HEAD TRAUMA

Neurologic Assessment

Levels of consciousness

Glassgow coma scale

Cranial nerve assessment

Definition – Traumatic Brain Injury (TBI)

is a result of an external mechanical

force to the brain that leads in a change to

cognitive, physical, psychosocial

functioning associated with

altered state of consciousness.

The impairments can be temporary or permanent

Risk Factor

Risk Factor

Risk Factor

• Firearms

Primary Brain Injury

Results from what has occurred to the brain at the time of the injury

Traumatic Brain Injury

Traumatic Brain Injury

Secondary Brain Injury

Physiologic and biochemical events which follow the primary injury

Categories of Brain Injuries Closed (Blunt) Brain Injury

Acceleration/Deceleration

If a moving object hits a movable head (e.g. head gets hit with a bat)If a moving head hits something stationaryShaken type of movement

(e.g. when head rocks back and forth in skull).

Non-AccelerationMuch more rare, referred to as a crushing injuryIf a moving object hits a head that is fixed (e.g. car falls on head while you’re working under it).

Low VelocitySkull is no longer intact, part of skull or debris gets into the brain.

High VelocityBullets penetrate the skull and goes into the brain matter.

Categories of Brain Injuries Open Brain Injury

CAUSES OF BRAIN INJURIESCAUSES OF BRAIN INJURIES

Coup and Countercoup InjuriesConcussion vs ContusionDiffuse Axonal InjuryEpidural HematomaSubdural HematomaIntracerebral HemorrhageCompound fracture Penetrating injury

Contusion Bruising type of injury to the brain resulting to

sudden loss of consciousness or coma. Contusion may occur with subdural/ extradural collection of blood, intracerebral hemorrhage.

Contusion is considered severe form of axonal injury with shearing of blood.

ConcussionMild bruising to the cerebral tissue

cause by jarring of the brain resulting in transient

loss of consciousness.

Concussion is considered a mild form of diffuse axonal injury

Categories of Diffuse Brain Injury

Mild Concussion (ŝ LOC) Grade I - confusion disorientation with amnesia. Grade II - confusion and retrograde amnesia (5-10 min)

Grade III - confusion with retrograde and anterograde.

Classic Cerebral Concussion (Grade IV) - Diffuse cerebral disconnection from brain. - LOC is lost for up to 6 hours. - Confusion for hours to days. - Retrograde and anterograde amnesia. - May experience post-concussive syndrome.

Categories of Diffuse Brain Injury

Categories of Diffuse Brain Injury

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Mild DAI - Coma > 6 -24 hrs - Persistent residual cognitive, psychologic, sensorimotor deficit.

Decorticate and decerebrate posturing Prolonged period of stupor

Decorticate vs Decerebrate

Moderate DAI

- Widespread impairment cerebral cortex,

diencephalon, tearing of axons both

hemisphere

- Transitory decortication or decerebration.

- Unconsciousness lasting days or weeks.

Categories of Diffuse Brain Injury

Severe DAI

- LOC more than weeks

- Severe mechanical disruptions of axons in

both hemisphere, diencephalon and brain

stem. - compromised coordinated movements, ver bal, written communication, inability to learn and reason, modulate behavior.

Categories of Diffuse Brain Injury

Diffuse Axonal InjuryDiffuse axonal injury is characterized by

extensive generalized damage to the white matter of the brain

Strains during high-speed acceleration/deceleration produced in lateral motions of the head may cause

the injury.

Video

Compound Fracture Object strikes the head with great force or head

strike the object forcefully temporal or occipital blow upward

impact of cervical vertebrae (basilar skull

fracture)

Penetrating Injury

Missile (bullets) or sharp projectile (knives, axes, screwdriver)

CENTRIPETAL APPROACH(outside to inside)

• –Scalp• –Cranium • –• –Subdural• –Subarachnoid• –Intra-parenchymal• –Intra-ventricular

- Epidural

Subgaleal

Subdural – ‘Epi-arachnoid’

Subarachnoid Parenchymal Hemorrhage Intra-ventricular

Cephalohematoma – Subperiosteal Outer Table

Epidural (Extradural) – Subperiosteal Inner Table

Traumatic Hemorrhage:

EPIDURAL HEMATOMASource of Bleeding

Arterial (high pressure)Venous (low pressure)

High flow, low pressure

Diploic veins (Fx)Marrow sinusoids

MENINGEAL VESSELS

DURAL SINUS

OTHERS

Epidural Hematoma:

Trauma -> fracture & concussionTearing/stripping of both layers from inner tableLaceration of outer periosteal layerLaceration of meningeal vesselsInner (meningeal dura) intactBlood between naked bone and duraNORMAL arterial pressurecontinues to dissect

EPIDURAL HEMATOMA

EPIDURAL HEMATOMA

EPIDURAL HEMATOMASignificant traumaFracture & concussion (l.o.c)

Delayed neurologic Sx (hrs. Later)

Herniation, coma and death

Lucid Interval – pt Wakes Up – 40% pts.

