Neurologic

Trauma

Head Injury

Brain Injury

Spinal Injury

Head Injury

Is a broad classification that includes injury to the

scalp, skull, and the brain.

Traumatic brain injury is the most serious type of

head injury.

The most common causes of traumatic brain injury

are motor vehicle crashes, violence, and falls.

Groups at the highest risks for traumatic brain injury

includes ages 15-24 years and males, who suffer

traumatic brain injury at a rate almost twice of the

females.

Brain suffers from traumatic injury

Brain swelling or bleeding increases intracranial volume

Rigid cranium allows no room for

expansion of contents so ICP

increasesPressure on blood vessels within the brain causes blood flow to the brain

slowly

Cerebral hypoxia and ischemia

occurs

Intracranial pressure

continues to rise. Brain may herniate

Cerebral blood flow decreases

Pathophysiology

Damage to the brain from traumatic injury takes tow forms: primary injury and secondary injury.

• Primary injury is the initial damage to the brain that results from the traumatic event. This may include contusions, lacerations, and torn blood vessels from the impact, acceleration, deceleration, or foreign object penetration.

• Secondary injury evolves over the ensuing hours and days after the initial injury and is due primarily to brain swelling or ongoing bleeding.

• Isolated scalp trauma is generally classified as a minor head injury. Because its many blood vessels constrict poorly, the scalp bleeds profusely when injured. • Trauma may result in a abrasion (brush wound), contusion, laceration, or hematoma beneath the layers of the tissue of the scalp (subgaleal hematoma). • Large avulsions of the scalp maybe potentially life-threatening and the true emergencies. • Diagnosis of any scalp injury is based on physical examination, inspection, palpation. • Scalp wounds are potentials portal of entry of organisms that causes intracranial infections. Therefore, the area is irrigated before the lacerations is sutured to remove foreign material and to reduce the risk of infection. • Subgaleal hematomas usually absorb on their own and do not any specific treatment.

Scalp Injury

Skull Fractures

• It is a break in the continuity of the skull caused by forceful trauma.

• It may occur with or without damage to the brain.

• Skull fractures are classified as linear, comminuted, depressed, or basilar.

• A fracture maybe open, indicating a scalp laceration or tear in the dura, or closed, in which the dura are intact.

Linear skull fracture

• A common injury, especially in children.

• A linear skull fractures is a simple break in the skull that follows a relatively straight line.

• It can occur after seemingly minor head injuries (falls, blows such as being struck by a rock, stick, or other object; or from motor vehicle accidents).

• A linear skull fracture is not a serious injury unless there is an additional injury to the brain itself.  

Depressed skull fractures

• These are common after forceful impact by blunt objects—most commonly, hammers, rocks, or other heavy but fairly small objects. • These injuries cause "dents" in the skull bone. If the depth of a depressed fracture is at least equal to the thickness of the surrounding skull bone (about 1/4-1/2 inch), surgery is often required to elevate the bony pieces and to inspect the brain for evidence of injury. • Minimally depressed fractures are less than the thickness of the bone. • Other fractures are not depressed at all. They usually do not require surgical treatment unless other injuries are noted.

Basilar skull fracture

• A fracture of the bones that form the base (floor) of the skull and results from severe blunt head trauma of significant force.

• A basilar skull fracture commonly connects to the sinus cavities. This connection may allow fluid or air entry into the inside of the skull and may cause infection.

• Surgery is usually not necessary unless other injuries are also involved.

Clinical Manifestations:

The symptoms, apart from those local injury, depend on the severity and the distribution of the brain injury. Persistent localized pain usually suggest that a fracture is present. Fractures of the cranial vault may or may not produced swelling in the region of the fracture; therefore, an x-ray is needed for diagnosis.

• Battle’s Sign - an area of ecchymosis (bruising) which is seen over the mastoid.

• CSF Otorrhea - cerebrospinal fluid leaking through the ears.

• CSF Rhinorrhea - cerebrospinal fluid leaking through the nose.

• Halo Sign - it is a blood stain surrounded by a yellowish stain (CSF) which is usually seen on bed linens or pillows.

Assessment and

Diagnostic Findings

Computed Tomography Scan (CT scan)

• Can detect less apparent abnormalities by the degree to which soft tissue absorbs the x-ray.

• It is fast, accurate, and safe diagnostic study that shows the presence, nature, location, and extent of acute lesions. • It is also helpful in the ongoing management of patients with head injury as it can disclose cerebral edema, contusion, intracerebral or extracerebral hematoma, subarachnoid and intraventricular hemorrhage, and late changes (infarction, hydrocephalus).

