Head Injury 4700 Exam 2

Scalp lacerations

Easily recognized type of external head trauma. Associated with profuse bleeding because the scalp is so vascular (with poor constrictive abilities). Risk for infection and blood loss are what we're concerned about (give tetanus if it's a rusty scalp laceration and if they haven't had one in 5y)

Parietal and basilar

Facial paralysis in which CN7 is involved is seen in which two types of fractures?

Skull fractures

Frequently occur with head trauma. Can be linear (hairline fracture from low-velocity injuries like a basilar skull fracture); depressed (bone has broken and pushed inward like with blunt trauma/baseball bat injury powerful blow); simple (no break in skin low to moderate impact), comminuted (community of fragments/3-4 bone shards shattered direct-high momentum impact), or compound (skin damage severe head injury...depressed skull fracture and scalp laceration with communicating pathway to intracranial cavity); and penetrating-missile

FALSE

T/F: Dextrostix or Tes-Tape strip is used to determine whether glucose is present, which would indicate CSF. This is accurate even in the presence of blood.

TRUE

T/F: anticoagulant use and coagulopathy are associated with increased hemorrhage, more severe head injury, and a higher mortality rate.

Focal injury laceration

Tearing of the brain tissue and occur IAW depressed and open fractures and penetrating injuries. Surgical repair is impossible because of the nature of brain tissue. Medical management=abx until meningitis r/o and prevention of secondary injury r/t IICP. If bleeding is deep then focal and general s/s develop. Associated with intracerebral hemorrhage, hematoma formation, seizures, and cerebral edema. As hematoma expands, s/s become worse of IICP. SAH and intraventricular hemorrhage can occur secondary to this.

CT scan

The best diagnostic test to evaluate for head trauma because it allows rapid diagnosis and intervention int he acute care setting. 15min vs 45.

Timely diagnosis, prevent secondary injury, surgery (if necessary)

3 focuses of head injury collaborative care

Diffuse injury AKA concussion

A sudden transient mechanical head injury with disruption of neural activity and a change in the LOC is considered a minor _____ AKA _____. Brief disruption in LOC for <5m. If more than 5 observation warranted. Retrograde amnesia (regarding the event), HA, and N/V and hypersensitivity to sound and light (might not see until the next day). Call MD if s/s persist and behavioral changes are noted. Watch for post___ syndrome which can develop 2w to 2mos after the injury to include lethargy, HA, personality and behavioral changes, shortened attention, decrease STM, and changes in intellectual ability (trouble w/ exams and classes)

Head injury

Any injury or trauma to the scalp, skull or brain. If it's serious form then it's a traumatic brain injury. 1.7 million people get TBI's every year

Subdural hematoma (SUBacute...not as important)

Bleeding b/w the dura mater and the arachnoid layer of the meninges. Usually CAUSED by injury to brain tissue and its blood vessels. Most common source of subdurals are veins that drain from surface of the brain into the sagittal sinus. May be slower to develop because of venousness. Elderly alcoholics are at increased risk

(Focal injury) contusion

Bruising of the brain tissue within a focal area. Usually associated with a closed head injury. Coup-contrecoup injury is often noted. Injuries range from minor to severe (comes from high-energy/impact injury mechanisms). Countercoup tends to be more severe. Can bleed or rebleed and 'blossom' on CT. Seizures common in first 7d. S/s include LOC/stupor and confusion. Monitor for 24-48h and f/u one week.

Temporal, parietal, and basilar

CSF otorrhea and Battle's sign are both seen in these three types of skull fractures

Frontal and basilar

CSF rhinorrhea is seen in 2

Head injury assessment nursing management

Determine whether CSF leak has occurred (halo and rhinorrhea). Assess for neurologic status with GCS, seizure activity, and CN deficits as observed in facial/basilar CN7 compression or CN3 compression with ptosis, sluggish rxn to light, etc. Check VS for cushings and physical s/s of trauma

Chronic subdural hematoma

Develops over weeks or months after a seemingly minor head injury. _____ more common in older adults because of a potentially larger ______ space (brain atrophy). When tension is increased on brain which is merely attached to supportive structures, it's subject to tear. Presenting complaint is focal s/s not increased ICP because the space is larger.

Transcranial Doppler; C-spine Xray

Doppler US of cranial blood vessels. Allows us to see how blood is flowing in the brain. So many head injuries are trauma and neck is also involved and took some pressure. So we look for this in the SECOND diagnostic study included in this one.

