Head Trauma Ryerson 2009

Head Trauma and Principles of Neuro Assessment : 

Ryerson University 2008 Head Trauma and Principles of Neuro Assessment Wendy Jones RN MS Mary Douglas RN MSN CNN

Head Injuries – Common Causes : 

Head Injuries – Common Causes Blunt trauma (being hit by something) or falling and hitting something Traumatic Trauma ( car accident) Sports related Injury (Wear your helmet!!) Cerebral Vascular Trauma (stroke, aneurysm) Penetrating Wounds -Stabbing or Gun Shot wounds

Primary Survey : 

Primary Survey ABC’s Stabilization of life threatening Injury Priorities Change with Assessment

Secondary Survey : 

Secondary Survey begins when primary survey and resuscitation complete 1st goal: assess response to initial resuscitative effort 2nd goal: systematic head to toe for hidden injuries early recognition and treatment of substantial injuries prevents further deterioration

Mechanism of Injury : 

Mechanism of Injury Knowing how a individual is injured is important information as it can help us to predict certain injuries which may be present. Obtaining a detailed history about the injury is therefore imperative

Health History : 

Health History What do you need to ask?

Neurological Status Exam : 

Neurological Status Exam Include: Level of consciousness – Neuro Assessment including Glasgow Coma Scale Lowest level of function (sensory & motor) – Spinal Cord Assessment Record Level of Awareness – Ranchos Los Amigos Scale

Glasgow Coma Scale : 

Glasgow Coma Scale

Neurological Observation Records : 

Neurological Observation Records Pupils – size matters, what else matters? GCS - Glasgow Coma Scale (level of arousal/consciousness) Best Eye Opening Best Verbal Response Best Motor Response Limb Strength Pronator Drift – what is THAT?

Level of Awareness : 

Level of Awareness Ranchos Los Amigos Scale More in-depth picture of the patient’s recovery Eight level scale identifying certain behaviours that exist during a patient’s recovery Describes specific behaviours that the patient may exhibit during recovery

Ranchos Los Amigos Scale : 

Ranchos Los Amigos Scale Level I No Response Level II Generalized Response Level III Localized Response Level IV Confused/Agitated Level V Confused/Inappropriate/Non- Agitated Level VI Confused/Appropriate Level VII Automatic/Appropriate Level VIII Purposeful/Appropriate

Slide 14: 

Ranchos Level 1: No Response provide heightened and organized presentation of stimulation to prevent sensory deprivation and attempt to elicit responses cluster care and talk to child as you do care Level 2: Generalized Response do as in above, once responses are elicited try to heighten the responses cluster care and talk to child as you do care

Slide 15: 

Level 3: Localized Response do as above, move towards meaningful spontaneous responses (i.e. catching a ball, batting a balloon) and have child participate in part of task cluster care do hand over hand activities (i.e wiping face) wait for response (count to 10 before repeating question/command) offer choices between two things Ranchos

Slide 16: 

Level 4: Confused Agitated structured environment to decrease stimulation so child can process external input, cluster care try for automatic responses to complete task (i.e. hand face cloth to child to wipe face if it is wet) quiet environment (limit visitors; talk softly and slowly to child and wait for a response decrease visual distractions (only one picture at bedside; TV off; dim lights restraints for safety may be needed Ranchos

Slide 17: 

Level 5: Confused Inappropriate generally not as agitated may follow simple commands stressful situations may provoke them may be frustrated with memory problems Level 6: Confused Appropriate speech makes sense can do simple tasks like eating, dressing, brushing teeth but may need to be told when to start and stop these activities Ranchos

Ranchos : 

Ranchos Level 7: Automatic Appropriatecan perform all self care and are usually coherentdifficulty with memoryrational judgement, calculations, multi-step problems present difficulties but may not know this Level 8: Purposeful Appropriateable to function appropriately

Increased Intracranial Pressure : 

Increased Intracranial Pressure pressure exerted within the cranial cavity by blood, brain tissue, and CSF An increase in the volume of one of these components must be balanced by a reduction in another Brain 80% Blood 10% CSF 10%

SIGNS AND SYMPTOMS : 

SIGNS AND SYMPTOMS INFANTS bulging/firm fontanel increased head circumference (>95th percentile) irritable, lethargic unusual eye movement/drifting sunset gaze sluggish/fixed pupils vomiting high-pitched cry seizures prominent forehead distended scalp veins split sutures Bradycardia apnea CHILD/ADOLESCENT Headaches – severe and unrelieved Changes in LOC behavioral changes (i.e. irritable) Vomiting without nausea unusual eye movement/drifting visual disturbances sunset gaze seizures elevated systolic BP (widening pulse pressure) ataxic sluggish/fixed pupils Bradycardia apnea

Managing ICP : 

Managing ICP Early detection via assessment Monitoring ICP w/bolt Burr hole Craniotomy Evacuation of blood, clots Shunt, EVD Other surgical interventions (removal of tumor)

