Head Trauma
Skull Fracture
Pathophysiology
- Skull comprised of (View image)
- Outer bone tablet (lamina externa)
- Middle layer of cancellous bone (diploe)
- Does NOT form where skull covered by muscle
- Vault is thus thin and vulnerable
- Inner bone tablet (lamina interna)
- Weakest points at
- Temporal and parietal bones over temple and sphenoid sinus
- Petrous temporal ridge
- Thin sphenoid wings at skull base
- Middle cranial fossa
- Cribriform plate
- Skull thickest at
- Glabella
- External occipital protuberance
- Mastoid processes
- External angular process
- Skull fx may be accompanied by intracranial injury
- Hemorrhage
- Contusion
- Edema
Diagnosis
- ALWAYS remember to assess for underlying brain injury
- Examine cranium
- Palpate for
- Depressions, step-offs or crepitus
- Look for
- Check for
- CSF rhinorrhea or otorrhea
- "Halo" or "double ring" sign (View image)
- Drop liquid on tissue paper
- See clear ring that extends beyond blood ring: CSF
- Measure tau-transferrin
- Protein present in CSF and aqueous humor
- Can distinguish the presence of CSF in body fluids
- Imaging
- Skull films can miss fxs
- CT scanning
- Gold standard for visualizing fxs
- 1-1.5 mm bone slices WITH sagittal reconstruction
- Helical CT for occipital condyle fxs
- MRI
- NOT very good for bony injuries
Linear Skull Fx
- Caused by low-energy blunt trauma over wide surface area
- Runs through entire thickness of bone
- More significant injury if
- Goes through vascular channel
- Can cause epidural hematoma
- Goes through venous sinus groove
- Can cause venous sinus thrombosis
- Goes through a skull suture line
- Can cause suture diastasis
- Clinical features
- Many pts are
- Asymptomatic
- Have NO loss of consciousness
- Swelling noted at site of impact
- Skin may not be violated
- Treatment
- Conservative
- Must r/o brain injury
- Consult trauma, neurosurgery
- Some pts may be discharged home
Basilar Skull Fx (View image)
- Linear fracture of base of skull
- Usually has associated dural tear
- Found at specific points of skull base
- Temporal skull fx
- Longitudinal (most common)
- In temporoparietal region
- Involve squamous temporal bone
- Run anterior or posterior to cochlea/labyrinth capsule
- End in middle cranial fossa or mastoid air cells
- Transverse (5-30%)
- Start at foramen magnum
- Extend through cochlea and labyrinth
- End in middle cranial fossa
- Mixed fxs
- Show elements of both types
- Occipital condyle fx
- Result from high-energy trauma
- Trauma with axial compression, lateral bending, rotation with respect to alar ligament
- Three types
- Type 1: Comminution of occipital condyle
- Results from axial compression
- Stable fx
- Type 2: More extensive injury
- Results from direct blow
- Stable (alar ligament/tectorial membrane intact)
- Type 3: Avulsion injury
- Results from forced rotation/lateral bending
- Potentially unstable fx
- Clinical features of basilar skull fx
- Petrous bone fx
- CSF otorrhea and Battle's sign
- May see hemotympanum
- Loss of consciousness and GCS are variable
- Anterior cranial fossa fx:
- Raccoon eyes
- CSF rhinorrhea
- Loss of consciousness and GCS are variable
- Longitudinal temporal bone fx
- Ossicle bone disruption
- Conductive deafness (>30 dB, lasts > 6-7 wks)
- May see CN symptoms
- V - facial palsy
- VI - nystagmus
- VII - facial numbness
- Transverse temporal bone fx
- Involve CN VIII and labyrinth
- Nystagmus, ataxia
- Permanent neural hearing loss
- Occipital condyle fx
- Very rare, very serious
- Most pts are in coma (esp. Type 3)
- Most have associated c-spine injuries
- Often have lower CN injuries
- Often have hemiplegia or quadriplegia
- Vernet syndrome
- Involvement of CN IX, X, XI
- Trouble phonating
- Risk of aspirating
- Ipsilateral vocal cord, soft palate paralysis
- Ipsilateral sternocleidomastoid and trapezius paralysis
- Collet-Sicard syndrome
- CN IX, X, XI, XII involvement
- Treatment
- Usually conservative
- MUST R/O brain injury
- AVOID nasal intubation with CSF rhinorrhea
- NO NG tube
- Consult trauma/neurosurgery
- Elevate HOB if CSF leak is present
