head injury/traumatic brain injury

what is a head injury?

blunt injuries: MVC and related injuries, falls, sports injuries, assaults

penetrating injuries: GSW, impalements

what is the mechanism of injury for head injury?

acceleration/deceleration: head moving suddenly causing shearing and shaking

rotation: multiple ways, more generalized, more edema

compression: force

penetrating: destroy tissue as go through

what are the types of injuries?

extra cranial: vascular, maxillofacial, spinal cord, soft tissue

cranial vault: linear skull (70% of fractures), basilar skull, comminuted fracture, compound fracture, depressed

describe basilar skull fractures

now have communication between brain and sinuses and outside worls

CSF leak through nose (anterior, rhinorea) or ear (posterior, suteria)

infront will see raccoon eyes and posterior will see behind ear bruising or battle signs

can test for CSf with halo sign (won’t mix with blood) and testing for glucose in fluid

what is the Glasgow coma scale?

look at eyes, verbal, and voluntary/involuntry movement

minor: 13-15, some trauma, a bit confused

moderate: 9-12, some moderate infactors

severe: 3-8, comatose, nothing

what is primary vs secondary injury?

primary: injury which occurs at the time of initial injury

secondary: occurs as cerebral auto regulatory ability decreases

1. auto regulation: ability of brain to maintain CBF despite changes in arterial perfusion pressure. fails with ICP > 40-50 and CPP < 40

what are concerns with secondary injury?

hypotensions: lose BF, could be due to other injuries

hypoxia: O2 and Co2 balance

ischemia, edema, IICP, hypercarbia, hyperemia

what is a focal vs diffuse injury?

focal: injury in a specific, localized area

diffuse: widespread damage over larger area

important to keep in mind as assessing pt is recovering, diffuse injury can later reveal a long lasting focal injury

what is a primary head injury?

concussion: mild, moderate, severe

contusion

coup and contra coup

diffuse axonal

hemorrhagic: hematoma, subdural, epidural, SAH, ICH

what is a cerebral injury?

concussion: mild form of diffuse injury, temporary, reversible neurodeficit

contusion: area of bruising, s and s vary

what are the s and s of concussion?

s/s: LOC, amnesia, headache, confusion, dizziness, fatigue, drowsiness, n/v, photophobia, noise sensitivity, irritability

can develop over time and hopefully doesn’t last too long

want Tylenol and head rest

what are symptoms of post concussive symptoms?

headaches, vestibular dysfunction, decreased memory and concentration, cervical and cranial myofascial pain, visual disturbances, mood disorders, sleep disorders

what are the grades of concussion?

1: transient confusions, no LOC, symptoms resolve < 15 min

2: transient confusions, no LOC, symptoms last > 15 min

3: any loss of consciousness

what is a contusion?

hemorrhagic/micro hemorrhages

non hemorrhagic

delayed radiographic evidence 24 hrs: may need to stay over night to get another image

what is coup and counter coup?

injury to brain largely at area of initial trauma due to force of trauma there is opposite injury

contra is at opposite side of injury, sometimes go together

2 areas of damage, bleeding, swelling, etc.

increase ICP issues often front to back

what is diffuse axonal injury?

consequence of rotational injury: shearing problems cause cell damage or bleeding in various areas, seen throughout brain

have to wait it out

describe hematomas

epidural: above dura

1. located in temporal area, associated with force on left or right side

2. middle menial artery, fast development

3. symptoms: brief LOC, then brief regain, then fast downhill

4. surgical treatment

subdural: below dura

1. acute (minutes to hours), subacute(hrs to days), chronic (weeks to months)

2. venous, slower development

3. treatment: pain neuro problems in area

4. age affects development

5. surgical clearing

ICH/SAH: blood vessel rupture in arachnoid space or brain tissue

1. 25 cc or more of blood

2. treatment: control edema and wait for it to reabsorb

on left side affect left cranial nerves and right body, vice versa

what are specific complications with head injuries?

other injuries: prioritize what is most concerning and acute, ABCs, long term goals then

edema: increased ICP, respiratory compromise

herniation

drugs and alcohol: effect exam in acute period, withdrawal due to ongoing problem

surgical interventions: craniotomy, decemporessive craniotomy, hemicrantiomy w

what is done to diagnosis head injuries?

blood work: CBC,coags, ABGs, chemostry’s, toxicology

radiographic: plain films, CT/CTA, MRi/MRA

angiographic: vascular injury

cerebral blood flow: TCD, CBF blood flow measurement

what is brain targeted therapy?

glucose for hypoglycemia

BP management: target CPP

sedatives, analgesics, paralytics

cerebral edema: mannitol, hypertonic saline, ICP monitoring

temperature

seizures: EEG monitoring

antibiotics, blood/blood products, HOB, fluid/electrolytes, antiemetics, GI prophylaxis

what are complications of head injury?

cerebrospinal fluid: leak or clear fluid. may need a drain or shunt if brain mechanism can’t do on own

hydration balance: measure I/O, watch cardiovascular status, SIADH/DI, monitor electrolytes and renal function

medical complications: pneumonia, hypotensions, DVT

what is rehab like after head injury?

mobility

physiologic needs: airway, wound

self care

communication: apahsia, dysarthria

cognition: memory, mood, behavior, neuropsychological

family/caregiver