aims of the session

Aims Of The SessionAims Of The Session

To gain knowledge and understanding of To gain knowledge and understanding of the anatomy of the brainthe anatomy of the brain

To gain knowledge and understanding To gain knowledge and understanding about head injuriesabout head injuries

To gain knowledge and understanding of To gain knowledge and understanding of neurological assessment and the skills neurological assessment and the skills involved in assessing patientsinvolved in assessing patients

IntroductionIntroduction

Each year 1.4 million people in the UK Each year 1.4 million people in the UK suffer head injury, 150,000 will be suffer head injury, 150,000 will be admitted to hospital with most being admitted to hospital with most being discharged within 48 hours.discharged within 48 hours.

Indications For AdmissionIndications For Admission

Patients who are unwell or who have a risk of Patients who are unwell or who have a risk of later deterioration from an intracranial later deterioration from an intracranial haematomahaematoma

Patients who have lost consciousness or who Patients who have lost consciousness or who have suffered amnesia of more than 5 minhave suffered amnesia of more than 5 min

Presence of abnormal neurological findingsPresence of abnormal neurological findings

Skull fracturesSkull fractures

Indications For SurgeryIndications For Surgery

Elevation of depressed skull fractureElevation of depressed skull fracture

Evacuation of a haematomaEvacuation of a haematoma

Arrest of a cerebral bleedArrest of a cerebral bleed

Anatomy - Bones Of The SkullAnatomy - Bones Of The Skull

Support and protect Support and protect the brainthe brain FrontalFrontal TemporalTemporal ParietalParietal OccipitalOccipital

The Coverings of the BrainThe Coverings of the Brain

Meninges: three Meninges: three connective tissue connective tissue membranes that cover membranes that cover the brain and spinal cordthe brain and spinal cord

Dura mater - white fibrous Dura mater - white fibrous tissue: outer layertissue: outer layer

Arachnoid - delicate Arachnoid - delicate membranes: middle layer membranes: middle layer contains cerebrospinal fluidcontains cerebrospinal fluid

Pia mater - inner layer Pia mater - inner layer contains blood vesselscontains blood vessels

Major Parts Of The BrainMajor Parts Of The Brain

CerebrumCerebrum Largest area of the brainLargest area of the brain Divided into left and right Divided into left and right

hemisphereshemispheres Right cerebral hemisphere Right cerebral hemisphere

controls the left side of the controls the left side of the bodybody

Left cerebral hemisphere Left cerebral hemisphere controls the right side of the controls the right side of the body body

Each hemisphere is divided Each hemisphere is divided into four lobes – frontal, into four lobes – frontal, parietal, temporal, occipitalparietal, temporal, occipital

Lobes Of The BrainLobes Of The Brain

Frontal LobeFrontal Lobe associated with reasoning, associated with reasoning,

planning, parts of speech, planning, parts of speech, movement, emotions, and movement, emotions, and problem solving problem solving

Parietal LobeParietal Lobe associated with movement, associated with movement,

orientation, recognition, orientation, recognition, perception of stimuli perception of stimuli

Occipital LobeOccipital Lobe associated with visual associated with visual

processing processing

Temporal LobeTemporal Lobe associated with perception and associated with perception and

recognition of auditory stimuli, recognition of auditory stimuli, memory, and speechmemory, and speech


CerebellumCerebellum Second largest part of Second largest part of

the brainthe brain It is connected to the It is connected to the

brain stembrain stem Helps provide smooth Helps provide smooth

coordinated body coordinated body movementmovement


Brain StemBrain Stem is responsible for basic is responsible for basic

vital life functions such vital life functions such as breathing, as breathing, heartbeat, and blood heartbeat, and blood pressure. pressure.

