Head Injuries in Nursing

• Head injuries in nursing involve trauma to the scalp, skull, or brain.

Types of Head Injuries

• Scalp injuries: Can cause significant bleeding due to high vascularity.
• Skull fractures: May be linear, depressed, comminuted, or basilar; basilar fractures can lead to CSF leaks.
• Brain injuries: Can be primary (at the time of impact) or secondary (evolving after the initial injury).
• Primary injuries include concussions, contusions, and diffuse axonal injury (DAI).
• Secondary injuries include edema, increased intracranial pressure (ICP), ischemia, and infection.

Concussion

• A mild traumatic brain injury (MTBI) resulting from blunt trauma or acceleration-deceleration forces.
• May involve a brief loss of consciousness, headache, dizziness, and confusion.
• Post-concussion syndrome can include persistent headaches, memory problems, and mood disturbances.
• Management involves physical and cognitive rest.

Contusion

• Bruising of the brain tissue, often associated with skull fractures.
• Can cause focal neurological deficits and seizures.
• Coup injury: Contusion at the site of impact.
• Contrecoup injury: Contusion on the opposite side of the impact.
• Symptoms vary depending on the location and extent of the contusion.

Diffuse Axonal Injury (DAI)

• Widespread damage to axons due to shearing forces.
• Often results in a prolonged coma.
• Difficult to detect on standard CT scans; MRI is more sensitive.
• Prognosis is often poor.

Hematomas

• Epidural Hematoma (EDH):
• Collection of blood between the skull and the dura mater.
• Often associated with a skull fracture and arterial bleed (middle meningeal artery).
• Can cause rapid neurological deterioration.
• May present with a brief loss of consciousness followed by a lucid interval and then rapid decline.
• Requires urgent surgical evacuation.
• Subdural Hematoma (SDH):
• Collection of blood between the dura and the arachnoid mater.
• Often caused by tearing of bridging veins.
• Acute SDH: Develops within 24-48 hours of injury.
• Subacute SDH: Develops within 2-14 days.
• Chronic SDH: Develops over weeks to months, more common in elderly.
• Symptoms vary depending on the size and rate of bleeding.
• Management may involve surgical evacuation or conservative monitoring.
• Intracerebral Hematoma:
• Bleeding within the brain tissue.
• Can be caused by trauma or non-traumatic factors (e.g., hypertension, aneurysm).
• Causes focal neurological deficits and increased ICP.
• Management depends on the size and location of the hematoma.

Increased Intracranial Pressure (ICP)

• Normal ICP is 5-15 mmHg.
• Elevated ICP can lead to brain ischemia and herniation.
• Causes include cerebral edema, hematomas, hydrocephalus, and space-occupying lesions.
• Signs and Symptoms:
• Decreased level of consciousness.
• Headache.
• Vomiting (often projectile).
• Pupillary changes (unequal, dilated, or non-reactive).
• Cushing's triad (late sign): hypertension with widening pulse pressure, bradycardia, and irregular respirations.
• Papilledema (swelling of the optic disc).

Monitoring ICP

• Invasive monitoring:
• Ventriculostomy: Catheter placed in the lateral ventricle to measure ICP and drain CSF.
• Intraparenchymal monitor: Sensor placed directly into the brain tissue.
• Epidural sensor: Sensor placed between the skull and the dura mater.
• Non-invasive monitoring:
• Transcranial Doppler: Measures cerebral blood flow velocity.
• Optic nerve sheath diameter measurement.

Management of Increased ICP

• Elevate the head of the bed to 30 degrees.
• Maintain normothermia.
• Optimize ventilation to maintain PaCO2 between 35-40 mmHg.
• Administer osmotic diuretics (e.g., mannitol) or hypertonic saline to reduce cerebral edema.
• Administer sedatives (e.g., propofol) and analgesics (e.g., fentanyl) to reduce metabolic demand.
• Administer neuromuscular blocking agents (e.g., vecuronium) to prevent straining and agitation.
• Barbiturate coma: Used as a last resort to reduce cerebral metabolic rate.
• Decompressive craniectomy: Surgical removal of a portion of the skull to allow for brain expansion.

