Educational purpose for nursing students

1. PRESENTATION
ON
HEAD INJURY
AND MANAGEMENT OF
UNCONSCIOUS PATIENT
Presented by:
Daka Lamare,
1st year M.Sc. (N)
RIMS, CON, Manipur

2. ANATOMY OF THE HEAD

3. ANATOMY OF THE BRAIN

4. INTRODUCTION
o Head injury is a general term used to describe any trauma to the head
and most specifically to the brain itself.
oMotor vehicle collisions and falls are the most common causes of
head injuries. It has a high potential for a poor outcome.
oDeaths from head trauma occur at three points after injury:
1. Immediately after the injury.
2. Within 2 hours after the injury.
3. Approximate 3 weeks after injury.

5. INTRODUCTION
oDeaths occurring 3 weeks or more after the injury results
from multisystem failure.
oThe GCS score on arrival at the hospital is also a strong
predictor of survival.
oGCS below 8 indicates a 30% – 70% chance of survival.
oGCS above 8 indicates a greater than 90% survival rate.

6. DEFINITION
oHead injury includes any injury of trauma to the brain, scalp, or
skull.
oA serious form of head injury is traumatic brain injury (TBI).
oTBI is defined as disruption of brain function resulting from a
blow or jolt to the head or penetrating head injury
oDamage to the brain from traumatic injury takes two forms:
primary injury (due to initial damage such as damage to scalp,
blood vessels, or foreign body penetration) and secondary injury
(evolve after initial damage such as cerebral edema, increase
ICP, ischemia or electrolyte disturbances)

7. MECHANISM OF HEAD INJURY
Acceleration injury: Occurs when a moving object strikes a non-
moving object. E.g., a missile fired into a head
Deceleration injury: Occurs when a moving head strikes a stationary
object such as in a fall
Acceleration – deceleration injury: It results from unrestricted and
sudden head movement. E.g., a motor vehicle suddenly decelerates
wand the head hit an immobile object such as the steering wheel.
Penetration injury: Occurs when an object enters the skull and
harms the brain

8. MECHANISM OF HEAD INJURY
Whiplash injury: A neck injury that can occur when the head
suddenly moves backward and then forward

9. MECHANISM OF HEAD INJURY
Rotational injury: Occurs when forces cause the brain to twist
within the skull and can cause injury to the nerve fibers in the brain
Rotational acceleration-deceleration injury: Brain is twisted inside
the skull which results in torsion and shearing of axons and possible
vascular disruption
Deformation injury: Results from the direct or indirect transmission
of energy to the skull. If the force is sufficient, the part is deformed
and fracture (skull fracture)

10. MECHANISM OF HEAD INJURY
Coup-countercoup injury:
• After the head strikes the wall, a coup injury
occurs as the brain strikes the skull
(primary impact).
•The countercoup injury (secondary impact) occurs
when the brain strike the skull surface opposite the
site of the original impact

11. CLASSIFICATION
According to GCS head injury is classified into:
1. MILD : GCS 13-15 with LOC to 15 minutes.
2. MODERATE : GCS 9-10 with LOC for up to 6
hours.
3. SEVERE : GCS 3-8 with LOC greater than 6
hours.

12. TYPES OF HEAD INJURY
1.Scalp
lacerations
2. Skull fracture 5. Brain injury
4. Closed
3. Open
a. Linear
b. Depressed
e. Compound
d. Comminuted
c. Simple
a. Diffused
Axonal injury
c. Focal injury
b. Diffused
injury

13. TYPES
1. Scalp lacerations:
•Are easily recognized
•Are associated with
profuse bleeding

14. TYPES
2. Skull fracture:
a. Linear
• Break in continuity
of bone
• Cause by low velocity
injuries

15. TYPES
b. Depressed:
•Inward indentation of skull
•Cause by powerful blow

16. TYPES
c. Simple:
•Without fragmentation
or communicating laceration
•Cause by low
to moderate impact

17. TYPES
d. Comminuted:
•Multiple fracture with
fragmentation of
bone into many pieces
•Direct, high - momentum
impact

18. TYPES
e. Compound:
•Depressed skull fracture and
scalp with laceration with
communicating pathway to
intracranial cavity
•Severe head injury

