2-39. HEAD INJURIES
a. Direct and Indirect Head Injuries. Head injuries are generally categorized as direct and indirect.
(1) Direct injuries result from a direct blow to the head.
(2) Indirect injuries result from the brain being jarred against the interior of the skull.
(3) Coup-contrecoup. This phenomenon is a combination of direct and indirect injury. A direct blow to one side of the skull causes the brain to be jarred inside the skull, causing an indirect injury on the side opposite the direct blow.
b. Brain Damage. Brain damage resulting from a head injury is dependent upon:
(1) The force of impact.
(2) The type of impact.
(3) The location of impact.
c. Skull Fractures. A skull fracture is a break in the continuity of the skull bones or a separation of the sutures.
(1) Basilar skull fractures are potentially serious injuries due to the proximity of the brain stem.
(2) Depressed skull fractures may be open or closed. In either case, the underlying brain tissue may be damaged.
(3) Linear skull fractures are “cracks.” They may be dangerous if they overlie vascular structures.
d. Hematomas. Hematomas are a result of bleeding within the closed compartment of the skull. They may cause compression of brain tissue.
(1) Epidural hematoma is caused by bleeding between the skull and the dura.
(2) Subdural hematoma is caused by bleeding between the dura and the arachnoid membrane.
(3) Subarachnoid hemorrhage/hematoma is caused by bleeding into the subarachnoid space.
e. Concussion. Concussion results from violent jarring of the brain against the interior of the skull. The patient experiences a brief loss of consciousness followed by confusion, headache, and irritability. Complete recovery is usual.
f. Contusion. This injury is more serious than a concussion. The severe jarring of the brain causes bruising of the brain. (This bruising is the result of blood vessel rupture.) Permanent damage may result.
2-40. INCREASED INTRACRANIAL PRESSURE
a. Definition. The cranium is a closed cavity filled with contents that are virtually noncompressible. Rapid or prolonged increases in an intracranial pressure present a serious threat to life. This increased pressure may result from edema, bleeding, trauma, or space-occupying lesions. Once the pressure exceeds the accommodation point, the brain will herniate through weak points (for example, the foramen magnum). Irreversible neurological damage or death will result.
b. Signs and Symptoms of Increased Intracranial Pressure.
(1) Change in level of consciousness.
(a) May occur over a period of minutes, hours, or days.
(b) Characterized by a diminished response to environmental stimuli.
(c) Responsiveness ranges from alert and oriented to no response to stimuli.
(d) Confusion, restlessness, disorientation, and drowsiness may be signs of an impending change.
(2) Headache–increases in severity with coughing, sneezing, or straining at stool.
(3) Vomiting.
(4) Papilledema/pupil changes.
(a) Edema and pressure of both the optic nerve and the oculomotor nerve at the point at which they enter the globe is caused by venous congestion resulting from increased intracranial pressure.
(b) Pupil on the affected side may be nonreactive.
(c) Pupils may be unequal, dilated, pinpoint, or nonreactive.
(5) Elevation of blood pressure with a widened pulse pressure.
(6) Decreased pulse rate (may be increased initially).
(7) Decreased respiratory rate (may be irregular).
c. Nursing Management.
(1) Monitor vital signs closely.
(a) Accurately assess and document neurological status.
(b) Evaluation of alterations of consciousness is crucial since symptoms progress rapidly.
(2) Maintain patent airway.
(a) Intubation and hyperventilation may be indicated to provide adequate cerebral perfusion of oxygenated blood and decrease carbon dioxide induced vascular spasm.
(b) If patient is not intubated, position the patient on his side to decrease the possibility of airway occlusion; use oral or nasopharyngeal airway, prn.
(c) Be aware that stimulation of coughing when suctioning increases intracranial pressure and may precipitate seizure activity.
(3) Administer medications as ordered.
(a) Mannital (osmotic diuretic, to decrease cerebral edema).
(b) Corticosteroids (to reduce cerebral edema).
(c) Dilantin (as a precautionary measure to prevent seizure activity).
(d) Antibiotics.
(4) Elevate head of bed (30º).
(a) Promotes return of venous blood.
(b) Under no circumstances should patient’s head be lower than the body.
(5) Administer hypertonic I.V. solutions as ordered.
(a) Dextrose in water (hypotonic) crosses the blood-brain barrier and increase cerebral edema and intracranial pressure.
(b) Fluids will be restricted to reduce intracranial pressure.
(c) Accurate intake and output records must be kept.
(6) Protect patient from injury should seizures occur.
(a) Pad side rails.
