Chapter 31 Objectives - Head Trauma

Identify the meningeal layer spaces into which intracranial bleeding can occur.

Epidural bleeding - between the dura mater and the skull. Subdural bleeding - Beneath the dura Subarachnoid hemorrhage - Bleeding that occurs between the arachnoid membrane and the surface of the brain.

Describe the various types of skull injuries. (Basilar)

-A fracture to the floor or bottom of the cranium. -Begins as a linear temporal fracture that extends downward and continues into the base of the skull. -Causes leakage of CSF from the ears, nose, or mouth. -Ecchymosis found around the eyes and behind the ears

Describe the various types of skull injuries. (Open)

-A fracture to the skull with an associated open wound to the scalp. -An open wound can lead to bacteria and other contaminants to enter the skull leading to infection. -If the dura mater is damaged, CSF can leak from the open wound.

Describe the various types of skull injuries. (Closed)

-An injury in which the skill is fractured but there is not an open wound to the overlying scalp.

Delineate between the types of brain injuries. (Diffuse axonal injuries)

-An injury to the brain that results from shearing, tearing, and stretching of nerve fibers. -Interferes with communication and transmission of nerve impulses throughout the brain.

Explain the assessment-based approach to brain injuries, including the incorporation of assessment findings into a field impression. (Primary Assessment)

-Be alert for and consider cervical spine injury. Maintain in-line stabilization and proceed with spine motion restriction if c-spine injury is suspected. -Because most patients may be unresponsive and have a blockage of their airway, just the jaw-thrust maneuver and maintain a patent airway while providing positive pressure ventilation with supplemental O2 (if necessary, overall). -Note the patient's mental status using AVPU, keeping in mind that the patient my deteriorate changing the status. If only responding to pain, note whether it is purposeful (moving away or remove pain) or nonpurposeful (reacting but not trying to stop it). With nonpurposeful movements, look for decorticate or decerebrate posturing.

Review the proper neurological assessment of patients with suspected traumatic brain injury.

-You can only assess neurological assessments with responsive patients who can answer questions and follow commands. -Assess motor functions by having them squeeze your hands together for equal grip strength. -Assess light touch and pain sensory functions by touching fingers to toes of the patient, without them looking, and also pinching or lightly pressing against the extremity in question (again without the patient looking). -AVPU and GCS

Review and discuss the anatomy and physiology of the central nervous system, including the scalp and skull, brain tissue layers, and lobes, CSF, meningeal layers, brainstem, and blood flow.

-CSF is the cushioning dense, serous substance that protects the brain and spinal cord. -The three brain tissue layers from outermost to inner is the dura mater, arachnoid, and pia mater. -The three anatomical components of the brain consist of the cerebrum, cerebellum, and the brainstem. -The cerebrum is divided into two major hemispheres (left and right) with four lobes in each (frontal, parietal, occipital, and temporal). -The cerebellum controls equilibrium and coordinates muscle activity and is located underneath the cerebrum. -The brainstem controls most automatic functions of the body and connects the brain to the spinal cord. It consist of the pons, midbrain, and the medulla.

Explain the assessment-based approach to brain injuries, including the incorporation of assessment findings into a field impression. (Secondary Assessment)

-Complete a head to toe rapid exam of the patient, being as thorough as possible. Keep in mind that with a head injury, along with other injuries, the patient may not respond appropriately to the other injuries. -With a head injury, know that the patient may be altered mental status or unresponsive, so obtain a history from family, friends, or bystanders. -Obtain a set of vital signs and constantly obtain a new set every 5 minutes.

Discuss the types of scalp injuries that can occur secondary to trauma.

-Contused -Lacerated -Abraded -Avulsed

Explain the assessment-based approach to brain injuries, including the incorporation of assessment findings into a field impression. (Scene safety)

-Ensure scene safety and determine the MOI. -Unresponsive or altered mental status should be suspected head injury. -Look for other MOI that would indicate a head or brain injury. -Nontraumatic injuries to the brain can be caused by clots or hemorrhaging.

Delineate between the types of brain injuries. (Open brain injury)

-Involves a break in the skill and a break in the scalp. -Involves direct local damage to the involved tissue but also results in brain damage from infection, lacerations of the brain tissue, or punctures to the brain by objects that invade the cranium after penetrating the skull.

Explain the pathophysiology of traumatic brain injuries, including a discussion of a secondary brain-injury mechanism.

-Occurs from a complex cascade of pathophysiologic processes following the primary brain injury. -Worsens with hypoxemia, hypercarbia, hypoglycemia, hyperglycemia, hyperthermia, and hypotension. -Pertaining to seizures, try to end it as quickly as possible. Contact medical control or for ALS intercept. Follow local protocol.