Nursing Assessment

• Neurological assessment:
• Level of consciousness using the Glasgow Coma Scale (GCS).
• Eye-opening (1-4).
• Verbal response (1-5).
• Motor response (1-6).
• GCS score ranges from 3 (deep coma) to 15 (fully alert).
• Pupillary response.
• Motor and sensory function.
• Cranial nerve assessment.
• Vital signs:
• Monitor for Cushing's triad.
• Monitor for signs of shock (hypotension, tachycardia).
• Respiratory assessment:
• Monitor for signs of respiratory distress.
• Assess airway patency and breathing effectiveness.
• Fluid and electrolyte balance:
• Monitor for signs of dehydration or fluid overload.
• Monitor serum electrolytes and osmolality.

Nursing Interventions

• Airway management:
• Ensure a patent airway.
• Suction as needed.
• Insert an oropharyngeal or nasopharyngeal airway if necessary.
• Prepare for intubation if indicated.
• Breathing support:
• Administer supplemental oxygen.
• Monitor respiratory rate, depth, and effort.
• Assist with ventilation if needed.
• Circulation support:
• Monitor blood pressure and heart rate.
• Administer intravenous fluids as prescribed.
• Monitor for signs of bleeding.
• Neurological monitoring:
• Continuously monitor level of consciousness.
• Assess pupillary response and motor function.
• Monitor ICP and cerebral perfusion pressure (CPP).
• CPP = MAP - ICP
• Maintain CPP > 60 mmHg.
• Medication administration:
• Administer medications as prescribed to manage ICP, pain, and seizures.
• Positioning:
• Elevate the head of the bed to 30 degrees.
• Maintain proper body alignment.
• Turn the patient frequently to prevent pressure ulcers.
• Seizure precautions:
• Pad side rails.
• Have suction and oxygen equipment readily available.
• Administer anticonvulsants as prescribed.
• Nutritional support:
• Initiate enteral or parenteral nutrition as soon as possible.
• Monitor fluid and electrolyte balance.
• Prevention of complications:
• Prevent infection by using sterile technique when performing invasive procedures.
• Prevent deep vein thrombosis (DVT) with prophylactic measures (e.g., sequential compression devices, anticoagulants).
• Prevent skin breakdown with frequent turning and pressure relief.
• Emotional Support:
• Provide emotional support to the patient and family.
• Explain procedures and answer questions.
• Offer resources for coping and support.

Complications of Head Injuries

• Increased ICP.
• Herniation:
• Uncal herniation: Lateral displacement of the temporal lobe, compressing the brainstem.
• Central herniation: Downward displacement of the brainstem.
• Signs include fixed and dilated pupils, altered level of consciousness, and respiratory arrest.
• Seizures.
• Infection (meningitis, encephalitis).
• Hydrocephalus.
• Diabetes insipidus (DI):
• Caused by decreased secretion of antidiuretic hormone (ADH).
• Results in polyuria, polydipsia, and hypernatremia.
• Managed with fluid replacement and vasopressin.
• Syndrome of inappropriate antidiuretic hormone secretion (SIADH):
• Caused by excessive secretion of ADH.
• Results in hyponatremia and fluid retention.
• Managed with fluid restriction and diuretics.
• Cognitive and behavioral deficits.
• Persistent vegetative state.
• Death.

Surgical Interventions

• Craniotomy: Surgical opening of the skull to remove hematomas, contusions, or tumors.
• Craniectomy: Surgical removal of a portion of the skull to relieve pressure.
• Burr holes: Small holes drilled into the skull to drain hematomas.
• Ventriculostomy: Placement of a catheter into the ventricle to drain CSF and monitor ICP.

Rehabilitation

• Physical therapy:
• Focuses on improving motor function, balance, and coordination.
• Occupational therapy:
• Focuses on improving activities of daily living (ADLs) and cognitive skills.
• Speech therapy:
• Focuses on improving communication, swallowing, and cognitive skills.
• Cognitive rehabilitation:
• Focuses on improving memory, attention, and executive function.
• Psychotherapy:
• Helps patients and families cope with the emotional and psychological effects of the injury.

Discharge Planning

• Provide education to the patient and family about medication management, wound care, and potential complications.
• Referrals to rehabilitation services, support groups, and community resources.
• Follow-up appointments with physicians and therapists.