Slide 22: 

ICP Bolt

HYDROCEPHALUS : 

HYDROCEPHALUS Hydrocephalus: progressive dilation of the cerebral ventricular system due to accumulation of CSF abnormalities in overproduction, absorption, and or circulation of CSF detected by physical assessment (head circumference; eyes; behaviour); CT/MRI; fetal ultrasound may be congenital or acquired if untreated adjacent white/gray matter will be compromised

VENTRICULAR SHUNTING : 

VENTRICULAR SHUNTING Purpose: to redirect CSF from ventricles to a place where superior absorption can occur treats both communicating and non-communicating hydrocephalus device consist of primary catheter, reservoir, one-way valve, and terminal catheter primary catheter is lodged in lateral ventricle reservoir is located under scalp where it is accessible for CSF aspiration if necessary (for simple or rapid reduction in ICP) CSF flows into primary catheter to reservoir, where fluid collects, and passes by the way of a one-way valve through the terminal catheter to “absorption site”

Slide 25: 

From: Cheek (1996) Atlas of Pediatric Neurosurgery W.B. Saunders Company

Slide 27: 

From: Cheek (1996) Atlas of Pediatric Neurosurgery W.B. Saunders Company

Slide 28: 

SUBGALEAL SHUNT

Head Trauma : 

Head Trauma

Acquired Brain Injury (ABI) Traumatic Brain Injury (TBI) : 

Acquired Brain Injury (ABI) Traumatic Brain Injury (TBI) Incidence/etiology under 5 years: falls; child abuse 5-14 years: sports/recreation related over 15 years: MVC’s head injuries are the leading cause of death in children: male : female injury ratio 2:1 male : female mortality ratio is 4:1 5-15 years is peak age of injury for males males sustain more severe injuries

Assessment Skills : 

Assessment Skills Inspect LOC (GCS) Facial Expression (Pain, Confused) Speech (clear , coherent, aphasic) Gait Posture Movements ( all limbs –gross motor) Appearance, Behaviour Cognition, Thought Processes

CONCUSSION : 

CONCUSSION No loss of consciousness is necessary for a concussion to occur. Could just be a series of symptoms: Headache, dizzy, dazed, seeing stars, light sensitive, ringing in the ears, tired, nauseated, vomiting, irritable, confused or disoriented Or signs: Poor balance or coordination, slow or slurred speech, poor concentration, delayed response to questions, vacant stare, decreased ability to play/perform, unusual emotions, personality change, inappropriate behaviour

CONCUSSION : 

CONCUSSION unconsciousness is related to damage to the Reticular Activating System Pons -; controls sleep-wakefulness cycle, consciousness, ability to direct attention to a specific task, and the perception of sensory input that might alter behaviour may not remember events preceding the concussion (retrograde amnesia)

Post Concussion Syndrome : 

Post Concussion Syndrome Re-occurrence of symptoms after an injury, difficulty concentrating, headache, dizziness, reduced attention span, memory loss (from several weeks up to 1 year), irritable and fatigues easily Management: Neurological assessment: GCS (LOC - reorientation, response to commands, pupils, vital signs) Monitor for increased ICP Possibly anticonvulsants if seizures (i.e. dilantin) Provide seizure precautions Rest - quiet environment

DIFFUSE AXONAL INJURY (DAI) : 

DIFFUSE AXONAL INJURY (DAI) a “shearing injury”, the severest form of diffuse brain injury almost exclusively caused by high speed MVA Rotational accelerative forces causes non rigid brain to move in the skull maximum stress occurs in areas where tissues of different density interface, i.e. between gray and white matter - gray matter is less dense than white matter, the gray matter is thrown forward while the more dense white matter lags behind hallmark: immediate and prolonged coma

Diffuse Axonal Injury (DAI) : 

Diffuse Axonal Injury (DAI) prolonged coma results from severe, widespread damage to conducting white matter, essentially disconnecting the cerebral hemispheres from the reticular activating system microscopic in nature - not seen on x-ray/CT, may see on MRI picked up by child's clinical characteristics and duration of coma Severity of DAI symptoms is often correlated with the length of coma Potential S&S include: hypertension, hyperthermia, hyperhidrosis (excessive sweating) as well as changes in cognition, memory, speech, motor function and personality

Sympathetic Storming : 

Sympathetic Storming An exaggerated stress response that can occur in up to 1/3 of severe brain injuries (especially with DAI) Can be an un-provoked response, or have a known source such as some change in neurological status If untreated – risk of secondary injury to the brain

Sympathetic Storming : 

Sympathetic Storming Signs and Symptoms Tachycardia Hypertension Hyperthermia Tachypnea Dystonia Pupils dilate Diaphoresis Slowing of bowel/bladder activity

CEREBRAL INJURIES : 

