INJURY

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HEAD INJURY (CRANIOCEREBRAL TRAUMA)

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.

Causes of Head Injury

According to different age group the causes of head injury can be described as follows –

 Neonates – Birth injury, instrumental delivery.


 Toddlers and Preschoolers – Fall from height, hard object falling on the head or hits on head by
hard object.
 Older children – Auomobile accidents, road-traffic accidents, sports and recreation injury, fall
from height, penetrating injury through eyes, crush injury, fall of heavy objects on head.

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.

Common pathological changes in brain in neonates following head injury include


cephalhematoma, skull fracture, sub-dural hematoma, intracerebral hematoma and brain swelling.

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.

TYPES OF HEAD INJURY

Fracture of the skull

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 of the Brain (Cerebral Concussion)

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.

Acute Subdural Hematoma (SDH)

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 –

 Level of consciousness can be altered as depressed, stuporous or comatosed.


 Hemiparesis, monoparesis or hemiplegia may be found due to focal brain damage. There can be
alteration of neurological reflexes and disturbances of vision, hearing or taste. Sensation to pain,
touch or temperature may be altered. Cranial nerve palsy is common. 7th cranial involvement
leads to facial palsy and change in facial expression.
 Bruises over ipsilateral ear, bleeding through ear, CSF otorrhea and hearing loss may be present.
 Unilateral or bilateral dilated fixed pupils may be found depending upon severity of injury. Optic
nerve injury may be present with fixed dilated pupil and positive consensual , consensual light
reflex, as pinpoint pupil size with slow, unequal or absent pupillary reaction.
 Acute subdural hematoma is commonly with deterioration of level of consciousness, progressive
hemiplegia, focal seizures, pupillary enlargement, changes in vital signs, decerebrate posture
and respiratory failure.
 Chronic subdural hematoma can develop with gradual onset and variable symptoms according
to age of the child. Early signs include anorexia, difficulty in feeding, vomiting, irritability, low
grade fever and retinal hemorrhage. Late signs are enlargement of head, bulging and pulsating
anterior fontanelle, glossy scalp with prominent scalp veins. Occular palsies (rare), strabismus,
pupillary inequality, hyperactive reflexes and convulsions are common. In older children
lethargy, anorexia, increased ICP, convulsions, and unconsciuosness are presenting feeatures.
Additional systemic injuries are found in about 50 percent cases with severe head injury. Limb fracture is
most common. Other associated injury like fracture long bone, spinal injury, chest injury with
hemopneumothorax, abdominal injury and pelvic injury may be present.

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.

After hospitalization, initial management should be done with following steps –

 Maintenance of airway – It should be done by positioning and removal of secretions by


oropharyngeal suctioning. Nasopharyngeal tube or simple oral airway tube may be needed for
some children. Endotracheal intubation or tracheostomy may be required in children with
respiratory obstruction.
 Establishment of breathing – It can be done by ventilatory support with simple bag and mask or
by mechanical ventilators. Intensive unit care may be necessary for these children.
 Maintenance of circulation – Intravenous fluid therapy to be started to maintain blood pressure
within normal range. Blood transfusion may be needed. CVP line should be made.
 Assessment of neurological status to be performed by modified Glasgow coma scale (GCS),
neurological examination, pupillary reaction etc. External and associated injury to be assessed.
Necessary investigations to be performed after stabilization of patient’s condition.
 Continuous urinary drainage by Foley’s catheterization.
 Nasogastric intubations to be done to prevent abdominal distension and aspiration of gastric
content.
 Intensive care unit placement for further management and continuous monitoring specially in
case of severe head injury, whether managed medically or surgically.

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

Surgical management is indicated in large intracranial hematoma, compound depressed fracture


and penetrating injuries along with deterioration of level of consciousness, neurological deficits,
generalized convulsions and abnormal pupillary reaction. In case of small subdural hematoma or
contusion, surgical intervention is not indicated. The following surgical interventions are commonly
performed –

 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.

b. Physical examination and assessment of neurological status are important to evaluate


effectiveness of management, deterioration of child’s condition and to plan further
management. The following aspects should be assessed with special attention along with
routine examination.
i. Signs of increased ICP and alteration of vital signs.
ii. Level of consciousness by GCS score.
iii. General behaviour – irritability, lethargy, change in personality.
iv. Pupillary and visual change – dilated or contracted pupil, no response to light,
double vision.
v. Convulsions, tremor, twitching and neck rigidity.
vi. Alteration of motor functions and abnormal movement.
vii. Incontinence of bladder and bowel.
viii. CSF leakage and presence of wound.
ix. Neurological reflex and paralysis.

Nursing Diagnosis

 Ineffective breathing pattern related to increased ICP.


 Impaired cerebral tissue perfusion related to head injury.
 Impaired hydration and nutrition related to unconsciousness.
 Risk for infection related to injury.
 Ineffective family coping related to life threatening situation.
 Knowledge deficit regarding care of injured child.

Nursing Interventions

Nursing interventions in a child with head injury can be same as the comatosed child with the
following strategies.

 Maintaining respiration and clearing air passage.


 Maintaining adequate cerebral perfusion.
 Organizing emergency measures for life saving.
 Providing perioperative care related to neurosurgery with specific precautions for children.
 Monitoring neurological status and vital functions with appropriate recording.
 Preventing complications of immobility.
 Providing care for specific conditions like convulsion, fever, fluid-electrolyte imbalance,
hemorrhage, wound etc.
 Maintaining nutrition and hydration status.
 Preventing infections and related complications.
 Strengthening family coping and promoting crisis interventions.
 Teaching the parent about routine care, long term care and prevention of accidental injury.

Prognosis

Prognosis in case of head injury depends upon type of injury, initiation of management and
available facilities for specialized care

 Maximum children with head injury recover within 24-48 hours.


 Approximately 70-75% of injured children will die, if the initial GCS score is 3-4 and about 20%
may be severely disabled.
 Post-traumatic sequelae may develop in some children with various complications. About 5%
children may have post-traumatic epilepsy.

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.

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