SUBDURAL HEMATOMA SUBDURAL HEMATOMA

SUBDURAL HEMATOMA HEMATOMA

TYPES OF INJURY

ONSET OF S/S

CLINICAL MANIFESTATION

Acute Severe Head Injury

within hours Rapid deterioration to drowsiness, agitation, stuporous, coma, signs of brain stem compression, pupil dilation contralateral hemiparesis.

Subacute Moderate Head Injury

2 hours to weeks after

Lucid , Drowsiness, stuporous coma, Increase ICP

Chronic Mild Head Injury weeks - months after

Dull headache, slowness in thinking, apathy, drowsiness, contralateral hemipareresis, progressive neurologic changes, aphasia, papilledema, LOC changes.

INTRACEREBRAL HEMATOMAINTRACEREBRAL HEMATOMA

INTRACEREBRAL HEMATOMA

• Usually frontal and temporal lobes

• May occur in hemispheric deep white matter

• Small blood vessels injured by shearing forces

• Acts as expanding mass, compresses tissue, and causes edema

• May appear 3- 10 days after head injury

TBI’s TBI’s Pathophysiology Pathophysiology

COMPLICATIONS of TBI’s

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Cerebral Cortex Lesion Aphasia

Conductive - abnormalities in speech repetition

Global - All language functions are affected.

Receptive (Wernicke’s area) - difficulty to express thoughts.

Expressive (Broca’s area) - difficulty in expressing words and phrases

A defect in either the production or comprehension of vocabulary

Cerebral Cortex Lesion Apraxia “әprak’ sea”

Types Ideational

- failure in carrying sequences of act

Kinetic - inability to execute fine acquired movements.

- Inability to perform purposeful act or to manipulate object in the absence motor power sensation or coordination. Deficit is present without weakness, sensory loss.

Cerebral cortex lesion Agnosia - failure to recognize when the appropriate sensory system are functioning adequately

Visual - failure to recognized object visually in the absence of defect of visual acuity.

Tactile - inability to recognized objects by touch when tactile and proprioreceptive sensibilities are intact

Auditory - failure of a patient with intact hearing to recognized what he or she hears.

Homonymous Hemianopia Homonymous Hemianopia

Diagnostics

Radiologic studies

Computed Tomography (CT) or (CAT)

Painless, noninvasive x-ray procedure that has the unique capabilities of distinguishing minor differences in the density of

tissues. It produce a three – dimensional image of the organ or structure.

Magnetic Resonance

Imaging (MRI)

noninvasive diagnostic scanning technique in which the client is placed in a magnatic

field. MRI provides a better contrast between normal and abnormal tissue than the CT scan. The procedure lasts between 60 and 90 minutes.

 

Radiologic studies Radiologic studies

Angiography– invasive procedure requiring informed consent

of the client. A radiopaque dye is injected into

the vessels to be examined.

- Using x-rays the flow through the vessels is

assessed and areas of narrowing or blockage

can be observed.

Radiologic studies Radiologic studies

The Ring SignThe 'ring sign': is it a reliable indicator for cerebral spinal fluid?

One drop of blood and one drop of either spinal fluid, saline, tap water, or rhinorrhea fluid were placed simultaneously on filter paper, and the

specimens were examined after ten minutes for the development of a ring.

RESULTS: All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not.

Spinal Cord Injury

Bowel, Bladderareas of the skin supplied by nerve

fibers originating from a single dorsal nerve root.

Dermatomes

What causes?

What causes?

What causes?

What causes?

Pathophysiology

Click Spinal cord injury

Clinical Manifestations

SPINAL SHOCK STAGEComplete spinal cord transection

Loss of motor function Cervical injury: Quadriplegia Thoracic injury: Paraplegic Muscle placidity below the level of injury Loss of all reflexes Loss of pain, temperature, touch, pressure, and proprioception.

