Severe brain and head injury

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Information about Severe brain and head injury

Published on March 12, 2014

Author: Godges


SEVERE BRAIN/HEAD INJURY INTRODUCTION: This refers to injury to the brain, skull or both. Such injuries are sufficient magnitude to require medical attention. CAUSES 1. Acceleration and deceleration: Brain is semi-solid so when subjected to trauma , if exposed to violent movement , a patient suffers from concussion - temporary diffuse injury to brain 2. Skull distortion or head rotation Responsible for serious head injury. The brain responds to force by grinding forward and rotating or turning within compartment. The rotational forces produces distortion of brain, tension and shearing of tissues- thus cerebral contusion ( bruising). PATHOPHYSIOLOGY CHANGES ASSOCIATED WITH SEVERE BRAIN INJURY  Cerebral edema  Increased intra-cranial pressure  Hemorrhage  Meningeal tear  Metabolic disorder  Temperature grossly elevated  Contusion of certain cranial nerves CEREBRAL EDEMA Due to injury there develops increased cerebral blood flow, then pressure within capillaries and venules…..then alteration of BBB which results of fluid into extracellular space-oedema. It increases cerebral mass and thus causes ICP.

INCREASED INTRA-CRANIAL PRESSURE Normal ICP average 10mmHg and rises when compensatory mechanisms are exhausted. Increased ICP is as a result of cerebral edema or expanding lesion such as hematoma. CLINICAL FEATURES OF INCREASED INTRA-CRANIAL PRESSURE  Rising systolic BP  Widening pulse pressure  Bradycardia  Respiratory irregularity due to pressure on medulla oblongata  Pupil abnormality- fully dilated  Papilloedema  Visual disturbance  Motor dysfunction  Headache  Vomiting  Altered level of consciousness  Altered temp  Loss of brain stem reflex MANAGEMENT OF INCREASED ICP  Osmotic diuresis eg IV mannitol 0.25-1.0 gm kg/bd/wt daily  IV dexamethasome 12-20 mgs 6 hourly, which is a corticosteroids that stabilizes cell membrane and decreases oedema. The dose is reduced gradually to prevent adrenal insufficiency.  Lasix may be used to supplement  Maintain normal temp  If hyperthermia, expose  If hypothermia warm gradually  Quiet environment nursing  Surgery maybe indicated to drain hematoma  Avoid dehydration or overhydration  Maintain head and neck stable HAEMORRHAGE Maybe epidural, subdural, intracerebral hematoma and sub-arachnoid bleeding. It contributes to increased ICP and subsequent herniation of brain through foramen magnum. Haemorrhage from basilar artery and carotid artery is always fatal

MENINGEAL TEAR MAY OCCUR CAUSING: Otorrhea- leakage of CSF through ear Rhinorrhea-leakage of CSF through nose TEMP ELAVATION This is because of injury to the hypothalamus CONTUSION OF CERTAIN CRANIAL NERVES Particilary olfactory, facial, auditory which shows dysfuntion NURSING DIAGNOSES  Altered cerebral tissue perfusion  Risk of increased ICP  Hyperthermia  Pain  Impaired physical mobility  Risk of infection DIAGNOSTIC PROCEDURES 1) History of trauma 2) Neurological examination and general physical examination e.g decreased level of consciousness, leakage of CSF from ears and nose 3) X-ray of skull, CT, MRI 4) Blood Hb, grouping and matching MANAGEMENT 1) Immobilize head and neck and lower limbs. Assume neck injury as well 2) Ensure clear airway and ventilate oxygen by nasal catheter. Anticipate need for intubatrion 3) Maintain a quiet environment 4) Institute seizure precautions:  Have padded side rails and keep them up  Have a tongue depressor in a receiver on bed side  Have sunction machine on bedside  Have oxygen by bedside

 If seizures occur: i. Stay with the patient , ensure clear airway ii. Put patient on iv diazepam 10mgs initially then phentyon 300mgs in 4 divided doses daily IV till controlled, then through N/G tube , then orally as condition allows for at least 2yrs to prevent post traumatic eplilepsy. 5) Prevent and manage infections: To avoid meningitis and wound infection, a combination of 2 antibiotics: Crystapen 2-4 mega units 6 hourly 7-10 days Flagyl IV 500mgs (over 20 mins) 8 hourly 6) Management of increased gastric secretions: This is due to stress. Will be reduced by antacids 4-6 hourly through N/G 7) Neurological assement:  Level of consciousness  Pupillary size, shape, and reaction  Check for gang reflex-if none prone to aspiration pneumoniae  Respiratory rate- rhythm and characteristics  Blood pressure- hypotension may indicate occult bleeding and aggressive search for bleeding must be done. Hypertension may indicate ICP  Pulse and temperature  Hyperthermia due to injury of hypothalamus GENERAL CARE If loss of corneal reflex, lubricate corneal 4 hourly and apply shield to prevent damage . visual adequacy to be evaluated as soon as possible. Encourage patient to wake up. Turn 2 hourly - side to back to side Maintain body hygiene , start physiotherapy to prevent complications. Start assessing functional problems e.g speech Encourage patient to do as much of their own personal hygiene and dressing. Encourage to express feelings PREPARATION FOR DISCHARGE Share health messages with family as patients needs are complex. Some may require intensive home care Plan arrange for follow up care- direct to community resources that offer support.

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