Closed Head Injury


CHAPTER 17
Closed Head Injury


Carol McCormick


(acknowledging Katie Dowdie)


ANSWERS TO QUESTIONS


Question 1. What is a closed head injury?


A closed head injury (CHI) is defined as non-penetrating injury to the brain and occurs when the head accelerates and then rapidly collides with another object (Steffen’ Albert 2010). Trauma causes injury to the brain as a result of a blow to the head, or sudden, violent motion that causes the brain to impact against the skull. No object penetrates through the skull to the brain tissue itself.


Brain injury is classified into phases: primary injury and secondary injury.


The primary injury is the initial brain insult as a result of traumatic impact.


According to Moppett (2007), oedema, capillary leakage, and systemic inflammatory response is associated with secondary injury. Furthermore, secondary injury is worsened by hypoxia and hypotension (Pigula et al. 1993).


Coup is injury on site of impact and contre-coup is injury on opposite side of impact. This is shown in Figure 17.1.


FIGURE 17.1 Coup and contre-coup injury (collection of L. Henry). Reproduced from Best Practice (https://bestpractice.bmj.com/search?q=Coup+and+contre-coup+injury+ – practice/monograph/967/resources/images.html) with kind permission.


Please refer to Table 17.1.


Table 17.1 Mead model.



























A Respiratory
B Cardiovascular
C Pain/sedation
D Neurology
E Nutrition/hydration
F Elimination
G (i) Skin/wound care
G (ii) Mobility
G (iii) Hygiene
H (i) Psychological and social/culture
H (ii) Circumstantial

Please see Chapter 1 for further reading.


Adapted from: McClune and Franklin (1987).


Question 2. When using the Mead model, how would the children’s nurse safely maintain the airway of a child with a Glasgow Coma Scale below 8?


Respiratory and cardiovascular needs should be looked at (McClune & Franklin 1987). Any child presenting with a Glasgow Coma Scale (GCS) <8 is classified as a severe head injury (Moppett 2007; Weinstein 2006). The most important initial interventions are:



  • Control of the airway and cervical spine
  • Breathing and circulation

Physical needs


Respiratory


Assess: continue to assess Leah’s level of consciousness and ability to maintain her:


Airway, Breathing, and Circulation (ABC).



  • Observe her colour – is Leah’s skin pink, pale, dusky, or cyanosed?
  • Check Leah’s chest movement – assess rate, depth, and rhythm.
  • Are there any abnormal breathing sounds, for example stridor?
  • Have an understanding of the different types of abnormal respiratory pattern, for example apnoea, hyperventilation/hypoventilation.
  • Monitor respiration rate, oxygen requirements, method of administration, and pulse oximetry.

Cardiovascular


Assess: this assessment has some overlap with the respiratory assessment:



  • Is Leah’s skin pink and warm to touch, or pale, mottled, and cool to touch?
  • Are her peripheries warm or cold?
  • What is Leah’s capillary refill time (normal CRT is 2–3 secs)?
  • Has intravenous (IV) access been established?
  • Monitor/record heart rate (HR), blood pressure (B/P) (systolic diastolic and mean), respiratory rate, pulse oximetry (SaO2), and temperature.
  • Understand the significance of the HR, BP, central, and peripheral perfusion.

It is important to know the cardiovascular stability of the child prior to intubation as the choice of drugs used for induction and intubation can have adverse effects.


These assessments are carried out very quickly and the child is then prepared for intubation and ventilation.


Plan: preparation for child



  • Prepare emergency/airway trolley for intubation (Table 17.2).

Table 17.2 Emergency/airway trolley for intubation.



































  • Oral and nasal ET tube (required size + a size smaller)


  • Introducer and bougie


  • Laryngoscope and appropriate blade


  • Magill’s forceps appropriate size


  • Yankauer sucker


  • Nasogastric tube and drainage bag


  • Elastoplast tape pre-cut


  • Dressed applicators


  • Friars’ Balsam and gallipot


  • Sterile lubricating gel and gauze
At the bedside:


  • Oxygen and suction supply


  • Facemask with bagging set


  • Suction catheters


  • Equipment to monitor vital signs


Table 17.3 Common drugs used for intubation (see BNFc 2023).


























































  • Thiopentone sodium
Intravenous anaesthetic used for induction of anaesthesia.
Side effects: apnoea, hypotension, arrhythmias, laryngeal spasm. In excessive doses, hypothermia and reduction in cerebral function.
Ketamine
Induction and maintenance of anaesthesia for short procedures.


  • Atracurium
Neuromuscular blocking drug, also known as muscle relaxant.
Side effects – skin flushing, hypotension, tachycardia.


  • Suxamethonium
Depolarising neuromuscular blocking drug. Used if fast action and brief duration of action is required.


  • Propofol
Intravenous anaesthetic used for induction of anaesthesia.
Side effects: hypotension, tachycardia, less common – thrombosis, pulmonary oedema, hyperkalaemia, cardiac failure.


  • Atropine
Antimuscarinic drug used in the treatment of bradycardia.
Side effects: tachycardia, dilatation of the pupils, dry mouth, nausea, and vomiting, confusion.


  • Adrenaline
Direct acting sympathomimetic agent. Used in CPR, acute anaphylaxis, low cardiac output. Side effects: nausea, vomiting, tachycardia, arrhythmias, hypertension, cold peripheries.


  • Morphine
Opioid analgesia used to relieve moderate to severe pain.
Side effects: nausea, vomiting, constipation, hypotension, respiratory depression.


  • Midazolam
Benzodiazepine used for sedation.
Side effects: gastro-intestinal disturbances, hypotension, heart rate changes, laryngospasm, respiratory depression.


  • Sodium chloride 0.9%
Used for drug/line flush.

Implement:



  • Leah will be admitted to paediatric intensive care Unit (PICU); it is the nurse’s responsibility to assist intubation and establishment of central venous access – one nurse to record observations and fluid balance.

NB The combination of drugs used will be decided by the anaesthetist, based on the clinical condition of the child.



  • Continue to administer 100% oxygen via bag and mask and apply suction when necessary.
  • Apply electrocardiograph (ECG) electrodes, B/P cuff and SaO2 probe to ensure continuous trend of cardiovascular status and oxygenation.
  • Pass nasogastric tube (NG), aspirate and attach to drainage bag to prevent aspiration of stomach contents and lung soiling.
  • The endotracheal tube (ET) is passed via the nose or orally if basal skull fracture is suspected, and secured firmly with elastoplast.
  • Anaesthetist/doctor will auscultate chest for equal air entry and bilateral chest movement.
  • Essential to confirm position of tubes (ET & NG) by X-ray.

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Mar 23, 2024 | Posted by in Uncategorized | Comments Off on Closed Head Injury

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