Head Injury

Last Updated on by FRCEM Intermediate

Different types of traumatic brain injury

 

Extradural hemorrhage (aka epidural hemorrhage)

  • Uncommon.
  • Lenticular shaped on CT
  • Most commonly (80%) due to tearing of middle meningeal artery due to a temporal fracture
  • Classically (i.e. <50%) have lucid period after injury before subsequently deteriorating (aka “talk and die”).

Subdural hemorrhage

  • More common — especially in the presence of cerebral atrophy (e.g. elderly and alcoholics)
  • Concave shaped on CT
  • Due to tearing of veins draining cerebral cortex.
  • May present as acute or chronic

Intracerebral hemorrhage/Contusions

  • Ranging from contusions to hematoma
  • do evolve over time (may not see on first CT) -> can cause a significant mass effect with herniation
  • Some advocate observation and/or repeat scanning in 24-48 hours
  • may cause a headache -> elevated ICP and coma.

Skull Fracture

  • from contact force
  • usually associated with a brief loss of consciousness
  • linear: lateral convexities of the skull
  • depressed: blunt force from an object with a small surface area (hammer)
  • BOS: severe blunt trauma to forehead or occiput

Management

  • Activate the trauma team
  • Airway maintenance with cervical spine immobilization
    • intubate if GCS <8
    • consider intubating patients with higher GCS if agitated, hypoxic or hypoventilating
    • avoid nasopharyngeal airways due to the risk of intracranial passage
    • maintain cervical spine precautions
  • Breathing and ventilation
    • high flow oxygen 15L/min via a non-rebreather mask
    • target PaCO2 4.5 – 5.0 kPa (34-38mmHg) (low-normal range)
  • Circulation with hemorrhage control
    • target MAP of 70 mmHg to maintain adequate CPP (CPP -50 – 70mmHg).some advise MAP 80-90 mmHg to allow for variations during resuscitation
    • avoid permissive hypotension in trauma patients with significant head injuries
  • Disability (neurological evaluation)
    • assess GCS, pupils and motor and sensory function in all limbs prior to sedation or intubation
    • suspect critically raised intracranial pressure if Cushing’s response (bradycardia, hypertension, apneas), fixed and dilated pupil(s), hemiparesis.
    • treat suspect critically raised intracranial pressure: head up 30 degrees, remove neck constrictions, administer mannitol 0.25 to 1 g IV bolus or 3% hypertonic saline according to local guidelines, urgently liaise with neurosurgery
    • treat seizures and consider prophylactic anticonvulsants according to local guidelines.
  • Exposure and Environmental Control
    • maintain T36-37; give antipyretics if T>38C
  • Consider transfer: Organize early transfer to a neurosurgical unit
  • Secondary survey:
    • Head-to-toe examination looking for other injuries
    • organize the CT head to define the nature of the traumatic brain injury
  • Post-resuscitation care and monitoring (Adequate oxygenation, Avoid hypoventilation, Avoid hypotension, Maintain normal intracranial pressure, Normal glucose)
    • Pa02 > 13 kPa (98mmHg)
    • PaC02 of 4.5 – 5.0 kPa (34-38mmHg)
    • MAP 80 mmHg
    • Glucose 4 — 8 mmol/l
    • Temperature < 37 Deg C
    • With ICP monitoring
      • CPP -50 – 70mmHg
      • ICP < 20mmHg

 

Indication for CT Brain – after a trauma

CT Scan in Head Injuries
Selection of adults for CT scan Selection of children (under 16 years) for CT scan
CT scan of the brain within one hour (with a written radiology report within one hour of the scan being undertaken):

  • Glasgow Coma Scale (GCS) <13 when first assessed or GCS <15 two hours after injury
  • Suspected open or depressed skull fracture
  • Signs of base of skull fracture*
  • Post-traumatic seizure
  • Focal neurological deficit
  • >1 episode of vomiting

All patients with a coagulopathy or on oral anticoagulants should have a CT brain scan within eight hours of the injury, provided there are no other identified risk factors, as listed above. Again, a written radiology report should be available within one hour of the scan being undertaken.

CT scan of the brain within one hour (with a written radiology report within one hour of the scan being undertaken):

  • Clinical suspicion of non-accidental injury
  • Post-traumatic seizure (no past medical history of epilepsy)
  • GCS <14 on initial assessment or, if <1 year, GCS <15
  • GCS <15 two hours after injury
  • Suspected open or depressed skull fracture or tense fontanelle
  • Signs of base of skull fracture*
  • Focal neurological deficit
  • Aged <1 – bruise, swelling or laceration >5 cm on the head

If none of the above are present then CT brain scan within one hour if more than one of the following are present (with a written radiology report within one hour of the scan being undertaken):

  • Witnessed loss of consciousness >5 minutes
  • Amnesia (antegrade or retrograde) >5 minutes
  • Abnormal drowsiness
  • ≥3 Discrete episodes of vomiting
  • Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-speed projectile)

If only one of the aforementioned risk factors is present then observe for a minimum of four hours – CT scan of the brain within one hour if any of the following occur (with a written radiology report within one hour of the scan being undertaken):

  • GCS <15
  • Further vomiting
  • Abnormal drowsiness
*Signs of basal skull fracture: haemotympanum, ‘panda’ eyes (bruising around the eyes), CSF leakage (ears or nose) or Battle’s sign (bruising which sometimes occurs behind the ear in cases of basal skull fracture).

NICE Guidelines

Discuss with neurosurgery regardless of imaging if:
  • CSF leak
  • progressive focal neurology
  • Penetrating head injury
  • GCS <8, persistent confusion
  • seizure without full recovery

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