Head Injuries, Brain Injury, and Spinal Cord Injury

• Lesson Title: Head Injuries, Brain Injury, and Spinal Cord Injury

Head Injuries

• Head injuries are broad classifications that include injury to the scalp, skull, or brain.
• Head injuries range from mild concussion to death, with the most serious form known as a traumatic brain injury (TBI).
• Common causes of TBIs include falls (28%), motor vehicle crashes (20%), being struck by objects (19%), and assaults (11%).
• The highest-risk group for TBI are individuals 15-19 years of age.
• Males are twice as likely as females to sustain a TBI.

Forms of Head Injury

• Primary injury involves contusions, lacerations, and torn blood vessels due to impact, acceleration/deceleration, or foreign object penetration.
• Secondary injury evolves over hours and days after the initial injury due to inadequate nutrient and oxygen delivery to cells.

Scalp Injury

• A large avulsion (tearing away) of the scalp may be life-threatening.

Skull Fractures

• Skull fractures are a break in the continuity caused by trauma.
• Skull fractures may occur with or without brain damage.
• Skull fractures are classified: simple, comminuted, depressed, or basilar.

Head Injury Pathophysiology

• The brain suffers traumatic injury.
• Brain swelling or bleeding increases intracranial volume (ICV).
• The rigid cranium doesn't allow for expansion, which increases intracranial pressure (ICP).
• Pressure on blood vessels slows blood flow to the brain.
• Cerebral hypoxia and ischemia occur.
• Intracranial pressure rises, potentially causing brain herniation.
• Cerebral blood flow ceases.

Head Injury Clinical Manifestations

• Persistent, localized pain.
• Fractures of the skull base cause hemorrhage from the nose, pharynx, or ears; blood under the conjunctiva; and ecchymosis over the mastoid (Battle's sign).
• Basilar skull fractures result in cerebrospinal fluid (CSF) escaping from the ears (CSF otorrhea) and nose (CSF rhinorrhea).

Head Injury Assessment and Diagnostics

• Physical and neurological examinations detect obvious brain injuries.
• X-rays confirm the presence and extent of skull fracture.
• Computed tomography (CT) scans show acute lesions; it assists in managing head injuries by disclosing edema, contusion, hematoma, hemorrhage, and late changes such as infarction or hydrocephalus..
• Magnetic resonance imaging (MRI) evaluates patients with head injuries when a more accurate picture of the injury's anatomic nature is needed and the patient is stable enough for the longer procedure.
• Cerebral angiography identifies supratentorial, extracerebral, and intracerebral hematomas and cerebral contusions.

Head Injury Medical Management

• Nondepressed skull fractures generally do not need surgery, but need close observation.
• Patients with no underlying brain injury may return home.
• Depressed skull fractures require surgery with elevation of the skull and debridement, usually within 24 hours of injury.

Brain Injury

• Minor brain injury can lead to significant damage due to obstructed blood flow and decreased tissue perfusion.
• Closed (blunt) brain injury is where the head accelerates, then rapidly decelerates or collides with another object. Brain tissue is damaged, but there is no opening through the skull and dura.
• Open brain injury occurs when an object penetrates the skull, enters the brain, and damages soft brain tissue is damaged or when severe blunt trauma opens the scalp, skull, and dura to expose the brain.

Concussion

• Concussion is a temporary loss of neurologic function with no apparent structural damage.
• Concussions are referred to as a mild TBI, and may or may not produce a brief loss of consciousness.
• Brain injury is commonly caused by blunt trauma from an acceleration-deceleration force, direct blow, or blast injury.
• Frontal lobe injuries may cause bizarre/irrational behavior, while temporal lobe injuries cause temporary amnesia or disorientation.

Types of Concussion

• Mild concussion can lead to a period of transient confusion, disorientation, or impaired consciousness.
• Memory lapse is common at the time of injury and loss of consciousness lasts less than 30 minutes.
• Classic concussion results in a loss of consciousness that lasts for less than 6 hours.
• Loss of consciousness is always accompanied by some degree of posttraumatic amnesia.
• Diagnostic studies show no structural injury with concussion, but the duration of unconsciousness indicates its severity.

Contusion

• Contusion is a moderate to severe head injury, where the brain is bruised and damaged because of severe acceleration-deceleration force or blunt trauma.
• Contusions can be identified by loss of consciousness associated with stupor and confusion.

Diffuse Axonal Injury (DAI)

• DAI results from widespread shearing and rotational forces that produce damage throughout the brain.
• Axons of the cerebral hemispheres, corpus callosum, and brain stem may be affected.
• The injured area may be diffuse, with no identifiable focal lesion.
• DAI is associated with prolonged traumatic coma; it is more serious and associated with a poorer prognosis than a focal lesion or ischemia.

Intracranial Hemorrhage

• Symptoms are frequently delayed until hematomas are large enough to cause distortion of the brain and increased ICP.
• Epidural hematoma is a collection of blood in the epidural space between the skull and dural mater.
• Subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid.
• Intracerebral hemorrhage and hematoma is the bleeding into the substance of the brain/within the brain.

