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Introduction   

As an emergency room (ER) nurse, you oversee hundreds of trauma patients with many of them having some type of head injury. Many times, a small bump on the head is nothing to worry about, but sometimes it can be serious even if there is no visible evidence on the outside. Head injuries are a serious public health problem and are often referred to as the “silent epidemic.” Head injuries are the major cause of hospital admissions for trauma patients who are seen in the ER. This course will explore how head injuries are caused, the types of head injuries, and the assessment and management of head injuries in the emergency room. We will also look at the differences between head injuries (HI) and traumatic brain injuries (TBI).

TBI is a major cause of death and disability in the United States and is on the rise (1). There were over 69,000 TBI-related deaths reported in the U.S. in 2021 which equates to about 190 Americans each day (1). Head injuries can affect people of all ages regardless of their race, ethnicity, sex, education, income, disability, and gender (1). Head injuries are often the most missed diagnosis and are often hard to identify. Certain groups are at greater risk of dying or experiencing long-term complications.

The ER is a crucial point where accurate assessment and identification of head injuries may prevent long-term complications (8). There are major barriers when it comes to assessing and identifying head injuries, often due to a lack of standardized assessment methods and a wide variety of criteria used for diagnosis (8). Poor identification through improper assessment contributes to up to 50% of misdiagnoses in the ER (8).

As you work your way through the section questions, I hope you will be able to recall some patients you have cared for and gain a better understanding of how to assess and care for patients who have experienced head injuries.

Okay, let’s get started!

Head Injury: Definition

The term head injury (HI) is a broad term that describes a large number of injuries that occur to the head including the scalp, skull, brain, and underlying tissue and blood vessels (2). Head injuries are commonly referred to as brain injury or TBI depending on the extent of the trauma. A head injury can be classified as mild bump, bruise, or cut on the head, and can be moderate to severe.

Different Types of Head Injuries

Concussion

A concussion is an injury to the head that affects brain function, and the effects are often short-term. The injury may cause loss of memory, headaches, and confusion. Some individuals can lose consciousness, but most do not (3).

Skull Fracture

• Defined as a break in the skull bone
• Can happen with impact injuries, falls, motor vehicle accidents (MVAs), sports injuries, or personal violence (4)
• Four major types:
• Linear skull fractures

Most common type where there is a break in the bone, but it does not move the bone and typically requires no interventions (2)

• Depressed skull fractures

Can be seen with or without a cut in the scalp and part of the skull is sunken in and often requires surgical intervention (2)

• Diastatic skull fractures

Occur along the suture lines in the skull and are typically seen in newborns and older infants (2)

• Basilar skull fracture

Most serious type and involves a break in the bone at the base of the skull. Patients typically have bruising around their eyes (also known as raccoon eyes or raccoon sign) and behind their ear, and may also have clear fluid draining from their nose or ears (2)

Diffuse Axonal Injury (DAI)

• Tearing of the brain’s axons
• Common and are caused by shaking the brain back and forth and severity can range from concussion to coma where injury occurs to different parts of the brain (2)
• Seen with car accidents, falls, or shaken baby syndrome

Traumatic Brain Injury (TBI)

A traumatic brain injury is a broad term to describe a brain injury caused by an external force that damages the brain and ultimately affects how the brain works. TBI can be caused when the head receives a forceful blow, bump, or jolt, or an object pierces the skull (5). The damage can be focal or diffuse, primary, or secondary, or penetrating or non-penetrating depending on the extent of the injury and the damage (5). A person can also experience both penetrating and non-penetrating TBIs at the same time.

