1. Head Injuries
Zafar Iqbal
Sr. Lecturer
Jinnah College of Nursing
Karachi

3. Head Injury
 Causes
Causes
– Motor vehicle accidents
Motor vehicle accidents
– Firearm-related injuries
Firearm-related injuries
– Falls
Falls
– Assaults
Assaults
– Sports-related injuries
Sports-related injuries
– Recreational accidents
Recreational accidents

4. Road Traffic Crashes

5. Sports injuries

6. Assaults
(Sickle injuries)

7. MECHANISM
 BLUNT INJURY
 High Velocity
 Low Velocity
 PENETRATING INJURY
 Gunshot
 Sharp instruments

8. Head Injury
 High potential for poor outcome
 Deaths occur at three points in time
after injury:
– Immediately after the injury
– Within 2 hours after injury
– 3 weeks after injury

9. Types of Brain Injury

10. Types of Head Injury
 Scalp injury : minor injury
resulting in laceration, abrasion
& hematoma
 Skull injury : may occur with
or without damage to brain.
 Brain injury

11. Head Injuries
 Closed or blunt: blunt object damages
the brain and its coverings without actually
perforating the skull or dura.
 Penetrating: when the skull and brain
are directly lacerated by an object such as a
bullet, or piece of bone.
 Coup-Contrecoup Injuries : same
blow causes injury on opposite sides
of the brain.

12. Skull Fractures
 Linear Skull Fracture: is a break in the continuity
of the bone, appear as thin lines on X-ray.
 Depressed Skull Fracture - The broken piece
of skull bone is pressed towards or embedded in the
brain.
 Comminuted and Compound Skull Fracture -
The scalp is cut and the skull is splintered, multiple
fractures.
 Basilar Skull Fracture
The skull fracture is located at the base of the skull
and may include the opening at the base of the skull

13. Skull Fractures

14. Basilar fractures

15. Some Signs of Skull
Fractures
– CSF or fluid draining from ear (“halo”
sign)
– Blood behind tympanic membrane
– Raccoon Eyes: periorbital ecchymoses
– Battles Sign: bruise over mastiod process
– Cranial nerve and inner ear damage

16. Battles’ sign
 Often occurs in
fractures at base of
skull (posterior cranial
fossa).
 Large "black and blue
mark" looking areas
below the ear, on the
jaw and neck.
 It may include damage
to the nerve for
hearing.
 CSF Otorrhea:
cerebral spinal fluid
may leak out of the

17. Raccoon Eyes
 The skull fracture
produces "black and
blue" mark looking
areas around the
eyes.
 CSF Rhinorrhea:
cerebral spinal fluid
may leak into the
sinuses and out of
nose.

18. Otorrhea

19. Traumatic Brain Injury

20.  Traumatic brain injury (TBI) is
An insult to the brain, caused by an
external physical force, that may
produce physical, intellectual,
emotional, social and vocational
changes.
 Major causes of TBI motor vehicle
accidents, falls, acts of violence, sports
& recreational injuries, blows to head,
child abuse (shaken baby syndrome).

22. Mechanisms of Brain
Injury
 Acceleration injury occurs
when the immobile head is struck
by a moving object.
 Deformation injury : the force
results in deformation and
disruption of the impacted part,
(skull fracture)

23. Mechanisms Cont’d
 Deceleration injury : head is moving
and hits an immobile object (car
accident-hitting steering wheel)
 Acceleration-deceleration injury :
moving object hits immobile head and
then head hits immobile object.
Associated with rotation injury where
brain is twisted in the skull (whiplash).

24. Injuries
 Blunt
 Penetrating
 Coup-
Contrecoup

26. Types of Brain Injury
 Concussion: is a head trauma that may or
may not result in loss of consciousness (for 5
minutes or less) and retrograde amnesia.
 Contusion: is a severe injury in which the
brain is bruised resulting in swollen brain
tissue, areas of hemorrhage, infarction,
necrosis, edema. Results in loss of
consciousness and symptoms of shock.

27. Concussion

May experience only dizziness and feel “dazed”.
 Retrograde amnesia
 Treatment involves observing patient for headache,
dizziness, lethargy, irritability and anxiety.
 Client should resume normal activities slowly and the
following should be watched for: difficulty in awakening or
speaking, confusion, severe headache, vomiting or
weakness on one side of the body.
 May or may not show up on CAT scan.
 Blood clot can occasionally occur causing death
 Months to years to heal

28. Contusion
 Depends on which areas of the brain
damaged – cerebral hemispheres, brain stem
(RAS)
 Can cause diffuse axonal type injury resulting
in permanent or temporary damage
 If widespread injury, abnormal eye movement
and motor function, increased intracranial
pressure and herniation - poor outcome.
 May have residual damage, seizures

29. Contusion resulting in
necrosis

30. Diffuse Axonal
Injury:
severe widespread
injury to axons in
the cerebral
hemispheres,
corpus collosum
and brain stem.

31. Diffuse Axonal Injury
 Extensive tearing of nerve tissue throughout the brain
causing the release of chemicals, causing additional
injury.
 Immediate coma, decerebrate & decorticate posturing,
and global edema
 The tearing of the nerve tissue disrupts the brain’s
regular communication and chemical processes
producing temporary or permanent widespread brain
damage, coma, or death.
 A person with a diffuse axonal injury could present a
variety of functional impairments depending on where
the shearing (tears) occurred in the brain.