MidbrainMidbrain

Pons Pons

Medulla oblongataMedulla oblongata

VentriclesVentricles

CSF And VentriclesCSF And Ventricles

Cerebrospinal fluid Cerebrospinal fluid Clear watery Clear watery

substance made in the substance made in the ventricles by the ventricles by the choroid plexuschoroid plexus

Cushions the brain Cushions the brain and spinal cordand spinal cord

It circulates through It circulates through the ventricles and sub-the ventricles and sub-arachnoid spacearachnoid space

Intra-cranial PressureIntra-cranial Pressure

When intra-cranial pressure begins to rise, the When intra-cranial pressure begins to rise, the body’s own compensatory mechanisms include body’s own compensatory mechanisms include decreasing the production of CSF and restricting decreasing the production of CSF and restricting the blood flow to the brain (by vasoconstriction). the blood flow to the brain (by vasoconstriction).

Once the capacity of these compensatory Once the capacity of these compensatory mechanisms is exceeded, the intra-cranial mechanisms is exceeded, the intra-cranial pressure can continue to rise. pressure can continue to rise.

In addition, as intra-cranial pressure rises, the In addition, as intra-cranial pressure rises, the cerebral blood vessels are constricted, reducing cerebral blood vessels are constricted, reducing blood flow further.blood flow further.

Intra-cranial PressureIntra-cranial Pressure

Normal intracranial pressure (ICP), usually Normal intracranial pressure (ICP), usually measured as a mean pressure, is often measured as a mean pressure, is often cited as 0-10mmHg cited as 0-10mmHg

Sustained high pressures can cause Sustained high pressures can cause 'coning' (tentorial herniation), when 'coning' (tentorial herniation), when brainstem tissue is forced through the brainstem tissue is forced through the foramen magnum into the spinal cord. foramen magnum into the spinal cord.

Cushing’s ResponseCushing’s Response

The following three symptoms are known The following three symptoms are known collectively as Cushing's response triadcollectively as Cushing's response triad Hypertension. Hypertension. Bradycardia. Bradycardia. Abnormal respiratory pattern. Abnormal respiratory pattern.

They indicate brainstem dysfunction and They indicate brainstem dysfunction and exhaustion of compliance (Hickey 1997a); exhaustion of compliance (Hickey 1997a); without urgent intervention, patients are likely to without urgent intervention, patients are likely to die. die.

Causes Of Raised Intra-Cranial Causes Of Raised Intra-Cranial PressurePressure

Anything that increases the volume of brain Anything that increases the volume of brain tissue, blood or CSF within the skull will raise tissue, blood or CSF within the skull will raise intra-cranial pressure:intra-cranial pressure: volume of brain (cerebral oedema): - injury volume of brain (cerebral oedema): - injury infection infection hypoxia hypoxia CSF (eg due to obstruction to drainage) CSF (eg due to obstruction to drainage) haemorrhage (eg subarachnoid) haemorrhage (eg subarachnoid) tumour tumour haematoma haematoma

Head InjuriesHead Injuries

Head injury is most likely to happen to young Head injury is most likely to happen to young men, with an average age of 30 who are men, with an average age of 30 who are involved in road traffic accidents involved in road traffic accidents

Other causes of adult injuries include contact Other causes of adult injuries include contact sports, such as rugby and boxing sports, such as rugby and boxing

Children often suffer head injury from bicycle Children often suffer head injury from bicycle accidents or pedestrian-vehicle collisions and accidents or pedestrian-vehicle collisions and very young children and old adults can suffer very young children and old adults can suffer injury from falls injury from falls


The head is vulnerable to injuryThe head is vulnerable to injury Analogy for a head injuryAnalogy for a head injury

Blancmange (brain)Blancmange (brain)Wrapped in cling film (arachnoid mater)Wrapped in cling film (arachnoid mater)In a paper bag (dura mater)In a paper bag (dura mater)Inside a cardboard box (skull)Inside a cardboard box (skull)Wrapped in brown paper (skin)Wrapped in brown paper (skin)

