head injury, tumor, and inflammation

what is a head injury

• Any trauma to the

  • Skull

  • Scalp

  • Brain

• Head trauma includes an alteration in consciousness, no matter how brief.

• A serious form of head injury is traumatic brain injury (TBI)

what factors can increase you rick for a poor outcome

• Intracranial hematoma

• Older age

• Abnormal motor responses

• Impaired or absent eye movements/pupillary light reflexes.

• Early sustained hypotension

• Hypoxemia or hypercapnia

• ICP levels >20 mm Hg

• GCS on arrival <8

types of head injuries

• Scalp lacerations

  • Scalp is highly vascular → Profuse bleeding

  • Major complications: Infection & Blood loss

• Skull Fractures

  • Closed (only skull, skin intact)

  • Open (skull and skin broken)

skull fractures and hemorrhage clinical manifestations

• Facial paralysis

• Battle’s sign (postauricular ecchymosis)

• Periorbital ecchymosis (racoon eyes)

• Cranial nerve deficits eyes and face

• Conjugate deviation of gaze (eyes gazing same direction)

• Change in LOC—report immediately

• Rhinorrhea or otorrhea

  • Leaking fluid should be tested to determine if fluid is CSF.

  • CSF fluid gives a positive reading for glucose (use Halo sign or Dextrostix to test for glucose)

  • Place sterile gauze under nose to catch drainage

types of head trauma

• concussion

• lacerations

• contusion

concussion

• A sudden transient mechanical head injury with disruption of neural activity and a change in LOC

• May or may not lose consciousness.

• Brief disruption in LOC (<5 min)

• Amnesia (possibly retrograde amnesia)

• Headache

• TX: Watch for further developments.

  • If grows into “stroke” symptoms, report immediately. Monitor LOC and neuro.

  • Post concussion syndrome: 2 weeks to 2 months

  • Headache, lethargy, behavior change, shortened attention span, decreased short-term memory, changes in intellectual ability

laceration

• Tearing of the brain tissue

• Often occur in association with depressed and open fractures and penetrating injuries

• Intracerebral hemorrhage is generally associated with cerebral laceration.

• Surgical repair of laceration is impossible.

• Prognosis is poor with large intracerebral lacerations.

• Clinical manifestations: Bleeding, Seizures, Cerebral Edema

contusion

• Bruising of brain tissue within a focal area

• Associated with closed head injury

  • Coup-contrecoup injury

• Can cause hemorrhage, infarction, necrosis, edema

• Seizures common complication

• Anticoagulants: Potential for ↑ hemorrhage

• Tx: Surgery

dxc studies for a head injury

• CT scan: Best diagnostic test to determine craniocerebral trauma

• MRI

• PET

• Glasgow Coma Scale (GCS)

intracerebral hemorrhage clinical manifestations

• Neurologic: Altered level of consciousness, seizure activity, pupil dysfunction, cranial nerve deficit(s), ¯ GCS, headache

• Skin: Lacerations, contusions, abrasions, hematoma, Battle’s sign, periorbital edema and ecchymosis, otorrhea (check for glucose), exposed brain matter

• Respiratory: Rhinorrhea, impaired gag reflex, inability to maintain airway, altered/irregular respiratory rate and pattern

• Cardiovascular: Cushing’s triad (systolic hypertension with widening pulse pressure, bradycardia, irregular resps)

• Musculoskeletal: Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity/increased tone, flaccidity, ataxia

intracerebral hemorrhage collaborative care

• Treatment of life-threatening conditions will take priority

• Major focus of nursing care relates to increased ICP

• Maintain cerebral perfusion and oxygenation

• Frequent monitoring for changes in neurologic status

  • Frequent GCS and neuro checks

• Correct any electrolyte imbalances

• Eye problems

  • Lubricating eye drops

  • Cold, later warm compresses

  • Eye patch

• Treat Hyperthermia

  • Goal: 36ºC (96.8 F) to 37º C (98.6F) to Prevent shivering

• Leaking CSF? Check for glucose.

  • Call provider immed, raise the head of bed, loose collection pad under nose, NO sneezing or blowing nose, NO NGT and NO naso-tracheal suctioning

• Seizure precautions

• Care of immobilized patient

  • Bladder and bowel function, skin care, infection

• Pain (headache)

  • Acetaminophen (not NSAIDs) or small doses of codeine

  • If opioid used, pupils would constrict and alter neuro check

• Patient/family education and support

complications of intracerebral hemorrhage

Epidural Hematoma

• Bleeding between the dura and the inner surface of the skull

• Neurologic emergency

Subdural Hematoma

• Chronic SH in elderly are misinterpreted/misdiagnosed as vascular disease (stroke, TIA) and dementia.

