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:
o Minor injury
• Mild headache
• Nausea
• Mild dizziness
• Mild blurred vision
o 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:
o Background
• Over 65 years of age?
• Previous history of brain surgery?
• Any history of bleeding/clotting disorder or currently on anticoagulant therapy?
o 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?
o 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.
o 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.
o 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.
o 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.
o 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).
o 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.
o 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
o Transfer to a neuroscience unit if:
• GCS 8 or less
o 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:
o Immediate:
• Extradural haematoma
• Subdural haematoma
• CSF rhinorrhea/otorrhoea → increase risk of meningitis
• Persistent vegetative state
• Death
o Chronic:
• Incomplete recovery
• Post-traumatic epilepsy
• The post-traumatic syndrome
• Benign paroxysmal positional vertigo
• Chronic subdural haematoma
• Hydrocephalus
• Chronic traumatic encephalopathy
o 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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