Hemorrhage

Definition

1. Epidural
2. Subdural
3. Intracerebral

Epidural hematoma 

Pathophysiology

Results from arterial bleeding into the space between the dura and inner skull

ICP increases

Is a neurosurgical emergency

Epidural Hematoma

Manifestations

• Lucid intervals lasting for minutes during which time patient is awake and talking
• Momentary unconsciousness occurs within minutes of injury
• ICP elevation
• Structural changes
• Loss of consciousness

Hemorrhage

Pathophysiology

Hemorrhage causes a brain hematoma or clot.

Occurs as part of the primary injury and can begin at the moment of impact.

May also arise later from vessel damage.

Bleeding is caused by vascular damage from the shearing force of the trauma or direct physical damage from skull fractures or penetrating injury. All hematomas are potentially life threatening because they act as space-occupying lesions and are surrounded by edema.

Subdural Hematoma

Pathophysiology

results from venous bleeding into the space beneath the dura and above the arachnoid.

Can occur from tearing of the bridging veins within the cerebral hemispheres or from a laceration of brain tissues

Bleeding occurs more slowly than from an epidural hematoma

Subdivided into acute, subacute, and chronic

Acute presents within 48 hours after impact

Subacute between 48 hours-2 weeks

Chronic 2 weeks-several months after injury

Subdural hematomas have the highest mortality rate.

Subdural Hematoma

Manifestations

• confusion
• loss of consciousness
• blurred vision
• severe headache
• vomiting
• loss of short-term memory
• slurred speech
• difficult walking
• dizziness
• weakness in one side or area of the body
• sweating
• pale skin color
• seizures
• behavior changes including irritability
• blood or clear fluid draining from the ears or nose
• one pupil (dark area in the center of the eye) looks larger than the other eye
• deep cut or laceration in the scalp
• open wound in the head
• foreign object penetrating the head

Intracerebral Hemorrhage

Pathophysiology

Intracerebral Hematoma

Manifestations

• Nuchal rigidity
• Photophobia
• Nausea
• Vomiting
• Dizziness
• Convulsion
• Decreased respiratory rate
• Progressive obtundation

Subarachnoid Hemorrhage

Pathophysiology

Subarachnoid Hemorrhage

Manifestations

Sudden and severe headache

Dizziness

Neck rigidity

unequal pupils

Remitting seizures

Drowsiness

Diaphoresis

Chills

Stupor

Decreased level of consciousness

Brain edema

ICP elevations

Hemorrhage

Nursing Interventions

• Establish a patent airway
• Assist with tracheotomy
• Perform neurologic examination
• Monitor ICP
• Insert indwelling catheter as ordered
• Monitor I&O
• Insert nasogastric tube-to prevent aspiration
• Enforce absolute bed rest
• Elevate head of bed-decrease ICP
• Monitor vital signs and respiratory regularly-abnormal respiration's could indicate a breakdown in the respiratory center in the brain stem and possible impending tentorial herniation
• Assess for restlessness, level of consciousness, and orientation
• Clean and dress superficial scalp wounds

Hemorrhage

Patient Teaching

Teach the patient to avoid activities that may cause coughing or sneezing-can increase ICP

Advise patient to blow gently when blowing nose-can increas ICP

Watch for CSF drainage and signs of infection

Tach family member how to observe the patient for mental status changes-may indicate worsening condition

Hemorrhage

Evaluation

Patient will remain oriented to time, place, and person.

Patient will maintain bed rest in a quiet environment until recovery is complete

Hemorrhage

Diagnostic Tests

Skull X-rays- rule out fractures

Cerebral angiography-outlines vasculature

CT scan-shows ischemic or necrotic tissue, cerebral edema, areas of petechial hemorrhages, and subdural, epidural, and intracerebral hematomas and may reveal a shift in brain tissue.

Hemorrhage

Drug Therapy

5% in half-normal saline solution-to prevent or control increased ICP

Mannitol IV-reduces cerebral edema

Dexamethasone IV-to control cerebral edema

Opioids-used to decrease agitation and control restless, and pain

Fentanyl-decrease agitation, control restless and pain

Neuromuscular blocking agents-used to decrease agitation

Barbituates-used for intracranial hypertension that is not controlled by other means

Hemorrhage

Laboratory Tests

• Arterial blood gases
• CBC
• Serum Glucose
• Electrolytes levels

Used to monitor hemodynamic status, identify electrolyte imbalance and detect infection

Hemorrhage

Surgical Management

ICP monitoring device-used to measure ICP

Intraventricular catheters-used to decrease ICP

Subarachnoid screw or bold-used for direct pressure measurement

Epidural catheter-ICP monitoring

Crainotomy-reduce ICP