manifestations of epidural hematoma

• Initial period of unconsciousness

• Brief lucid interval followed by decrease in LOC

• Headache

• Nausea, vomiting

• Focal neurologic deficits (ie. visual field cuts, aphasia, weakness, numbness)

manifestations of subdural hematoma

• Acute signs develop within 24 to 48 hours of the injury

• Symptoms related to increased ICP

• ↓ LOC

• Headache

• Drowsy and confused

• Ipsilateral pupil dilates and becomes fixed

txmnt for epidural hematoma

• Tx: evacuate hematoma and decrease ICP

• Emergency treatment

  • Maintain oxygenation

  • Assume neck injury

  • Administer fluids cautiously

• Surgical intervention

  • Craniotomy, Craniectomy, Cranioplasty, Burr hole

  • Carefully monitor O2 after sx

complications of cranial surgery

• Intracranial hypertension

• Surgical hemorrhage

• Fluid imbalance

• CSF leak

• Venous Thromboembolism

• Pneumonia

caregiver instructions following a head injury

• No alcohol

• Have someone stay with you until cleared by MD

• Avoid driving or using heavy machinery

• Avoid contact sports

• Return to hospital or call provider if:

  • Increased ­Drowsiness or confusion

  • Inability to be awaken (dec LOC)

  • Vomiting or nausea (increased ICP)

  • Seizures

  • Bleeding from the ear or nose

  • Motor problems or weakness

  • Blurred vision slurred speech

what are intracranial tumors

• Tumors of the brain result from a metastasis elsewhere

• Classified according to the tissue from which they arise

  • Gliomas: arise inside brain tissue:  Astrocytoma, Glioblastoma, or Multiforme

  • Meningioma: arise outside (the layers surrounding) of brain tissue, meninges, which are the membranes that cover and protect the brain and spinal cord

intracranial tumor clinical manifestations

• Depends on size & location of tumor

• Increased ICP

• Headache; dull, throbbing, worse at night

• Seizures

• N, V

• Cognitive dysfunction, decreased LOC

• Muscle weakness

• Sensory losses, aphasia

• Visual changes

dxc studies for intracranial tumors

• CT

• MRI

• PET

intracranial tumors collaborative care

• Surgical Intervention

• Shunt for hydrocephalus

• Radiation. If cerebral edema, use corticosteroids

• Chemotherapy:  Nitrosoureas class (ie. carmustine, lomustine) are effective to cross blood brain barrier.

• Chemo drugs such as methotrexate, can be given intrathecally (in the subarachnoid space of the spinal cord).

• Temozolomide is oral chemo

inflammatory conditions of the brain

• Meningitis, Bacterial and Viral

• Encephalitis

• Brain abscesses

dxc studies for inflammation of the brain

• Blood test and culture

• CT scan

• Diagnosis verified by lumbar puncture and analysis of CSF

  • Specimens of CSF, sputum, nasopharyngeal secretions to identify causative organism

  • Gram-stained smear to detect bacteria

what is bacterial meningitis

• Medical emergency.

  • Untreated bacterial meningitis has a mortality rate near 100%

  • Usually follows viral respiratory disease-may enter brain through sinuses

bacterial meningitis clinical manifestations

• Fever

• Severe headache

• Nausea, vomiting

• Nuchal rigidity

• Increased ICP: Photophobia, Decreased LOC

bacterial meningitis collaborative care

• Respiratory isolation until cultures are negative, Bacterial Meningitis is highly contagious (resp prec)

• Vitals, neuro, and LOC every hour

• Antibiotics

• Codeine for neck pain

• Dark room and cool cloth for photophobia

• Minimize environmental stimuli

• Antiseizure medication (phenytoin, levetiracetam)

• Manage increased ICP

• Acetaminophen or ASA for fever, cooling blanket, or tepid sponge bath

• Check I/O and encourage fluids

viral meningitis: what is it, s/s, dxc, tx

• Most common causes are enterovirus, arbovirus, HIV, and HSV. Most often spread through direct contact with respiratory secretions

• Clinical manifestations:

  • Headache, fever, photophobia, stiff neck

• Diagnostics:

  • Lumbar puncture: cerebrospinal fluid (CSF) shows lymphocytosis

  • Blood test for viral specific DNA or RNA

• Self-limiting virus

what is encephalitis & s/s

• Acute inflammation of brain

• Caused by a number of viruses. Ticks or mosquitoes can transmit epidemic encephalitis

• Clinical Manifestations: Fever, headache, N, V. Later, if no tx, mental status changes.

encephalitis: dxcs, tx

• Diagnostic: Blood test for West Nile Virus

• Tx: Antiviral, antibacterial, antifungal, or anticonvulsant medications can help treat the underlying cause and manage symptoms. Corticosteroids can reduce brain swelling, and sedatives can help with irritability or restlessness 

what is a brain abscess; s/s, dxcs, tx

• Accumulation of pus within brain tissue from a local or systemic infection

• Clinical manifestations: Headache, fever, N, V, signs of increased ICP, and symptoms of area abscess is located in.

• Diagnostic: CT, MRI

• Tx: Antimicrobial and symptom management