Primary Brain Injury

• Damage is immediate and the injury to the brain occurs due to impact either by penetration, blunt force, or rapid acceleration-deceleration (7)
• Injuries can cause contusions, hematomas, or axonal injuries (10)
• Damage is irreversible

Secondary Brain Injury

• Damage/symptoms occur hours, days, or weeks after the initial trauma injury (7)
• Caused by systemic hypotension, hypoxia, or increased intracranial pressure (ICP)

Penetrating Traumatic Brain Injury

• Involves an open wound to the head from an object piercing the skull (bullet, shrapnel, bone fragment, hammer, or knife) (5)
• Caused by focal damage including a fractured skull, torn meninges, and damage to brain tissue

Non-Penetrating Traumatic Brain Injury

• Also known as closed-head injury or blunt TBI
• Caused by a force strong enough to move the brain inside the skull (5)
• Often caused by falls, MVAs, sports injuries, blast injuries, or being struck by an object (5)

Causes of a Head Injury

The most common causes of head injuries in adults and children are motor vehicle accidents (automobiles, motorcycles, or being struck as a pedestrian), violence, falls, or child abuse (2). Even though TBI can affect individuals of all ages, data shows us that there are groups of people at greater risk of dying or experiencing long-term complications from TBIs (1). These include older adults, racial or ethnic minorities, service members and veterans, people who experience homelessness, people in correctional and detention facilities, survivors of intimate partner violence, and people who in live in rural areas (6).

Older Adults

People aged 75 years and older have the highest number of TBI-related deaths and hospitalizations, accounting for 32% of TBI-related hospitalizations and 28% of TBI-related deaths (6).

Racial or Ethnic Minorities

TBIs are highest among American Indian/Alaska Native children and adults compared to any other racial or ethnic groups due to MVA crashes, substance abuse, suicide, and difficulties accessing appropriate healthcare (6).

Service Members and Veterans

Service members and veterans are at risk due to military conflicts and often due to MVA crashes and not deployment (6).

People Who Experience Homelessness

People who experience homelessness are two to four times more likely to experience a TBI than the general population (6).

People In Correctional and Detention Facilities

Research has shown that 46% of individuals in prisons and jails have experienced a TBI (6). TBIs also occur in individuals in correctional and detention facilities with a history of TBI and:

• Mental health problems (depression and anxiety)
• Substance abuse
• Anger issues
• Suicidal ideations and attempts

Survivors of Intimate Partner Violence

Survivors of intimate partner violence are often at risk due to assault.

People Living in Rural Areas

People living in rural areas are at greater risk of dying from a TBI compared to those living in urban areas (6). Reasons include:

• More time needed to travel to receive medical care
• Less access to trauma centers
• Difficulty getting care specializing in TBI

Assessing Head Injuries

Around 50% of TBI-related deaths occur within the first few hours of injury. Delays in appropriate assessment and care contribute to secondary injury which in turn increases morbidity and mortality rates (17). Rapid and appropriate assessment by ER staff is crucial in facilitating the timely management of patients to prevent secondary brain injury (17).

Head injuries are classified by severity which is determined by assessment. They are categorized as mild, moderate, or severe (9). Key steps to early and accurate identification of head injuries are consistency in standardized assessments and diagnostic criteria. Classification is determined by key features such as (8):

• Level of consciousness
• Confusion or disorientation
• Post-traumatic amnesia (PTA)
• Transient neurological abnormalities

All patients in the ER for traumas and other emergencies must receive a thorough and organized ABCE assessment which checks airway, breathing, circulation, disability, and exposure (11). In addition to the ABCE assessment, TBI severity is assessed using the Glasgow Coma Scale (GCS) which measures the level of consciousness. Severity is further determined according to the duration of post-traumatic amnesia which uses the Galveston Orientation and Amnesia Test (GOAT) or Westmed PTA scale (9). A third assessment is the pupil examination which helps to indicate severity of head injury and progression.

If a patient is suspected of having severe head trauma, often a complete neurological assessment will be performed. A neurological examination focuses on identifying and assessing the patient’s mental status, cranial nerves (CN), sensation, motor ability, and reflexes (21).

