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Head Trauma
Anatomy of Nervous System
 The nervous system is composed of
 Brain
 Spinal cord
 The nervous system is divided into:
 Central nervous system (Brain & Spinal Cord)
 Peripheral nervous system
Superior view of the skull
Physiology of Nervous System
 Cerebral Blood Flow (CBF)
 Main Arterial Pressure (MAP)
 Intracranial Pressure (ICP)
 Cerebral Perfusion Pressure (CPP)
Injuries to the Brain & Skull
 Scalp injuries
 Skull injuries
 Brain injuries
Scalp Injuries
 Scalp has many blood vessels so injury may bleed profusely.
 Control bleeding with direct pressure.
 Don’t apply pressure when there is possible skull injury.
Anatomy of skull
Injuries to the scalp
Scalp injuries
Scalp injuries
Skull injuries
 It include fractures to the
cranium and the face,
can be associated with
brain injury.
 It is divided into:
 Open skull fracture:
cranium is fractures and
scalp is lacerated.
 Closed skull fracture:
scalp is lacerated but
cranium is intact.
 Basal skull fracture
S & S of Skull Fractures and Brain Injuries
 Visible bone fragments
 Altered mental status
 Deep lacerated or severe bruise or
 Depression or deformity of the skull
 Severe pain at site of injury
 Battle’s Sign
 Unequal or unreactive pupils
 Raccoon’s eye
 Sunken eye
 Bleeding from the ears and/or nose
 Clear fluid flow from ears and/or
 Personality change
 Increased blood pressure, decreased pulse
rate and widening pulse pressure (Cushing’s
 Irregular breathing pattern
 Temperature increase
 Blurred or multiple vision
 Impaired hearing or ringing
 Equilibrium problems
 Forceful or projectile vomiting
 Posturing
 Paralysis or disability on one side of the
 Seizures
 Deteriorating vital signs
Battle’s sign
 Indication of fracture of middle
cranial fossa of the skull, and
may suggest underlying brain
 It appears as a result
of extravasation of blood along
the path of the posterior
auricular artery
Raccoon eyes
 Raccoon eyes may be bilateral or
 If unilateral, it is highly
suggestive of basilar skull
fracture, with a positive
predictive value of 85%
 Most often associated with
fractures of the anterior cranial
CSF rhinorrhea & otorhea
 Suggestive of basal skull fracture
Brain Injuries
 Primary (Direct) Brain Injuries
 Secondary (Indirect) Injuries
Assessment of TBI
 Alert Verbal Pain Unresponsive
 Vital signs
 GCS : Eye opening, Best motor response and Best verbal response
 History and mechanism of injury
Primary Brain Injuries
 It occur at the time of original insult
 Direct damage done to brain parenchyma and associated with
vascular injuries
 Brain tissue can be lacerated, punctured or bruised by broken bones
or foreign bodies
 Damage is already done
 Irreversible
 Damage control (debridement)
Secondary Brain Injury
 Damage that occurs after the initial insult (ongoing injury processes)
 Expanding mass lesions, swelling or bleeding quickly overwhelm
 End result is increased intracranial pressure (ICP) and/or herniation
 Diagnosis and treatments target minimizing the effects of these
indirect insults
Herniation types
Secondary Injury Mechanisms
 Mass effect and subsequent elevated ICP and mechanical shifting
leading to herniation
 Hypoxia
 Hypotension and inadequate CBF
 Cellular mechanisms
Intracranial Causes
 Herniation: displaced brain parenchyma
 Damage to brain from trauma against the dura itself as well as producing
ischemia as well
 Cerebral Edema: intracellular fluid collection within neurons and
interstitial spaces.
 Intra-cerebral Hematomas
Brain Injuries – Brain Concussion
 Usually caused by blunt injuries.
 Injuries patient shows transient alteration in neurologic function
 Mild injury usually with no detectable brain damage.
 May have brief loss of consciousness.
 Headache grogginess and short memory loss are common.
Brain Injuries – Brain Contusion
 A bruised brain or contusion can occur with closed head injuries.
 Usually caused by blow that causes the brain to hit inside the skull
 Unconsciousness or decreased level of consciousness can occur
Brain Injuries – A hematoma
 Is a collection of blood within tissue.
 Hematoma inside the cranium is named according to its location:
Subdural hematoma: blood collection between brain and dura
Epidural hematoma: blood collection between dura and the skull
Subarachnoid Hemorrhage:
Intracerebral hematoma: blood collection within the brain
Epidural Hematomas
 Blood between
inner table of the
skull and the dura
 Lens shaped
hematomas that do
not cross suture
lines on CT
Subdural Hematomas
 Blood beneath the
dura, overlying the
brain and arachnoid,
resulting from tears to
bridging vessels
 Crescent shaped
density that may run
length of skull
 Very common in the
Subarachnoid Hemorrhage
 Bleeding beneath the arachnoid
membrane on the surface of the
Intracranial Hematoma
 Focal areas of
within the
ER Care of Skull Fractures and Brain Injuries
 Take appropriate body substance
isolation precautions.
 Assume spine injury
 Monitor conscious patient for changes
in breathing
 Apply rigid collar, immobilize the neck
and spine
 Administer high concentration oxygen
 Control bleeding
 Keep patient at rest
 Talk to conscious patient (emotional
 Dress and bandage open wounds
 Mange the patient for shock
 Be prepared for vomiting
 Transport patient promptly
 Monitor vital signs every five minutes