TRAUMATIC BRAIN INJURY (EPIDURAL HEMATOMA)

Introduction

Traumatic brain injury (TBI) is a complex injury with a broad spectrum of symptoms and
disabilities. Traumatic brain injury occurs when an external mechanical force causes brain
dysfunction. It usually results from a violent blow or jolt to the head or body. An object
penetrating the skull, such as a bullet or shattered piece of skull, also can cause traumatic brain
injury.

Mild traumatic brain injury may cause temporary dysfunction of brain cells. More serious
traumatic brain injury can result in bruising, torn tissues, bleeding and other physical damage to
the brain that can result in long-term complications or death.

Epidural Hematoma, also known as Extradural Hematoma, forms between the skull and the
dura matter. Bleeding is continuous and there is a large clot form which separates the dura from
the skull and is associated with skull fracture that causes a rupture or laceration of the middle
meningeal artery

After a head injury, blood may collect in the epidural space between the skull and the
dura mater. This can result from a skull fracture that causes a rupture or laceration of the middle
meningeal artery, the artery that runs between the dura and the skull inferior to a thin portion of
temporal bone. Hemorrhage from this artery causes rapid pressure on the brain.
Case

Ms. Alaine Yves L. Peduca, a 17-year- old female of Timuay Danoa, Kabasalan, Zamboanga
Sibugay has been diagnosed of Mild Brain Injury secondary to Blunt Head Trauma secondary to
Vehicular Accident. Last July 23, 2016 at around 9:00 pm she has been into a Vehicular Accident.
She has a family history of Hypertension, Diabetes Mellitus and Cancer of the Lungs. She is
non-smoker and non- alcoholic beverage drinker, and has allergies to seafood, particularly to
shrimp. Accordingly, she experienced loss of consciousness for an unknown length of time,
several episodes of vomiting, dizziness, epistaxis and bilateral otorrhea.

Epidemiology

In the United States, a haed injury is experienced approximately every 15 seconds. Head
injuries occur about 7 million Americans every year. Among these head-injured people, more
than 500, 000 are hospitalized, 100, 000 experience chronic disability, and approximately 2000
are left in persistent vegetative state.

Head injuries are fatal in more than 30% of cases before the injured person arrives at the
hospital owing to the seriousness of the injury. An additional 20% of people die later because of
secondary brain injury.

Of clients admitted to the emergency room, 50% have evidence of ingestion of alcohol or
other subsatances of abuse. Most are males younger than 30 years of age. Peak occurrence is
during evenings, nights and weekends.

Mechanisms of Injury

The following mechanisms contribute to head trauma:

Acceleration injury- occurs when the immobile head is struck by a moving bject.
Deformation- refers to injuries in which the force results in deformation and disruption of the
integrity of the impacted body part, as in skull fracture.
Deceleration injury- occurs when the head is moving and hits an immobile object

In an acceleration-deceleration injury, a moving object hits the immobile head and the head
then hits an immobile object. This injury is associated with rotation injury, in which the brain is
twisted within the skull.

PRIMARY INJURY

It is an injury that occurs at the moment of impact. It can involve a specific lobe of the
brain or can involve the entire brain. Sometimes the skull may be fractured, but not always.
During the impact of an accident, the brain crashes back and forth inside the skull causing
bruising, bleeding, and tearing of nerve fibers.
 Figure 1. During impact to the head, the soft brain
crashes back and forth against the inside of the hard
skull causing bruising, bleeding, and shearing of the
brain.

SECONDARY INJURY

It follows after the initial impact occurs, the brain undergoes a delayed trauma it swells
pushing itself against the skull and reducing the flow of oxygen-rich blood. This is often more
damaging than the primary injury.

Classification

o Closed/ Blunt Brain Injury- occurs when the head accelerates and then rapidly
decelerates or collides with another object and brain tissue is damaged but there is no
opening through the skull and dura
o Open Brain Injury- occurs when an object penetrates the skull, enters the brain and
damages the soft brain tissue in its path, or when the blunt trauma to the head is severe
that it opens the scalp, skull and dura to expose the brain.