History Taking

On arrival at the ER, initial assessment should include a patient’s history, mechanism of injury, symptoms, physical assessment, and any previous treatment (13). To ensure patients receive prompt diagnosis, healthcare professionals should include the following in their initial assessment (15):

• Questioning the patient about all and any TBI symptoms
• Assessing for loss of consciousness
• Asking how long they were unconscious
• Gathering information about the force of the injury
• Questioning involved persons or witnesses of the trauma about the individual’s behavior or change in behavior

ABCDE Approach

The ABCDE (airway, breathing, circulation, disability, exposure) approach is a well-known assessment method that allows healthcare providers to identify and respond to life-threatening injuries in order of priority (20).

• Airway
  • Assess using the “look and listen” approach: look for obstruction or foreign objects and listen for snoring noises or silence (which indicate partial or complete obstruction)
  • Suction the airway as needed
• Breathing

Use a “look and listen” approach to assess for:

• • How much effort is involved
  • Use of accessory muscles
  • Chest symmetry (bilateral chest rise and fall): unilateral can indicate pneumothorax.
  • Respiratory rate (12-20 breaths per minute)
  • Rhythm of breathing
  • Color of skin, lips, and mucous membranes
  • Listen for abnormal sounds (wheezes, gurgling, crackling)
  • Arterial blood gas measurements
  • Pulse oximetry measurements
• Circulation

Essential to ensure the brain receives adequate oxygen and nutrients via cerebral perfusion; assess for any bleeding or hemorrhage; involves a “look, listen, and feel” approach to assess for:

• • Skin color, mucus membranes
  • Peripheral temperature
  • Capillary refill time (<2 seconds)
  • Peripheral pulses (rhythm and quality)
  • 12-lead electrocardiogram (ECG) rhythm
  • Blood pressure
  • Lab work (full blood count, coagulation, urea, electrolytes, and liver function)
• Disability

Check neurological status and level of consciousness by use of GCS and pupil examination; assess serum blood glucose level to rule out hyper/hypoglycemia; use of ACVPU acronym for a quick and easy assessment of consciousness

• • Alert
  • Confusion (new or recent or delirium)
  • Voice (responds to voice)
  • Pain (responds to pain)
  • Unresponsive
• Exposure
  • Assess for injuries or wounds
  • Pay close attention to the head where hair may cover wounds or bruising
  • Assessment should include front, back, abdomen, skin rashes, evidence of intravenous (IV) drug use, and old bruising

Glasglow Coma Scale

The Glasgow Coma Scale (GCS) is a structured assessment used to score or measure the level of impaired consciousness according to three aspects of responsiveness: eye-opening, motor, and verbal response (see Table 1) (12). Each aspect provides a clear picture of a patient’s condition and is used to classify a TBI by its severity level (12). The findings in each component of the scale are used to guide the early care management of patients with a head injury. The GCS is also used to assess for impaired consciousness related to alcohol consumption, sedation, seizures, stroke, brain abscess, diabetes, excess insulin, or poisoning (12).

Abbreviated Westmead Post-Traumatic Scale

Post-traumatic amnesia (PTA) is the period during which a person suffers from disorientation, confusion, inability to recall new information, or behavior changes following a head injury (8). The Westmead PTA scale is a standardized assessment tool designed to provide objective information and measures PTA. The test consists of seven questions assessing orientation and five questions assessing memory for a total of 12 questions.

In the ER, an Abbreviated Westmead Post-Traumatic Amnesia Scale (A-WPTAS) is used to assess and manage the care of patients who have suffered isolated and mild TBIs. The test is administered hourly for a maximum of four hours and is used for patients with a GCS of 13-15, 24 hours post-injury (18). This screening helps identify patients with cognitive impairment, and the need for admission, further investigation, education, and follow-up care (18). The test is provided in a quiet environment free of distractions in the following steps (19).

