EMERGENCY NURSING (TRAUMA)

• Blunt acceleration forces

• Deceleration forces

• Penetrating forces

Most common forces involved in head trauma are:

Blunt acceleration forces

when the head is struck with an object

Deceleration forces

when the head is moving and strikes a stationary object

Penetrating forces

when an object enters the head

• Missed injuries

• secondary neurologic injuries (i.e. injuries to the brain and brainstem)

— are common in emergency care settings.

• to identify any obvious signs of head trauma and underlying neurological injury

• to provide baseline data which can be used to identify a developing neurological injury

Two fundamental goals for neurological assessment:

• intracranial hemorrhage

• edema of the soft tissues of the brain

Problems with PERRLA are often the first signs of increased ICP due to, for example, an — or —, etc

• disconjugate gaze (deviation of one eye)

• ptosis (drooping of the eyelid/s)

— are common signs of neurologic injury:

Decorticate / flexion (where the patient's arms are drawn rigidly up against their chest)

-– affects vision, hearing, eye movement, motor control and consciousness

Decerebrate / extension (where the patient's arms turn rigidly outwards against the sides of their body)

– affects coordination, sensation, facial expression, swallowing, breathing

• hypertension (a compensatory mechanism to maintain cerebral blood flow)

• cardiac dysrhythmia (due to brainstem dysfunction)

• hyperthermia (as cerebral dysfunction and metabolism increases)

Signs of a serious brain injury include:

• Hypertension

• Widening pulse pressure (i.e. increasing distance between systolic and diastolic BPs)

• Bradycardia

A patient with a severe late brain injury, where there is significant pressure on the brainstem, will often demonstrate signs known as 'Cushing's triad':

• a CT scan be undertaken if a patient has a GCS of 13 on initial presentation or a GCS of <15 2 hours after the injury

• a suspected skull fracture

• a post-traumatic seizure

• any focal neurological deficit

• more than 1 episode of vomiting

The National Institute of Health and Clinical Excellence's Head Injury: Assessment and Early Management (CG176) guideline recommends that:

Scalp lacerations

• — is highly vascularised and — often bleed profusely

• typically managed by direct pressure to control initial hemorrhage, and subsequent wound repair using sutures, staples or clips

• linear

• depressed

Skull fractures:

linear skull fracture

• the fracture is non-displaced, and there is no or minor neurological damage

• usually only require supportive care (e.g. rest, pain management, etc.)

depressed skull fracture

• one side of the fracture displaces below the other, and there is moderate to severe neurological damage

• often require surgical repair, including plating.

• hemotympanum (leakage of blood from the ears)

• 'panda' or 'raccoon' eyes (circular bruising around the eyes)

• leakage of cerebrospinal fluid from the ear/nose

• Battle's sign (bruising behind the ears)

Signs of a suspected skull fracture:

Contusion

a bruise on the scalp or on the surface of the brain

• Coup

• Contrecoup

When acceleration-deceleration forces are involved in the injury, two contusions on the surface of the brain may result:

Coup

the initial site of impact

Contrecoup

the opposite side of the brain, as it rebounds inside the skull

• an altered LOC

• nausea and or vomiting

• visual disturbances

• weakness

• difficulties with their speech.

Patients with contusion typically present with:

Subdural or epidural hematoma

bleeding beneath or between the skull and one of the layers of the dura mater or arachnoid mater

• severe headache

• pupillary dilatation on the same side of the body to that which they sustained the traumatic injury

• hemiparesis (i.e. one-sided weakness) on the opposite side

Patients with haematoma often present with:

Concussion

mild traumatic brain injury that involves a loss of consciousness with associated disruptions to neurological functioning

• nausea/vomiting

• temporary amnesia

• minor confusion and disorientation

• Headache

• Dizziness

• Drowsiness

• Irritability

• visual disturbances

People with concussion will display mild, transient neurological symptoms such as:

• non-narcotic analgesia

• anti-emetics

• fluid therapy

Care for a patient who has experienced a concussion involves regular observation to identify more serious brain injury, and symptomatic management —

Diffuse axonal injury (DAI)

a severe traumatic brain injury that results in shearing of axons, key structures within the white matter of the brain

• extended loss of consciousness

• flexion or extension posturing

• dysfunction of the autonomic nervous system

Patients with DAI typically present with:

• cerebral edema

• increase in cerebral blood flow (e.g. hemorrhage, acute hypertension, etc.)

Increased ICP Causes:

• decreased LOC

• changes in vital signs (including Cushing's triad)

• pupillary dilatation

• decrease in motor function

• severe headache

• nausea/vomiting

Patients with increased ICP will present with:

brain death

Where ICP is very high, pressure on the brainstem may result in — where brain function completely and irreversibly ceases.

• treating the greatest threat to life first (management of airway, breathing and circulation)

• effectively managing patient’s pain (contributes to an increase in ICP)

• use small but frequent doses of intravenous opioid

Providing care to a person with injuries resulting from head and/or neurologic trauma

Focus treatment on:

Orthopedic Trauma

bones, surrounding soft tissue, and associated neurovascular structures including the nerves and blood vessels