CHAPTER 5 Nervous System^213
rhage causes blood to accumulate within the area below the arachnoid mater and
above the pia mater. The cerebrospinal fluid is found in this area. An intracerebral
bleed is an accumulation of blood within the tissues of the brain. This may be due
to a shearing force on the brain tissue from a twisting motion between the upper
part of the brain (cerebrum) and the brain stem or tearing of small vessels within
the brain. There will be associated edema and elevation of intracranial pressure.
Simple skull fractures are displaced and do not require specific intervention.
Depressed skull fractures have bone fragments that have been broken off from the
skull and pressed down toward the brain tissue. These fractures need to be cor-
rected surgically. A basilar skull fracture has classic signs that include periorbital
bruising (raccoon sign), blood behind the ear drum (Battle’s sign), and leaking of
cerebrospinal fluid from the nose or ear (check for glucose content to distinguish
from a runny nose).
PROGNOSIS
The prognosis following head injury varies greatly depending on the location of
the injury, the severity of the damage that occurred, and the treatment that was
received. Patients with loss of consciousness over 2 minutes have a more severe
injury and therefore worse prognosis. Patients who have loss of memory, either
about the incident or the events immediately following, also have a more severe
injury and worse prognosis. Some patients develop hemorrhage as a late effect of
head injury, occurring hours, or in some cases, days after the initial injury. Post-
traumatic seizure disorder can also occur as a late effect of head injury.
HALLMARK SIGNS AND SYMPTOMS
- Headache due to direct trauma and/or increasing intracranial pressure
- Disorientation or cognitive changes
- Changes in speech
- Changes in motor movements
- Nausea and vomiting due to increased intracranial pressure
- Unequal pupil size—important to determine if due to neurologic change or
if patient has always had unequal pupil size (small percentage of population
has unequal pupil size) - Diminished or absent pupil reaction due to neurologic compromise
- Decreased level of consciousness or loss of consciousness
- Amnesia