• Step 1: Glasgow Coma Scale (GCS) Assessment
  • Assess eye opening and motor response. The patient must open their eyes spontaneously and obey commands to qualify for A-WPTAS testing.
  • Assess verbal response (orientation questions): The patient must correctly answer all five questions to achieve a score of 5/5 for a verbal response.
    • What is your name?
    • What is the name of this place?
    • Why are you here?
    • What month are we in?
    • What year are we in?
  • Assess limb strength and pupil response.
• Step 2: Picture Recognition
• Show the patient three picture cards and ensure they can repeat the names of the items on each picture (cup, keys, bird). After one hour, the patient is required to remember the items.
• For patients who cannot freely recall, or who can only partially recall the three correct pictures, present the three target pictures again and re-test in one hour.
• Step 3: Hourly Assessment
• Return to the patient one-hour post initial assessment and repeat Step 1 (GCS).
• Ask the patient to recall the three pictures shown the previous hour.
• If the patient fails to recall pictures after prompting, repeat Step 2.

Pupil Examination

In addition to the GCS and PTA screening, patients should also have a pupil examination conducted in the ER. Assessment of pupil size and reactivity are essential clinical parameters in monitoring patients who have experienced head injuries (17). The assessment of the pupils can indicate information about the severity of the injury as well as its progression (Table 2) (17). The pupil examination assesses four characteristics: size, reactivity to light, shape, and presence of anisocoria (unequal pupil size) (17).

Mental Status Examination

A mental status examination assesses the level of consciousness (21). While speaking to the patient, the nurse assesses their memory and language function.

• Awake: normal level of consciousness or can easily be awakened
• Alert: appropriate to visual or verbal cues
• Oriented: knows who and where they are, the date and time, and the situation/place\

Cranial Nerve Assessment

Assessment of the cranial nerves (CN) provides information about other possible injuries including injuries to the brain stem (21). There are 12 cranial nerves, 11 of which are routinely assessed when severe head injury is suspected.

• Optic nerve (CN2)
  • Can be assessed using a Snellen eye chart (assess both eyes separately)
  • Assessed via pupil response
• Oculomotor nerve (CN3)
  • Assess via pupil response
  • Assessed by having the individual close one eye and focus on a finger while it is moved in space (assesses conjugate gaze functions)
• Trochlear nerve (CN4) and abducens nerve (CN6)
  • Assessed by having the individual close one eye and focus on a finger while it is moved in space (assesses conjugate gaze functions)
• Trigeminal nerve (CN5) and facial nerve (CN7)
  • Assessing muscle tone and symmetric sensation
• Vestibulocochlear nerve (CN8)
  • Assessed through conversation
• Glossopharyngeal nerve (CN9) and vagus nerve (CN10)
  • Assessed via gag reflex
• Accessory nerve (CN11)
  • Assessed by asking the patient to shrug shoulders upward against resistance and rotate head in both lateral directions against resistance
• Hypoglossal nerve (CN12)
  • Assessed by asking the patient to stick the tongue straight out, move it side to side, and push it forcefully against the inside of the cheek

Sensory Examination

A sensory examination relies on the patient’s ability to report what they are feeling, which can be difficult depending on the situation. For this assessment, various types of sensations are delivered to the brain via different pathways (21).

Motor Examination

This assessment has several components including inspection, palpitation, and function testing with tone and strength of individual muscle groups (21). Muscle tone is assessed by palpation of the muscles of the extremities and by passive movements of the joints (12). Muscle strength should be assessed in the extremities, neck, and trunk by providing resistance to the movement of muscle groups in both directions (21). The following scale is universally used to describe muscle group strength, rated on a scale of 0/5 to 5/5 as follows:

• 0/5 – No contraction
• 1/5 – Muscle flicker, but no movement
• 2/5 – Movement possible, but not against gravity (contraction in the horizontal plane)
• 3/5 – Movement possible against gravity, but not resistance
• 4/5 – Movement possible against some resistance (can be subdivided further, +/-)
• 5/5 – Normal (full) strength

Symptoms of Head Injuries

An individual may have varying degrees of symptoms often associated with the severity of their head injury. Most people will have one or more symptoms that affect how they feel, think, act, or sleep. Symptoms may also change over time depending on when the injury was sustained. The following are the most common symptoms; however, everyone may experience them differently (2). The following are symptoms of mild, and moderate to severe head injuries (2).