(b) Secure a tongue blade to the head of the bed for easy access.
(7) Maintain normal body temperature.
(a) Intracranial bleeding is frequently accompanied by increases in body temperature that are resistant to antipyretic agents.
(b) Monitor rectal temperature frequently.
(c) Place patient on hypothermia blanket, as ordered, for temperature over 102ºF.
d. Patient Education. Family members of patients who return home following injury to the head should be instructed to return the patient to the hospital if any of the following problems occur.
(1) Fever greater than 100ºF.
(2) Pulse less than 50 beats per minute.
(3) Vomiting.
(4) Slurred speech.
(5) Dizziness.
(6) Blurred or double vision.
(7) Unequal pupil size.
(8) Blood or fluid discharge from ears or nose.
(9) Increased sleepiness.
(10) Inability to move extremities.
(11) Convulsions.
2-41. SPINAL CORD INJURIES
a. Facts about Spinal Cord Injuries.
(1) Common causes of spinal cord injuries include:
(a) Automobile accidents.
(b) Athletic injuries (diving, hard-contact sports).
(c) Falls.
(d) Gunshot wounds, stab wounds.
(e) Industrial accidents.
(2) Common locations of spinal cord injuries.
(a) Flexion-extension injuries are commonly located at C4 – C7 (“whiplash”).
(b) T11, T12, and L1 are frequent sites of spinal cord injury resulting from falls.
(3) Mechanisms of spinal cord injury.
(a) Flexion-extension: whiplash, seen with rapid deceleration injuries.
(b) Subluxation: incomplete or partial dislocation.
(c) Torsion: twisting of the spinal cord.
(d) Compression.
(4) Pathophysiological changes associated with spinal cord injuries.
(a) Damage to the cord may be a concussion, contusion, laceration, compression, or complete transection of the cord.
(b) Cord’s response to injury includes hemorrhage, ischemia, and edema.
b. Signs and Symptoms.
(1) Patient’s symptoms will mirror the level of the cord injury.
(2) There will be total sensory loss and motor paralysis below level of the injury.
(a) Cervical spinal cord injuries will produce quadriplegia–loss of function of all four extremities.
(b) Injuries to the thoracic spinal cord below the level of T1 will produce paraplegia–paralysis of the lower extremities.
(3) Loss of bowel and bladder control; usually urinary retention and bladder distention.
(4) Loss of sweating and vasomotor tone below the level of the cord injury.
(5) Marked reduction of blood pressure due to loss of peripheral vascular resistance.
(6) Neck/back pain.
(7) Priapism–persistent, painful erection of the penis.
c. Medical and Nursing Management.
(1) Objectives of care:
(a) Reduce the fracture/dislocation and obtain immobilization of the spine as soon as possible to prevent further cord damage.
(b) Observe for symptoms of progressive neurological damage.
(2) Maintain patient on a turning frame or Circo-lectric bed to maintain spinal alignment.
(3) Patient with cervical spine injury will have some form of skeletal traction. Maintain traction and provide nursing care IAW local policy.
(4) Continuously observe patient’s breathing pattern.
(a) Patients with injuries at high levels are at risk for respiratory failure.
(b) Observe strength of cough effort.
(5) Continuously observe patient for motor and sensory changes due to cord edema or hemorrhage, which may further compromise cord function.
(a) Test patient’s motor ability by asking him/her to spread fingers, grip your hands, shrug houlders, etc.
(b) Test sensory level by gently pinching the skin at shoulders and progressing down sides; ascertain level at which patient can no longer feel pinch.
(c) Note presence/absence of sweating.
(d) Carefully record findings in patient’s clinical record; report changes in patient’s motor/sensory level immediately to professional nurse.
(6) Be alert for signs of spinal shock and report immediately.
(a) Spinal shock represents a sudden loss of continuity between the spinal cord and higher nerve centers.
(b) It is characterized by a complete loss of motor, sensory, reflex, and autonomic activity below the level of the injury.
(c) Though temporary, spinal shock may last for several weeks.
(7) If turning is allowed and patient is not on a turning frame or turning bed, the patient must be carefully log-rolled with the spine maintained in alignment.
(8) Surgery, depending upon the injury and pathological findings, may have to be performed to stabilize the spine before rehabilitation can begin.
(9) Patient will require passive range of motion exercises.
(10) Assist with active rehabilitation procedures when patient is stable.
(a) Program is designed according to neurological deficit.
(b) Usually involves 6 weeks of gradual mobilization with brace or cast, depending upon level of injury.
(11) Provide constant encouragement and psychological support to the patient with a spinal cord injury.