INJURY
INJURY
INJURY
Meaning
Head injury includes any injury involving scalp, skull, meninges or any portion of the brain
caused by external forces. It is one of the important causes of childhood mortality and morbidity. One-
third of all head injury cases are children. They are by nature accident prone and injury of the head is
common among accidental injury.
According to different age group the causes of head injury can be described as follows –
Pathology
Pathological changes due to head injury depends upon various factors like thickness of the skull,
presence of open fontanelles, type of suture and developing brain.
Pathological changes in brain may be primary or secondary. Primary injury includes all types of
hematoma, cerebral contusion and laceration. Secondary changes mostly include cerebral edema,
hypoxia and ischemic injury.
In toddlers the common pathological changes are found as depressed or comminuted fracture,
extradural or subdural hematoma, concussion, contusion, laceration and brain swelling.
In older children the common pathological changes are extradural or subdural hematoma,
cerebral contusion and laceration, intracerebral hemorrhage, ischemic hypoxic injury and brain swelling.
The external force transmitted to the intracranial structure and produces acceleration of the
skull with subsequent injury and distortion with movement of the brain. Injury of the brain can occur at
the site of trauma, i.e. coup, or at some distance from the area of injury, i.e. countercoup. The force of
injury can cause tearing of small arteries and veins causing hemorrhage or can lacerate the brain tissue
and meninges or can stretch and shear nerve fibre tracts.
In neonates, a typical ‘ping-pong’ fracture may occur due to elasticity of the bone. The fracture
may be fissured or depressed type. The linear fracture is the most common.
Older children may have comminuted fracture with dural tear and laceration with brain damage.
There may be CSF rhinorrhea or CSF otorrhea. Fracture of anterior fossa may involve orbit and leads to
orbital hematoma and black eyes.
Intracranial Hemorrhage
It is found in neonates due to excessive moulding of skull bones or forceps delivery. Rupture of
delicate surface veins leads to acute subdural hemorrhage and intracerebral hematoma which may
cause neonatal death. About 20 to 25 percent neonatal death are due to intracranial hemorrhage, which
is usually non-traumatic and found in sick preterm babies.
Concussion is the reversible neurologic dysfunction. Transient loss of consciousness and loss of
memory are the part of concussion. The child may be stunned for a short time. The cause of concussion
may be an injury at the occipital area and shearing strain at the brain stem level due to violent blow on
head. The children recover promptly and completely from concussion.
Cerebral Contusion
It is bruising or petechial hemorrhage in the brain tissue at the site of blow following direct
trauma. It may occur due to angular head down motion producing high tensile strains throughout the
brain. Cerebral contusion consists of hemorrhagic brain necrosis and infarction. Contusion at frontal and
temporal lobes are common.
Extradural Hematoma
It may occur following head injury mostly in the temporal lobe or in posterior fossa. Hematoma
may be arterial or venous depending upon the type of fracture and vessels involved by the fracture.
Blood may be collected due to bleeding from fracture line and form a thin layer of clot.
It results from severe injury but may occur due to minor injury with bleeding disorders in the
patients. SDH is an accumulation of fluid, blood and its degradation products within the potential
subdural space between dura and arachnoid. It can be acute or chronic depending on the time between
injury and the onset of symptoms. Frequent fall and injury to the head accounts for higher incidence of
SDH. When the sutures are not fused, the hematoma can grow slowly. The hematoma may remain silent
for sometimes, because the skull can expand to accommodate the SDH.
Brain Swelling
It may be found in association with head injury and may be due to vascular congestion. It can
cause fatal outcome due to generalized brain swelling. Focal brain swelling occurs in contussion or
intracerebral hematoma due to release of neurotransmittors. Cerebral edema may occur due to
hypoxia. Brain swelling due to vasocongestion may be due to neurogenic vasoparalysis or vasodilatation
and increased blood flow.
Clinical Manifestations
The child with head injury may arrive at hospital with history of trauma, presence or absence of
wound on the scalp, respiratory obstruction and loss of consciousness. The child may be drowsy,
irritable or lethargic. Features of shock, alteration of vital signs and signs of increased ICP may be
present. Severe head ache, vomiting, convulsions and loss of memory may be found. There may be
bladder-bowel dysfunction as incontinence. Fracture skull may be evident on examination.
The neurological features which may be noticed in case of head injury include the following –
Complications
Head injury has number of complications. These include shock, persistent increased ICP,
epidural hematoma, leptomeningeal cyst, visual disturbances, convulsive disorders or post traumatic
epilepsy, post traumatic amnesia, hydrocephalus, behavioural disturbances (aggressiveness), mental
retardation, learning disabilities, growth failure and psychiatric illness.
Diagnostic Evaluation
Detailed history about the injury with description of the event is very important. Thorough
physical examination must be done to detect the severity of cerebral trauma and presence of additional
injuries.
Assessment of level of consciousness by Modified Glasgow coma scale for children and presence
of focal neurological deficits are the most vital aspects of neurological examination in case of
craniocerebral trauma.
Although adequate baseline clinical evaluation is major importance, but the investigations are
also needed to detect the site, size, nature and extent of brain injury for better management.
The diagnostic evaluation should include CT scan and X-ray (skull, abdomen, pelvis, chest, and
spine). EEG may be done to determine focal destructive lesions or seizure activity.
Echoencephalography and cerebral angiography also can be done. Blood for ABG analysis and other
routine examination is important. Lumbar puncture is not done generally in presence on increased ICP
due to danger of Herniation of brain.
Management
Emergency Management
Emergency management in first 5 to 6 hours after head injury is the most crucial aspect. First aid
at the place of injury with basic life support measures promotes better prognsois. First aid measures
include resuscitation (clear airway, breathing support and maintenance of circulation), prevention of
further accidents, and safe transport to the hospital under optimum support. Immediate hospitalization
is necessary for close observation (12-24 hours), continuous neurological assessment and subsequent
management.
Medical management
Continuous monitoring of neurological status, vital signs and intracranial pressure (ICP).
Management of increased ICP by slight head up position, controlled hyperventilation,
barbiturate, osmotic diuretic and corticosteroid therapy.
Prevention and treatment of convulsion, fever and other problems.
Prevention of infections.
Supportive expert nursing care as unconscious patients.
Surgical management
Craniotomy or Burr hole operation is required in acute subdural hematoma for evacuation of
the clot.
Subdural tap or V-P shunting is done to remove collecting fluid in case of chronic subdural
hematoma.
In penetrating wound, repair of CSF leakage may be necessary along with debridement of the
wound.
Elevation of fracture segment is done in depressed fracture skull.
Nursing management
Nursing Assessment
a. Nursing history should include mode and time of injury, duration of unconsciousness, presence
of vomiting, convulsions, headache, loss of memory, loss of vision, any discharge from ear, nose
and bleeding. Routine history to be collected when the patient is stabilized.
Nursing Diagnosis
Nursing Interventions
Nursing interventions in a child with head injury can be same as the comatosed child with the
following strategies.
Prognosis
Prognosis in case of head injury depends upon type of injury, initiation of management and
available facilities for specialized care
Conclusion:
Head injury includes any injury involving scalp, skull, meninges or any portion of the brain
caused by external forces. One-third of all head injury cases are children. The child with head injury may
arrive at hospital with history of trauma, presence or absence of wound on the scalp, respiratory
obstruction and loss of consciousness. Emergency management in first 5 to 6 hours after head injury is
the most crucial aspect. Surgical management is indicated in large intracranial hematoma, compound
depressed fracture and penetrating injuries. Prognosis in case of head injury depends upon type of
injury, initiation of management and available facilities for specialized care.