Any layer may be damaged byAny layer may be damaged byDirect impact on the box (blow)Direct impact on the box (blow)Dropping the box (fall)Dropping the box (fall)Shaking the box (acceleration/deceleration)Shaking the box (acceleration/deceleration)


Skull fractureSkull fracture Simple: Simple: Linear or hairlineLinear or hairline Depressed fracture – Depressed fracture –

fragments are driven fragments are driven inwardsinwards


Intracranial haemorrhageIntracranial haemorrhage The dura and arachnoid membranes and their The dura and arachnoid membranes and their

associated blood vessels are readily torn by impact or associated blood vessels are readily torn by impact or fractured bone fragmentsfractured bone fragments

There are four types of intracranial haemorrhagesThere are four types of intracranial haemorrhagesExtradural Extradural

Subdural Subdural

SubarachnoidSubarachnoid

Intracerebral Intracerebral


Extradural haemorrhageExtradural haemorrhage Results from rupture of one Results from rupture of one

of the meningeal arteries of the meningeal arteries that run between the dura that run between the dura and the skull.and the skull.

The middle meningeal The middle meningeal artery is most commonly artery is most commonly affected.affected.

Usual cause is a skull Usual cause is a skull fracturefracture


Subdural haemorrhageSubdural haemorrhage More common than More common than

extradural haemorrageextradural haemorrage Associated with sudden Associated with sudden

jarring or rotation of the jarring or rotation of the headhead

Shears and tears the small Shears and tears the small veins which bridge the gap veins which bridge the gap between the dura and between the dura and cortical surface of the braincortical surface of the brain


Intracerebral haemorrhage: Intracerebral haemorrhage: May beMay be natural, due to spontaneous rupture natural, due to spontaneous rupture

of a small blood vessel which has been of a small blood vessel which has been weakened by the effects long-standing high weakened by the effects long-standing high blood pressure. blood pressure.

Traumatic due to extension of haemorrhage Traumatic due to extension of haemorrhage from surface contusions deep into the from surface contusions deep into the substance of the brain. substance of the brain.

Assessment Of Head InjuriesAssessment Of Head Injuries

Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS)Scoring system originally described for Scoring system originally described for patients with head injury; now applied to patients with head injury; now applied to other causes of coma other causes of coma The Glasgow coma scale (GCS) is a The Glasgow coma scale (GCS) is a reliable and universally comparable way of reliable and universally comparable way of recording the conscious state of a person. recording the conscious state of a person.

Assessment Of Head InjuriesAssessment Of Head Injuries

Three types of response are measured, Three types of response are measured, and added together to give an overall and added together to give an overall score. score. The lower the score the lower the patient's The lower the score the lower the patient's conscious state. conscious state. GCS 13-15 (Mild) GCS 13-15 (Mild) GCS 9-12 (Moderate) GCS 9-12 (Moderate) GCS 3-8 (Severe) GCS 3-8 (Severe)

Eye OpeningEye Opening EE

spontaneousspontaneous 44

to speechto speech 33

to painto pain 22

no responseno response 11

Best Motor ResponseBest Motor Response MM

To Verbal Command:To Verbal Command:

obeysobeys 66

To Painful Stimulus:To Painful Stimulus:

localizes painlocalizes pain 55

flexion-withdrawalflexion-withdrawal 44

flexion-abnormalflexion-abnormal 33

extensionextension 22


Best Verbal ResponseBest Verbal Response VV

oriented and conversesoriented and converses 55

disoriented and conversesdisoriented and converses 44

inappropriate wordsinappropriate words 33

incomprehensible soundsincomprehensible sounds 22


E + M + V = 3 to 15•8 is the critical score •Less than or equal to 8 at 6 hours - 50% die •9-11 = moderate severity •Greater than or equal to 12 = minor injury Coma is defined as: (1) not opening eyes, (2) not obeying commands (3) not uttering understandable words.

