Study Notes on Emergency Care for Head Injuries

Emergency Care for People With Head Injuries

Types of Head Injuries

• Skull fractures
• Traumatic brain injuries
• Focal injuries
• Diffuse injuries

Learning Objective #4

• Description of skull fractures types, clinical signs identification, and collaborative treatment approaches in patient care.

Skull Fractures

Scalp Lacerations

• Etiology:
    - Results from blunt or penetrating forces tearing the skin and underlying soft tissue against the skull.
• Clinical Manifestations:
    - Often results in profuse bleeding.
• Collaborative Interventions:
    - Apply direct pressure if heavy bleeding occurs.
    - Clean and inspect the laceration.
    - Irrigate the wound.
    - May require sutures, staples, or surgical repair.
    - Often indicative of significant injuries to the skull and brain.

Types of Skull Fractures (Cranial Bone Fracture)

• Typically caused by blunt force trauma, common causes include:
    - Motor vehicle collisions.
    - Falls.
    - Contact sports.
• Classification by:
    - Pattern of the fracture: Linear, comminuted, depressed, etc.
    - Type of fracture: Simple (closed) vs compound (open).
    - Location of fracture: Cranial vault fracture vs basilar skull fracture.

Skull Fracture Patterns

• Linear Fracture:
    - Resembles a thin line.
• Comminuted Fracture:
    - Bone is shattered into many fragments.
• Depressed Fracture:
    - Involves broken skull bone sinking inward toward the brain.
• Closed (Simple) Fracture:
    - Skull is fractured but the scalp remains intact.
    - Treated based on the depth of depression.
• Open (Compound) Fracture:
    - Skull is fractured, with the scalp lacerated, exposing brain and bone fragments to air.
    - Considered a medical emergency requiring urgent surgery to clean and elevate bone fragments.

Treatment of a Significant Depressed Skull Fracture

• Refer to the specific surgical protocols outlined in literature for detailed interventions.

Parts of the Skull

• Cranium:
    - Comprised of eight cranial bones:
      - Frontal (1)
      - Sphenoid (1)
      - Ethmoid (1)
      - Parietal (2)
      - Temporal (2)
      - Occipital (1)
• Facial Bones: Additional structures that make up the skull.

Classification by Location of the Fracture

• The cranium can be divided into:
    - Cranial Vault (skull cap):
      - Frontal bone
      - Parietal bone
      - Upper portion of the temporal bone
      - Upper portion of the occipital bone
    - Cranial Base (skull base):
      - Lower portion of the temporal bone
      - Lower portion of the occipital bone
      - Sphenoid bone
      - Ethmoid bone
      - Sometimes includes lower portion of frontal bone.

Basilar Skull Fracture

• Generally considered more serious than cranial vault fractures due to:
    - Involvement of a break in one or more bones at the base of the skull.
• Typically caused by substantial blunt force trauma.

Symptoms of Basilar Skull Fracture

• Symptoms can vary depending on the fracture location and may include:
    - Headache
    - Dizziness
    - Nausea and vomiting
    - Facial paralysis
    - Bleeding from the ear
    - Loss of smell or hearing impairment
    - Potential cerebrospinal fluid (CSF) leak:
      - Clear or bloody fluid leaking from nose or ear.
    - Risk of meningitis (infection of the meninges).

Classic Triad of Meningitis

• Fever
• Neck stiffness (nuchal rigidity)
• Altered mental status

Basilar Skull Fracture Fluid Tests

• Halo Test:
    - If the fluid is bloody, allow it to drip onto a gauze pad; if a yellow halo forms around the blood, it may indicate CSF.
    - Note: This test is not highly reliable.
• Beta-2 Transferrin Assay:
    - If a CSF leak is suspected, collect a sample for testing.

Later Signs of a Basilar Skull Fracture

• Battle sign:
    - Bruising behind the ear.
• Raccoon’s Eyes:
    - Ring-like pattern of bruising around the eyes.

Learning Objective #5

• Compare types of focal and diffuse traumatic brain injuries based on mechanism of action, clinical manifestations, and collaborative treatment approaches.

Traumatic Brain Injury

Classifying Traumatic Brain Injuries

• Focal Injuries:
    - Occur at a specific location in the brain. Examples include:
      - Contusion.
      - Intracranial hematomas.
      - Penetrating injuries.
• Diffuse Injuries:
    - Occur over a widespread area of the brain. Examples include:
      - Diffuse axonal injury.
      - Shaken baby syndrome.
      - Concussion.

Cerebral Contusion

• Definition:
    - Bruising of brain tissue due to blunt trauma.
• Mechanism:
    - Commonly occurs with a coup-contrecoup injury resulting in localized bleeding and swelling.
• Clinical Signs:
    - More severe than concussion and includes:
      - Severe headaches.
      - Confusion.
      - Dizziness.
      - Vomiting.
      - Blurred vision.
      - Loss of consciousness, slurred speech, pupil dilation, weakness/numbness, and seizures.
    - Symptoms can manifest immediately or develop over time with cerebral swelling.
• Diagnosis:
    - Visible structural damage on CT or MRI.

Intracranial Hematomas

• Definition: Collection of blood within the skull.
• Types:
    - Epidural Hematoma
    - Subdural Hematoma
    - Subarachnoid Hematoma
    - Intracerebral Hematoma

Epidural Hematoma

• Definition:
    - Bleeding occurs between the skull and the dura mater.
    - Often occurs when a skull fracture tears the middle meningeal artery above the dura mater.
• Clinical Signs:
    - Period of unconsciousness followed by a lucid phase and then rapid decline in level of consciousness (LOC).
    - Symptoms include headache, ipsilateral pupillary dilation, contralateral hemiparesis, vomiting, seizures.
• Diagnosis:
    - Confirmed by CT scan.

