HEAD INJURY

Recognition

Definition

• “Any trauma to the head other than superficial injuries to the face” (NICE guidance CG 176)

History

If possible, ascertain if patient has:

• The mechanism of injury and if it was witnessed
• If following the injury, the patient has had:
  • Amnesia
  • Episodes of loss of consciousness
  • Headache
  • Seizures
  • Vomiting
• If the patient has recently consumed alcohol
• If the patient has previously been:
  • Diagnosed with a neurological condition
  • Taking medication for a neurological condition
• If the patient has previously had any operations on their head or spine
• Any allergies

General symptoms

• Dizzy
• Focal neurological deficit for example:
  • Blurred vision or double vision
  • Difficulties walking
  • Loss of power
  • Slurred Speech
• Headache
• Nausea and Vomiting
• Photophobia
• Seizures
• Tinnitus

General Signs

• Hypertensive
• Tachycardic or Bradycardic
• Signs of basal skull fracture
  • Hemotympanum
  • “Panda” eyes
  • Cerebrospinal fluid leakage from ear or nose
  • Battle’s sign (Bruising over the mastoid process)
• Confused
• Reduced Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Cushing’s triad of signs is an indication of impending brain herniation. Cushing’s triad is made up of:
  • Cheyne-Stokes breathing
  • Hypertension
  • Bradycardia

Initial Assessment and Investigations

• If the patient has obtained the head injury through high-energy transfer mechanism then the patient’s cervical spine must be stabilised throughout the initial assessment of ABCDE
• Continue with ABCDE assessment
• Assess patient’s airway– call an anaesthetist if airway compromised
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Examine Patient’s chest. With reduced consciousness there is a risk of aspiration
• Arterial blood gas (ABG) if concerned about patient’s ventilation
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Liver Function Tests (LFTS), Clotting, Group and Save, and Venous Blood Gas (VBG)
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
• Monitor heart rate and blood pressure
• Listen to patient’s heart sounds
• Check urine output and consider catheterisation
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale (GCS). Ensure this is done carefully as it is important to notice and highlight to seniors any change in GCS
• Do full neurological examination of upper and lower limbs
• Do full cranial nerve examination
• Call for senior help
• Imaging
  • See Algorithm 1 below: selection of adults for Computed Tomography (CT) head scan
  • Potential diagnosis:
    • Subdural haemorrhage
    • Epidural haemorrhage
    • Subarachnoid haemorrhage
    • Intraparenchymal haemorrhage
    • Skull fractures
  • Patients at risk of Cervical spine injury require Cervical spine X-rays unless they meet any of NICEs criteria for CT scan of the cervical spine (NICE guidance CG 176)
• Check patient’s temperature and blood sugar
• Examine patient’s abdomen and legs
• Ensure patient is in head up position (15-30^o) to reduce intracranial pressure

CT Head algorithm (NICE guidance) page 1

CT Head algorithm (NICE guidance) page 2

CT Head algorithm (NICE guidance) page 3

CT Head algorithm (NICE guidance) page 4

Response

Management

• Pharmacological
  • Correction of any coagulopathies
  • Following discussion with neurosurgery team patient may require:
    • Prophylactic antiepileptics
    • Mannitol
• Non-pharmacological management
  • Surgical decompression with a craniotomy

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Referral to neurosurgeons
• Consider referral to Intensive Care Unit (ICU) if:
  • Patient requires transfer to centre with neurosurgical team
  • Patient requires ventilator support
  • Patient requires blood pressure support
  • Deterioration of blood gases

Future management

• Ensure patient receives Occupational therapy and Physiotherapy review prior to discharge