DECORTICATEDECORTICATE

Decorticate posturing is also called Decorticate posturing is also called decorticate responsedecorticate response, , decorticate decorticate rigidityrigidity, , flexor posturingflexor posturing

DECEREBRATEDECEREBRATEDecerebrate posturing Decerebrate posturing ::typically the head typically the head is arched back, the arms are extended by is arched back, the arms are extended by the sides, and the legs are extendedthe sides, and the legs are extended

Neurological ObservationsNeurological Observations

Assess conscious levelAssess conscious level SpeechSpeech Mental stateMental state

EyesEyes Can the patient seeCan the patient see Is there an eye injury – eye maybe closedIs there an eye injury – eye maybe closed Can the patient focusCan the patient focus

Neurological AssessmentNeurological Assessment

It is important to assess a patient’s neurological It is important to assess a patient’s neurological state if a patient has a head injury, in a coma or state if a patient has a head injury, in a coma or have had neuro surgery performedhave had neuro surgery performedThis assessment can indicate quite quickly a This assessment can indicate quite quickly a need for interventionneed for interventionNeurological assessment may be carried out Neurological assessment may be carried out every fifteen minutes or half hourly depending every fifteen minutes or half hourly depending on the condition of the patienton the condition of the patientThe most serious situation is the deterioration of The most serious situation is the deterioration of conscious level due to raised intracranial conscious level due to raised intracranial pressurepressure

Patient APatient A

21 yr Male Bicycle Trauma (no PMH)21 yr Male Bicycle Trauma (no PMH)

Can’t open eyesCan’t open eyes

Can’t answer questionsCan’t answer questions

Doesn’t respond to stimuliDoesn’t respond to stimuli

What is the GCS ?What is the GCS ?

Patient BPatient B

52 Female (2 week history of headache)52 Female (2 week history of headache)

Responds to verbal commandsResponds to verbal commands

Responds to questions is coherent but Responds to questions is coherent but confusedconfused

Localises to pain (moves hand away from Localises to pain (moves hand away from site)site)

What is the GCS ?What is the GCS ?


Pupillary observationsPupillary observations What is their size – normal, moderately What is their size – normal, moderately

dilated or fully dilateddilated or fully dilated What is the pupil reaction to light – brisk, What is the pupil reaction to light – brisk,

sluggish or fixedsluggish or fixed


Limb movement & toneLimb movement & tone Can the patient move their limbs on commandCan the patient move their limbs on command

Movement is it normal, weak, severely weak or Movement is it normal, weak, severely weak or absentabsent

If absent does the patient respond to painful stimuli If absent does the patient respond to painful stimuli Is there any abnormal involuntary movementIs there any abnormal involuntary movement


Blood pressureBlood pressure

PulsePulse

RespirationRespiration

TemperatureTemperature

Signs Of Raised ICPSigns Of Raised ICP

HeadacheHeadacheVomitingVomitingIncreasing Increasing drowsinessdrowsinessDeterioration in Deterioration in mental and verbal mental and verbal responseresponseInequality of the Inequality of the pupils with sluggish pupils with sluggish reaction to lightreaction to light

Development of Development of hemiparesishemiparesisIncontinenceIncontinencePulse rate becomes Pulse rate becomes slowerslowerBlood pressure risesBlood pressure risesRespiration – depth, Respiration – depth, rate and rhythm rate and rhythm change when patient change when patient loses consciousness loses consciousness

Any Questions?Any Questions?

BibliographyBibliography

Verran B, Aisbett P.(1988) Neurological Verran B, Aisbett P.(1988) Neurological and Neurosurgical Nursing. London and Neurosurgical Nursing. London Edward Arnold PublishingEdward Arnold Publishing

aims of the session

Documents

blood pressure

blood flow

mean pressure

blood vesselsmajor parts

cerebral blood vessels

parietal lobeassociated

bodyleft cerebral hemisphere

brainfrontal lobeassociated