Mild Head Injury

• Raised, swollen area from a bump or a bruise
• Small, superficial cut to the scalp
• Headache
• Sensitivity to noise and light
• Irritability
• Confusion
• Lightheadedness or dizziness
• Problems with balance
• Nausea
• Problems with memory and/or concentration
• Change in sleep patterns
• Blurred vision
• “Tired” eyes
• Ringing in the ears (tinnitus)
• Alteration in taste
• Fatigue or lethargy

Moderate to Severe Head Injury

• Requires immediate medical attention
• Loss of consciousness
• Severe headache that does not go away
• Repeated nausea and vomiting
• Loss of short-term memory, such as difficulty remembering the events that led right up to and through the traumatic event
• Slurred speech
• Difficulty walking
• Weakness in one side or area of the body
• Sweating
• Pale skin color
• Seizures or convulsions
• Behavior changes including irritability
• Blood or clear fluid draining from the ears or nose
• One pupil is dilated and doesn’t constrict when exposed to light
• Open wound in the head
• Foreign object penetrating the head
• Coma
• Vegetative state
• Locked-in syndrome

Diagnosing Head Injuries

A traditional medical exam and assessment is often the first step in diagnosing potential head injuries. The assessment typically includes a neurological exam that evaluates thinking, motor function, sensory function, coordination, eye movement, and reflexes (16). Neurological exams are best performed on well-oxygenated patients with normal blood pressure, blood glucose levels, and no sedation.

In addition to the use of the Glasgow Coma Scale (GCS) as previously discussed to monitor the level of consciousness, radiological studies are also used to diagnose a potential brain injury. These two combined helps determine the severity of the head injury and assist in treatment.

Not all patients who present to the ER with head injury will require imaging. Some can safely discharge after a history and physical is obtained along with a brief period of observation (13). Computed tomography (CT) and magnetic resonance imaging (MRI) scans help to rule out more serious brain injuries and are not intended to be used alone for diagnosis. These scans play a critical role in detecting intracranial injuries, such as depressed skull fracture, extradural hematoma, subdural hematoma, intracerebral hemorrhage, and contusion, all of which may require immediate surgical intervention (13).

Management of Head Injuries

Management considerations in the ER are the key to avoiding secondary injuries. The causes of secondary head injuries are hypotension, hypoxia, hypercapnia, and worsening ICP (13). In order to help avoid secondary injuries, once the patient has been in the ER and it has been determined they have a brain injury healthcare professional should (14):

• Connect to continuous monitoring equipment to the patient
• Establish adequate vascular access
• Insert an indwelling urinary catheter
• Continue resuscitation and stabilization
• Conduct relevant diagnostic tests

Respiratory management is important in all patients with severe TBIs who have a depressed level of consciousness. Those with severe TBIs often require intubation to protect the airway and ensure adequate oxygenation and ventilation (13). Hypoxia is a cause of secondary brain injury and can lead to cerebral edema if left untreated. Hypoxia causes vasodilation and impairs cerebral autoregulation, resulting in increased ICP (13). Therefore, patient’s arterial blood gases (ABGs) should be monitored, and pulse oximetry readings should remain above 90% (13).

Hypercapnia is equally important to assess and monitor because it can result in cerebral vasodilation which in turn can cause cerebral edema, decreasing cerebral perfusion. PaCO2 can be assessed via blood gas or an end-tidal CO2 detector and should be kept between 35-40 mm Hg. Long-term cerebral constriction caused by increased PaCO2 levels will lead to cerebral ischemia, increased ICP, and worsening neurological outcomes in patients who have sustained head injuries (13).

