Head Injury, Brain Injury, and Spinal Cord Trauma Flashcards

What is a head injury, and how severe can it be?

Trauma to the:

Scalp

Skull

Brain

Severity can range from:

Concussion

Coma

Permanent neurologic damage

Brain death

Death

What is a traumatic brain injury, or TBI?

TBI is brain damage caused by an external force that is severe enough to interfere with normal brain function or daily life.

What is a primary brain injury?

A primary brain injury is the initial damage that occurs at the time of the traumatic event.

Examples include:

Concussion

Cerebral contusion

Skull fracture

Diffuse axonal injury

Intracranial hematoma

What is a secondary brain injury?

Secondary brain injury develops during the hours and days after the original trauma because brain cells receive inadequate oxygen and nutrients. Early treatment is important to prevent worsening edema, ischemia, and permanent brain damage.

What factors can worsen secondary brain injury?

Hypoxia

Hypotension

Hypercarbia

Cerebral edema

Increased ICP

Intracranial bleeding

Fever

Seizures

Infection

Anemia

Fluid or electrolyte imbalances

What is the Monro-Kellie doctrine?

The skull is a closed space containing brain tissue, blood, and CSF. If the volume of one component increases, one or both of the others must decrease, or intracranial pressure will rise.

What is the pathophysiologic cycle of traumatic brain injury?

Injury → change in intracranial volume → increased ICP → brain displacement → restricted cerebral blood flow → inadequate oxygen and nutrients → cells become anoxic and cannot metabolize → ischemia → infarction → irreversible brain damage → brain death.

How does the brain initially compensate for increasing intracranial volume?

The body initially shifts or absorbs CSF and decreases cerebral blood volume. Once these mechanisms are exhausted, even a small increase in blood or edema can cause a major rise in ICP

Why do scalp injuries bleed profusely?

The scalp contains many blood vessels that constrict poorly, so even a relatively small laceration may bleed heavily.

What are the common types of scalp injury?

Scalp injuries include:

Abrasions

Contusions

Lacerations

Subgaleal hematomas

Scalp avulsions

What is a subgaleal hematoma?

A subgaleal hematoma is a collection of blood beneath the tissue layers of the scalp. It usually reabsorbs without specific treatment.

How are scalp wounds treated?

Control bleeding

Inspect and palpate the injury

Irrigate and cleanse the wound

Remove foreign material

Suture the wound when indicated

Monitor for infection

Assess for an underlying skull or brain injury

Why must a scalp wound be irrigated before suturing?

Irrigation removes dirt and foreign material and reduces the risk of organisms entering the wound and causing an intracranial infection.

Can a patient bleed to death from a scalp injury?

Most isolated minor scalp wounds are not fatal, even though they may look dramatic. However, a large scalp avulsion or uncontrolled bleeding can cause significant or life-threatening blood loss.

What is a skull fracture?

A skull fracture is a break in the continuity of the skull caused by forceful trauma. It may occur with or without an underlying brain injury.

What is a simple or linear skull fracture?

A simple or linear fracture is a single break in the skull, often caused by blunt trauma. The bone is not displaced inward.

What is a comminuted skull fracture?

A comminuted fracture occurs when the skull is broken into multiple fragments, usually by a heavy or forceful impact over a wider area.

What is a depressed skull fracture?

A depressed skull fracture occurs when fragments of the skull are pushed inward and press on or penetrate brain tissue. Surgical elevation and debridement may be necessary.

What is a basilar skull fracture?

A basilar skull fracture occurs at the base of the skull where the brain rests. It can be life-threatening because it may cause bleeding, CSF leakage, cranial nerve injury, and meningitis.

What is the difference between an open and closed skull fracture?

An open fracture involves disruption of the scalp or penetration of the dura. In a closed fracture, the dura remains intact.

What symptom may indicate a skull fracture?

Persistent, localized pain after head trauma may suggest a skull fracture. Swelling or a palpable depression may also be present.

. How are skull fractures diagnosed?

