Head Injury, Intracranial Tumor, Inflammatory Conditions

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)

Head Injury

• High potential for poor outcome

• Intracranial hematoma- none stop bleeding 

• 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

• Fixed and dilated pupils

Types of Head Injuries

scalp lacerations, skull fractures

Scalp lacerations

• Scalp is highly vascular → Profuse bleeding

• Major complications: 

  • Infection

  • Blood loss

Skull Fracture

• Closed (only skull damage, skin intact) 

• Open (skull and skin broken)

• Skull Fractures and Hemorrhage Clinical Manifestations

• Location of fracture alters the presentation of the manifestations 

• Facial paralysis

• Battle’s sign (postauricular ecchymosis)- behind ear 

• Periorbital ecchymosis (racoon eyes)

• Cranial nerve deficits- 3,4,6

• Conjugate deviation of gaze (eyes gazing same direction)

• Change in LOC—report immediately

• Rhinorrhea (runny nose) or otorrhea (drainage from ear) 

Rhinorrhea or otorrhea

• Leaking fluid should be tested to determine if fluid is CSF (clear liquid with dot of blood in center).

• 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

Raccoon Eyes, Battle’s Sign, Halo Sign

• Halo sign: 

  • Red (blood) 

  • Cerebrospinal fluid 

• Raccoon eyes and Rhinorrhea: 

  • Periorbital edema and ecchymosis 

• Battle signs with otorrhea

  • Postauricular ecchymosis 

Types of Head Trauma: 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): in the moment 

• Amnesia (possibly retrograde amnesia)

• Headache

Concussion treatments

• Watch for further developments.

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

  • Post concussion syndrome: can take up to 2 weeks to 2 months

    • Headache, lethargy,

    • behavior change, shortened attention span,

    • decreased short-term memory, changes in intellectual ability

Types of Head Trauma Lacerations

• Tearing of the brain tissue

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

• Intracerebral hemorrhage: associated with cerebral laceration. 

• Surgical repair of laceration: impossible- neurons in the brain can’t regenerate 

Lacerations prognosis

• Prognosis is poor with large intracerebral lacerations.

Lacerations clinical manifestations

• Bleeding→ leads to hematoma, Seizures, Cerebral Edema

Types of head injuries: Contusion

• Bruising of brain tissue within a focal area 

• Associated with closed head injury

  • Coup-contrecoup injury

• Cause hemorrhage, infarction, necrosis, edema

• Anticoagulants: Potential for ↑ hemorrhage (ASA and NSAID) if they are on it

Contusion treatment

• Tx: Surgery

• Seizures common complication

Diagnostic Studies

• CT scan: Best diagnostic test to determine craniocerebral trauma 

• MRI

• PET

• Glasgow Coma Scale (GCS): NEURO STATUS IMPORTANT 

Intracerebral Hemorrhage Clinical Manifestations: neurological

• Altered LOC, seizure activity, pupil dysfunction, cranial nerve deficit(s),  GCS, headache (with N/V)

Intracerebral Hemorrhage Clinical Manifestations: skin

• Lacerations, contusions, abrasions,

• hematoma, Battle’s sign, periorbital edema and ecchymosis,

• otorrhea (check for glucose), exposed brain matter

Intracerebral Hemorrhage Clinical Manifestations: respiratory

• Rhinorrhea, impaired gag reflex,

• inability to maintain airway,

• altered/irregular respiratory rate and pattern

Intracerebral Hemorrhage Clinical Manifestations: cardiovascular

• Cushing’s triad (systolic hypertension with widening pulse pressure, bradycardia, irregular resps)- poor prognosis

Intracerebral Hemorrhage Clinical Manifestations: muscoloskeletal

• Motor deficit/impairment, weakness, palmar drift,

• paralysis, spasticity, decorticate or decerebrate posturing,

• muscular rigidity/increased tone, flaccidity, ataxia

Collaborative Care

• Treatment of life-threatening conditions will take priority 

• Major focus of nursing care: increased ICP 

• Maintain cerebral perfusion and oxygenation

• Frequent monitoring for changes in neurologic status

  • Frequent GCS and neuro checks

• Correct any electrolyte imbalances

Collaborative Care: eye problems

• Lubricating eye drops

• Cold, later warm compresses

• Eye patch

Collaborative Care treating hyperthermia

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

Collaborative Care

• Leaking CSF? Check for glucose.

• Seizure precautions: frequent neuro checks 

• Care of immobilized patient

  • Bladder and bowel function, skin care, infection

• Pain (headache)

• Patient/family education and support

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

Collaborative Care: pain

•  (headache)

  • Acetaminophen (not NSAIDs) or small doses of codeine

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

Complications of Head Injury:

• Epidural Hematoma

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

  • Neurologic emergency

Epidural Hematoma signs include

• 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)

Epidural Hematoma treatment

•  evacuate hematoma and decrease ICP

Complications of Head Injury: Subdural Hematoma (SH)

• 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. 

