HEAD INJURY

Introduction
A head injury is any trauma to the scalp, skull, or brain. The injury may be only a minor bump
on the skull or a serious brain injury. A head injury may be mild or severe depending on what
caused it. Some injuries produce bleeding within your skull. Others cause damage on the outside
of your head. Brain injuries account for thousands of deaths each year in the U.S. As well,
significant numbers of people suffer temporary and permanent disability due to brain injury.
Head injury does not necessarily mean brain injury. Bleeding in the brain usually occurs at the
time of injury and can continue increasing pressure within the skull.

Types of head injury

 Closed head injury: A closed head injury means you received a hard blow to the head
from striking an object, but the object did not break the skull. It doesn't open your skull or
penetrate brain tissue. It can still cause bruising or swelling of the brain.
 0pen injury: An open injury is any damage that penetrates the skull. The damage may
cause bleeding within the brain’s tissues. This is more likely to happen when you move at
high speed, such as going through the windshield during a car accident. It can also
happen from a gunshot to the head.

Head injury may include:

1. Concussion: Concussion is jarring of the brain within the skull with temporary
loss of consciousness for 5 minutes or less and retrograde amnesia. There is no break in the
skull or dura and no visible damage on a CT or MRI scan.

2. Contusion: Contusions are associated with more extensive damage than that
from concussion. With contusions, areas of petechial and punctuate hemorrhage and bruised
areas in brain tissue.

3. Diffuse axonal injury: Diffuse axonal injury is the most severe form of head
injury because there is no focal lesion to remove. The injury involves the tissue of the entire
brain and occurs at the microscopic level. Diffuse axonal injury is classified as mild,
moderate and severe.
 Mild – Loss of consciousness lasting 6 to 24 hrs and may be short term
disability
 Moderate – Less than 24 hrs with incomplete recovery awakening
 Severe – Primary injury to the brain stem. Pt. may present with abnormal
posturing and in coma but there is no evidence of cerebral edema or increased ICP.
Immediate loss of consciousness, prolonged coma, abnormal flexion or extension,
posturing, hypertension and fever.

4. Skull fracture: a force sufficient to the skull and cause brain injury often causes
Skull fractures. The three types of skull fractures are as follows:
 Linear skull fracture: Appears as thin lines radiographically and do not
require treatment; they are important only if there is significant underlying brain damage.
  Depressed skull fractures: Displacement of fractured fragment in the
skull. It may be palpated and are seen radiographically.
 Basilar skull fractures: It occurs in bones over the base of the frontal
and temporal lobes. These are not observable on plain radiographs but may be manifested
as ecchymosed around the eyes or behind the ears.

5. Epidural Hematoma: The most serious types of hematoma form rapidly and
result from arterial bleeding. Epidural hematoma forms between the dura and the skull from
a tear in the meningeal artery. Epidural hematoma is a surgical emergency.

6. Subdural Hematoma: Subdural hematoma forms slowly and results from a

venous bleed. It occurs between dura matter and arachnoid matter as a result of tears in the
veins crossing the subdural space.

7. Subarchnoid Hemorrhage: Bleeding occurs directly into the brain, the

ventricles or subarachinoid space (between arachnoid matter and pia matter)

8. Intracerebral hemorrhage: Intracerebral hematoma occurs less often than

epidural hematoma. It occurs in brain tissues and may also occur at the area of injury or deep
within the brain. These hematoma cause problems with increased ICP.

Causes
 Gun shot wounds
o It can cause head injuries when the bullet penetrates the skull and enters your brain.
o This can damage the blood vessels and cause bleeding.
 Vehicle accidents

o  It is common causes of traumatic head injuries.

o This can lead to open or closed brain injuries.
o You may also get a concussion or scalp injury in a vehicle accident.

 Violent shaking 
o It is a common cause of brain trauma in infants and young children.
o When a child is shaken, the brain violently strikes the skull.
o This produces swelling and bleeding in its tissue.
o Shaken baby syndrome can cause severe brain injury.

 Falling and hitting your head

o It can damage the skull, scalp, or brain.
o Falls may cause any type of head injury.