Risks Associated with Epidural Hematoma

• Brain Herniation Risk:
    - Rapid accumulation of blood creates increasing pressure inside the skull, compressing brain tissue.
    - Can lead to brain herniation, which pushes the brain into areas it shouldn't be and causes severe complications, including death.

Surgical Intervention for Epidural Hematoma

• Craniotomy and hematoma evacuation involves:
    - Skin incision, drilling through the skull, removing blood clots, and suturing closed.

Subdural Hematoma

• Definition:
    - Primarily involves veins that bleed slowly and is more common than epidural hematomas.
• Types:
    - Acute: Symptoms develop in 24 to 48 hours; danger of LOC changes, pupillary changes, hemiparesis.
    - Subacute: Symptoms develop 48 hours to 2 weeks post-injury.
    - Chronic: Symptoms may appear weeks or months later, often mimicking a stroke due to minor injury.

Symptoms of Acute and Chronic Subdural Hematomas

• Headache
• Confusion, behavior changes
• Dizziness
• Nausea and vomiting
• Weakness on one side of the body
• Difficulty walking
• Seizures
• Diagnosis made via CT or MRI.
• Treatment: Surgical evacuation as needed.

Subarachnoid and Intracerebral Hematoma

• Subarachnoid Hematoma:
    - Bleeding inside the brain caused by hypertension or small artery tears due to injury. Signs include headache, neurological deficit, and altered consciousness, diagnosed by CT or MRI.
• Intracerebral Hematoma:
    - Bleeding in the subarachnoid space caused by trauma or aneurysm rupture, leading to symptoms like severe headache. Requires blood pressure control and possible surgical intervention.

Penetrating Head Injury

• Occurs when a foreign object pierces the skull and enters brain tissue. Approximately 12% of all traumatic brain injuries in the U.S.

Statistics on Penetrating Head Injury

• Gunshot wounds lead to high mortality rates:
    - 70-90% of patients with penetrating TBIs die before reaching the hospital.
    - Among survivors, 50% die during resuscitation in the ED.
• Note: Never remove any penetrating object from the skull.

Classifying Traumatic Brain Injuries

• Reiterates the classifications of focal vs diffuse injuries with examples as previously described.

Diffuse Axonal Injury (DAI)

• Definition:
    - Axonal injury occurs at the junction of grey and white matter.
• Mechanism:
    - Caused by rapid head movement leading to differential motion between grey and white matter.

Symptoms and Impact of Diffuse Axonal Injury

• Diagnosis:
    - Microscopic damage not visible on CT or MRI; clinical diagnosis based on LOC, neurological deficits, and neuropsychological assessments.
• Disruptions: Variable consequences range from mild to severe DAI leading to coma or minimally conscious state.

Concussion

• Definition:
    - A mild traumatic brain injury (mTBI) disrupting brain function due to rapid acceleration and deceleration.
• Prognosis:
    - Generally good; complete resolution of symptoms is typical.
• Symptoms vary including confusion, headache, dizziness, fatigue, and nausea.
• Diagnosis: Neurological exam typically reveals no visible structural damage on CT/MRI.

Signs of Concussion in Infants and Young Children

• Signs include:
    - Dazed appearance
    - Listlessness
    - Irritability
    - Balance and coordination issues
    - Excessive crying
    - Changes in eating or sleeping habits.

Recovery from a Concussion

1. Immediately Post-Injury:
      - Rest and limit physical and cognitive activities.
2. Within a Few Days:
      - Gradual return to non-strenuous activities, monitor for symptom exacerbation.
3. When Symptoms are Nearly Gone:
      - Return to normal activities while taking breaks if symptoms return.
      - Obtain clearance from a physician for sports activities.

Post-Concussion Syndrome

• Affects 10% to 30% of those with mTBI featuring symptoms lasting beyond the typical three-month recovery period.

Blast Injuries

• Common cause of combat-related concussions; primarily due to improvised explosive devices (IEDs).
    - Majority result in mild TBI.

Types of Blast Injuries

• Primary Blast Injury: Caused by the blast wave.
• Secondary Blast Injury: Caused by fragments that may injure soft tissue.
• Tertiary Blast Injury: Resulting from body displacement.

Long-Term Effects of mTBI

• Repeated mild TBIs increase risks for epilepsy, Parkinson’s, and dementia.
• Chronic Traumatic Encephalopathy (CTE):
    - Degenerative brain condition leading to cognitive, personality, and behavioral changes due to repetitive brain trauma.

Screening for TBIs

• Recognizing overlaps between mTBI symptoms and other disorders like PTSD.
• TBI screening programs implemented for veterans in healthcare settings.

Summary Questions

• Concussion symptoms can include nausea, vomiting, confusion, and vision problems.
• True or False: A concussion can occur without hitting the head? (Answer: True)
• True or False: A person must lose consciousness for a concussion diagnosis? (Answer: False)
• True or False: Brain injury will always be visible on a CT scan? (Answer: False)
• Attention to symptoms such as severe headache, large contusion, bilateral periorbital ecchymosis, or fever is crucial in basilar skull fracture assessments, indicating possible complications and the need for reporting to healthcare providers.