Closed Head Injury - Assignment Example

Closed Head Injury Subdural Haematoma Closed Head Injury Order No: 182206 No. of pages: 6 Premium writer – 6530 Closed Head Injury…2 Subdural Haematoma ABSTRACT The head is a delicate part of the body and hence prone to get injured if care is not taken. An injury to the skull, scalp or brain is what we call a “Head Injury”. They are primarily caused due to traffic or work place accidents, on the sports field, or during a fall or an assault. A traumatic brain injury is the most serious cause of head injury. It is very difficult for a person who has had a head injury to recuperate quickly. In fact, the person has to undergo a lot of trauma before he gets better thoroughly. Closed Head Injury…3 Subdural Haematoma Sub – dural Haematoma Martin Sheedy, 52 year old, fell during his daily run in the park. He hit his head on the right side and was knocked unconscious. A bystander called an ambulance, which arrived in 10 minutes to transport him to the local hospital. He is diagnosed as having a subdural haematoma. 1. What signs and symptoms are likely to be evident? Symptoms of a Head Injury: A SDH or subdural haematoma is categorized by the amount of time that has elapsed since the incident occurred. If the period is less than a week, the subdural haematomas behave as acute haematomas. (emedicine, January, 2002) There are two prime categories of head injury; they are penetrating head injury and closed head injury. In a penetrating head injury, the object lacerates the scalp, fractures the skull and penetrates the brain. A closed head injury is caused by a direct collision with a very hard surface such as a wall, floor, windshield or any such surface. Both the types of injury causes damage ranging from mild to very severe sometimes resulting in disability and even death. In Mr. Martin Sheedy’s case his head had hit a hard surface like a platform.. Many high risk clinical factors are taken into account after a head injury has occurred and a close physical examination and history are taken from the injured Closed Head Injury…4 Subdural Haematoma person. “Alterations in brain-derived neurotrophic factor expression have been reported in multiple brain regions acutely after traumatic brain injury” (Neuroscience, Medline, January 2005) Tell tale signs of vital symptoms would help to gauge the extent of the injury and which category it belongs to, so that the right medical service could be rendered. An acute SDH is commonly always associated with extensive primary injury to the brain. This diffuse parenchymal injury correlates strongly with the outcome of the patient. In one study, 82% of comatose patients with acute SDH had parenchymal contusions (emedicine, Kotwica, 1993). Monitoring of the patient is of utmost importance in order to treat the injured person. The Physician checks to see, how many times a patient has vomited because this would show the extent of damage to the brain. Vomiting more than twice, indicates a fracture to the skull. Coumadin or other blood thinner is used. The physician also checks to see if there are any other concomitant diseases such as hemophilia or Thrombocytopenia, which predisposes a patient to incessant bleeding. …”excessive activation of both the clotting and fibrinolytic systems are Closed Head Injury…5 Subdural Haematoma emphasized to be the possible etiological factor for the origin and development of chronic subdural haematoma” (Neurosurgery.  1989; 25(1):25-9) 2. Describe the anatomy involved in the formation of a sub-dural haematoma. The mechanism usually involved in producing an acute SDH is a high speed impact to the person’s skull. During a sub- dural haematoma, the anatomy undergoes a lot of changes. The brain tissue is accelerated in relation to a fixed dural structure which tears the blood vessels. Hence the mechanism leads to brain edema, associated contusions and diffuse axonal injury. When such a massive impact takes place, often the vein that connects the dural sinuses to the cortical surface gets ruptured. In one study, “the ruptured cortical artery always was located around the Sylvian fissure” (emedicine, Matsuyama, 1997). Older Patients with acute SDH experienced a lucid interval before neurological deterioration could take place. Cerebro- spinal fluid fills into the dura-arachnoid interface and the border cells proliferate around the CSF collection and produces a neo-membrane. Fragile new blood vessels grow into this membrane are sometimes the source of hemorrhage, resulting in chronic SDH. Closed Head Injury…6 Subdural Haematoma 3. What diagnostic tests would confirm the diagnosis? After such preliminary findings based on the patient’s symptoms, the clinician investigates the prognostic factors of intracranial pressure of the injured person. It is only after this step, that the treatment modalities are discussed and finalized. Computed tomography such as CT scans can be taken instead of the ancient X-ray as they are much more in vogue and easier to handle. CT scans are much more accurate and innovative in determining the extent of the head injury and the amount of bleeding in the patient’s head. In some cases, an MRI scan may be used when the patient becomes more stable. (emedcine, Grant, P. Sinson, MD, G. Timothy Reiter, MD, 22nd January, 2002) The first and foremost step