Brain Injury Clinical Manifestations

• Altered level of consciousness
• Confusion
• Pupillary abnormalities (changes in shape, size, and response to light)
• Altered or absent gag reflex
• Absent corneal reflex
• Sudden onset of neurologic deficits
• Changes in vital signs (altered respiratory pattern, widened pulse pressure, bradycardia, tachycardia, hypothermia, or hyperthermia)
• Vision and hearing impairment
• Sensory dysfunction
• Headache
• Seizures

Brain Injury Assessment and Diagnostic Findings

• Physical and neurologic examinations
• CT and MRI scans for evaluating the brain structure

Brain Injury Management

• Any patient with a head injury is presumed to have a cervical spine injury until proven otherwise.
• Patients should be transported on a board with their head and neck aligned with the axis of the body.
• Apply a cervical collar.
• Prevent secondary injury.
• Treat increased intracranial pressure.
• Provide supportive measures.
• Provide end-of-life care to patients with brain death.

Brain Injury Collaborative Problems and Potential Complications

• Decreased cerebral perfusion
• Cerebral edema and herniation
• Impaired oxygenation and ventilation
• Impaired fluid, electrolyte, and nutritional balance
• Risk of posttraumatic seizures

Brain Injury Nursing Interventions

• Monitor neurologic function, including Level of Consciousness (LOC) and Vital Signs (Signs of increasing ICP: Cushing's triad).
• Glascow Coma Scale (GCS) is used to assess LOC at regular intervals.
• Motor function assessment.
• Pupillary Assessment (size and equality of the pupils).
• Maintain airway with elevation of head of the bead; suction.
• Monitor fluid and electrolyte balance.
• Promote adequate nutrition.
• Increase calorie consumption.
• Pad siderails to prevent injuries, avoid opioids, and reduce environmental stimuli.
• Maintain body temperature (give Acetaminophen, use cooling blankets, and culture for potential sites of infection).
• Maintain skin integrity, Turning and positioning; check skin integrity.
• Improve Cognitive Function.
• Monitor and Manage Potential Complications.
• Promote Home and Community-Based Care.

Spinal Cord Injury

• Spinal cord injury (SCI) is primarily an injury of young adult males, with 50% of those injured between 16 and 30 years of age.
• Predominant risk factors include young age, male gender, alcohol and drug use.
• Most spinal cord injuries (~80%) occur in men.
• Major causes of death due to SCI are pneumonia, pulmonary emboli (PE), and septicemia.

Spinal Cord Injury Pathophysiology

• Spinal cord injury ranges from transient concussion to contusion, laceration, and compression of spinal cord substance.
• Complete transection (severing) of the spinal cord results in paralysis below the injury level.
• The 5th, 6th, and 7th cervical vertebrae (C5 to C7), the 12th thoracic vertebra (T12), and the 1st lumbar vertebra (L1) are most commonly involved, due to a greater range of motion within the vertebral column.
• Primary injuries and secondary injuries are two categories.

Spinal Cord Injury Clinical Manifestations

• Acute pain in the back or neck, which may radiate along the involved nerve.
• Fear that the neck or back is broken.
• Incomplete spinal cord lesions affects sensory or motor fibers, or both, are preserved below the lesion.
• This consists of (a) total sensory and motor paralysis, (b) loss of bladder and bowel control (usually with urinary retention and bladder distention), and (c) loss of sweating and vasomotor tone, and marked reduction of blood pressure.
• A complete spinal cord lesion results in total loss of sensation and voluntary muscle control below the lesion, which results in paraplegia or tetraplegia.

Spinal Cord Injury Assessment and Diagnostic Tests

• X-rays (lateral cervical spine x-rays) and CT scan.
• MRI (myelogram if MRI is contraindicated).
• Continuous electrocardiographic monitoring is a diagnostic tool due to bradycardia (slow heart rate) and asystole (cardiac standstill).

Spinal Cord Injury Emergency Management

• All patients with a motor vehicle crash, a diving/contact sports injury, a fall, or any direct trauma the head and neck must be considered to have SCI.
• Rapid assessment, immobilization, stabilization of life-threatening injuries, and transportation must occur.
• If SCI and bone instability have been ruled out, the patient may be moved to a conventional bed or the collar may be removed.

Spinal Cord Injury Medical Management - Acute Phase

• Management goals are to prevent secondary injury, observe progressive neurologic deficits symptoms, and prevent complications. Involves:
• Pharmacologic intervention with high-dose IV corticosteroids.
• Respiratory therapy.
• Skeletal fracture reduction and traction.

Spinal Cord Injury Surgical Management Indicatons

• Compression of the cord.
• A fragmented or unstable vertebral body.
• A wound that penetrates the cord.
• Bony fragments in the spinal canal.
• A patient's deteriorating neurologic status.

Management of Acute Complications of Spinal Cord Injury

• Spinal and neurogenic shock.
• Spinal shock: use intestinal decompression through the insertion of a nasogastric tube.
• Neurogenic shock: close observation is needed for early detection as shown by abrupt onset of fever.
• Deep Vein Thrombosis (DVT) prevention with low-dose anticoagulation therapy and use of anti-embolism stockings/pneumatic compression devices.
• Calves or thighs should never be massaged.
• Other complications: respiratory failure, pneumonia, autonomic dysreflexia, pressure ulcers, and infections.

Spinal Cord Injury Nursing Interventions

• Promote adequate breathing & airway clearance with oxygenation monitoring; and suctioning of secretions.
• Improve mobility by maintaining proper body alignment and ROM exercises.
• Promote adaptation to sensory and perceptual alterations through the stimulation of senses.
• Maintain skin integrity.
• Maintain urinary elimination.
• Improve bowel function.
• Provide comfort measures.
• Monitor and manage potential complications (thrombophlebitis, orthostatic hypotension, and autonomic dysreflexia)