CT scan:

Primary test for skull fractures

Identifies acute intracranial bleeding

Skull x-ray:

May identify certain fractures

MRI:

Provides clearer imaging of brain and soft-tissue injuries

What bleeding can occur with a basilar skull fracture?

Blood may drain from the:

Nose

Ears

Pharynx

Blood may also appear beneath the conjunctiva.

What is Battle sign?

Battle sign is bruising over the mastoid area behind the ear. It is associated with a basilar skull fracture and may not appear immediately after the injury.

What are CSF rhinorrhea and CSF otorrhea?

CSF rhinorrhea: Leakage of cerebrospinal fluid from the nose

CSF otorrhea: Leakage of cerebrospinal fluid from the ear

Both can occur with a basilar skull fracture.

Why is CSF leakage dangerous?

A CSF leak indicates a possible tear in the dura and creates a route through which organisms may enter the cranial cavity and cause meningitis.

What is the halo sign?

When bloody drainage containing CSF is placed on absorbent material, the blood may remain in the center while a clearer or lighter ring forms around it. This may suggest CSF leakage but is not definitive by itself.

What precautions are needed with a suspected basilar skull fracture?

Avoid:

Nasogastric tube insertion

Nasal suctioning

Nasotracheal intubation

Other nasal instrumentation

If gastric decompression is required:

Use an oral route as ordered

Monitor for:

CSF leakage

Meningitis

Neurologic deterioration

How are nondepressed and depressed skull fractures managed?

Nondepressed fracture:

Close observation

Frequent neurologic assessments

Monitoring for underlying brain injury

Depressed fracture:

Surgical elevation

Debridement

Repair of dural injury

Treatment of associated brain damage

What is a closed brain injury?

A closed brain injury occurs when the brain is damaged without the skull and dura being opened.

Common causes include:

Acceleration-deceleration injury

Blunt trauma

Motor vehicle crash

Fall

Collision with another object

What are examples of acceleration-deceleration brain injury?

Motor vehicle collision

Rapid forward and backward movement of the head

Severe rotational movement

Abusive head trauma

These forces may cause:

Cerebral contusions

Subdural bleeding

Diffuse axonal injury

What is an open brain injury?

Scalp, skull, and dura are opened.

Brain tissue is exposed or penetrated.

Causes may include:

Gunshot wound

Stab wound

Penetrating object

Severe blunt trauma

What is the difference between focal and diffuse brain injury?

A focal injury affects a specific area, such as a contusion or hematoma.

A diffuse injury causes widespread damage, such as a concussion or diffuse axonal injury.

What is a concussion?

A concussion is a temporary alteration or loss of neurologic function without obvious structural brain damage.

May cause:

Headache

Dizziness

Confusion

Amnesia

Disorientation

Brief loss of consciousness

How were mild and classic concussions described in the original course notes?

The original notes describe:

Mild concussion: Loss of consciousness for less than 30 minutes

Classic concussion: Loss of consciousness for less than 6 hours

Current clinical classification may use different criteria, so follow the terminology required by the course.

Why should a patient with a concussion not be left alone?

A responsible person should monitor for:

Decreasing LOC

Difficulty awakening

Worsening headache

Repeated vomiting

Seizures

Unequal or abnormal pupils

Weakness

Numbness

Slurred speech

Increasing confusion or irritability

What is postconcussion syndrome?

Persistent symptoms after a concussion, including:

Headache

Neck pain

Fatigue

Dizziness

Sleep disturbances

Mood changes

Difficulty concentrating

Memory problems

What is a cerebral contusion?

A cerebral contusion is bruising of brain tissue caused by blunt trauma or acceleration-deceleration force. Bleeding and edema occur in a localized part of the brain.

What are the manifestations of a cerebral contusion?

Loss of consciousness

Stupor

Confusion

Focal neurologic deficits

Cerebral bleeding

Cerebral edema

Increased ICP

Possible herniation

Effects often peak approximately 18 to 36 hours after injury.

Does bleeding from a brain contusion always stop without complications?

