; yellow ring= + CSF  Glucose test strip (+) = CSF  No nasal suctioning  Check nuchal rigidity (c-spine cleared 1st)  Battles sign/racoon eyes o Treatment:  High risk for infection so watch for s/s of infection  Follow up with diagnostic testing  Possible need for antibiotics  High risk for bacterial meningitis  Contusion o Contusion: bruising of the surface of the brain o Type of focal lesion (acceleration-deceleration injuries, coup & contrecoup) o Causes:  Head trauma /blunt trauma  Falls  MVA’s  Violence/ penetrating wounds  Sport injuries o Found in the frontal/temporal lobe o More serious than a concussion o S/S:

o Acute: * hours*  Changes in LOC  Pupillary signs  Hemiparesis  Coma  Cushing’s Triad (increase BP, decreased HR/RR) o Subacute: 48 hours – 2 weeks o Chronic: 2 weeks – months  Seen commonly in the elderly who are prone to brain atrophy (a normal part of the aging process)  Can be mistaken for a stroke  Most often overlooked/forgotten or blamed on being a part of the aging process  Blood becomes thicker and darker coming to look like motor oil with its consistency as well  S/S:  Severe headache coming and going  Alternating focal neurological signs  Personality changes  Mental deterioration  Focal seizures  Treatment:  Clot evacuation  Reversal of coagulopathies  Burr holes  Craniotomy  Intracerebral Hemorrhage o Intracerebral hemorrhage: a blood clot deep in the middle of the brain that is hard to remove o Pressure from the clot may cause brain damage

o Can be caused by nontraumatic events such as an aneurysm rupture, systemic HTN, bleeding disorders, or complications from anticoagulant therapy o S/S:  Neurological deficits  HA  Change in LOC  Increased ICP  Focal changes (“thunder clap”) o Treatment: surgery to relieve the pressure  Concussion o Concussion: temporary loss of neurologic function with no apparent brain damage  Most common brain injury o S/S:  Brief loss of consciousness  HA  Dizziness  N/V  Confusion  Drowsiness  Irritability  Giddiness  Visual & gait disturbances  Normal neuro exam o Injury to the frontal lobe can present as bizarre irrational behavior, temporal lobe produces temporary amnesia or disorientation o NEVER leave someone with a bad concussion alone as they can develop traumatic encephalopathy o CT or MRI is used to diagnosis a concussion as there is no structural brain damage o Anticipate: HA, difficulty concentrating, amenia

 Immediate coma  Global cerebral edema  Unexplained neuro deficit  Assessments o ABC’s o Details of the injury o History  LOC, amnesia, GCS o GSC:  Mild TBI= 13-15 with LOC up to 15 min  Moderate TBI= 9-12 with LOC up to 6 hours  May have difficulty with work, learning, or role function  Severe TBI= 3-8 with LOC >6 hours  Requires management of hemodynamic status and intracranial pressure o The lower the GCS= greater the injury  Medica Management

Manage ICP  Osmotic diuretics: Mannitol  Calcium channel blockers: prevent vasospasm

Ventilatory support

Prevent seizures  Keppra  Anticonvulsa nts

Fluid & electrolyte balance

Nutritional support  Within 24 hours needed to think of this

Decrease anxiety  Anxiety + Pain= increase in ICP Pain control  Avoid opioids due to change in LOC and effect it can

Evacuate clots Debridement

have on the neuro checks Elevate skull fractures

Craniectomy Burr holes

Bone flaps Ventriculostomy  Allows for ICP monitoring and draining

Family support and gift of life as this can lead to brain death

 Assessment & Nursing Problems

Respiratory  Ineffective airway clearance  Impaired gas exchange

Neurologic  R/F ineffective cerebral tissue perfusion

Cardiovascular  Decreased cardiac output

Integumentary  R/F impaired skin integrity

Musculoskeletal  Impaired mobility

GI

 Pain-decreased motility GU  Increased risk for infection, skin breakdown incontinence

Metabolic  Imbalanced nutrition less than body requirements

Psychological  Ineffective coping

 Nursing Interventions o Maintain the airway  Vents, O2, suction, prevent aspiration, ABG’s, oral care o Neuro assessments  LOC, GCS, neuro checks, reflexes, pupils, ICP, CPP  Prevent increasing ICP o Monitor  VS, CM, end tidal Co2, temperature, CSF leaks

o Caregiver role strain

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