- Abx prophylaxis
- NOT recommended for CSF otorrhea/rhinorrhea in first wk
- If fever, etc - consider meningitis
- If CSF leak persists >10 days, OR repair is needed
Depressed skull fx
- Come from high-energy blunt trauma to small area of skull
- Most are over frontoparietal region
- To be clinically significant/require elevation
- Bone should be depressed greater than adjacent inner table
- May be closed or open
- Open fx
- Scalp laceration overlying fx OR
- Fx runs through paranasal sinus/middle ear structures
- Results in communication with external environment
- Treatment
- Admit
- R/O brain injury
- Trauma/neurosurgery consult
- Prophylaxis for post-traumatic seizures
- Phenytoin
- Load: 15-20 mg/kg IV (give at < 50 mg/min)
- May follow with 100-150 mg after 30 min
- May require surgery for fragment elevation
Fracture/Suture Differences
- Fractures
- Usually > 3 mm wide
- Widest at center, narrow at ends
- Appear dark
- Go through inner and outer bone lamina
- Usually in temporoparietal area
- Usually run in straight line
- Any turns are usually angular
- Sutures
- Usually < 2 mm wide
- Same width throughout
- Lighter in appearance
- At specific anatomic sites
- Do NOT run in straight line
- Have many curves
- Relatively symmetric (with compression to contralateral side of a head)
Nursing Considerations
- Freq ABC assessment
- Monitor neurologic status closely esp observing for S/S of inc ICP
- Decr LOC
- Drowsiness
- Soft spot on top of the head (bulging fontanelle)
- Vomiting
- Behavior changes
- Headache
- Progressive decr consciousness, lethargy
- Neurologic problems
- Seizures
- Careful I/O
- Check for bleeding from ear or nose in cases of suspected CSF leak
- "Halo" or "double ring" sign (View image)
- Drop liquid on tissue paper
- See clear ring that extends beyond blood ring: CSF
- Provide psychological support to pt/family
- Prepare pt for surgery, if indicated
- Monitor operative site for S/S of infection
- Pain assessment and interventions as indicated
- Basilar skull fx
- Battle's sign
- Keep pt in a supine position to decr pressure on dural tears and to minimize CSF leakage
- Avoid NG intubation and nasopharyngeal suction, which may cause cerebral infection
- Caution pt against blowing his nose, which may worsen a dural tear
- Elevate HOB if CSF leak
- Prophylactic abx to prevent onset of meningitis from CSF leaks
- Close observation for secondary hematomas and hemorrhages
- Depressed fx
- Shave head so surgery can be completely clean
- Check VS and alertness
- Explain healing process to pt/family and what symptoms to expect first days post-injury
- Head injury discharge inst
- Linear skull fx
- FU in 24-48 hrs of observation at home
- Teach S/S to observe for esp those that require immediate med attn
- Severe headache
- Vomiting
- Convulsions
- Weakness, or abnormal drowsiness
- Basilar skull fx
- Explain which activities pt should avoid, and emphasize importance of bed rest for several days to wks
- Teach pt/family S/S to look for and report, such as
- Changes in mental status
- LOC
- Breathing difficulty
- Take acetaminophen for headaches, as needed
- Teach S/S to observe for esp those that require immediate med attn
- Raccoon eyes
- Vomiting
- Headache
- Hearing loss
- Depressed fx
- Teach seizure precautions
- Teach pt/family S/S to look for and report, such as
- Changes in mental status
- LOC
- Breathing difficulty
- Take acetaminophen for headaches, as needed
- Teach S/S to observe for esp those that require immediate med attn
- Seizures
- Vomiting
- Headache
- Teach pt/family operative site care
- Teach S/S of infection to report to surgeon
- Offer to assist with referral for home care and or PT
- Nursing Dx
- Pain
- Risk for fluid vol imbalance
- Alteration in mobility
- Risk for alteration in skin integrity
- Risk for activity intolerance
References
- Biros MH, Heegaard W. Head Injuries. In: Marx (ed);Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed; 2002. Mosby pp 286-314
- Cantu RC: Head and spine injuries in youth sports. Clin Sports Med 1995 Jul; 14(3): 517-32