Head Injuries

  • Aim is to prevent secondary injury

Emergency Management

Airway

Breathing

Circulation

Assessment / Establish Diagnosis

  • History

    • mechanism of injury

    • pre-and post-injury functioning

    • document and communicate

    • reassess

  • Vital Signs

    • neurologic and systemic

    • pressure hypotension due to hypovolaemia

  • Mini-CNS exam

    • GCS

    • Pupils

    • Motor Lateralisation

    • aim to determine severity, detect deterioration and categorise injuries

Further

  • Assess need for Op

  • Early Neurosurgical Consult

Prevent secondary injury

  • maintain cerebral perfusion

  • prevent / treat increasing intracranial pressure

    • 100mls 20% mannitol

    • hyper-ventilation to keep pCO2 3.5-5kPa (monitor ABGs)

Pathology

  • May bleed profusely
  • Linear fracture with no displacement may be unimportant
  • Risk is of intracranial bleeding
  • If doubt admit for 24 hours
    • reduced consciousness
    • history of loss of consciousness
    • abnormal neurology
    • pallor
    • vomiting
    • sleepiness
    • skull fracture
    • raised intracranial pressure
      • decreased pulse
      • increased blood pressure
  • Observe
    • pulse
    • respiratory rate
    • blood pressure
    • level of consciousness
    • pupillary size
    • reaction
  • Anatomy
  • Loss of consciousness
  • Skull fractures
  • Brain Injury
  • Management of patients following head injury
  • Glasgow Coma Scale

Statistics

  • 106 head injuries /year
  • 150,000 need admitting
  • 6000 need a neurosurgeon

Primary Damage

  • Concussion
  • Laceration
  • Contusion Against
    • Base of skull
    • Tentori
    • Diffuse axonal injury

Secondary damage

  • Haemorrhage and its effects
  • Hypoxia
  • Hypotension

X-rays needed if:

  • History of loss of consciousness
  • Neurological signs or symptoms
  • Boggy swelling of scalp (>10cm)
  • Scalp laceration
  • Difficulty assessing patient:
  • Alcohol
  • Epilepsy
  • Children - if there's a chance of non-accidental injury

CT scan if:

  • Blood/CSF leakage - nose, ear
  • GCS of 8 or less or falling - will also need intubation so call an anaesthetist
  • Confused
  • Depressed fracture
  • Neurological signs, esp. if evolving

Signs of a basal skull fracture

  • Bruising around eyes - "Panda" or "Raccoon"
  • Subconjunctival haemorrhage - esp. if no posterior edge
  • Papilloedema
  • Haemotympanum
  • Facial nerve palsy
  • Nasopharyngeal bleeding
  • Bruising over mastoid -(Battle sign)

Haemorrhage

  • Subdural - most common, from diploic veins and sinuses
  • Extradural - from middle meningeal artery, lucid interval after injury preceds sudden deterioration
  • Subarachnoid
  • Have to be evacuated if moderate or large
  • Complain of headache
  • Coning - vital centres in brainstem comopressed
  • Need to guard against brain swelling or oedema
  • Mointor ICP
  • Cerebral perfusion pressure = MAP-ICP, can maintain perfusion down to 40 mmHg. But must guard against hypotension

Need to monitor:

  • BP - May rise initially then falls as brainstem compressed
  • Pulse - falls (bradycardia ≤60, tachycardia ≥100)
  • Respiratory rate - irregular, apnoeic, Cheyne-Stokes breathing
  • Temperature rises

Fitting gives a poor prognosis, can be treated with phenytoin

Misleading features

Contre-coup

  • Symptoms indicate lesion opposite side from that of injury

Haematoma

  • Ipsilateral dilatation of pupil
  • Contralateral motor weakness
 

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