32. Intracranial
Hemorrhage
Intracranial hematomas
are collections of blood
that develop within the
cranial vault.
Three kinds: epidural,
subdural & intracerebral

33. Types of Cerebral
Hemorrhage

34. Meninges
Epidural
Scalp
Hematoma:
mostly arterial
Skull (blood collects
Dura matter b/t the skull &
Arachnoid the dura mater
of the brain)
Pia
Brain tissue
grey
white

35. Subdural
hemorrhage
- usually
Scalp
venous (blood
Skull
collects b/t the
Dura matter dura & the
arachnoid
mater). May be
classified as
acute, subacute
or chronic.

36. Acute & Subacute Subdural
Hematoma
 Usually result from brain or blood vessel
laceration
 Symptomatic within 24 to 48 hours of injury
 Symptoms include loss or variable levels of
consciousness, headache, irritability,
increasing signs of increased ICP (increased
BP, decreased pulse, slowing respiratory
rates)
 Requires prompt treatment!

37. Intracerebral
Hematoma
Bleeding directly
into the brain
tissue.

38. Diagnostic Tests
 CT or MRI: data on structural causes such
as tumor or hemmorhage.
-Metabolic – will be unremarkable
 LP: infection or bleeding (cloudy or
bloody)
 EEG: structural or metabolic, seizure
activity
 Lab tests: LFTs, kidney function, glucose
levels, toxicology, ABGS

39. Diagnostic Tests for
Abnormal Reflexes
 Oculocephalic reflex
response – abnormal
if eyes remain in fixed
position when head
turned
 Oculovestibular reflex
response – absence
of eye movement
when water instilled in
ear = brain death

40. * Level of consciousness is
*
the single most important
indicator of neurological
function and change*

41. Medical Management
 Prompt recognition and treatment of
hypoxia & acid-base disorders (why?)
 Control of increasing ICP resulting from
increased cerebral edema and
expanding hematoma
 Surgical treatment
– Burr holes
– Craniotomy

42. Burr holes

43. Craniotomy (Pre)

44. Craniotomy

45. Craniotomy

46. Post Head Injury
 Observe for 24 hrs
 Take to emergency if any of following::
– decreasing LOC (confusion, drowsy)
– loss of consciousness/inability to wake
– vomiting
– convulsions
– bleeding or drainage from ears/nose
– weakness or loss of sensation in arm or leg
– blurring of vision/slurring of speech
– changes in pupil

47. Nursing Assessment:
Brain Injury
 ABCDs
 Maintaining airway
 History if possible
 Determine LOC, ability to respond to verbal
commands, reactions to tactile stimuli, status of
reflexes.
 Glasgow Coma scale
 Fluid and electrolyte balance
 Monitoring/managing potential complications

51. The Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a
universally used neurological
assessment tool to assess degree of
consciousness impairment. CGS
measures eye, verbal, and motor
response. It is an excellent scale to
measure arousal. It is less helpful
related to content measurement.
Know the difference b/
content & arousal

52. GLASGOW COMA SCALE SCORE (GCS)
Eyes 1 Closed at all times
2 Opens to pain
3 Opens to voice command A score of 10 or less
4 Open spontaneously indicates a need for
Motor 1 No response emergency
2 Extension (decerebrate) attention
3 Flexion posturing (decorticate) 15 (top score)
4 Flexion withdrawal
5 Localizes painful stimulus A score less than 7
6 Obeys commands is interpreted as
Verbal 1 No response coma
2 Incomprehensible sounds
3 Inappropriate words
4 Disoriented and converses
5 Oriented and converses

53. Nursing Diagnoses
– Altered Tissue Perfusion
– Risk for Suffocation/Aspiration
– Altered Oral Mucous Membranes
– Risk for Impaired Skin Integrity
– Risk for Contractures
– Altered Nutrition: Less than Body
Requirements
– Fluid volume deficit
– Risk for Injury
– Altered family processes

54. Nursing management
– Maintaining the airway
– Protecting the patient
– Fluid balance
– Mouth care, skin and joint integrity
– Corneal integrity
– Thermoregulation

55. Emergency Care
 ABCs
 Airway maintenance, intubation with oxygenation
(PO2 > 90mmHg), mild hyperventilation – avoid
hypercapnia.
 Ensure adequate fluid however avoid lowering the
blood osmolarity.
 Initial neuro assessment and Glasgow Coma Scale
 Etiology of the brain injury will dictate further
evaluation & treatment

56. Emergency Care Cont’d
 osmotic diuretics (mannitol IV)
 steroids (controversial)
 vasoactive medication (100-150mmHg
systolic)
 elevate HOB (30 degrees)
 sedate as needed (barbituates IV)
 drain CSF (keep ICP < 20)
 maintain fluid status (normal serum Na &

58. Nursing Management Cont’d
 Administer prescribed meds to reduce ICP:
barbituates, mannitol analgesics, narcotics
 Maintain fluid balance with NaCl or RL solution
 Avoid noxious stimuli (explain)
 Maintain cerebral perfusion pressure >70mmHg
 Maintain normal body temperature – avoid
hyperthermia

59. Osmotic Diuretic (Mannitol)
 Reduces cereberal edema by osmotic dehydration.
Preferred b/c it is confined to extracellular space & does
not normally cross an intact blood brain barrier.
 Carefully monitor vitals, CVP, B.P, intake & output,
catheter patency, signs of fluid overload, eye response
/acuity & electrolyte imbalance?? Why??
 NOTE: If blood-brain barrier is damaged the medication
enters the brain and increases swelling!!