- Considered an extreme emergency; marked neurologic deficit or even respiration arrest

can occur within minutes

Clinical Manifestations

Unconsciousness immediately after head trauma followed by a lucid interval in which the
patient is awake and conversant
During this lucid interval, compensation for the expanding hematoma takes place by
rapid absorption of CSF and decreased intravascular volume, both of which help maintain
a normal ICP.
When these mechanisms can no longer compensate, even a small increase in the volume
of the blood clot produces a marked elevation in ICP.
The patient then becomes increasingly restless, agitated and confused as the condition
progresses to coma
 Pupil dilation response rapidly deteriorates, with onset of eye movement paralysis on the
same side as that of the hematoma
confusion
dizziness
drowsiness
varying levels of alertness
severe headache
nausea
vomiting
seizures
enlarged pupil in one eye
weakness on one part of the body, typically on the side opposite the enlarged pupil
bruises around the eyes
bruises behind the ears
clear fluid draining from the nose or ears
shortness of breath or other changes in breathing patterns

Pathophysiology

The brain is not a hard, fixed substance. It is soft and jelly-like in consistency, composed
of millions of fine nerve fibers, and "floats" in cerebral-spinal fluid within the hard, bony skull.
When the head is struck suddenly, strikes a stationary object, or is shaken violently, the
mechanical force of this motion is transmitted to the brain.
When the head has a rotational movement during trauma, the brain moves, twists, and
experiences forces that cause differential movement of brain matter. This sudden movement or
direct force applied to the head can set the brain tissue in motion even though the brain is well
protected in the skull and very resilient. This motion squeezes, stretches and sometimes tears the
neural cells. Neural cells require a precise balance and distance between cells to efficiently
process and transmit messages between cells. The stretching and squeezing of brain cells from
these forces can change the precise balance, which can result in problems in how the brain
processes information.

Causes
Traumatic brain injury is caused by a blow or other traumatic injury to the head or body. The
degree of damage can depend on several factors, including the nature of the event and the force
of impact.
Injury may include one or more of the following factors:

Damage to brain cells may be limited to the area directly below the point of impact on the
skull.
 A severe blow or jolt can cause multiple points of damage because the brain may move
back and forth in the skull.

A severe rotational or spinning jolt can cause the tearing of cellular structures.

A blast, as from an explosive device, can cause widespread damage.

An object penetrating the skull can cause severe, irreparable damage to brain cells, blood
vessels and protective tissues around the brain.

Bleeding in or around the brain, swelling, and blood clots can disrupt the oxygen supply
to the brain and cause wider damage.
Common events causing traumatic brain injury include the following:
Falls. Falling out of bed, slipping in the bath, falling down steps, falling from ladders
and related falls are the most common cause of traumatic brain injury overall,
particularly in older adults and young children.
Vehicle-related collisions. Collisions involving cars, motorcycles or bicycles and
pedestrians involved in such accidents are a common cause of traumatic brain
injury.
Violence. About 20 percent of traumatic brain injuries are caused by violence, such as
gunshot wounds, domestic violence or child abuse. Shaken baby syndrome is
traumatic brain injury caused by the violent shaking of an infant that damages brain
cells.
Sports injuries. Traumatic brain injuries may be caused by injuries from a number of
sports, including soccer, boxing, football, baseball, lacrosse, skateboarding, hockey,
and other high-impact or extreme sports, particularly in youth.
Explosive blasts and other combat injuries. Explosive blasts are a common cause of
traumatic brain injury in active-duty military personnel. Although the mechanism of
damage isn't yet well-understood, many researchers believe that the pressure wave
passing through the brain significantly disrupts brain function.
Traumatic brain injury also results from penetrating wounds, severe blows to the head
with shrapnel or debris, and falls or bodily collisions with objects following a blast.

Diagnostic Exams

Complete blood count (CBC) with platelets - To monitor for infection and assess hematocrit
and platelets for further hemorrhagic risk.
Type and hold an appropriate amount of blood - To prepare for necessary transfusions needed
because of blood loss or anemia.
Hemoglobin: 117g/ L -low
 Hematocrit: 0.36 volume %- low
RBC Count: 3.9 x10^12/L - low
WBC Count: 12.5 x10^9/L- high
Patients Hemoglobin, Hematocrit and Red blood cells count is below the normal range. This
implies that patient is in need of blood transfusion which has been done after undergoing cross
matching. Her blood type, accordingly is B+. Patients blood transfusion has been done
successfully. On the other hand, her white blood cells count is higher than the normal level, this
indicates presence of infection.