Small contusions may stabilize, but bleeding and edema can worsen. The patient requires monitoring because a contusion can increase ICP and cause secondary brain injury or herniation.

What is diffuse axonal injury?

Diffuse axonal injury is widespread, nonfocal damage caused by shearing and rotational forces that tear or stretch axons throughout the brain.

What areas are commonly damaged in diffuse axonal injury?

Cerebral hemispheres

Corpus callosum

Brain stem

What are manifestations of severe diffuse axonal injury?

Immediate, prolonged coma

No lucid interval

Decorticate posturing

Decerebrate posturing

Global cerebral edema

Poor neurologic prognosis

How can severe shaking cause diffuse axonal injury?

Rapid rotational movement causes the brain to move within the skull, producing widespread shearing of axons. This type of mechanism may occur in abusive head trauma.

What is an intracranial hematoma?

An intracranial hematoma is a collection of blood in or around the brain that can compress brain tissue and increase ICP.

What are the three main types of intracranial hematomas?

Epidural: Above the dura

Subdural: Below the dura

Intracerebral: Within the brain tissue

What determines the effects of cerebral ischemia from a hematoma?

Size of the hematoma

Volume of blood

Location

Speed of development

Time available for ICP compensation

A rapidly developing small hematoma may be more dangerous than a larger, slowly developing one.

What is an epidural hematoma?

An epidural hematoma is blood collected between the skull and dura, usually from rupture of the middle meningeal artery after a temporal skull fracture.

Is an epidural hematoma arterial or venous?

It is usually an arterial bleed, making it a rapidly developing neurologic emergency.

Who commonly experiences epidural hematomas?

They are often associated with head trauma in children and younger adults because the dura is less firmly attached to the skull than in older adults.

What is the classic sequence of an epidural hematoma?

Brief loss of consciousness → lucid interval → increasing restlessness, agitation, or confusion → focal neurologic deficits → coma, herniation, or respiratory arrest.

What happens during the lucid interval of an epidural hematoma?

The brain temporarily compensates for the expanding blood collection by shifting CSF and reducing cerebral blood volume, allowing the patient to appear awake and alert.

What indicates decompensation in an epidural hematoma?

Restlessness

Agitation

Confusion

Decreasing LOC

Fixed or dilated pupil

Extremity weakness or paralysis

Herniation

Respiratory arrest

How is an epidural hematoma treated?

Emergency:

Burr holes

Craniotomy

Treatment goals:

Decrease ICP

Remove the clot

Control arterial bleeding

Prevent blood from reaccumulating

What is a subdural hematoma?

A subdural hematoma is a collection of blood between the dura and brain, usually caused by rupture of bridging veins.

Is a subdural hematoma arterial or venous?

It is generally a venous bleed, although an acute subdural hematoma may still expand quickly and become life-threatening.

What are the timing categories of a subdural hematoma?

The original course notes identify:

Acute: Symptoms typically develop within 24 to 48 hours

Subacute: Symptoms develop from about 48 hours to 2 weeks

Chronic: Symptoms develop about 3 weeks to months after injury

What are manifestations of an acute subdural hematoma?

Loss or change in LOC

Pupillary changes

Hemiparesis

Headache

Increased ICP

Rapid expansion may cause:

Coma

Increasing blood pressure

Bradycardia

Slowed or irregular respirations

Why may an acute subdural hematoma need to be differentiated from a stroke?

Both conditions may cause:

Altered LOC

Pupillary changes

Hemiparesis

Focal weakness

Speech problems

Other focal neurologic deficits

What is a subacute subdural hematoma?

A subacute subdural hematoma develops more slowly, often after a less severe contusion or traumatic injury. Symptoms may appear between approximately 48 hours and 2 weeks.

Who is at greatest risk for a chronic subdural hematoma?

Older adults

Patients with cerebral atrophy

Patients taking:

Anticoagulants

Antiplatelet medications

People with a history of minor head trauma

Why does cerebral atrophy increase the risk of chronic subdural hematoma?

Brain tissue shrinks.

Bridging veins become stretched.