19. TYPES
3. Open:
•Cranium is fracture and/or
the membrane that surround
the brain (dura mater)
are breached

20. TYPES
4. Closed:
• Does not cause damage
to the dura mater and skull

21. TYPES
5. Brain injury:
a. Diffuse axonal injury (DAI)
• Widespread axonal damage
or shearing of axons
resulting in axonal
disconnection

22. TYPES
b. Diffuse injury:
• Concussion: A sudden transient mechanical head injury
with disruption of neural activity and change in
the LOC, considered as minor injury
• Signs include a brief disruption in LOC,
retrograde amnesia and headache
• Postconcussion syndrome include persistent
headache, lethargy, personality and behavioural
changes, shortened attention span and short-
term memory loss

23. TYPES
c. Focal injury:
• Contusion: A bruising of the brain tissue within
a focal area associated with head injury
• May contain areas of haemorrhage, infarction,
necrosis and edema and it frequently occur at a
fracture site
• Seizures are a common complication of brain
contusion especially in the first 7 days after injury
• With contusion a phenomenon of coup-counter-
coup phenomenon is noted

24. RISK FACTORS
oColour blindness
oAlcohol addiction
oVertigo
oChildren up to 4 years old
oYoung adult between 15 to 24 years
oAdult age 60 and above
oMilitary personnel
oMales

25. ETIOLOGY
Blunt
Motor vehicle collision
Pedestrian events
Falls
Assault
Sport injuries
Explosive blasts
Penetrating
Gunshot
Arrow

26. PATHOPHYSIOLOGY OF TBI
Due to etiological factors
Brain swelling or bleeding, increases intracranial
volume
ICP continues to rise. Brain may herniate
Pressure on blood vessels within the brain causes
blood flow to the brain to slow
Brain suffers traumatic injury
Rigid cranium allows no room for expansion of
contents so ICP increases
Ischemia and cerebral hypoxia occur
Interruption in cerebral blood flow

27. CLINICAL MANIFESTATION
Increase ICP
Dilated pupils
Altered consciousness
Drainage of bloody or clear fluids from ears or nose
Seizure
Headache, vertigo
Disorientation

28. CLINICAL MANIFESTATION
 Altered or absent cough or gag reflex
Agitation, restlessness and dizziness
Nausea and vomiting
Changes in behaviour such as irritability or confusion
Changes in vitals : tachycardia, tachypnea
Sensory, visual or hearing impairment
Hemiparesis

29. CLINICAL MANIFESTATION
Memory or concentration problems
Problems with speech
Increase mood swing
Lethargy
Difficulty in sleeping
Pupillary abnormalities

30. MANIFESTATION OF SKULL
FRACTURES
Frontal fracture:
Air in forehead tissue
CSF rhinorrhea
Pneomocranium
Orbital fracture:
Raccoon eyes
Optic nerve injury

31. MANIFESTATION OF SKULL
FRACTURES
Temporal fracture:
Oval shaped bruise behind ears in
mastoid region (battle’s signs)
CSF otorrhea
Epidural haematoma
Buggy temporal muscle

32. MANIFESTATION OF SKULL
FRACTURES
Parietal fracture:
Deafness
CSF or brain otorrhea
Bulging of tympanic membrane
Facial paralysis
Loss of taste
Battle’s sign

33. MANIFESTATION OF SKULL
FRACTURES
Poterior fossa fracture:
Visual field defects
Occipital bruising resulting in cortical blindness
Basilar skull fracture:
CSF or brain otorrhoea
Bulging of tympanic membrane
Battle’s sign
Tinnitus
Vertigo
Facial paralysis

34. METHODS TO DETERMINE CSF
LEAKAGE
1. Using dextrostix
oTo determine whether glucose is present
oIf blood is present in the fluid, testing for glucose is unreliable since blood
also contain glucose
2. Halo or ring sign
oAllow the leakage fluid to drip into a white gauze and then observe the
drainage
oWithin few minutes the blood coalesces into the centre and yellowish ring
encircle the blood if CSF is present
oNote the colour, appearance and amount of leaking fluid