The Glasgow Coma Score (GCS) is a 15-point test used to grade a patient's level of
consciousness. Doctors assess the patient's ability to 1) open his or her eyes, 2) ability to
respond appropriately to orientation questions, (What is your name? What is the date
today?), and 3) ability to follow commands (Hold up two fingers, or give a thumbs up). If
unconscious or unable to follow commands, his or her response to painful stimulation is
checked. A number is taken from each category and added together to get the total GCS
score. The score ranges from 3 to 15 and helps doctors classify an injury as mild, moderate,
or severe. Mild TBI has a score of 13-15. Moderate TBI has a score of 9-12, and severe TBI
has a score of 8 and below.
Recent assessment has been conducted and patients score in Glasgow Coma Scaling
is 15 out of 15. This implies that patient is completely conscious and indicates that
patients Brain damage is mild.
Computed tomography (CT) scan is a noninvasive X-ray that provides detailed images of
anatomical structures within the brain. A CT scan of the head is taken at the time of injury to
quickly identify fractures, bleeding in the brain, blood clots (hematomas) and the extent of
injury (Fig. 3). CT scans are used throughout recovery to evaluate the evolution of the injury
and to help guide decision-making about the patient's care.
Patient has been diagnosed of having Epidural Hematoma at Right Cerebellar and
Right Occipital Area. Official report indicates that patients skull is negative for
fracture in the views obtained; Sella turtuca is normal in size and shape with
preserved bony walls; vascular grooves and intracranial sutures are within normal
limits, cranial vault is intact. Overall impression is intact.

Serum chemistries, including electrolytes, blood urea nitrogen (BUN), creatinine, and
glucose - To characterize metabolic derangements that may complicate clinical course.
BUN- 4.25 mmhol/L : within normal range
Creatinine- 52.16 umol/L : below normal range
Low level of creatinine indicates decreased renal function
Sodium- 132. 70 mmol/L : within normal range
Potassium- 3.54 mmol/L: within normal range
 Prior admission, patient has manifested loss of consciousness for an uknown length of time.
Upon admission, patient has several episodes of vomiting, dizziness, nausea, epistaxis, and
bilateral otorrhea. These are all actual indicators that patient has epidural hematoma.

Treatment

MAJOR GOALS

Prompt recognition and treatment of hypoxia and acid-base disorders that can contribute to
cerebral edema.
Control of increasing ICP resulting from factors
Stabilization of other conditions

Medical Management: Supporting all organ systems

Ventilatory support (airway, breathing, circulation)

Management of fluid balance and elimination
Management of nutrition and gastrointestinal function

- There is a high association of cervical fracture with head injury, therefore the client must be
immobilized at the scene of the injury. And lateral cervical spine x-ray films obtained.
- Interventions include achieving oxygenation and lowering ICP with hyperventilation by
mechanical ventilation or by manually hyperventilating the client with a bag-valve-mask
device if the client has evidence of herniation.
- Open head wounds should be covered and pressure applied to control bleeding, unless there
is underlying depressed or compound skull fracture. And do not attempt to remove foreign
objects from the wound.
- Ongoing care to maintain cerebral perfusion and reduce ICP is the focus of critical care. The
cerebral metabolic rate is reduced with sedatives, paralytic agents, antipyretics, barbiturates,
and hypothermia. Respiratory depression is controlled in the client who is intubated and
ventilated.

Surgical Management
Surgery is sometimes necessary to repair skull fractures, repair bleeding vessels, or remove large
blood clots (hematomas). It is also performed to relieve extremely high intracranial pressure.
 Craniotomy involves cutting a hole in the skull to remove a bone flap so that the surgeon
can access the brain. The surgeon then repairs the damage (e.g., skull fracture, bleeding vessel,
remove large blood clots). The bone flap is replaced in its normal position and secured to the
skull with plates and screws

Decompressive craniectomy involves removing a large section of bone so that the brain
can swell and expand. This is typically performed when extremely high intracranial pressure
becomes life threatening. At that time the patient is taken to the operating room where a large
portion of the skull is removed to give the brain more room to swell (Fig. 6). A special biologic
tissue is placed on top of the exposed brain and the skin is closed. The bone flap is stored in a
freezer. One to 3 months after the swelling has resolved and the patient has stabilized from the
injury, the bone flap is replaced in another surgery, called cranioplasty.

Other surgical procedures may be performed to aid in the patient's recovery:

Tracheotomy involves making a small incision in the neck to insert the breathing tube
directly into the windpipe. The ventilator will then be connected to this new location on the
neck and the old tube is removed from the mouth.