Minor trauma may cause the brain to shift.

Stretched bridging veins can tear and bleed.

How does the blood in a chronic subdural hematoma change over time?

Within about 2 to 4 days, the blood becomes darker and thicker. Over several weeks, the clot breaks down and may eventually calcify or ossify.

What are manifestations of a chronic subdural hematoma?

Fluctuating headache

Alternating focal neurologic findings

Personality changes

Mental deterioration

Confusion

Seizures

Stroke-like manifestations

How are acute and chronic subdural hematomas treated?

Acute bleeding may require emergency craniotomy. Chronic bleeding may be evacuated with burr holes or craniotomy, and anticoagulation or a bleeding disorder may need reversal.

What is an intracerebral hemorrhage?

An intracerebral hemorrhage is bleeding directly into the brain tissue.

What can cause an intracerebral hemorrhage?

Penetrating trauma

Gunshot wound

Stab wound

Hypertension

Ruptured aneurysm

Vascular abnormality

Brain tumor

Bleeding disorder

Anticoagulant therapy

How is an intracerebral hemorrhage managed?

Supportive care

ICP control

Careful fluid management

Electrolyte management

Blood pressure control

Surgical removal when:

The clot is accessible

Removal can be performed safely

What are the immediate priorities after a serious head injury?

Maintain airway.

Support breathing.

Maintain circulation.

Provide adequate oxygenation.

Maintain cerebral perfusion.

Control bleeding.

Stabilize the cervical spine.

Perform frequent neurologic assessments.

Prevent secondary brain injury.

Why is a cervical collar used after head trauma?

A cervical spine injury must be ruled out before the patient is moved extensively. The collar maintains alignment and helps prevent an incomplete spinal injury from becoming complete.

What does the Glasgow Coma Scale assess?

Eye-opening response

Verbal response

Motor response

Total score:

3 to 15

A score of 3 to 8 generally indicates:

Severe brain injury

A downward trend is more concerning than one isolated score.

What is the earliest and most sensitive indicator of neurologic deterioration?

A change in level of consciousness, including:

Restlessness

Confusion

Agitation

Increasing drowsiness

Difficulty awakening

Stupor

Coma

What are early signs of increased ICP?

Change in LOC

Restlessness

Confusion

Worsening headache

Vomiting

Pupillary changes

New motor weakness

What is the Cushing response?

Bradycardia

Increasing systolic blood pressure

Widening pulse pressure

Irregular respirations

It is a late, dangerous sign of:

Increased ICP

Brain compression

Possible herniation

What interventions help control increased ICP?

Elevate the HOB as ordered.

Maintain neutral head and neck alignment.

Provide oxygen.

Prevent hypoxia.

Prevent hypotension.

Prevent hypercarbia.

Limit suctioning.

Avoid painful or noxious stimulation.

Reduce agitation.

Prevent fever and shivering.

Avoid coughing and straining.

Prevent the Valsalva maneuver.

Why are stool softeners used after brain injury?

Prevent constipation

Reduce straining

Prevent the Valsalva maneuver

Help avoid a sudden increase in ICP

What supportive treatments may be required after severe TBI?

Mechanical ventilation

Seizure prevention

Fluid and electrolyte management

Nutritional support

Pain management

Anxiety and agitation management

Temperature control

Skin care

DVT prevention

Bowel management

Bladder management

What is a spinal cord injury?

Traumatic damage involving the:

Spinal cord

Vertebral column

Supporting soft tissues

Intervertebral discs

It may impair:

Motor function

Sensory function

Reflexes

Autonomic function

Respiration

Bowel and bladder function

What spinal cord functions may be lost after SCI?

Voluntary movement

Sensation

Reflexes

Vasomotor control

Sweating

Temperature regulation

Bowel control

Bladder control

Sexual function

Where does functional loss generally occur after SCI?

Loss of function usually occurs in body areas supplied by nerves that leave the spinal cord below the level of injury.

What forms of spinal cord damage can occur?

Spinal cord concussion

Contusion

Compression

Laceration

Partial transection

Complete transection

What secondary damage occurs after SCI?