35. DIAGNOSTIC EVALUATION
1. History collection, physical and neurological examination
•Complete history collection
•Complete physical examination – racoon eyes, signs of skull
fractures, battle’s sign, CSF rhinorrhoea and otorrhoea
•Neurological examination – mental status,
cranial nerve function, motor function,
sensory function, reflexes, pupil size and
response, GCS

37. DIAGNOSTIC EVALUATION
2. CT SCAN: Create a detailed view of the brain. Visualize fractures,
bleeding, blood clot, tissue swelling, bruise tissue
3. MRI: Can detect small lesions
4. PET SCAN: To reveal the metabolic and chemical function of the
brain
5. Transcranial Doppler (TCD) ultrasound: To determine cerebral
blood flow, blood velocity, to assess cerebral vasospasm
6. X-ray of skull and cervical spine

38. MANAGEMENT
INITIAL MANAGEMENT
Ensure patient airway
Stabilize cervical spine
Administer O2 if required
Establish IV to infuse normal saline or lactated ringer’s solution
Intubate if GCS is <8
Control external bleeding with sterile pressure dressing
Remove patient’s clothing

39. MANAGEMENT
MEDICAL MANAGEMENT
Antiepileptic: To prevent seizure, e.g., Phenytoin, 10-15
mg/kg IV, Levipil, 500 mg IV
Osmotic diuretics: To prevent increase ICP, e.g., Mannitol
25%, 1.5 – 2 g/kg IV infused over 30-60 minutes.
Antipyretics/Analgesics: To treat fever and relieve pain,
e.g., Paracetamol, 1g IV.

40. MANAGEMENT
Calcium channel blockers: To maintain blood pressure and
to prevent exacerbation of intracranial haemorrhage in
hypertensive encephalopathy, e.g., Nicardipine, 20mg q8hrly
orally or 0.5 mg/hr IV
Tetanus prophylaxis: To prevent tetanus infection, e.g., Inj.
TT, 0.5 ml, IM.
Antibiotic: It is required to prevent infection with open
skull injuries and penetrating wound. It is usually not
required in closed head injury.

41. MANAGEMENT
SURGICAL MANAGEMENT
Craniotomy:
 A bone flap is removed to exposed the cranium and dura mater to drain blood or relieve
increased ICP, remove free fragments, repair damaged area, and elevated depressed bone
Craniectomy:
 Removal of bone flap or fragments if large amount of bones are destroyed
Burr hole:
 Opening into the cranium with a drill to remove fluid and blood collection beneath the dura
Cranioplasty:
 Repair of cranial defect. Artificial materials are used to replace damaged or lost bone

42. MANAGEMENT
SELF CARE MANAGEMENT
Bleeding under the scalp but outside the skull create “goose egg” or
large bruises at the site of a head injury, these will go away on their
own. Using ice immediately after the trauma may help decrease their
size
Do not apply ice directly on the skin instead use a washcloth as a
barrier and wrap the ice pack
Ice should be applied for 20-30 minutes at a time and can be
repeated about 2-4 hours as needed. There is little benefit after 24
hours

43. LIST OF NURSING DIAGNOSIS
1. Fluid volume deficit related to loss of fluid via bleeding
2. Impaired physical mobility related to decrease LOC, fatigue or fracture
3. Hyperthermia related to infection and hypothalamic injury
4. Anxiety related to change in health status, hospital environment and outcome of
disease
5. Risk for ineffective cerebral tissue perfusion related to interruption of CBF associated
with haemorrhage, hematoma and edema
6. Risk for potential complication: increased ICP related to cerebral edema and
haemorrhage
7. Risk for secondary injury related to decrease level of consciousness

44. NURSING MANAGEMENT/INTERVENTION
Assess for CSF leakage. Monitor vitals
Administer fluids cautiously to prevent fluid overload and increase ICP
Maintain the position and patency of ET tube if present, to maintain O2 saturation
Provide suctioning
Keep the head of the bed elevated about 30 degree to decrease or maintain intracranial pressure
Allow rest between nursing activities to avoid increase in ICP
Provide mouth, skin and eye care to prevent tissue damage
Change the position q2hrly to prevent pressure ulcer