Ambulatory and home care nursing management

May require management for poor nutritional status, bowel and bladder management, spasticity, dysphagia, DVT, and hydrocephalus. Many pt's who are comatose for >6h have some personality change. Might also see loss of concentration and memory. SW needed etc.

Acute intervention nursing management

Monitor for changes in neuro status. Might deteriorate rapidly, necessitating emergency surgery. Close association b/w hemodynamic status and cerebral perfusion so be aware of preexisting conditions. Explain need for frequent neuro assessments to pt and caregiver. Eye problems include loss of corneal reflex (might need lubricating eyedrops or taping shut for abrasion prevention), periorbital ecchymosis (cold then warm compresses), edema, diplopia (use eye patch). Hyperthermia may occur from injury/inflammation to the hypothalamus. Elevations in body temperature can result in increased CBF>blood volume>ICP. 96.8 is the goal temp. Elevate HOB so that tear causing rhinorrhea and otorrhea can seal. Lies collection pad placed under nose or over ear. don't place dressing IN them. Don't blow or sneeze the nose. No NG or nasal suctioning b/c r/f meningitis. HA control with aceta and small codeine. Assume neck injury. Manage for ICP s/s and edema. Decrease metabolic demands with barbiturates and hypothermia (but no shivering). Turn q2h like ICP.

Subacute subdural hematoma

Occurs within 2-14d after the injury. After initial bleeding, the ____ may appear to enlarge over time as breakdown products of blood draw fluid into subdural space.

Acute subdural hematoma

Occurs within 24-48h. S/s are similar to brain tissue compression in increased ICP and include decreasing LOC and HA. Size determines patient's clinical presentation and prognosis. Ipsilateral pupil dilates and becomes fixed if really high ICP. Blunt force injuries produce ______ may also cause significant underlying brain injury that causes cerebral edema.

MRI

Picks up diffuse axonal injury in the brain well.

Health promotion nursing management

Prevent MVA's! Prevent car and motorcycle accidents. Wear safety belts and seatbelts. Helmets worn. People at r/f falls (older people) should be evaluated for safety in the home (falls second leading cause of head injuries)

Basilar and facial

Raccoon eyes or periorbital ecchymosis is present in which two types of skull fractures?

Epidural hematoma

Results from bleeding between the dura and the inner surface of the skull. This is a neurologic emergency because it's usually associated with linear fracture crossing a major artery in the dura. Bad because hematoma develops rapidly. Caused by linear fracture

Epidural hematoma s/s

S/s include initial period of unconsciousness at the scene, followed by brief lucid interval followed by a decrease in LOC. Unconscious, conscious, then unconscious again and even worse. Also HA, n/v, or focal findings. Surgery used to evacuate hematoma and prevent cerebral herniation (b/c of that rapid increase in ICP)

Battle's sign

Seen in basilar (linear) fracture. Postauricular ecchymosis. Can be accompanied by periorbital ecchymosis. Fracture associated with tear in dura and subsequent leakage of CSF. Can see Rhinorrhea (can manifest as postnasal sinus damage)and otorrhea. Look for the halo and allow leaking fluid to drip onto a white gauze pad (yellow ring should encircle the blood if CSF is present). Also see hemotympanium with basilar fracture (blood in the ear)

Types of Head Traumas

These include diffuse injury (concussion), diffuse axonal injury, and focal injury.

Collaborative care

Treatment of skull fractures is conservative. For depressions and fractures with loose fragments, craniotomy is necessary to elevate depressed bone and remove fragments. Craniectomy performed with large amounts of bone destroyed. Large acute subdurals and epidural hematomas, Burr-hole openings may be used for rapid decompression followed by craniotomy to visualize and allow control of the bleeding vessels. Drain placed postop to prevent reaccumulation of blood. In cases of extreme swelling expectation (DAI and hemorrhage), craniotomy performed to cut a hole for reduced pressure and reduce r/f herniation.

Epidural and subdural hematoma

Two complications of head injuries

Immediately after the injury, within 2 hours after injury, and 3 weeks after injury

What are the three times that death from a head trauma can occur?

Diffuse axonal injury (DAI...shearing is kind of outdated because it's a gradual process not from the immediate trauma)

Widespread axonal damage occurring after a mild, moderate, or severe TBI. Occurs around axons in subcortical white matter of cerebral hemis, basal ganglia,thalamus, and brainstem. Damage not preceded by an immediate tearing of axon from impact but rather the trauma changes function of the axon, resulting in axon swelling and disconnection (takes 12-24h). S/s include decreased LOC, increased ICP, posturing, global cerebral edema, etc. 90% go vegetative. MRI >CT. SHEARING