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Brain, Cranial, Ocular, Maxillofacial and Neck Trauma

Brain, Cranial, Ocular, Maxillofacial and Neck Trauma. Jami Windhorn RN BSN CPN TNCC ENPC. 1. I have nothing to disclose I have no conflict of interest. Objectives. Identify Common Mechanisms for Brain Injury Describe Pathophysiology of Brain Injury

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Brain, Cranial, Ocular, Maxillofacial and Neck Trauma

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  1. Brain, Cranial, Ocular, Maxillofacial and Neck Trauma Jami Windhorn RN BSN CPN TNCC ENPC 1

  2. I have nothing to disclose I have no conflict of interest

  3. Objectives Identify Common Mechanisms for Brain Injury Describe Pathophysiology of Brain Injury Describe Nursing Assessment and Interventions for Brain Injury Patient

  4. Brain 4

  5. Brain Injury • 1.7 million annually • 50,000+ deaths per year • At least 125,000 are left with permanent disabilities • Approximately 715/100,000 ED visits per year are related to brain injuries 5

  6. Brain Injury At Risk Populations: • Males 15-24 • Infants • Young Children • Elderly 6

  7. Brain Injury • Risks: • Alcohol use • Substance Abuse • Anticoagulants • Not using safety restraints or using incorrectly • No bike helmets or other safety equipment 7

  8. Brain Injury • Causes of Injury • Motor vehicle crashes • Falls • Sports • Assault • Firearms 8

  9. Brain Injury • Mechanisms of Injury • Open Head Injury • Closed Head Injury • Deceleration Injury (Diffuse Axonal Injury) • Chemical or Toxic • Hypoxia • Tumors • Infection • Stroke 9

  10. Open Head Injury • Caused by penetrating wounds 10

  11. Open Head Injury • Scalp Wounds are highly vascular • Bleeding could lead to shock, esp in children • If no skull fracture treat with direct pressure and dressings to the wound • Unstable skull fractures apply dressings but no direct pressure 11

  12. Open Head Injury • Skull Fractures • Linear • Depressed • Basilar 12

  13. Skull Fracture • Linear • Nondisplaced fracture of the skull • May be indicative of brain injury under fracture line • Signs • Headache • Decreased Level of Consciousness 13

  14. Skull Fracture • Depressed • Extends below the surface of the skull and can cause compression of brain tissue Signs: Headache Decreased Level of Consciousness Palpable depression of skull 14

  15. Skull Fracture • Basilar • Fracture that involves any of the five bones in the base of the skull • Associated with brain injury, dura laceration and cranial nerve damage • Signs • Headache • Altered Level of Consciousness • Facial Nerve Palsy • CSF otorrhea or rhinorrhea 15

  16. Basilar Skull Fracture • Raccoon Eyes * Orbital Fractures Battle’s Sign * Auditory canal fracture 16

  17. Skull Fracture • Any skull fracture causing a laceration into the dura has the potential for Cerebrospinal Fluid (CSF) leaks from the ear (otorrhea) or nose (rhinorrhea) • CSF is clear, odorless fluid • Leaking of Spinal fluid can lead to meningitis or encephalitis • Infected CSF may be cloudy with blood 17

  18. Cerebral Physiology • Delivery of oxygen and nutrients to the brain is dependent on adequate cerebral perfusion pressure and autoregulatory mechanisms in the brain • Any alterations in any of these systems can damage the brain 18

  19. Cerebral Physiology Cerebral Perfusion Pressure: Mean Arterial Pressure - Intracranial Pressure (CPP= MAP-ICP) • CPP needs to be maintained >60mmHg to allow for adequate cerebral perfusion • Increasing the blood pressure with medications may be necessary to increase the CPP 19

  20. Cerebral Physiology • Intracranial Pressure is comprised of three volumes within the skull – Brain, Cerebrospinal fluid, and Blood Volume • Body can compensate for loss of blood volume and low blood pressure for a short time before the ICP will increase • Normal ICP is 10 • ICP above 20 is concerning 20

  21. Increased ICP • Early Signs • Headache • Nausea and Vomiting • Altered Level of Consciousness • Restlessness • Lethargy • Amnesia • Confusion 21

  22. Increased ICP • Late Signs • Changes in Pupil response • Unresponsive to verbal or tactile stimuli • Posturing • Changes in Respiratory pattern • Cushing’s Response – Very late sign • Increased SBP with wide pulse pressure • Bradycardia • Decreased respiratory effort 22

  23. Closed Head Injury • Blunt trauma to the head • No penetrating trauma • Diffuse damage to the brain • Several forces of injury • Shearing • Tensile • Compressive • Coup-contrecoup 23

