HEAD INJURIES – Classification, Causes, Types, Symptoms, Diagnostic Evaluations, Head Care Management, Medical and Nursing Management
Head injury is a general term used to describe any trauma to the head, and most specifically to the brain itself. Head injury refers to trauma to the head. This may or may not include injury to the brain. However, the terms traumatic brain injury and head injury are often used interchangeably in the medical literature.
An open head injury occurs when the cranium is fractured and/or the membranes that surround the brain (dura mater) are breached; in contrast, a closed head injury does not cause damage to the dura mater or skull.
According to GLAS GOW coma scale (GCS) head injury is classified into:
- Mild (GCS 13-15 with loss of consciousness to 15 minutes)
- Moderate (GCS 9-10 with loss of consciousness for up to 6 hours)
- Severe (GCS 3-8 with loss of consciousness greater than 6 hours)
CAUSES OF HEAD INJURY
When an injury occurs, loss of brain function can occur even without visible damage to the head. Force applied to the head may cause the brain to be directly injured or shaken, bouncing against the inner wall of the skull. The trauma can potentially cause bleeding in the spaces surrounding the brain, bruise the brain tissue or damage the nerve connections within the brain.
Head injury commonly occurs from
- Penetrating trauma
- Blunt head trauma – direct blow
- Motor vehicle accidents
- Falls by recreational activities such as biking, skating, or skateboarding
- Sports injuries
- Violence and abuse
- Cerebral edema
- Intracranial hemorrhage
- Skull fracture
- Contusion and concussion
TYPES OF HEAD INJURY
Anytime the skull is fractured, the patient is said to have an open head injury. If the skull is intact, the term closed head injury is used. Types of head injuries include injuries to the scalp and skull and brain
- Scalp Injury: Head Injuries may be closed or open. A closed head injury is one in which the skull is not broken. A penetrating head injury occurs when an object pierces the skull and breaches the dura mater. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area.
- Skull Injury: A head injury may cause a minor headache skull fracture, which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures
- Skull Fracture: A skull fracture is a break in the bone surrounding the brain and other structures within the skull.
- Linear Skull Fracture: A common injury, especially in children. A linear skull fracture is a simple break in the skull that follows a relatively straight line. It can occur after seemingly minor head injuries (falls, blows such a being struck by a rock, stick, or other object; or from motor vehicle accidents). A linear skull fracture is not a serious injury unless there is an additional injury to the brain itself.
- Depressed Skull Fractures: These are common after forceful impact by blunt objects-most commonly, hammers, rocks or other heavy but fairly small objects. These injuries cause “dents” in the skull bone. If the depth of a depressed fracture is at least equal to the thickness of the surrounding skull bone (about ¼-1/2 inch), surgery is often required to elevate the bony pieces and to inspect the brain for evidence of injury. Minimally depressed fractures are less than the thickness of the bone. Other fractures are not depressed at all. They usually do not require surgical treatment unless other injuries are noted.
- Basilar Skull Fracture: A fracture of the bones that form the base (floor) of the skull and results from severe blunt head trauma of significant force. A basilar skull fracture commonly connects to the sinus cavities. This connection may allow fluid or air entry into the inside of the skull and may cause infection. Surgery is usually not necessary unless other injuries are also involved.
Common symptoms of head injury include:
- Disturbances in consciousness – confusion to coma
- Increased intracranial pressure
- Headache, vertigo and disorientation
- Agitation, restlessness and dizziness
- Nausea and vomiting
- Pupillary abnormalities
- Respiratory regulatory
- Changes in vital signs – tachycardia, tachypnea
- Altered or absent cough and gag reflex
- Sensory, visual and hearing impairment
- Hemiparesis or hemiplegia
- Personality change
- Impaired mental function
- Difficulty concentrating
- Increased mood swings
- Lethargy or aggression
- Altered sleep habits
- History and physical examination
- CT scan and MRI
- X – ray of skull and cervical spine
- Position Emission Tomography
- Neuropsychological tests
HEAD INJURY MANAGEMENT
SELF CARE MANAGEMENT
Emergency medical personnel should immediately treat any serious or potentially serious head injury. Minor head injuries may be cared for at home. If have any worrisome symptoms, such as loss of consciousness, vomiting, weakness, visual changes, confusion, or severe headache, you should see immediate medical treatment
- Bleeding under the scalp, but outside the skull, creates “goose eggs” or large bruises at the site of a head injury. They are common and will go away on their own with time. Using ice immediately after the trauma may help decrease their size.