Magnetic Resonance Imaging (MRI)

• Used to evaluate patients with head injury when a more accurate picture of the anatomic nature of the injury is warranted and when the patient is stable enough to undergo this longer diagnostic study.

Cerebral Angiography

• Identifies supratentorial, extracerebral, and intracerebral hematomas and cerebral contusions. • Lateral and anteroposterior views of the skull are obtained.

Medical Managemen

t

• Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the patient is essential.

• Nursing personnel may observe the patient in the hospital, but if no underlying brain injury is present, the patient may be allowed to return home.

• If the patient is discharged home, specific instructions must be given to the family.

• Many depressed skull fractures are manage conservatively; only contaminated or deforming fractures require surgery.

• If surgery is necessary, the scalp is shaved and cleansed with copious amounts of saline to remove the debris.

• The fracture is then exposed. After the skull fragments are elevated, the skull is debrided.

• Large defects can be repaired immediately with bone or artificial grafts; if significant cerebral edema is present; repair of the defect can be delayed for 3 to 6 months. Penetrating wounds require surgical debridement to remove foreign bodies and devitalized brain tissue and controlling hemorrhage.

• Antibiotic treatment is instituted immediately ,and blood component therapy is administered if indicated.

• As stated previously, fractures of the base of the skull are serious because they are usually open (involving the paranasal sinuses or middle or external ear) and results CSF leakage.

• The nasopharynx and the external ear should be kept clean. Usually a piece of sterile cotton is placed loosely on the ear, or a sterile cotton pad maybe tapped loosely under the nose or against the ear to collect the draining fluid.

• The patient who is conscious is cautioned against sneezing or blowing the nose.

• The head is elevated 30 degrees to decreased ICP and promote spontaneous closure of the leak, although some neurosurgeons prefer that the bed to be kept flat.

• Persistent CSF Otorrhea and Rhinorrhea usually requires surgical intervention.

Traumatic brain injury

• A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain.

• Not all blows or jolts to the head result in a TBI.

• The severity of such an injury may range from "mild," i.e., a brief change in mental status or consciousness to "severe," i.e., an extended period of unconsciousness or amnesia after the injury.

• A TBI can result in short or long-term problems with independent function.

Causes of TBI:

The leading causes of TBI are:

•Falls (28%) •Motor vehicle-traffic crashes (20%) •Struck by/against (19%)•Assaults (11%)

Blasts are a leading cause of TBI for active duty military personnel in war zones.

Who is at highest risk for TBI?

• Males are about 1.5 times as likely as females to sustain a TBI.

• The two age groups at highest risk for TBI are 0 to 4 year olds and 15 to 19 year olds.

• Certain military duties (e.g., paratrooper) increase the risk of sustaining a TBI.

• African Americans have the highest death rate from TBI.

Signs and symptoms:

• The signs and symptoms of a traumatic brain injury (TBI) can be subtle.

• Symptoms of a TBI may not appear until days or weeks following the injury or may even be missed as people may look fine even though they may act or feel differently.

Mild Traumatic Brain Injury

• Clinicians classify head (or, more correctly, brain injury) based on quality or length of change in consciousness and length of amnesia (memory loss).

• Both loss of consciousness (or even a semi-conscious state) and amnesia are directly caused by the sudden trauma and tearing of nerve cells.

• When this trauma occurs, the brain simply cannot maintain its normal functioning and shuts down (causing unconsciousness) or partially shuts down (causing a feeling of being dazed), until cellular functioning can recover.

The diagnosis can be made if even one of the following conditions is observed:

(1) Loss of consciousness of any length (2) Amnesia of any length (3) Altered consciousness (e.g., being "dazed") (4) Focal neurological deficits (e.g., temporary vision loss, or a seizure).

Even a "mild" traumatic brain injury can result in permanent, life-altering consequences.

Effects of Traumatic Brain Injury

Some of the functional consequences of mild traumatic brain injury include :

• Slowed thinking• Memory and concentration problems• Poor judgment• Emotional disorder• Difficulty making decisions.

These problems are a result of "diffuse axonal injury," or damaged nerve cells.

Diagnosis of Traumatic Brain Injury:

• X-ray, MRI (magnetic resonance imaging), and CT (computerized tomography) can sometimes diagnose head and brain injuries by showing areas of fracture, hemorrhage, or other kinds of tissue injury.

• These techniques are usually employed initially in the case of any head trauma to check for life threatening bleeding or swelling in brain tissue.