Edema

Hemorrhage

Decreased spinal cord blood flow

Ischemia

Necrosis

Scar-tissue formation

Secondary damage may convert a partial injury into a permanent complete injury.

Which vertebrae are most commonly injured?

C5, C6, C7, T12, and L1 because these areas have greater movement and are more vulnerable to traumatic force.

What determines the manifestations and severity of SCI?

The level of injury determines which body functions are affected, while the completeness and degree of injury determine how much function is lost.

. What are major SCI risk factors?

High-risk lifestyle activities

Male sex

Adolescence or young adulthood

Motor vehicle crashes

Contact sports

Diving

Falls

Alcohol use

Illicit drug use

Violence

Tumors affecting the spine

What is paraplegia?

Paraplegia is paralysis of the legs and possibly part of the lower trunk, usually from an injury at T1 or below.

What is tetraplegia?

Tetraplegia, formerly called quadriplegia, is paralysis involving all four extremities and the trunk due to a cervical spinal cord injury.

What are the effects of a C1 to C3 injury?

Complete or severe respiratory paralysis

Extensive tetraplegia

Flaccidity during spinal shock

Loss of reflexes during spinal shock

Dependence on mechanical ventilation

Need for extensive assistance with care

What are the effects of a C4 injury?

Ventilation is limited because diaphragm function is impaired.

The patient may have a weak cough and may lose an effective sigh reflex, increasing the risk for atelectasis.

What function may remain with C5 to C6 injuries?

Some function of the deltoids, biceps, shoulder girdle, and wrist may remain. Physical and occupational therapy help maximize these abilities. Reflexes may initially be lost during spinal shock.

What are common findings with a thoracic SCI?

-Paraplegia

-loss of sensation and movement below the injury

-impaired trunk balance

-possible impairment of the intercostal or abdominal muscles.

A high thoracic injury may affect the lower abdomen.

What are common findings with a lumbar SCI?

-Lower-extremity flaccid paralysis or weakness

-decreased or absent DTRs

-urinary retention

-fecal incontinence

-lower-back pain

-sensory loss in the lumbar or lower-extremity area.

What are common signs and symptoms of SCI?

-Motor and sensory loss below the injury

-respiratory instability

-loss of reflexes

-orthostatic hypotension

-pain

-paraplegia or tetraplegia

-weak cough

-bowel and bladder dysfunction

-immobility-related complications.

Why may a patient with SCI have a decreased cough reflex?

Cervical or thoracic injuries can weaken the diaphragm, intercostal muscles, and abdominal muscles, reducing the patient's ability to cough and clear secretions.

Why can hypercalcemia develop after SCI?

Prolonged immobility causes calcium to leave the bones and enter the bloodstream. This contributes to osteoporosis and may increase the risk of kidney stones.

Why may corrected calcium be important when evaluating calcium levels?

A portion of calcium is bound to albumin.

A low albumin level may make total calcium appear lower.

Corrected calcium:

Accounts for the albumin level

Provides a better estimate when albumin is abnormal

Ionized calcium is the physiologically active form.

What imaging studies are used to assess SCI?

CT scan:

Identifies vertebral fractures

Evaluates spinal alignment

Identifies bone fragments

MRI:

Identifies spinal cord edema

Shows hemorrhage

Shows ligament damage

Identifies cord compression

Why can absence of neck or back pain not rule out SCI?

Spinal injury may exist without reported pain when the patient has:

Altered consciousness

Distracting injuries

Impaired sensation

Shock

Intoxication

Head injury

What are the broad collaborative goals for SCI?

Maintain airway, breathing, and circulation.

Stabilize and align the spine.

Prevent extension of the injury.

Preserve remaining neurologic function.

Maintain functional abilities.

Prevent complications.

Begin rehabilitation early.

What is the priority when moving a patient with possible SCI?

Apply cervical stabilization, maintain the spine in neutral alignment, and avoid flexion, extension, rotation, or twisting until the injury is fully evaluated.