Head Injury

If the pupils are unequal, diagnose rising intracranial pressure (ICP), e.g. from extradural hemorrhage, and summon urgent neurosurgical help.

Retinal vein pulsation at fundoscopy helps exclude increased ICP.

Investigations

• Urea & Creatinine
• Electrolytes
• Glucose
• CBC
• Blood Alcohol
• Toxicology screen
• ABGs
• Clotting

Management

Write full notes, Record times

1. Initial Priority:

   • Stabilization of airway, breathing, and circulation (ABC) remains the 1st priority.
   • Oxygen if sat < 92%
   • Intubate and hyperventilate if necessary
   • Immobilize neck until injury to cervical spine excluded
   • Treat for shock if required, stop bleeding and support circulation
   • Treat seizures with lorazepam and/or phenytoin (see status epilepticus article)
   • Assess level of consciousness (GCS)
   • If GCS ≤8 then involve ICU to manage airway.
   • Assess anterograde amnesia (loss from the time of injury, i.e. post-traumatic) and retrograde amnesia (for events prior to injury)—extent of retrograde loss correlates with severity of injury, and never occurs without anterograde amnesia.
   • Rapid examination survey
   • Do investigations (see above)
   • Record pulse, BP, T°, respirations, and pupils every 15min.
   • CNS examination and Brief History
   • Evaluate lacerations of face or scalp (skull/facial fracture?)
   • Check for CSF leak from nose or ear or any blood behind the ear drum
     • if either is present, suspect basilar skull fracture
     • Do CT
     • Give tetanus toxoid
     • Refer to neurosurgeons urgently
   • Palpate the neck posteriorly for tenderness and deformity,
     • If detected, or if the patient has other indicators for neck imaging
     • Immobilize the neck
     • Get cervical spine X-ray or CT neck (see below)
   • Radiology: As indicated: CT of head/neck (see below)
   • Consider need for trauma series (e.g. CT chest/abdo/pelvis)
   • Involve neurosurgeons early, especially if reduced GCS, or if increased ICP suspected
   • Positioning: Semi-prone if no spinal injury, with attention to airway and bladder care.

2. CT Head Scanning Criteria:

   • <1h CT If:
     • GCS \<13 on initial assessment, or GCS \<15 at 2h following injury.
     • Focal neurological deficits.
     • Suspected open or depressed skull fractures,
     • signs of basal skull fractures e.g. periobital ecchymoses (‘panda’ eyes/racoon sign), postauricular ecchymosis (Battle’s sign), CSF leak through nose/ears, hemotympanum.
     • Post-traumatic seizure
     • Vomiting more than once.
   • <8h CT If:
     • Any loss of consciousness or amnesia, with one of the following:
       • Age ≥65
       • Coagulopathy
       • High-impact injury (e.g., vehicle collision, fall >1m)
       • Retrograde amnesia >30min.

3. If Cervical Spine Injury suspected:

   • <1h CT if:
     • GCS <13,
     • patient intubated,
     • Requires urgent definitive diagnosis of cervical spine injury (e.g., before surgery).
     • Requires being scanned for injuries in other parts of the body, such as with multiple injuries.
     • High-risk features like age >65, high-impact injury, focal neurological deficit, or paraesthesia in limbs.
   • < 1h X-ray of cervical spine can be done if the above-listed criteria are NOT met.

4. Admission Criteria:

   • New clinically significant CT abnormalities.
   • GCS \<15 after CT, regardless of CT result or continuing worrying signs (e.g. vomiting).
   • when CT indications met but CT unavailable
   • Suspicion of non-accidental injury, drugs/alcohol, Meningism, CSF leak, or shock.

5. Transfer and Neurosurgical Consultation:

   • Discuss cases with significant CT abnormalities, persistent GCS ≤ 8, deteriorating GCS (especially motor component), or persistent confusion, progressive focal neurology, seizure without full recovery, penetrating injuries, or CSF leak.
   • Ensure skilled medical escort and consider intubation before transfer if needed.

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