Percutaneous Endoscopic Gastrostomy Tube (PEG) is a feeding tube inserted directly

into the stomach through the abdominal wall. A small camera is placed down the patient's
throat into the stomach to aid with the procedure and to ensure correct placement of the PEG
tube (see Surgical Procedures for Accelerated Recovery).
Nursing Management

Assessment. As soon as possible after head injury, assess and document the clients vital signs
and neurologic status. The physician should be notified promptly of any findings that indicate
the possible development of complications.
Risk for Ineffective Airway Clearance. Also increased risk for aspiration. Maintain adequate
airway clearance include clearing the mouth and oral pharynx of foreign bodies and
suctioning the oropharynx and trachea every 1 or 2 hours and as needed.
A semiprone lateral position may facilitate drainage of secretions and prevent aspiration.
Ineffective Cerebral Tissue Perfussion. Maintaining all physiologic parameters within normal
limits, positioning the client for optimal venous return, and monitoring extracerebral systems
for complications.
Communicating a clients neurologic status accurately and completely through verbal
reporting and documentation is essential to early identification of change and early
intervention.
ICP monitoring may be required.
Prognosis

Prognosis differs depending on the severity and location of the lesion, and access to
immediate, specialized acute management. People with epidural hematoma are expected to have
a good outcome if they receive surgery quickly. Following the acute stage, prognosis is strongly
influenced by the patient's involvement in activity that promotes recovery, which for most
patients requires access to a specialized, intensive rehabilitation service.

Most people who suffer minor head injuries have no lasting consequences. People who have
suffered serious head injuries may face permanent changes in their personality or physical and
cognitive abilities. Patient may also experience seizures for up to two years.

Prevention

Wearing a helmet while riding a motorcycle or bicycle helps minimize the risk of brain
injury. Seatbelt can help prevent a head injury during a motor vehicle crash. Since alcohol is a
risk factor for falls and other injuries, it should be used responsibly. Falls are a concern in the
elderly.

Recommendations

Patients with Head Trauma are advised not attempt to treat this condition at home. Seek
immediate medical care once head trauma is experienced and symptoms of an epidural
hematoma if suspected.

After surgery, recovery can take time. Most improvement will occur within the first six
months after the injury. Additional improvement may take up to two years. Recommendations
for home recovery will likely include:

Ample amount of rest

Adequate sleep
Gradual return to normal activities
Avoidance from contact to recreational sports
Avoidance from alcohol.
Recording of important information until full memory skills return.

Updates

Management of brain injury: THE EYE AND BRAIN SHRINKAGE

Another study, among many, showing observable objective changes in the brain after
mild-TBI. Here brain volume in several parts of the brain, including the putamen, thalamus,
amygdala and hippocampus seemed to be smaller than controls after the injury. They gradually
resume most of their size after about a year, indicating recovery. (Zagorchev, L. et al. 2015).
 The study of those treated at an emergency room for mild TBI show the most commonly
reported symptoms at first follow up where headache (27%), trouble falling asleep (18%),
fatigue (17%), difficulty remembering (16%) and dizziness (16%). The following factors predict
worse outcome:

Consumption of alcohol prior to injury.

The head injury resulted from a motor vehicle accident or fall.
The presence of post injury headache.
Headache was more robustly associated with continued symptoms, more than loss of
consciousness or alteration of consciousness or amnesia.

METHYLENE BLUE HELPS WITH TBI

Methylene blue, an old well used drug, has proved to be neuroprotective to the brains of
rats after a concussion. It was protective against the size of lesions and the length of functional
cognitive deficits. Clinically trials are under way.

DIFFUSION TENSOR IMAGING: A POWERFUL TOOL

The prognostic value of DTI/MR was shown in 61 patients with mild TBI who were
scanned early after trauma. The results of the abnormalities in white matter shown by DTI
correlated with the patients lowered performance on neuropsychological testing and contrasted
sharply with controls. DTI continues to prove itself as a biomarker for TBI in the human brain.

A NEW TOOL
Microhemorrhages are one of the most common results of TBI, and with more powerful magnets
and SWI/MR (Susceptibility Weighted Imaging), these micro hemorrhages can be identified.
Taking it to another level, a program called SWIM (Susceptibility Weighted Imaging and
Mapping) has been developed along with a Quantitative Susceptibility Mapping (QSM).

One of the problems with SWI is distinguishing between microhemorrhages and veins.
These two programs substantially raise the accuracy of the identification of microhemorrhages.
They can be done in a semi-automated manner with reasonable sensitivity and specificity. (Liu J.
et al., 2015)

References
http://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/basics/definition/con-
20029302
http://www.traumaticbraininjury.com/
https://en.wikipedia.org/wiki/Traumatic_brain_injury