Glasgow Coma Scale + TBI

Scoring Meaning

<8= severe TBI

9-12 = moderate TBI

13-15 = mild TBI

Categories

Eye 4

Verbal 5

Motor 6

Traumatic Brain Injury Mechanism

Blunt: motor vehicle accident, motorcycle accident, falls, assault

Penetrating: gun shot, wound stabs, shrapnel, arrows

Primary: direct impact

Secondary: following damage = hypoxia, hypotension, increased ICP, fever

Skull Fractures = focal injuries

simple linear= single crack

depressed= skull sinked inward

comminuted= multiple linear with bone fragments

compound= depressed fracture with communication pathway open to the outside

Basillar= fracture at the base of the skull

Basilar Skull Fracture Clinical Manifestations BRRO

Battle Sign: bruising behind the ear above mastoid area

Raccoon eye: brusing behind the eyes periorbital

Rhinorrhea; CSF leaking from nose

Ottorrhea: CSF leaking from ears

Halo Sign Diagnostics

a drip of drainage collected onto a gauze= blood in center with yellow ring around it

indication of leaking

Nursing Interventions of Suspected CSF for TBI

1. no nasal suction

2. no NG tube

3. No nose blow/sneeze

4. no packing of the nose/ear

Risk of TBI/CSF leak

meningitis monitor for fever/nuchal rigidity

Eye Diagnostics

Pupils: size, shape, reaction to light (TBI=fixated +dilated)

Eye: Doll’s eye (oculocephalic)

eye is moving opposite of the head= normal

eye fixation moving with the head=TBI

Eye: Caloric test (oculovestibular)

ice water in ear canal with no eye movement = no brainstem

Concussion

sudden, transient mechanical head injury with disruptive neural activity

• disruption of LOC+headache

• retrograde amnesia= forget what just happened before hand

• education: return/report if headaches worsen, confusion, vomiting, unequal pupils, hard arousal

Contusion

• bruising of brain tissue-focal area, closed head injury

• depression fracture

• coup-countercoup: injury at impact site and opposite side