Delineate between the types of brain injuries. (Brain lacerations)

-Occurs with an open or closed head injury, especially when an object penetrates the skull and lacerates the brain. -Hematomas -Cushing reflex

Describe the various types of skull injuries. (Linear)

-Resembles a line -No gross deformity

Describe the various types of skull injuries. (Depressed)

-The bone ends are pushed inward toward the brain. -Poses an issue when the bone ends damage the brain tissue.

Explain the pathophysiology of traumatic brain injuries, including a discussion of a primary brain-injury mechanism.

-The result of trauma to the brain that occurs at the time of insult from direct impact, acceleration/deceleration, or a penetrating wound. -Results in contusion to the brain tissue, bleeding within the brain, or laceration of the brain.

Delineate between the types of brain injuries. (Closed brain injury)

-The scalp or skull can be lacerated but the skull remains intact and there is no opening to the brain

Explain the assessment-based approach to brain injuries, including the incorporation of assessment findings into the appropriate prehospital emergency care.

1.) Take spine motion restriction precautions 2.) Establish and maintain a patent airway, using the jaw-thrust maneuver. 3.) Establish and maintain adequate breathing, providing positive pressure ventilation and supplemental O2 as necessary. 4.) If breathing is adequate, maintain adequate oxygenation. Any patient with a suspected head injury should receive supplemental O2 to maintain an SpO2 of 95% or higher. 5.) Control any major sources of bleeding. Do not apply pressure to open/depressed skull injuries or to the ears with blood/CSF leaking out. Never try to remove a penetrating object. 6.) Be prepare to provide care for seizures. 7.) Continuously monitor the mental status and report and document any deterioration. 8.) Transport immediately.

Delineate between the types of brain injuries. (Subdural bleeds)

A collection of blood between the dura mater and the arachnoid layer of the brain, commonly associated with contusions. Caused by low-pressure venous bleeding from small bridging veins that are torn during impact. -Weakness or paralysis to one side of the body -Deterioration in level of responsiveness -Vomiting -Dilation of one pupil -Abnormal respirations or apnea -Possible increase systolic BP -Decreases pulse rate -Headaches, seizures, or confusion -Personality changes (chronic type of injury)

Delineate between the types of brain injuries. (Concussion)

A mild diffuse axonal injury which causes a disturbance in brain function. -Momentary confusion to complete unresponsiveness -Confusion that lasts for several minutes -Inability to recall the incident and, sometimes, the period just before it (retrograde amnesia) and after it (anterograde amnesia) -Repeated questions about what happened -Mild to moderate irritability or resistance to treatment -Combativeness -Inability to answer questions or obey commands appropriately -Nausea and vomiting -Restlessness

Delineate between the types of brain injuries. (Contusion)

Bruising or swelling of the brain tissue that may accompany a concussion. Bleeding in the surrounding tissue of the brain may cause ICP. Typically is caused by a coup (on the side of impact), contrecoup (on the opposite side of the impact), or an acceleration/deceleration injury. -Decreasing mental status or unresponsiveness -Paralysis -Unequal pupils -Vomiting -Alteration of vital signs -Profound personality changes -Swelling of the brain

Explain the importance of and how to complete the reassessment of the patient with an injury to the brain or skull.

It is important to recheck the patient every 5 minutes to note any change in their condition. Some injuries may see a decline in the responsiveness or condition of the patient and it is important to note the specific change and reformulate their care around said change. You will want to pay attention to their airway, mental status, and the physical exam for any noticeable change in their condition.

Delineate between the types of brain injuries. (Epidural bleeds)

Rapid, profuse, and severe bleeding pools between the skull and the dura. This occurs in low-velocity impacts to the head or from deceleration injury. Commonly associated with a temporal skull fracture, because of its proximity to the meningeal arteries. -Decreasing mental status -Loss of responsiveness followed by a return to responsiveness (lucid interval) and then rapidly deteriorating responsiveness. -Severe headaches -Fixed and dilated pupils (late sign) -Seizures -Vomiting -Apnea or abnormal breathing pattern -Systolic hypertension and bradycardia (Cushing reflex) -Posturing (decorticate/flexion or decerebrate/extension)

Delineate between the types of brain injuries. (Brain herniation)

With the build up of ICP, blood and CSF is compressing the brain downward toward and through opening in base of the skull. -Dilated or sluggish pupils on one side from compression of the third cranial nerve -Weakness or paralysis -Severe alteration in consciousness -Posturing (decorticate/flexion or decerebrate/extension) -Abnormal ventilation pattern -Cushing reflex (increased systolic BP and decreased HR)