Hypotension is also a cause of secondary brain injury and therefore normal hemodynamics need to be monitored and assessed frequently through an arterial line if possible. The use of isotonic fluids and vasopressors are also considered when trying to achieve hemodynamic stability (13). Post-traumatic seizures increase cerebral metabolism and ICP which in turn leads to poor patient outcomes (13). Hypoglycemia is also associated with poor outcomes and therefore blood glucose levels should be assessed regularly (13).

• Airway
  • Keep airway patent by using nasopharyngeal or oropharyngeal airway
  • GCS < 8 intubation for airway protection (13)
  • Intubation and ventilation for GCS <8, loss of laryngeal reflexes, and irregular respirations
• Breathing
  • Oxygen therapy to achieve and maintain oxygen saturations of 94-98%
  • Avoid hypoxemia (provide supplemental oxygen to maintain oxygen saturations > 90% and PaO2 > 60 mm Hgb)
  • Do not hyperventilate
  • Avoid aspiration with the placement of a nasogastric tube if facial trauma has been ruled out.
  • Obtain serial ABGs with a goal of PaO2 > 97mm Hg and PaCO2 35-40 mm Hg
• Circulation
  • Maintain systolic blood pressure (SBP) > 110 and mean arterial pressure (MAP) 80-90 mm Hg (give isotonic fluids (normal saline or lactated ringers); use vasopressors (epinephrine or norepinephrine) if MAP < 80 with fluids) (13)
• Disability
  • Check blood glucose and give dextrose for hypoglycemia
  • Elevate the head of the bed to greater than 30 degrees to reduce ICP levels and promote venous return from the brain (13)
  • If seizing, bleeding, or midline shift noted on CT, administer antiepileptic (phenytoin)
  • Early and aggressive pain control and sedation to avoid ICP spikes
• Environment
  • Avoid hyperthermia and give paracetamol if needed to decrease cerebral metabolism (13)

Due to the close need for hemodynamic monitoring and frequent neurological checks and possible surgical intervention, patients with severe TBI are often monitored and frequently assessed in the ER before being transferred to a neurosurgical ICU. The top priority while the patient is in the ER is to avoid a secondary brain injury (13).

Nursing Management/Care

As previously discussed, brain injuries are on the rise and the leading cause of morbidity and mortality. Patients who have suffered a brain injury are at high risk for developing secondary brain injury and further deterioration (17). Nurses often care for and assess patients who have suffered from brain injuries and therefore could alter a patient’s course of recovery through their assessment and interventions.

Key points for nursing management and care include:

• Assess vital signs, ICP, intake and output
• Assess neurological status/changes (pupillary response)
• Assess for other injuries including any symptoms of scalp, facial, spine, intra-abdominal, and long-bone injuries
• Assess and manage pain
• Assess cough and gag reflex
• Administer IV fluids and supplemental oxygen if indicated
• Provide suctioning
• Maintain semi Fowler’s position and seizure precautions
• Provide prophylaxis against deep vein thrombosis (DVT) and pressure injuries
• Keep the patient in a quiet room with minimal traffic
• Provide sensory input and stimuli
• Educate patients and family about head trauma
• Reposition the patient in bed every few hours to prevent pressure injuries

Conclusion

Brain injuries can result in long-term neurological disability if left untreated or there is a delay in treatment due to assessment inaccuracy. Brain injuries are time-critical and therefore accurate and timely assessment of patients who come to the ER with suspected head injuries is crucial in preventing secondary brain injury.

Assessment of patients with a head injury starts with a basic ABCDE assessment, and re-assessment is based on clinical judgment. Proper assessment enables the healthcare providers and team to identify changes in the patient’s condition, adjust treatment, and prevent further brain injury while prioritizing interventions. Appropriate assessment of brain injuries in the ER requires a knowledge of the causes, types, assessments, and management of head injuries in this setting.

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