45. COMPLICATIONS
1. Epidural haematoma: Results from bleeding between the dura mater and the inner surface of
the skull
2. Subdural haematoma: Results from bleeding between the dura mater and the subarachnoid
layer
a) Acute: 24-48 hours after severe injury
b) Sub-acute: 48 hrs – 2 weeks after severe trauma
c) Chronic: weeks or months, usually >20 days after injury
3. Sub-arachnoid haematoma: Results from bleeding between the arachnoid and pia mater
4. Intracerebral haematoma: Result from bleeding within the brain tissue in approximately 16%
of head injuries. May be intra-parenchymal or intraventricular
5. Others: Coma, post-traumatic memory loss, chronic headache, loss/change in sensation, taste,
vision, smell and hearing, paralysis, seizures, speech and language problems and death

46. MANAGEMENT OF
UNCONSCIOUS PATIENT

47. DEFINITION
oUnconscious means that the person is not aware of what is going on
around him and is unable to make purposeful movement and respond
meaningfully to external stimuli.
oUnconscious patient is completely dependent on others for all of his
needs.
oUnconsciousness is a symptom rather than a disease.
oDegrees of unconsciousness vary in length and severity:
Brief – Fainting
Prolonged – Coma (deepest state of unconsciousness)

48. MANAGEMENT
GENERAL NURSING CONSIDERATIONS
Always assume that the patient can hear even though he make no response
Always address the patient by name and tell him what we are going to do
Keep patient’s room at a comfortable temperature
Keep side rails up to protect the patient from injury
If restrain is needed, use “mitten” to avoid skin irritation
Regularly observe and record patient’s vitals and level of consciousness
 Report if any changes in vitals
 Note return of protective reflexes such as blinking the eyelids or swallowing saliva

49. Cont.
AIRWAY AND BREATHING
Maintain a patent airway by proper positioning of the patient. Whenever
possible position the patient on his side (lateral recumbent) with the chin
extended, this prevent the tongue from obstructing the airway
Reposition the patient from side to side to prevent pooling of mucous and
secretion in lungs
Suction the mouth, pharynx and trachea as often as necessary to prevent
aspiration of secretions
Administered oxygen as ordered

50. Cont.
NUTRITIONAL NEEDS
Always observe patient carefully when administering anything by gavage
Do not leave the patient unattended
Keep accurate records of all intake ( feeding formula, water, liquid, medication)
Always place the patient in fowler’s position and support with pillows while
feeding
Since fluids are maintained by IV, keep record of intake and output
Observe patient for signs of dehydration or fluid overload

51. Cont.
EYE CARE
Observe for signs of irritation, corneal drying, abrasion and edema
Gentle cleaning with gauze with 0.9% sodium chloride to prevent
infection
Artificial tears drop can also be used to help moisten the eyes
MOUTH CARE
Provide mouth care daily using chlorhexidine solution
Apply petroleum jelly to lips to prevent drying

52. Cont.
SKIN CARE
Bed bath should be provided to prevent dry skin, paying special
attention to folds and perineal area. Hair care should not be neglected
The skin should be lubricated with moisturizing lotion after bath
Nails should be kept short and clean
Gently massage the skin to improve circulation

53. Cont.
ELIMINATION
Assess for diarrhoea, constipation and bladder distention
Keep accurate record of bowel and bladder elimination
A liquid stool softener may ne ordered by the physician to prevent constipation
or impaction
If enemas are ordered, use proper technique to ensure effective administration
The bladder should be emptied to prevent infection
Report low urine output
Provide catheter care for catheterized patients to prevent infection

54. Cont.
POSITIONING
When positioning an unconscious patient, pay particular attention to maintain
proper body alignment
Limbs must be supported, do not allow flaccid limbs to rest unsupported
Change the position q2hrly
Utilize a foot board at the end of the bed to decrease the possibility of foot drop
ROM exercises should be performed to avoid contractures