 Assault
o Being kicked, punched, or struck in the head can cause a concussion, closed or open brain
injury.
o Damage varies with the force of the assault.
  Alcohol consumption
 Driving without seat belt
Pathophysiology
Brain suffers traumatic injury

Brain swelling or bleeding increases intracranial volume

Rigid cranium allows no room for expansion of contents so intracranial pressure

increases

Pressure on blood vessel within the brain causes blood flow to the brain to slow
Cerebreal hypoxia and ischemia occurs

Intracranial pressure continues to rise. Brain may herniated

Cerebral blood flow ceases

Sign and symptoms

 Mild head injury

• inability to stand or balance
• Confusion
• small cuts or bumps
• headache
• nausea
• temporary memory loss
• ringing in the ear

 Severe head injury

• bleeding from deep cuts or wounds in the scalp
• loss of consciousness
• abnormal eye movements
• inability to focus the eyes
• loss of muscle control
• Seizures
• Vomiting
• difficulty tolerating bright lights,
• leaking cerebrospinal fluid from the ear or nose,
• bleeding from the ear,
• speech difficulty
 • paralysis
• difficulty swallowing, and
• Numbness of the body.
Diagnostic Investigation

 History taking and physical examination

 Skull x-ray
 CT scan
 MRI
 EEG
 ECG
 Cerebral angiographies
 Lumber puncture: Lumber puncture is often omitted because of fear of brainstem
herniation due to increased intracranial pressure.
 Blood investigations
 Urine examinations

Treatment
First aid
Recognize a serious head injury and give basic first aid can save someone's life.
 For a moderate to severe head injury , seek for medical help right away if the person-
• Becomes very sleepy
• Behaves abnormally
• Develops a severe headache or stiff neck
• Has pupils (the dark central part of the eye) of unequal sizes
• Is unable to move an arm or leg
• Loses consciousness, even briefly
• Vomits more than once

Then take the following steps:

 Check the person's airway, breathing, and circulation.
 If necessary, begin rescue breathing and CPR.
 If the person's breathing and heart rate are normal but the person is unconscious, treat as if
there is a spinal injury.
 Stabilize the head and neck by placing your hands on both sides of the person's head.
 Keep the head in line with the spine and prevent movement.
 Wait for medical help.
 Stop any bleeding by firmly pressing a clean cloth on the wound.
 If the injury is serious, be careful not to move the person's head.
 If blood soaks through the cloth, do not remove it.
 Place another cloth over the first one.
 If you suspect a skull fracture, do not apply direct pressure to the bleeding site, and do not
remove any debris from the wound.
 Cover the wound with sterile gauze dressing.
  If the person is vomiting, to prevent choking, roll the person's head, neck, and body as one
unit onto his or her side.
 This still protects the spine, which you must always assume is injured in the case of a head
injury.
 Children often vomit once after a head injury.
 This may not be a problem, but call a doctor for further guidance.

Do not
 Do NOT wash a head wound that is deep or bleeding a lot.
 Do NOT remove any object sticking out of a wound.
 Do NOT move the person unless absolutely necessary.
 Do NOT shake the person if he or she seems dazed.
 Do NOT remove a helmet if you suspect a serious head injury
 Do NOT pick up a fallen child with any sign of head injury.
 Do NOT drink alcohol within 48 hours of a serious head injury.
 A serious head injury that involves bleeding or brain damage must be treated in a
hospital.
 For a mild head injury, no treatment may be needed.
 However, watch for symptoms of a head injury, which can which can show up later.

Treatment
 If the patient with simple head injury with no history of concussion and vomiting, the
medical treatment includes;
 Keeping the patient in observation for 24 hour.
 Complete bed rest.
 Symptomatic treatment and advice the patient to report if he develops severe headache,
vomiting drowsiness or consciousness.
 Prophylactic antibiotics are administered to prevent potential CNS infection.
 Sedatives such as paraldehyde 8 to 10 mg or phenobarbitone 100mg should be given.
 Medical decompression is done to reduce the cerebral edema. It includes
• Dexomethasone 4 to 8 mg im or iv at 4 to 6 hours.
• Inj mannitol 50gm iv to improve diuresis.
• Frusemide 40mg iv to reduce the size of the edematous brain.
• Lumber puncture is contraindicated for fear of coning.
• Restrict the fluid intake to keep patient slight dehydrated.

