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What are the types of head injuries?
- closed head injury
- open head injury
- traumatic brain injury
Closed Head Injury
- occurs when a person receives an impact to the head from an outside force, but the skull does not fracture or displace
- brain swells
In a closed head injury, what happens as the brain swells?
- the brain may expand through any available opening in the skull (including eye sockets)
- can cause CNs controlling eye mm to be impaired (CN III impaired = pupil appears dilated)
in a closed head injury, when herniation or cranial compression occur
What type of injury occurs when the force that hits a person's head is great enough that the skull can fracture or become displaced?
Open Head Injury
What is good about an open head injury?
brain has room to swell, which can reduce compression of brain tissue and ICP
What is bad about an open head injury?
b/c skull is damaged or open, it can't protect the brain as it did before (exposed and vulnerable to infection and damage)
What is ugly about an open head injury?
if skull is fractured or displace, bone fragments from the skull can enter the brain and cause further injury
Which type of injury has an observable pulse on the side of a patient's head?
open head injury w/ obvious skull deficits
What may doctors or therapists prescribe to protect the brain post open head injury when the person begins to get out of bed?
What are the types of skull fractures?
What are other appearances that occur from skull fractures?
- raccoon eyes
- battle's sign
depressed skull fracture:
broken piece moves in towards the brain (open or closed)
compound skull fracture:
scalp is disrupted and the skull is fractured
basilar skull fracture:
located at base of skull (neck area) and may include the opening at the base of the skull
bruising around eye orbits
blood collects behind the ears and causes bruising
Where might CSF leak through after head injury?
eyes and nose
What type of head injury encompasses both open and closed and is a broader term that describes an insult to the brain, not of a degenerative or congenital nature, but caused by external physical force?
Traumatic Brain Injury
What are the different terms for TBIs?
- diffuse axonal injury
- coup-contrecoup injury
- second impact syndrome
- locked-in syndrome
- shaken baby syndrome
Diffuse Axonal Injury
injury is greatest in where the density difference is greatest
In a diffuse axonal injury, where does most tearing occur?
gray-white matter junction
In what type of brain damage does a diffuse axonal injury occur?
What causes a diffuse axonal injury?
- shaking or strong rotation of the head, or by rotational forces
- the stable brain lags behind any movement of the skull causing long tracts in the brain to stretch and then tear
What diagnoses diffuse axonal injury?
MRI (not CT)
What happens when nerve tissue in the brain tears?
tracts are disrupted
What are recruited for damage control during diffuse axonal injury?
white blood cells (this causes more damage when they mistakenly target both healthy and unhealthy tissue)
What is the result of diffuse axonal injuries?
- temporary, permanent, localized, or widespread brain damage
could have variety of functional impairments depending on where shearing occured
Concussion occurs when:
brain receives trauma from an impact or a sudden movement or momentum change
What happens to blood vessels in the brain during concussion?
- become stretched or torn (causing hemorrhage)
- CN damage can also occur
What causes a concussion?
- direct blow to head
- gunshot wound
- violent shaking of the head
Do closed or open head injuries produce concussions?
What is the most common type of TBI?
If a person looses consciousness from concussion, it won't exceed __ minutes.
How does a person with a concussion feel if they remain conscious?
dazed or punch drunk
Can concussions be seen on diagnostic imaging test (CT)?
may or may not b/c damage may only be microscopic, non-localized, but widespread
B/c skull fractures, bleeding, or swelling may or may not be present, concussions are sometimes a diagnosis of exclusion and are considered a _______.
complex neurobehavioral syndrome
What happens from a concussion?
can cause diffuse axonal type injury resulting in permanent or temporary damage
How long can it take to recover from a concussion?
few months to a few years
- may report problems w/ concentration, recent memory, abstract thinking
- dizziness, irritability, fatigue, double vision, and personality changes
- elderly pts are particularly affected by disequilibrium and chronic dizziness
What is a contusion a result of?
direct impact to the head
localized bruise (bleeding) on the brain (macroscopic)
Where do large contusions that may need to be surgically removed most commonly occur?
orbitofrontal cortex, anterior temporal lobe, and posterior portion of superior temporal gyrus area (w/ adjacent parietal area)
contusions that occur from the impact, w/ damage at the site of the blow as well as damage from "rebound" when the brain hits the opposite side of the brain
When do coup-contrecoup injuries occur?
when the force impacting the head is not only great enough to cause a great contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, causing additional damage
What is another name for second impact syndrome?