SPINAL SHOCK STAGE

Complete spinal cord transection Below the level of injury

– Pain at injury site caused by zone hyperesthesia– Paralytic ileus and distension – Loss of vasomotor tone; Low and unstable BP– Loss of perspiration– Loss of erection and bulbocavernous reflex. – Dry pale skin, possible ulceration over bony prominences. – Respiratory impairment.

Clinical ManifestationsClinical Manifestations

Partial spinal cord transection Below the level of injury - Asymmetric flaccid motor paralysis - Asymmetric reflex loss. - Vasomotor instability, bowel, bladder impairment are less severe - Preservation in ability to perspire in some areas of the body.

Clinical Manifestations

Partial spinal cord transectionBrown Séquard Syndrome Ipsilateral paralysis or paresis. Loss of touch, pressure, vibration Contralateral loss of pain and temperature sensation

Clinical Manifestations

Central cord syndrome - Loss of motor function is more pronounce in

the hand with bladder dysfunction.

Partial spinal cord transection

Clinical ManifestationsClinical Manifestations

Partial spinal cord transectionBurning hand syndrome - Severe burning paresthesias dysthesias in the hands or feet. Anterior cord syndrome - Loss of motor function - Loss of pain and temperature sensation - Touch, pressure, position and vibration senses are intact.

Clinical Manifestations

Partial spinal cord transection

Posterior cord syndrome Impaired light touch and proprioception

Conus medularis syndrome (injury to T12 – L1)

-Flaccid paralysis of legs, bowel and bladder areflexia- If damage is limited to the upper sacral segment erection and micturation reflex is intact.

Clinical Manifestations

Partial spinal cord transection

Cauda equina syndrome - Injury below conus medullaris - Areflexia of bladder, bowel lower reflexes. Syndrome of neuropraxia - posttraumatic injury) - Transient neurologic deficit including quadriplegia

Clinical Manifestations

Partial spinal cord transection

Clinical Manifestation of SCI’sClinical Manifestation of SCI’s

Horner’s syndrome - Ipsilateral pupil smaller than contralateral - Sunken ipsilateral eyeball - Ptosis of affected eyeball - Lack of perspiration on ipsilateral side.

Cervical Injuries • Injury to C2-C5 is fatal

• C4 inervation of the diaphragm

by phrenic nerve.

• above C4 injury causes respiratory difficulty and quardriplegia

• C5 injury, may have movement of shoulder.

Thoracic Level• Loss of movement of the chest,

trunk, bowel, bladder, and legs

• (T6) Leg paralysis (paraplegia)

• Autonomic dysreflexia

- lesion above T6

- distention bladder or impacted

rectum may cause reaction.

Lumbar and Sacral Injuries

• lower ext. loss of movement and sensation• S2 – S3 (micturition center) - bladder will contract but will not empty. • Injury above S2

– males allows erection– unable to ejaculate because SN damage.

• Between S2 and S4– preventing erection and ejaculation – due to damages SN and PNS.

Complications• Loss of locomotion

– Damage of descending and ascending parts of SC

which transmit sensory and motor impulses from

and to the brain.

• Bowel and bladder dysfunction– S1 injury, infection of the bladder, and anal incontinence

• Impaired breathing– damage to thoracic nerve which control intercostal and

abdominal muscle.

Complications

• Reduced ability regulate BP, HR, sweating, body temp-

ant. intermedial tract of the spinal cord where autonomic functions is regulated.

• Osteoporosis (loss of calcium) and bone degeneration-r/t paralysis and immobility

• Atrophy – due to prolonged immobility

• Pressure sores- areas of skin that have broken down because of continuous pressure on the skin.

Nursing Diagnosis

• Impaired sensory perception r/t destruction of sensory

tract with altered sensory reception, transmission, and

integration.

• Situitional Low Self-Esteem r/t traumatic injury.

• Constipation r/t denervation to bowel and rectum.

• Impaired urinary elimination r/t denervation of bladder

• Risk for Autonomic Dysreflexia r/t altered nerve function

(T6 SC injury and above)

Diagnostic exams

• X ray – can reveal vertebral problem, tumors, fracture or degenerative changes in the spine.

• Computerized tomography- better look at abnormalities on x ray.

• Magnetic resonance imaging- extremely helpful

for looking herniated disk, bld clots masses that

may compress the cord.

Myelography

- visualization of the

spinal nerves

Diagnostic examsDiagnostic exams

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