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Head Injury — Nursing Guide

1. Definitions & Terminology

The nurse's primary aim in TBI care is preventing secondary brain injury, because primary injury is not reversible. — Rosen's Emergency Medicine, p. 367

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2. Classification by Severity (GCS-based)

Glasgow Coma Scale (GCS) — Full Scoring Table

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3. Types of Head Injury

3a. Concussion (MTBI)

• Functional, not structural, brain injury from shaking/impact
• Standard CT/MRI are normal — imaging not required for pure concussion
• Symptoms: headache, dizziness, cognitive slowing, sleep disturbance, emotional changes
• Management: 24–48 h of rest, then graded return to activity (bed rest is no longer recommended)
• All children with concussion need monitoring by a primary care physician or concussion specialist

3b. Epidural Hematoma (EDH)

• Arterial bleed (usually middle meningeal artery) between skull and dura
• Caused by skull fracture crossing the meningeal groove
• Classic presentation: lucid interval → sudden deterioration
  • Only 15–20% have this classic pattern; many have minimal initial symptoms
• Rapid progression: headache → impaired consciousness → herniation signs within hours
• CT appearance: biconvex (lens-shaped) hyperdense collection
• Look for signs of basal skull fracture: Battle's sign (mastoid bruising), raccoon eyes (periorbital bruising), blood behind tympanic membrane

3c. Subdural Hematoma (SDH)

• Venous bleed from torn bridging veins between brain and dural sinuses
• More common in elderly (brain atrophy stretches bridging veins) and patients on anticoagulants
• Develops more slowly; may wax and wane
• CT appearance: crescent-shaped hyperdense collection following the brain surface
• Warfarin/clopidogrel users with even minor head injury → immediate non-contrast CT regardless of symptoms; check INR

3d. Diffuse Axonal Injury (DAI)

• Shearing of axons from rotational forces (e.g., motor vehicle crashes)
• More common in children due to less myelination and higher brain water content
• CT may appear normal or show small petechial hemorrhages
• Associated with prolonged coma and poor outcome

3e. Cerebral Contusion & Intracerebral Hemorrhage

• Bruising/hemorrhage within the brain parenchyma
• Commonly at frontal/temporal poles (coup–contrecoup)

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4. Neurological Assessment — Nursing Priorities

ABCs First

Pupil Examination (assess simultaneously with GCS)

Cushing's Triad — Sign of Impending Herniation

1. Hypertension (widened pulse pressure)
2. Bradycardia
3. Irregular breathing

Signs of Raised ICP in Children

• Bulging fontanelle (infants)
• Vomiting, irritability, altered consciousness
• Papilledema (late)
• Cushing's triad

Herniation Syndromes

• Transtentorial (uncal): ipsilateral dilated pupil, contralateral hemiplegia, decreasing consciousness
• Central: bilateral pupil changes, decorticate → decerebrate posturing

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5. Secondary Brain Injury — What Nurses Must Prevent

Hypotension (SBP < 90 mmHg) is an independent predictor of poor outcome in TBI. — Rosen's Emergency Medicine

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6. ICP Monitoring & Management

When ICP Monitoring is Indicated

• GCS ≤ 8 with structural injury on CT
• High-risk patients (large contusions, coagulopathy)
• Moderate TBI undergoing urgent non-neurosurgical surgery

Targets

• ICP < 20–22 mmHg
• CPP (= MAP − ICP) = 60–70 mmHg

Tiered ICP Management (Sabiston / ACS-TQIP)

• Head of bed 30°, head in neutral position (ensure cervical immobilisation devices don't compress jugular veins)
• Short-acting sedation (propofol, fentanyl) to allow periodic neurological checks
• CSF drainage via EVD/ventriculostomy when available

• Hyperosmolar therapy: mannitol or hypertonic saline
• Monitor serum Na every 6 h (hold if Na > 160 mEq/L or osmolality > 320 mOsm/L)
• Consider controlled hyperventilation to PaCO₂ 30–35 mmHg (temporary; monitor for cerebral ischaemia)
• Neuromuscular blockade trial dose

• Decompressive craniectomy
• Continuous NMB infusion
• Barbiturate coma (with continuous EEG to titration burst suppression)

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7. Nursing Management of the Head-Injured Patient

Emergency Phase (ED/Trauma Bay)

1. Immobilise cervical spine until cleared (assume C-spine injury with significant head trauma)
2. Airway: intubate if GCS ≤ 8, airway unprotected, or rising ICP signs
3. Breathing: ventilate to ETCO₂ 35–45 mmHg; avoid hyperventilation unless herniation is imminent
4. Circulation: aggressive fluid resuscitation to maintain SBP ≥ 90 mmHg
5. Disability: GCS + pupils; identify lateralising signs
6. Exposure: full assessment for other injuries; remove clothing carefully

Ongoing Neurological Monitoring (ICU/Ward)

• GCS every 1 hour (or more frequently if deteriorating)
• Pupils size, symmetry, reactivity hourly
• Vital signs including BP, HR, RR, temperature
• ICP values and CPP calculations if monitored
• Limb movement/power comparison (drift, pronator)
• Seizure activity — document duration, type, post-ictal state
• Fluid balance — strict hourly urine output; target euvolemia

Positioning

• HOB 30° (unless haemodynamically unstable)
• Head midline — avoid neck flexion/rotation (obstructs venous drainage)

Anticoagulation Reversal

• Warfarin → prothrombin complex concentrate (PCC); check INR
• Clopidogrel → desmopressin (DDAVP)
• Low threshold for CT in any anticoagulated patient with head injury, even if asymptomatic

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8. Special Populations

Elderly

• Higher risk of subdural and intraparenchymal haemorrhage (brain atrophy stretches bridging veins)
• Less likely to develop EDH (dura more adherent to skull)
• Brain atrophy creates extra intracranial space → bleeding may accumulate before symptoms appear → delayed diagnosis
• Any mental status change: do not attribute to baseline dementia; CT first
• Anticoagulant use is common — immediate CT even with minor mechanism

Children

• Larger head-to-body ratio → higher torque forces on cervical spine
• Less myelinated brain → higher risk of DAI and post-traumatic seizures
• Pliable skull → parenchymal injury without skull fracture
• CPP target > 40 mmHg; ICP target < 20 mmHg
• Consider non-accidental injury (NAI) in any infant/toddler with unexplained TBI, especially with retinal haemorrhages or patterned bruising

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9. Red Flag Signs — Escalate Immediately

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10. Discharge Advice (Mild/Concussion)

• Return to ED if: worsening headache, repeated vomiting, increasing confusion, seizure, one-sided weakness, or slurred speech
• No alcohol for 48 hours
• Rest 24–48 h, then graduated return to activity (not prolonged bed rest)
• No driving until cleared by clinician
• Family/carer should observe overnight — wake patient every 2–4 h on night of injury

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• Rosen's Emergency Medicine, Head Injury chapter
• Sabiston Textbook of Surgery (10e), TBI chapter — GCS table, ICP tiers
• Plum and Posner's Diagnosis and Treatment of Stupor and Coma — Epidural Hematoma section
• Tintinalli's Emergency Medicine — Elderly & Pediatric Head Injury