Head injuries

[بقايا رسام]

HEAD INJURIES

Head injuries can include fractures to the skull and face, direct injuries to the brain (as from a bullet), and indirect injuries to the brain (such as a concussion, contusion, or intracranial hemorrhage).

Head injuries commonly occur from motor vehicle accidents, assaults, or falls.

Concussion: A temporary loss of consciousness that results from a transient interruption of the brain's normal functioning.

Contusion: A bruising of the brain tissue. Actual small amounts of bleeding into the brain tissue.

Intracranial hemorrhage: Significant bleeding into a space or a potential space between the skull and the brain. This is a serious complication of a head injury with a high mortality due a rising intracranial pressure (ICP) and the potential for brain herniation. Intracranial hemorrhages can be classified as epidural hematomas, subdural hematomas, or subarachnoid hemorrhages, depending on the site of bleeding.

NURSING *****
Assume a cervical spine fracture for any patient with a significant head injury, until proved otherwise.

Primary Assessment

Airway: assess for vomitus, bleeding, and foreign objects. Ensure cervical spine immobilization.
Breathing: assess for abnormally slow or shallow respirations. An elevated carbon dioxide partial pressure can worsen cerebral edema.
Circulation: assess pulse and bleeding.
Disability: assess the patient's neurologic status.

Primary Interventions

Open the airway using the jaw-thrust technique without head tilt. Oral suction equipment (to handle heavy vomitus) should be at hand. Make sure that you do not stimulate the gag reflex as this can cause increases in ICP.
*****ister high-flow O2: the most common cause of death from head injury is cerebral anoxia.
Assist inadequate respirations with a bag-valve mask as necessary. Prophylactic hyperventilation is not indicated.
Control bleeding do not apply pressure to the injury site. Apply a bulky, loose dressing. Do not attempt to stop the flow of blood or cerebrospinal fluid (CSF) from the nose or ears; apply a loose dressing if needed.
Initiate two I.V. lines. The rate of flow should be determined by the patient's hemodynamic status.

Subsequent Assessment

History
<UL type=circle>Mechanism of injury
Duration of loss of consciousness
Memory of the event
Position found
</UL>LOC
<UL type=circle>Change in the LOC is the most sensitive indicator of a change in the patient's condition.
Glasgow Coma Score (see page 475).
</UL>Vital signs
<UL type=circle>Hypertension and bradycardia are late signs of increasing ICP.
Head-injured patients may have associated cardiac dysrhythmias, noted by an irregular or rapid pulse.
Changing patterns of respiration or apnea may indicate a head injury.
Elevated temperature high temperatures may be associated with head injury.
</UL>Unequal or unresponsive pupils
Confusion or personality changes
Impaired vision
One or both eyes appear sunken
Seizure activity
Periauricular ecchymosis a bluish discoloration behind the ears (indicates a possible basal skull fracture)
Rhinorrhea or otorrhea (indicative of leakage of CSF)
Periorbital ecchymosis (indicates anterior basilar fracture)

NURSING *****
If basilar skull fracture or severe midface fractures are suspected, a nasogastric (NG) tube is contraindicated. An orogastric tube may be considered for insertion.

General Interventions

Keep the neck in a neutral position with the cervical spine immobilized.
Establish an I.V. line of normal saline or lactated Ringer's fluid volume should be restricted.
Be prepared to manage seizures if seizures occur, they should be controlled immediately.
Maintain normothermia.
Pharmacologic interventions may include:
<UL type=circle>Anticonvulsants to control seizures.
Mannitol (Osmitrol) to reduce cerebral edema and decrease ICP.
Antibiotics.
Antipyretics to control hyperthermia.
</UL>

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