Head injury overview

Introduction

o Head injury is any trauma to the head other than superficial injuries to the face.
o Commonest cause of death in 1-40 age group in the UK.
o In England and Wales’s 1.4 million patients attend emergency departments with head injury.
o 200,000 patients are admitted to annually, one fifth of these patients have evidence of skull fracture or brain damage.

Presentation

Minor injury

• Mild headache
• Nausea
• Mild dizziness
• Mild blurred vision

Severe injury

• Unconsciousness
• Concussion
• Seizures
• Dysphasia/Aphasia
• Recurrent vomiting (more than 3 episodes since the injury)
• Basal skull fracture signs
• Battle’s sign
• Raccoon eyes
• Cerebrospinal fluid rhinorrhea
• Amnesia (good indicator of long term prognosis for patients)
• Focal pressure
• Movement/co-ordination problems

History

Background

• Over 65 years of age?
• Previous history of brain surgery?
• Any history of bleeding/clotting disorder or currently on anticoagulant therapy?

What happened? (Mechanism of injury)

• Polytrauma
• High-speed road traffic accident as pedestrian, cyclist or vehicle occupant
• Fall from a height (>3 metres)
• High-speed injury from a projectile or other object
• Sharp/blunt object
• Penetrative/Non-penetrative injury
• Non-accidental injury (is the patient vulnerable?)
• Drug or alcohol intoxication?

Events after injury

• Any loss of consciousness?
• Any amnesia?
• Focal neurology?
• Paraesthesia in the upper or lower limbs (cervical spine injury)
• Any vomiting?
• Persistent headache since injury?
• Change in behaviour? In what way?

Vital Signs

o Observe for cushing’s triad (raised blood pressure, irregular breathing and bradychardia).
• Examination findings:
o Head injury’s should be seen within 15 minutes to be categorised in to low or high risk
o Initial airways, breathing, and circulation assessment.
o Glasgow coma score (If 8 or less, then immediate involvement of anaesthetist/critical care team).

Radiological investigations

o Computerised Tomography (CT) is the primary investigation of choice.

Brain injury:

• CT head should be performed in the first hour if:
• GCS is less than 13 at initial emergency department assessment.
• GCS is less than 15 at 2 hours after initial emergency department assessment.
• Suspected open, depressed or basal skull fracture.
• Post-traumatic seizure.
• Presence of focal neurological deficit.
• Greater than 1 episode of vomiting.
• CT head should be performed within 8 hours if:
• 65 years or older.
• Bleeding or clotting disorders.
• Dangerous mechanism of injury.
• More than 30 minutes of retrograde amnesia of events before the injury.

Cervical spine injury:

• CT cervical spine scan should be performed in 1 hour if:
• GCS is less than 13 at initial emergency department assessment.
• The patient has been intubated
• Cervical spine injury diagnosis needed urgently.
• Poly-trauma.
• Suspected injury from the history.

Management

o Stabilisation of airways, breathing and circulation.

Initial supportive treatment should be provided if needed.

• Pain managment as per the analgesia ladder.
• Catheterisation of a full bladder.
• Splintage of any concomitant limb fractures.

If CT head is not indicated and risk of clinically significant brain injury is low then discharge.

• Discharge when patient’s GCS is 15.
• Provide verbal and printed discharge advice to patient (see nice guidelines).

If CT cervical spine not indicated then assess range of neck movement. If range of movement normal and cervical spine x-ray not subsequently needed then discharge.

Admit into hospital for observation if:

• Clinically significant abnormalities on imaging.
• GCS hasn’t returned to 15.
• CT cannot be carried out.
• Persistent concerning signs (vomiting, severe headache)
• Other indications:
• Drug/Alcohol intoxication.
• Other injuries
• Shock
• Suspected non-accidental injury
• Meningism
• Cerebrospinal fluid leak

Transfer to a neuroscience unit if:

• GCS 8 or less

Patients should be intubated and ventilate in the following circumstances:

• Immediately
• Coma (GCS8 or less).
• Loss of laryngeal reflexes.
• Ventilatory insufficiency (PaO2 < 13kPa on oxygen or PaCO2 > 6kPa)
• Spontaneous hyperventilation causing PaCO2 < 4kPa
• Irregular respirations
• Before start of journey to neuroscience unit:
• Deteriorating conscious level (1 or more points on motor score).
• Unstable facial skeleton fractures.
• Significant bleeding into the mouth (basal skull fracture).
• Seizures.
• On ventilation aim for PaO2 greater than 13kPa and PaCO2 between 4.5-5.0 kPa and maintain a mean arterial pressure at 80mmHg.
• If clinical evidence of raised intracranial pressure, more aggressive hyperventilation is justified.

Complication

Immediate:

• Extradural haematoma
• Subdural haematoma
• CSF rhinorrhea/otorrhoea → increase risk of meningitis
• Persistent vegetative state
• Death

Chronic:

• Incomplete recovery
• Post-traumatic epilepsy
• The post-traumatic syndrome
• Benign paroxysmal positional vertigo
• Chronic subdural haematoma
• Hydrocephalus
• Chronic traumatic encephalopathy

Follow up is dependent on condition. Severe cases are cared for by an multi-disciplinary team consisting of:

• General Practitioner
• Clinical psychologist
• Neurologist
• Neurosurgeon
• Specialist in rehabilitation medicine

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