• However, traumatic brain injury (especially if mild) often involves scattered disconnection among neurons and supportive tissue, stretched and damaged axon membranes (known as diffuse axonal injury), chemical injury due to neurotransmitter toxicity, and cellular dysfunction due to changes in brain chemistry.

• These kinds of changes to brain cells often do not result in sufficient change in the tissue density to be detected by conventional imaging techniques.

• Often, more elaborate imaging techniques such as SPECT (single-photon emission computed tomography) or PET (positron emission tomography) can detect changes due to brain injury because these techniques measure brain cell metabolism, not tissue density.

• In addition to these imaging techniques, a variety of neurological and behavioral tests are used to diagnose brain injury.

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Brain injury

BRAIN INJURY

• The brain cannot store oxygen and glucose to any significant degree. Because the cerebral cells need an interrupted blood supply to obtain this nutrients, irreversible brain damage and cell death occur when the blood supply is interrupted for even a few minutes.

• Closed ( blunt )brain injury - Occurs when the head accelerates and then rapidly decelerates o collides with another object and brain tissue is damage, but there is no opening through the skull and dura.

• Open brain injury - Occurs when an object penetrates the skull, enters the brain and damages the soft brain tissue in its path or when blunt trauma to the head is so severe that it opens the scalp, skull and dura to expose the brain.

• Concussion

- A cerebral concussion after head injury is temporary loss of neurologic function with no appear structural damage. - A concussion generally involves a period of consciousness lasting from few seconds to a few minutes. - The jarring of the brain may be so slight as to cause only dizziness and spots before the eyes or it may be severe enough to cause complete loss of consciousness for a time. - A concussion was once thought of as a minor head injury without significant sequelae.

• CONTUSION

- Cerebral contusion is a more severe injury in which the brain is bruised, with possible surface hemorrhage.

- Contusions or bruising is likely to occur when outside energy causes a portion of the brain to crash into the inner surface of the skull. While contusions can occur anywhere, they are most common in the frontal and temporal lobes of the brain.

- The wings of the sphenoid, temporal bone, ethmoid bone, and anterior clinoid process have very rough edges that line the surface of the lower portion of the skull. This part of the skull cradles the lower tips of the frontal and temporal lobes of the brain.

- The remaining surface of the skull is relatively smooth. - When the frontal and temporal lobes slide over these hard areas, bruising and tearing is common.

- This mechanism explains why damage to the frontal and temporal lobes of the brain is the most common area of traumatic brain injury.

• Diffuse axonal injury

- Involves widespread damage to axons in the cerebral hemispheres, corpus callosum and brain stem.

- It can be seen in mild, moderate or severe head trauma and result in axonal swelling and disconnection.

- The brain is somewhat like Jell-O in a bowl. It is a soft substance with the consistency of custard and composed of millions of nerve cells that are interconnected or wired together by nerve fibers that run throughout the brain.

-The hard bony skull contains the brain and protects it from direct penetrating blows. Unfortunately the skull cannot protect the brain from the energy of such blows. -This process is very similar to what happens when you shake Jell-O that is in a bowl. Just as the shaking action causes parts of the Jell-O to pull away from each other, the energy applied to the brain causes it to bounce and swirl around within the skull causing widespread trauma. -The nerves no longer communicate with each other as efficiently because the stretching and tearing of the nerve fibers set in motion electrochemical damage to the brain's wiring system.

Intracranial hemorrhage

• Hematomas that develop within the cranial vault are the most serious brain injuries.

• A hematoma may be epidural, subdural or intracerebral.

• An epidural hematoma forms between the skull and the dura mater, the tough outer membrane that covers the brain.

• Epidural hematomas are most commonly seen in conjunction with a skull fracture. If the hematoma is not removed it can cause brain damage by putting pressure on the brain.

• Is considered an extreme emergency, marked neurologic deficit or even respiratory arrest can occur within minutes.

• A subdural hematoma forms between the dura mater and the underlying membranes that cover the brain.

• These hematomas are seen most often in association with direct damage to the brain.

• Symptoms from hematomas may appear immediately or gradually as blood seeps out of torn blood vessels.

• Collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid. Is more frequently venous in origin and is due to the rupture of small vessels that bridge the subdural space.

• May be acute, subacute or chronic, depending on the size of the involved vessel and the amount of bleeding.

ACUTE SUBDURAL and SUBACUTE SUBDURAL HEMATOMA

• Acute subdural hematoma

- Associated with major head injury involving contusion or laceration.

- Clinical symptoms develop over 24 to 48 hours.

