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Management of Head Injuries
The key aspects in the management of head injury include:
Accurate clinical assessment of neurological and other injuries.
Determination of the pathological process involved.
Changes in the neurological signs indicate a progression in the pathological process.
The management of patients with a head injury must follow a planned
program as follows:
1) Dealing with the life saving priorities.
2) Initial evaluation and examination.
3) Necessary investigations.
4) Continuing care and observations.
5) Possible need for surgery to evacuate an intracranial haematoma.
Dealing with the life saving priorities: (ABC)
1) Protection of the AIRWAY. (Cleaning and putting airway tube or endotracheal tube).
2) Maintenance of adequate BREATHING. Prevention of Hypoventilation.
3) CIRCULATION: arrest of bleeding, correction of shock, and maintaining adequate blood pressure.
important notes:
a. Patients with a head injury are more likely to die from airway obstruction than from any other
treatable intracranial lesions.
b. The presence of shock in a patient with a head injury is most likely due to internal
haemorrhage in the thorax or abdomen.
c. Care must be taken to secure the neck and spine (by putting collar around the neck and by
careful body movement until be sure of no spinal injury).
Initial evaluation and examination:
This is so important because it provide a base level for subsequent observations.
A. Important points in the History:
1. Cause, Circumstance and Mechanism of injury.
2. Period of loss of consciousness.
3. Period of post-traumatic amnesia.
4. Presence of headache and vomiting.
5. Level of consciousness at scene and on transfer.
6. Evidence of seizures.
7. Any weakness.
8. Pre-existing medical conditions.
9. Medications (especially anticoagulants).
10. illegal drugs and alcohol.
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B. Initial examination: thorough examination of the patient as a whole, as in
many cases there is an associated abdominal or thoracic injury:
1. Vital signs: pulse, blood pressure and respiratory rate.
2. Scalp: for any scalp wound or haematoma.
3. Skull: for any fracture.
4. Assessment of Level of Consciousness: by using Glasgow Coma scale
5. Pupils size and response: both pupils should be examined for their size and reaction to light
1. Immediately dilated pupil after the trauma is most likely due to direct
trauma of the orbit or the oculomotor nerve.
2. Pupil dilated later indicates lateralization due to supratentorial
haematoma (e.g. extradural haematoma).
3. Lateralising signs: Hemiplegia in the acute phase is more likely due to primary cerebral injury
rather than due to a compressing intracranial haematoma.
4. Signs of base of skull fracture.
5. Full neurological examination: tone, power, sensation and reflexes.
6. Limbs: for any fracture or vascular injury.
7. Chest: examine for fractured ribs, pneumothorax or haemothorax.
8. Abdomen: examine for internal haemorrhage or peritonitis.
9. Back: for the possibility of fractures or dislocations of spines.
C. Indications for admission to the hospital of patients with head injury include:
1. Any depression of level of consciousness (or any loss of consciousness for more than 5 minutes).
2. Skull fracture.
3. Focal neurological sign.
4. Persistent headache or vomiting.
5. Patients who are difficult to assess e.g. those who are also intoxicated or under alcohol effect.
6. Those with concomitant diseases or medications that pose increased risk (for example,
coagulopathies and anticoagulants).
7. Absence of responsible relatives who can observe the patient for the first 24 hours.
INVESTIGATIONS:
a. Plain skull x-ray:
1. Can demonstrate the site and type of a skull fracture.
2. A foreign body can also be seen.
Indications for skull x-ray in head injury include:
1. Impaired consciousness or neurological signs.
2. History of loss of consciousness, amnesia, or fits.
3. High speed injury or suspected penetrating injury.
4. Scalp laceration to bone, large haematoma, or suspected fracture on palpation.
5. Persisting vomiting or headache.
6. Loss of cerebrospinal fluid or blood from ear or nose.
7. Difficulty in assessing the patient (children, drug or alcohol intoxication).
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b. Cervical spinal x-ray to exclude fracture or dislocation of spines.
c. CT scan: done immediately and sometimes need to be repeated.
Indications for immediate CT scan in head injury:
1. Glasgow Coma Score (GCS) <13 at any point.
2. GCS 13 or 14 at 2 hours.
3. Focal neurological deficit.
4. Suspected open, depressed, or basal skull fracture.
5. Seizure.
6. Vomiting more than one episode.
7. Age more than 65.
8. Coagulopathy (e.g. on warfarin).
9. Dangerous mechanism of injury (CT within 8 hours).
10. Antegrade amnesia more than 30 minutes (CT within 8 hours).
Indications to repeat CT scanning include:
1. Delayed deterioration in the mental state.
2. A persistent rise in intracranial pressure (ICP).
3. Failure to improve over24 hours.
IV. Continuing Care and Observations:
a. Continuous care includes:
1.
Attention to the airway as described before.
2.
A Foley’s catheter: to facilitate the nursing care and to estimate the urine output.
3.
Frequent change of posture to avoid bed sores (every 2 hours).
4.
Physiotherapy of the joints and massage to the muscles.
5.
Intravenous isotonic maintenance fluids should be given (crystalloids) until nasogastric
feeding can be started. 5% dextrose not used to avoid an increase in brain oedema.
6.
Nasogastric tube feeding: this should begin as early as possible.
7.
Measures to decrease the intracranial pressure (see the second lecture): pay good
attention to the following points:
Before Mannitol is given it is essential to exclude an intracranial haematoma
and to check that the renal function is satisfactory.
As Mannitol reduces normal brain volume, it will increase the size of extradural
haematoma and so it will increase the mass effect.
Steroids in severe head injury are associated with increased mortality.
b. Repeated observations for the following:
1. Level of consciousness using the Glasgow Coma Scale.
2. Pulse, blood pressure, and temperature and respiration.
3. Pupils.
4. Reflexes.
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c. Causes of DETERIORATION of the patient:
1. BRAIN OEDEMA leading to increased intracranial pressure.
2. Airway obstruction and/or hypoventilation leading to brain swelling and
increased intracranial pressure.
3. Intracranial haematoma. This can be confirmed by CT scan.
4. FEVER due to respiratory infection or meningitis.
5. Over transfusion by hypotonic fluid or dehydration.
6. Epilepsy.
V. Surgery to evacuate an acute intracranial haematoma:
Long-Term Sequelae Of Head Injury:
1. Neurological deficits: This needs neurorehabilitation by medical, nursing,
physiotherapy and speech and occupational therapy teams.
2. Post-traumatic epilepsy.
3. Cerebrospinal fluid (CSF) fistula.
4. Neuropsychological sequalae: Post-concussion syndrome: is a complex
of symptoms persisting months after head injury and consist of various
combinations of headache, dizziness, impaired short –term memory and
concentration, easy fatigability, emotional dysinhibition and depression.
5. Neuroendocrine and metabolic disorders.
Outcomes after Head Injury: Glasgow outcome Score (GOS))
Good recovery
5 independent
Moderate disability
4 independent even with deficit
Severe disability
3 dependent
Persistent vegetative state
2 awake but not aware
Dead
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Head injury - DON'T FORGET
Changes in the GCS are more important than the absolute score.
Be aware of associated injuries - manage severe head injuries as multiply injured
patients until other injuries are excluded.
Stabilize the neck.