- Do not apply ice directly to the skin. Ice should be applied for 20 to 30 minutes at a time and can be repeated about every 2 to 4 hours as needed. There is little benefit after 24 hours.
- Use a light washcloth as a barrier and wrap the ice in it. Patient can also use a bag of frozen vegetables wrapped in cloth. This conforms nicely to the shape of the head.
- Make own ice pack by adding 1/3 cup of 70% isopropyl alcohol (green colored kind is best to help identify it later) to 2/3 cup of water in a zip-lock-style bag (double bag it to prevent leaking). The mixture turns into “slush.” Freeze this homemade ice pack for use when needed. Commercially available ice packs use chemicals to create cold. They are designed to be kept in a first-aid kit and need not be kept frozen. These can be applied directly to the skin, although a barrier can also be used if bleeding is present. They must be disposed of after a single use but can be handy in case of emergencies.
- When a minor head injury results from a fall into carpet or other soft surface and the height of the fall is less than the height of the person who fell and there is no loss of consciousness, a doctor’s visit is not usually needed. Apply ice to lessen swelling.
- The person should not be alone and driving or operating machinery should be restricted for 24 hours.
Treatment varies widely depending on the type and severity of injuries. Minor head injuries are often treated at home as long as someone is available to watch the person. Medications commonly are used in the acute setting to control early seizures, reduce intracranial pressure, and correct electrolyte abnormalities. Brain-injured patients may be partially or completely dependent for maintenance of respiration, nutrition, elimination, movement, and skin integrity.
1. Management of Increased Intracranial Pressure
- Maintaining adequate oxygenation
- Administering mannitol (osmotic diuretics)
- Drainage of cerebrospinal fluid
- Elevation of the head of the bed
- Complete bed rest
- Administering high – dose barbiturate therapy
- Dopamine to maintain cerebral perfusion pressure above 50 mmHg
- Glucocorticoid; dexamethasone (Decadron) to reduce cerebral edema
- Surgery to create a “window” in the skull to accommodate swelling and drain excess fluids
2. Antibiotic Therapy: administration of antibiotics is required to prevent infection with open skull fractures and penetrating wound. Antibiotics are usually not required in closed head injuries.
3. Antiepileptic Therapy: Medication to prevent seizures may be given to prevent or treat seizures that occur from the head injury. Seizures cause a profound elevation in intracranial pressure. Phenytoin most often used to control seizures.
4. Supportive Measures
- Ventilator support
- Vasopressors may be required to maintain blood pressure
- Seizures prevention
- Fluid and electrolyte maintenance
- Nutritional support
- Pain and anxiety management
- Evacuation of blood clots
- Debridement of penetrating
- Elevation of depressed fractures of the skull
- Suturing of severe scalp lacerations
- Decompressive craniectomies
POTENTIAL NURSING DIAGNOSIS
- Ineffective breathing pattern related to increased ICP or brain stem injury
- Ineffective airway clearance and ventilation related to hypoxia
- Impaired gas exchange related to altered level of consciousness
- Altered cerebral tissue perfusion related to increased intracranial pressure
- Fluid volume deficit related to disturbances of consciousness and hormonal dysfunction
- Impaired nutrition, less than body requirements related to metabolic changes, fluid restriction
- Risk for injury related to disorientation, restlessness and brain damage
- Potential for impaired skin integrity related to bed rest, hemipharesis and immobility
- Altered thought process related to head injury
- Compromised family coping related to unpredictability of outcome