Surgical management
Is indicated when;
• Depressed facture of the skull to elevate the bone.
• Scalp wound with severe bleeding
• Subdural and epidural hematoma.
• Dural tear and CSF leakage require immediate repair,
• Unexplained unconsciousness warrant diagnostic burr hole.

1. Burr holes: It is done for subdural and epidural hematomas. In this clots are
 evacuated through burr holes and sometime craniotomy.
2. Craniotomy: Surgical removal or opening of a portion of the skull, performed to
expose the brain. During surgery the wound may be drained and bleeding vessels are
ligated. Usually craniotomy is done to treat simple skull depressions to remove bone
fragments, to repair lacerated dura and to evacuate the intra-cerebral hematomas.

Nursing management
ASSESSMENT
Obtain health history, including time of injury, cause of injury, direction and force of
blow, loss of consciousness and condition following injury.
Assess the patient including determining the patients loss of consciousness using the
Glasgow coma scale and if patient is unconscious light, corneal and check papillary
response to light, corneal and gag reflexes and motor function.
a. Monitor vital signs
• Monitor patient at frequent intervals to assess intracranial status.
• Assess for increases ICP, including slowing of pulse, increasing systolic pressure, and
widening pulse pressure.
• As compression increases, vital signs are reserved pulse and respiration become rapid,
and blood pressure may decrease
b. Monitor for complication.
• Peak swelling occurs about 72 hours after injury, with resulting elevation of ICP.
• After injury, some patients develop focal nerve palsies, such as anomies ( lack of sense
of smell) or eye movement abnormalities and focal neurologic defect, memory defect,
seizure etc.

Nursing diagnosis

1. Ineffective airway clearance and ventilation related to hypoxia

• Position the unconscious patient to facilitate drainage of secretions,
• Elevate head of bed 30 degrees to decrease ICP.
• Establish effective suctioning procedures.
• Monitor arterial blood gases to assess adequacy of ventilation.
• Monitor patient on mechanical ventilation.
• Monitor for pulmonary complications (ARDS and pneumonia).

2. Deficient fluid volume related to disturbances of unconsciousness

• Monitor of serum and urine electrolyte levels.
• Record daily weights (which may indicate fluid loss from diabetes insipidus).
• Monitor intake and output chart.
• Monitor for continue nausea, vomiting and seizure.

3. Imbalanced nutrition less than body requirement related to inadequate intake.

 nutrition is maintained by oral or tube feeding as the patient condition permits.
 Parental fluid is administered to provide caloric and fluid balance.
  Give small, frequent feeding to lessen the possibility of vomiting and diarrhea.
 Elevate head of bed while feeding.
4. Risk for injury related to seizures, disorientation and restlessness.
 Observe for restlessness, which may be due to hypoxia, fever, pain, or full bladder.
 Avoid bladder destination.
 Keep environment stimuli to minimum
 Do not disrupt sleep/wake cycle.
 Protect patient from injury by keeping side rails.

5. Risk for impaired skin integrity related to bed rest, immobility or restlessness
 Assess all body surfaces and documenting skin integrity every 8 hourly.
 Turning and reposting the patient every 2 hourly
 Providing skin care every 4 hourly.
 Assisting the patient to get out of bed to at least 3 times a day.

PREVENTATION
 Falls are the number one cause of head injury. Some, like toddlers falling when learning
to walk are unavoidable but others may be preventable, especially in the elderly.
 Proper floor coverings should be used in the bathrooms and stair.
 Head injuries are major consequence of motor vehicle crashes. Lives can be saved by
wearing seatbelts, avoiding risky driving behavior like drinking and driving, texting
while driving.
 Helmets may decrease head injury while riding a bicycle or motorcycle. And also while
sporting activities like skateboarding, snowboarding.

COMPLICATION
 Seizure
 Coma
 Hypoxia
 Infection
 Nerve damage
 Sensory problems
 Difficulty swallowing
 A persistent headache

PROGNOSIS
 The recover from head injury depends upon the amount of damage inflicted upon the
brain. Not surprisingly the brain cannot recover from server injury, but goal of treatment
is to return as much as function possible.