in the diagnosis of a patient suffering from a closed head injury is to procure reliable results after the physical examination. When the history of the patient is being checked, he should not be drugged or intoxicated because it is not possible to get the right results from a demented patient. If there are barriers such as language, limiting communication between the physician and patient, a head CT scan should be immediately considered. The next step would be to carry out a detailed physical examination of the patient and also delve deep into the patient’s history. The GCS or the Glasgow Coma Scale is a very valuable tool to examine a patient’s closed head injury. Patients Closed Head Injury…7 Subdural Haematoma scoring less than 15 on the GCS or those above 65 years of age are considered as high risk patients. Identifying high risk patients for increased intracranial pressure caused by traumatic brain injury is a major task for any physician and more so rendering the right kind of treatment procedure. Monro-Kellie, in the early 19th century, proposed a model of the head as: Intracranial volume = brain volume + CSF volume + blood volume + mass (lesion, bleeding, etc.) volume. 0-10 mmHg is the normal ICP (intracranial pressure) In case there is an increase of volume from a mass lesion, then the Cerebral Spinal Fluid (CSF) may decrease as a compensatory mechanism. But if the volume of the mass lesion has reached critical heights, then the ICP rises drastically. When this happens, a catastrophic situation faces both the patient as well as the clinician leading to herniation of the brain and in some bad cases death. Based on the extent of ICP, therapeutic decisions are made. High risk patients with a dangerous ICP are treated in the ICU (Intensive care unit), because they have to be monitored throughout the time, until they exit the danger zone. 4. What would be the immediate surgical intervention for this condition and why? Nursing Diagnosis: Risk for Ineffective Tissue Perfusion: Cerebral related to increased intracranial pressure and oedema. Closed Head Injury…8 Subdural Haematoma Nursing Interventions: Identifying high risk patients for increased intracranial pressure caused by traumatic brain injury is a major task for any physician and more so rendering the right kind of treatment procedure. Monro-Kellie, in the early 19th century, proposed a model of the head as: Intracranial volume = brain volume + CSF volume + blood volume + mass (lesion, bleeding, etc.) volume. 0-10 mmHg is the normal ICP (intracranial pressure) Rational: In case there is an increase of volume from a mass lesion, then the Cerebral Spinal Fluid (CSF) may decrease as a compensatory mechanism. But if the volume of the mass lesion has reached critical heights, then the ICP rises drastically. When this happens, a catastrophic situation faces both the patient as well as the clinician leading to herniation of the brain and in some bad cases death. Based on the extent of ICP, therapeutic decisions are made. High risk patients with a dangerous ICP are treated in the ICU. Nursing Diagnosis: Risk for Aspiration: related to altered level of consciousness. Nursing Interventions: ... Dysphagia raises the risk of aspiration. Aspiration is the most common procedure and it is performed usually with the help of a CT scan. In case an abscess is formed, drainage is done through the help of a burr hole. Closed Head Injury…9 Subdural Haematoma Rationale: …In order to manage subdural or epidural empyema, surgical evacuation is necessary along with antimicrobial therapy. Nursing Diagnosis: Risk for Impaired Skin Integrity: related to immobility. Nursing Interventions: ...Most patients who suffer from a massive head injury have potential mass lesions which require surgery. They are unable to move as they drift in and out of coma. Rationale: ... The patient is scrutinized under the Glasgow Coma Scale score following deterioration into coma, the highest intracranial pressure is measured, the degree of midline shift, and the type of intracranial lesions that have occurred. In addition, the patient’s, age is taken into consideration. Nursing Diagnosis: Risk for Imbalanced Nutrition: Less Than Body Requirements related to inability to eat. Nursing Interventions: ... Dysphagia also raises the risk of inadequate nutrition. During this condition, the patient finds it very difficult to swallow both liquid and solid foods. The patient finds it difficult for the food to pass from the mouth to the throat as he feels a kind of blockage. Rationale: ...As a result the patient’s in take of food is very much less and he becomes weak as a result of low nutrition. References: MedlinePlus Medical Encyclopedia/ Chronic Subdural Haematoma www.nlm.nih.gov/medlineplus/ency/article/000781.htm Library.umc.edu Head Injury www.library.umc.edu/TopicTracks/tt-headinjuries.html emedicine Subdural Haematoma. http://www.emedicine.com/med/topic2885.htm Dysphagia Dysphagia and Swallowing Resource Center www.dysphagia.com Medline Bullock R, Chesnut RM, Clifton G: Guidelines for the management of severe head injury. Brain Trauma Foundation. Eur J Emerg Med 1996 Jun; 3(2): 109-27[Medline]. Medline Kawakami Y, Chikama M, Tamiya T: Coagulation and fibrinolysis in chronic subdural hematoma. Neurosurgery 1989 Jul; 25(1): 25-9[Medline Read More