- Signs and symptoms include: - changes in LOC - pupillary signs - hemiparesis

• Subacute Subdural hematoma

- Are the result of less severe contusions and head trauma. - Clinically manifestations usually appear between 48 to 2 weeks after the injury.

• Chronic subdural hematoma

- Can develop from seemingly minor head injuries and are seen most frequently in the elderly. - Resembles other conditions and may be mistaken for a stroke. - The bleeding is less profuse and there is compression of the intracranial contents.

• Intracerebral hematomas - result from accumulation of blood within the brain caused by bleeding in and around the brain.

- Is bleeding into the substance of the brain.

- It is commonly seen in head injuries when the forced exerted to the head over a small area.

- These hemorrhages within the brain may also result from systemic hypertension, which causes degeneration and rupture of a vessel; rupture of a saccular aneurysm; vascular anomalies; intracranial tumors; systemic causes, including bleeding disorders such as leukemia, hemophilia, aplastic anemia and thrombocytopenia and complications of anticoagulant therapy.

CLINICAL MANIFESTATION: • Altered level of consciousness• Confusion• Pupillary abnormalities• Altered or absent gag reflex• Absent corneal reflex• Sudden onset of neurologic deficits• Changes in vital signs• Vision and hearing impairment• Sensory dysfunction• Spasticity• Headache• Vertigo• Movement disorders• Seizures

Management:

• Care of the client with ICP• Monitor drainage from ears and nose• Monitor for S/Sx of meningitis, atelectasis, pneumonia, UTI• CT scan• MRI• Positron emission tomography

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Spinal Injury

SPINAL INJURY

• Spinal cord injury causes myelopathy or damage to white matter or myelinated fiber tracts that carry sensation and motor signals to and from the brain.

• It also damages gray matter in the central part of the spinal, causing segmental losses of interneurons and motoneurons.

Pathophysiology:

• Damage to the spinal cord ranges from transient concussion to contusion, laceration and compression of the cord substance, to complete transaction of the cord.

Separated into 2 categories:• Primary injuries - are the result of the initial insult or trauma and are usually permanent.• Secondary injuries - are usually the result of a contusion or tear injury, in which the nerve fibers begin to swell and disintegrate.

• A secondary chain of events produces ischemia, hypoxia, edema and hemorrhagic lesions, which in turn result in destruction of myelin and axon.

• These secondary reactions, believed to be the principal causes of the spinal cord degeneration at the level of injury, are now thought to be reversible 4 to 6 hours after injury.

2 Most Familiar Types Of Spinal Cord Injury Are:

• Injury from Trauma

- Injuries incurred due to accidents, gunshots, falls and so on.

• Injury from Disease

- Injuries occurring from diseases like spina bifida, tumors, polio or Friedreich's ataxia.

Causes:

• Trauma - such as automobile accidents, falls, gunshots, diving accidents, war injuries, etc. • Tumor - such as meningiomas, ependymomas, astrocytomas, and metastatic cancer. • Ischemia - resulting from occlusion of spinal blood vessels, including dissecting aortic aneurisms, emboli, arteriosclerosis. •Developmental disorders - such as spina bifida, meningomyolcoele, and other.

• Neurodegenerative diseases - such as Friedreich's ataxia, spinocerebellar ataxia, etc.

• Demyelinative diseases - such as Multiple Sclerosis.

• Transverse myelitis - resulting from spinal cord stroke, inflammation, or other causes.

• Vascular malformations - such as arteriovenous malformation (AVM), dural arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and aneurysm

Traumatic spinal cord injury is classified into five types.

• A indicates a "complete" spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5. A complete injury is one in which there is some neurological below which there is no motor or sensory function. Since the S4-S5 segment is the lower segmental, absence of motor and sensory function indicates "complete" spinal cord injury.

• B indicates an "incomplete" spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. This is typically a transient phase and if the person recovers any motor function below the neurological level, that person essentially becomes a motor incomplete, i.e. ASIA C or D.

• C indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3.

• D indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.

• E indicates "normal" where motor and sensory scores are normal. Note that it is possible to have spinal cord injury and neurological deficit with completely normal motor and sensory scores.

There are several clinical syndromes associated with incomplete spinal cord injuries.

• The Central Cord syndrome - is associated with greater loss of upper limb function compared to lower limbs.

• The Brown-Séquard syndrome - results from injury to one side with the spinal cord, causing weakness and loss of proprioception on the side of the injury and loss of pain and thermal sensation of the other side.

• The Anterior Spinal syndrome - results from injury to the anterior part of the spinal cord, causing weakness and loss of pain and thermal sensations below the injury site but preservation of proprioception that is usually carried in the posterior part of the spinal cord.