  24. Glasgow Coma Scale (GCS) 24

  25. Head Injury Classifications • Minor: GCS 13-15 • Risk of deterioration depends on clinical presentation • Moderate: GCS 9-13 • High potential for deterioration to severe head trauma in first 48 hours • Severe: GCS <8 • Coma, abnormal pupil response, posturing 25

  26. Concussion • Traumatic injury effecting the away the brain functions temporarily • Direct blow to the head, fall or any injury that shakes the head • Mild: No loss of consciousness • Classic: Temporary loss of consciousness and neurologic dysfunction 26

  27. Concussion • Signs • Possible loss of consciousness • Headache • Confusion • Memory Loss • Dizziness • Nausea and Vomiting • Fatigue 27

  28. Concussion • Diagnosis • Health History ex. Sports Injury • CT • MRI • Neuropsychological Tests – Memory, Emotions Treatment • Rest • Pain Medicine • Avoiding Strenuous activities and contact sports 28

  29. Postconcussive Syndrome • Seen days to months after injury • Signs • Headache • Dizzy • Irritable • Insomnia • Anxiety or Depression • Trouble paying attention 29

  30. Diffuse Axonal Injury • Blunt head trauma • Skull is moving in one direction (acceleration) and stops abruptly (deceleration) causing the brain be jarred inside the skull • During the jarring the axons are stretched and torn resulting in neuron death and diffuse brain damage 30

  31. Diffuse Axonal Injury • Brainstem may be involved leading to coma • Severe injury carries high morbidity and mortality rates 31

  32. Diffuse Axonal Injury • Signs • Immediate Unconsciousness lasting hours to months • Increased ICP • Posturing • Hypertension • Hyperthermia • Sweating 32

  33. Diffuse Axonal Injury • Diagnosis • History of trauma • CT • MRI Treatment Attempt to control the increased ICP 33

  34. Closed Head Injury 34

  35. Contusion • Bruised brain tissue • Blunt head trauma • Capillary bleeding into brain tissue • Most frequently seen in frontal or temporal lobes • Swelling and bleeding peak at 18-36 hours 35

  36. Contusion • Symptoms • Altered level of consciousness • Posturing • Changes in Speech, Motor or Behavior • Signs of Increased ICP 36

  37. Contusion 37

  38. Hematoma • 3 Types: • Epidural • Subdural • Intracerebral 38

  39. Hematoma • Epidural • Collection of blood between the skull and dura * Blood is usually arterial * Bleeds rapidly **Requires immediate Surgical intervention 39

  40. Hematoma • Epidural • Classic Sign: Trauma → Transient loss of consciousness → Lucid Period → Rapid Neurologic Decline • Severe Headache • Sleepy and Dizzy • Contralateral Hemiparesis or Hemiplegia • Posturing • Unilateral fixed and dialated pupil 40

  41. Hematoma • Subdural • Venous pooling in subarachnoid space Bleeds slowly Seen with direct injury to the brain and diffuse axonal injuries 41

  42. Hematoma • Subdural • High risk patients are those on anticoagulants and the elderly • Acute: Symptoms appear within 48 hours of injury • Chronic: Symptoms may not be seen for days to weeks after the injury 42

  43. Hematoma • Intracerebral • Bleed deep in brain tissue Usually in Frontal and Temporal lobes 43

  44. Hematoma • Intracerebral Symptoms Progressive decline in LOC Increased ICP Abnormal Pupils Contralateral Hemiplegia 44

  45. Concurrent Injuries Primary Injury Direct injury to the brain Ex. Skull Fracture or Epidural Hematoma Secondary Injury Pathophysiologic changes related to the primary injury Compound initial damage and reduce the ability of compensatory mechanisms Ex. Hypotension, Increased ICP

  46. Concurrent Injuries Common concurrent injuries are cervical spine injuries and facial injuries. However depending on the type of trauma concurrent injuries could involve any or all other body systems

  47. Patient History Loss of consciousness? How Long? Complaints? Impact to the Head? Amnesia? Headaches? Nausea? Vomiting? Drugs or Alcohol? History of brain injury or seizures?

  48. Nursing Assessment Airway Respiratory Effort – Rate, Depth Pupil response Posturing Examine face for bleeding and bruising Look for drainage from ears or nose Palpate head for tenderness or deformities

  49. Pupils Both dilated Unilaterally dilated Anisocoria Eyelid closure • Slow: cranial nerve III • Fluttering: often hysteria Head Trauma - 49 Reactive: ICP increasing Nonreactive (altered LOC): increased ICP Nonreactive (normal LOC): not from head injury Nonreactive: brainstem Reactive: often reversible

  50. Extremity Posturing Head Trauma - 50 Decorticate • Arms flexedand legs extended Decerebrate • Arms extendedand legs extended

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