CEREBRAL INJURIES Contusion: bruising, hemorrhage & edema of cerebral cortex, resulting from blunt trauma, severity depends upon amount of direct tissue injury Coup Injury: injury occurs directly beneath the site of injury Contrecoup Injury: injury occurs on the side of brain opposite the side of impact as the brain (opposite side of impact) strikes the skull Laceration: tearing or shearing of brain tissue with disruption of pia mater always complicated by hemorrhage cerebral edema: an increase of fluid in the brain caused by any type of head injury

SKULL FRACTURES : 

SKULL FRACTURES Simple/Linear #: linear skull # is 3/4 of all fractures; no break in the skin, bone fragments remain approximated; dura mater not pierced heal spontaneously within 6 months; observe for signs of epidural or subdural bleeding (NVS, GCS); no other treatment required

SKULL FRACTURES : 

SKULL FRACTURES Depressed Skull #: occurs if one or more bone fragments are detected below normal contour of skull; profuse bleeding may occur if fracture over saggital or lateral sinus can be surgically elevated if 5mm below contour of skull, bleeding present; one of the most common indications for surgery following a head injury Comminuted #: bone broken in several places. need to decompress to treat

SKULL FRACTURES : 

SKULL FRACTURES Compound Skull #: scalp broken and depressed skull fracture present; results from direct communication from scalp into cranium; dura may be pierced surgical elevation and repair, debridement of hair, dirt, other debris, antibiotic treatment

SKULL FRACTURES : 

SKULL FRACTURES Basal skull # involves break in base of skull (posterior inferior portion, can be anterior); usually produces dural tears, therefore associated with CSF leak, rhinorrhea/ottorrhea meningitis, URT infections can occur from organisms gaining access to the cranium by way of the nose, ear, or parasinal sinuses through the dural tear management: no nose blowing, no nasal suctioning, no straws obtain a written doctor’s order for NG tube insertion due to possible risk of tube going into cranial vault

Slide 46: 

From: Cheek (1996) Atlas of Pediatric Neurosurgery W.B. Saunders Company SKULL FRACTURE

EPIDURAL BLEED : 

EPIDURAL BLEED accumulation of blood between skull and dura usually in temporal region results from low velocity direct blow often associated with skull # secondary to rupture of middle meningeal artery arterial bleeding therefore rapid accumulation, increasing pressure on brain which can cause herniation of brain stem through the foramen magnum signs/symptoms: awake and talking (“talk and die” kids), temporary LOC with recovery in 1-2 hours (lucid), increased drowsiness with headaches, ipsilateral pupil dilation (same side as bleed), contralateral hemiparesis management: report "stat" any changes in patient condition, elevate head of bed, may give mannitol (osmotic diuretic) to lessen ICP, surgery required

FOCAL HEAD INJURIES- CEREBRAL HEMATOMAS : 

FOCAL HEAD INJURIES- CEREBRAL HEMATOMAS EPIDURAL HEMATOMA SUBDURAL HEMATOMA SUBARCHANOID HEMATOMA INTRACEREBRAL HEMATOMA

Natasha Richardson : 

Natasha Richardson

Epidural Bleed : 

Epidural Bleed

SUBDURAL HEMATOMA : 

SUBDURAL HEMATOMA

Subarachnoid Hemorrhage : 

Subarachnoid Hemorrhage Source :www.symptomlog.com/Subarachnoid+Hemorrhage/Wh...

INTRACEREBRAL HEMATOMA : 

INTRACEREBRAL HEMATOMA

SUBDURAL BLEED : 

SUBDURAL BLEED accumulation of blood between dura and arachnoid membrane slow bleed - venous frequent in children < 2 years (birth trauma, abuse) can be acute or chronic more common than epidural (is 30% of head injuries)

SUBDURAL BLEED : 

SUBDURAL BLEED poorer prognosis than epidural because of further brain damage sign/symptoms: unilateral seizures, facial weakness, headache, hemiparesis of contralateral side, increased ICP, progression of decreasing LOC management: prevention of increased ICP and cerebral herniation, taps may be performed on infants, shunting for chronic subdurals

SUBARACHNOID INTRACEREBRALBLEED BLEED : 

SUBARACHNOID INTRACEREBRALBLEED BLEED associated with trauma and aneurysms vessels tear d/t shearing rapid development of increased ICP and seizures signs/symptoms: headache, neck stiffness, gradual decrease on LOC management: immediate surgery to control bleeding, treatment of symptoms - increase ICP and cerebral edema following severe head injury bleeding into cerebral substance venous or arterial high mortality signs/symptoms: headache, nausea and vomiting, seizures (generalized or focal), aphasia, hemiparesis management: surgery may be necessary, treatment of symptoms - increase ICP and cerebral edema

Head Trauma and Beyond : 

Head Trauma and Beyond Holistic Care CNO Standards Therapeutic Nurse Client Relationship Crisis Intervention Interdisciplinary Team of Caregivers Research