Second impact syndrome occurs when:
a person sustains a second TBI before the damage from the 1st TBI has healed
When does the second injury (of a second impact syndrome) occur?
from days to weeks following the 1st
Is loss of consciousness required in second impact syndrome?
In second impact syndrome, the second impact is more likely to cause:
brain swelling and widespread damage
Why must emergency medical treatment occur ASAP after second impact syndrome?
b/c death can occur rapidly
What are the long term effects of recurrent brain injury?
- muscle spasms
- increased muscle tone
- rapidly changing emotions
- difficulty thinking and learning
Penetration injury occurs from:
- impact of a bullet, knife, or other sharp object that forces hair, skin, bone, and other foreign fragments into the brain
- objects traveling at low rates of speed through the skull and brain that can ricochet w/in the skull, widening the area of damage
What is a 'through-and-through' penetration injury?
- occurs if an object enters the skull, goes through the brain and exits the skull
- --include effects of penetration injuries plus additional shearing, stretching, and rupture of brain tissue
- rare neurological condition in which a person can't physically move any part of the body except the eyes
- person is conscious and able to think
- vertical eye movements and eye blinking can be used to communicate w/ others and operate environmental controls
Acquired Brain Injury
describes any trauma that occurs to the brain after birth
Types of acquired brain injuries:
- disease processes (brain tumors, stroke, infection, substance disease)
lack of blood supply to the brain
Anoxic Brain Injury occurs:
when the brain does not receive any oxygen
hypoxic brain injuries occur:
when the brain has insufficient oxygen
Which type of brain injury causes people to demonstrate the MOST SEVERE types of symptoms (tone, lack of consciousness....)?
anoxic brain injury
Which type of brain injury has the worst prognosis?
anoxic brain injury
What causes anoxic brain injuries?
- near drwoning
- pts w/ myocardial infarctions who survive but whose brains are w/o O2 for too long
- unsuccessful attempts of suicide
- smoke inhalation
- chest trauma
- occur with or w/o open brain injury
- some kind of trauma causes vessels to leak
What are the types of intracranial/intracerebral hematomas?
- subdural hematoma
- epidural hematoma
- subarachnoid hematoma
- intraparynchemal hematoma
collection of blood below the inner layer of the dura but external to the brain and arachnoid membrane
What is the most common type of traumatic intracranial mass lesion?
Subdural hematoma symptoms
- appear soon after trauma (24-48 hrs)
- initial loss of consciousness, but then appear fine
- later, may become unconscious as bleeding in brain continues
- may report feeling drowsy, having bad headache, nausea, and/or vomiting
- may become confused and/or develop weakness of limbs on one side of the body and speech difficulties
- some have seizures
Epidural hematoma (EDH)
traumatic accumulation of blood b/w inner table of skull and dural membrane
Epidural hematoma often occur from:
a focused blow to the head, such as that produced by a hammer or baseball bat
In 85-95% of pts, trauma from epidural hematoma results in:
an overlying fracture of the skull
What are the sources of the hemorrhage and epidural hematoma?
blood vessels in close proximity to the skull fracture
Prognosis of epidural hematoma:
- b/c underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively
- outcome from surgical decompression and repair is related directly to pt's preoperative neurologic condition
Epidural hematoma symptoms:
- depend on severity of brain injury
- brief period of unconsciousness followed by a period of alert consciousness before returning to unconsciousness or even coma
- symptoms occur w/in minutes to hours
- confusion/dizziness/drowsiness/varied alertness
- severe headache
- nausea and/or vomiting
- enlarged pupil in one eye
- weakness on one part of body, typically side opposite of enlarged pupil
- bruises around eyes/behind ears
- CSF draining from nose or ears
- SOB or changes in breathing
blood leaking into the CSF (bathing and circulating around the brain under the arachnoid)
subarachnoid hemorrhage symptoms
- primarily headache (worst of pt's life)
- some dizziness
- blood pools in white matter of brain
- can cause diffuse axonal injury
Brain trauma can cause several severe intraparynchemal hemorrhage and can result in:
white matter shear injury -- extensive loss of axons w/ extensive brain injury
What diagnoses brain injury?
head CT, MRI (subarachnoid by lumbar puncture - blood in CSF); cerebral angiography (exact location of bleed)
Medical Mangagment of brain injury:
- craniotomy, blood evacuation, ICP monitoring
- meds: anti-seizure, diuretics to reduce swelling, hyperosmotic agents, anti-hypertensives, calcium channel blockers
- head of bed elevated to relieve cerebral pressure (reverse trendelenberg)
- hydrate, but avoid fluid overload