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

Subdural Hematoma (SH) treatment

evacuate hematoma and decrease ICP

Collaborative Care: Emergency treatment

• Maintain oxygenation

• Assume neck injury:  stabilize neck 

• Administer fluids cautiously

Collaborative Care: surgical treatment

• Craniotomy, Craniectomy, Cranioplasty, Burr hole 

• Carefully monitor O2 after surgery

Complications of Cranial Surgery

• Intracranial hypertension

• Surgical hemorrhage

• Fluid imbalance

• CSF leak: headaches 

• Venous Thromboembolism in the brain causing stoke 

• Pneumonia

Patient and Caregiver Instructions Following a Head Trauma: returning to hospital or call provider is

• Drowsiness or confusion, seizures

• Inability to be awaken (dec LOC)

• Vomiting or nausea (increased ICP)

• Bleeding from the ear or nose

• Motor problems or weakness

• Blurred vision slurred speech

Patient and Caregiver Instructions Following a Head Trauma

• No alcohol

• Have someone stay with you until cleared by MD

• Avoid driving or using heavy machinery, Avoid contact sports

• Should sleep 3-4 after concussion: can’t tell if its LOC or them sleeping 

Intracranial Tumors

• Tumors of the brain result from a metastasis elsewhere

Classified according to the tissue from which intracranial tumors arise

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

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

Intracranial Tumors 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

Intracranial Tumors Diagnostics

• CT

• MRI

• PET

Intracranial Tumors Collaborative Care

• Surgical Intervention

• Shunt for hydrocephalus

• Radiation. If cerebral edema, use corticosteroids

• Chemotherapy

Intracranial Tumors Collaborative Care: chemo therapy

•  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

Inflammatory Conditions of the Brain diagnosis

• 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

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 manifestions

• Fever, Severe headache

• Nausea, vomiting

• Nuchal rigidity 

• Increased ICP

• Photophobia: sensitivity to light 

• Decreased LOC

Bacterial Meningitis Collaborative Care

• Respiratory isolation (N95 mask and all PPE) until cultures are negative, Bacterial Meningitis is highly contagious (resp prec)

• Vitals, neuro, and LOC every hour

• Dark room and cool cloth for photophobia

• Minimize environmental stimuli

• Manage increased ICP

• Check I/O and encourage fluids

Bacterial Meningitis Collaborative Care medications

• Antibiotics

• Codeine for neck pain

• Antiseizure medication (phenytoin, levetiracetam)

• Acetaminophen (1) or ASA (2) for fever, cooling blanket, or tepid sponge bath

Viral Meningitis

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

Viral Meningitis clincial manifestations

• Headache, fever, photophobia, stiff neck

Viral Meningitis diagnosis

• Diagnostics:

  • Lumbar puncture: cerebrospinal fluid (CSF) shows lymphocytosis

  • Blood test for viral specific DNA or RNA

• Self-limiting virus: give antiviral, and tx→ usually goes away 

Encephalitis

• Acute inflammation of brain

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

• Clinical Manifestations: 

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

  • Starts with headache and N/V then fever, mental status changes 

Encephalitis diagnosis

• Blood test for West Nile Virus

Encephalitis treatment

• 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. 

Brain Abscess

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

Brain Abscess clincial manifestations

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

Brain Abscess diagnosis and treatment

• Diagnostic: CT, MRI

• Tx: Antimicrobial and symptom management

Which of the following is appropriate care for the patient with bacterial meningitis?

A. administering antibiotics immediately following collection of specimens for culture.

B. waiting for results of a CSF culture to identify an organism before initiating treatment.

C. obtaining skull x-rays and CT scans to determine the extent of the disease before treatment is started. 

D. providing symptomatic and supportive treatment because drug therapy is not effective in treatment.

When assessing a patient with a brain injury, the nurse tests fluid dripping from one ear for glucose.  What is the nurse testing for?

Infection

Blood

CSF

Serum

The nurse is caring for a patient who is diagnosed with an intracerebral hemorrhage. Which symptomology would the nurse anticipate? Select all that apply.

A. Glasgow Coma Scale rating of 8

B. Battle’s sign

C. Respiratory rate of 14

D. Blood pressure 126/84

E. Muscle rigidity

During admission for a patient that was hit in the head with a bat during an assault, which is the nurse’s highest priority?

A. Neurologic status with Glasgow Coma Scale

B. Assessment for CSF leak from nose or ears

C. Patency of airway

D. Determination of external bleeding