• Tabes Dorsalis - results from injury to the posterior part of the spinal cord, usually from infection diseases such as syphilis, causing loss of touch and proprioceptive sensation.

• Conus Medullaris syndrome - results from injury to the tip of the spinal cord, located at L1 vertebra.

• Cauda Equina syndrome - is strictly speaking, not really spinal cord injury but injury to the spinal roots below the L1 vertebra.

Effects of Spinal Cord Injury

The specific effects of spinal injuries can vary as per the type and level of the injury, which can be categorized in two types:

1.Complete Spinal Injuries - In a complete spinal cord injury there

can be no voluntary movement or physical

sensation.

- These spinal injuries are bilateral meaning that both

sides of the body get affected similarly.

- There can be no function below the level of the injury.

2. Incomplete Spinal Injuries

- In an incomplete spinal injury there can be

some sensation below the level of injury.

- There can be some voluntary movements

and one side of the body may function more

than the other.

Some Other Effects Of Spinal Injuries Are :

• The injuries that are very crushing on the spinal cord (C-1, C-2) may result in cessation of many involuntary functions like phrenic nerve pacing and breathing.

• Chronic pain

• Bowel and bladder function is regulated by the sacral region of the spine, so it is very common to experience dysfunction of the bowel and bladder, including infections of the bladder, and anal incontinence.

• Sexual function is also associated with the sacral region, and is often affected.

• Inability or reduced ability to regulate heart rate, blood pressure, sweating and hence body temperature.

• Spasticity (increased reflexes and stiffness of the limbs).

• Neuropathic pain.

• Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances.

• Atrophy of muscle. • Osteoporosis (loss of calcium) and bone degeneration. • Gallbladder and renal stones.

Some Typical Spinal Cord Injury Effects By Location:

1.Cervical injuries - Cervical (neck) injuries usually result in full

or partial tetraplegia. Depending on the exact

location of the injury, one with a spinal cord injury at the

cervical may retain some amount of function as detailed

below, but are otherwise completely paralyzed.

• C3 vertebrae and above: Typically lose diaphragm function

and require a ventilator to breathe.

• C4: May have some use of biceps and shoulders, but weaker

• C5: May retain the use of shoulders and biceps, but not of the wrists or hands.

• C6: Generally retain some wrist control, but no hand function.

• C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the hand and fingers. C7 is generally the level for functional independence.

2. Thoracic injuries - Injuries at the thoracic level and below result in paraplegia. - The hands, arms, head, and breathing are usually not affected.

• T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury.

• T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good.

3. Lumbar and Sacral injuries

- The effect of injuries to the lumbar or sacral region of the spinal canal are decreased control of the legs and hips, urinary system, and anus.

Central Cord and Other Syndromes

1. Central cord syndrome - is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs.

- This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly.

- Most often the damage is to the cervical or upper thoracic regions of the spinal cord, and characterized by weakness in the arms with relative sparing of the legs with variable sensory loss.

• This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord (the large nerve fibers that carry information directly from the cerebral cortex). Corticospinal fibers destined for the legs are spared due to their more external location in the spinal cord.

• This clinical pattern may emerge during recovery from spinal shock due to prolonged swelling around or near the vertebrae, causing pressures on the cord.

• The symptoms may be transient or permanent.

2. Anterior cord syndrome - is also an incomplete spinal cord injury. Below the injury, motor function, pain sensation, and temperature sensation is lost; touch, proprioception (sense of position in space), and vibration sense remain intact.

3. Brown-Séquard syndrome - usually occurs when the spinal cord is hemisectioned or injured on the lateral side. On the ipsilateral side of the injury (same side), there is a loss of motor function, proprioception, vibration, and deep touch. Contralaterally (opposite side of injury), there is a loss of pain, temperature, and light touch sensations.

Treatment:

• Treatment for acute traumatic spinal cord injuries have consisted of giving high dose methylprednisolone if the injury occurred within 8 hours.

• Breakthrough medical research shows stem cell transplants could have the potential to help or cure paralysis caused by spinal injury.

• Stem cells are primal cells found in all multi-cellular organisms. They can be made to differentiate into a range of specialized cells including nerve cells, which can be transplanted into the body.

Interventions:

Diving injuries may be prevented by:

• Education about diving hazards and safe behaviour • Supervision by life guards • Diving instruction • Access to emergency services for rapid first aid and treatment.

Where appropriate, the provision of safe access to water supplies in rural areas will help reduce injuries and damage to the spine due to carrying water.