If the GCS < 9 then immediately call an anaesthetist and get airway protected. They can manage the ABC whilst you can sort out the neurology
Airway: Check airway is patent; consider manoeuvres and airway and suction
Breathing: If no respiratory effort then CALL ARREST TEAM
Circulation: If no palpable pulse then CALL ARREST TEAM
Disability: If GCS < 9 then CALL ANAESTHETIST
- Head injury can be defined as any trauma to the head, other than superficial facial injuries.
- This term is often used interchangeably with both brain injury and traumatic brain injury
- Most are minor and need few interventions.
Mechanism of Injury
- Direct trauma to brain with axonal shearing and micro/macrohaemorrhage
- Bleeding or oedema and raised ICP as brain contained in bony box of skull
Specific Worrying Events
- High speed motor vehicle accident
- Fall from ≥ 3 m height
- Fall in elderly patients or with alcohol involved
- Altered GCS
- Bimodal age: Young adults (15 to 29 years) and the elderly
- Men are twice as likely to suffer head injuries compared to women.
- Main causes are RTA, Falls, Assaults
- Subdural : older patient
- Extradural: younger patient. Tear of middle meningeal artery. Lucid then coma
- Traumatic ICH and traumatic SAH
- Traumatic brain injury
Factors involved in Falls/head injury
- See Falls assessment for older pts
- Falls from height
- Road traffic : Seatbelt, speed, type of impact, damage to car
- Assault and violence
Clinical: Part of a full trauma assessment
- Mechanism of injury. Was there LOC for how long
- Reduced GCS should suggest raised ICP and urgent CT
- Pupil dilation suggests brainstem compression in comatose patient
- Look for other injuries - broken ribs, femur, NOF
- CSF leaks from nose or ears suggests skull fracture
- Blood in the ear canals or behind the ear drum suggests skull fracture
- Battle's sign (bruising over the mastoid processes) suggests skull fracture
- Panda eyes suggests significant injury
- If awake then full neuro assessment for vision, weakness, tingling
- Assess for headache, vomiting
Pre fall history
- Why did they fall - seizure, vasovagal, arrhythmia, hypoglycaemia
- Are they on anticoagulants is key
- Relevant past medical history
Who gets a CT head (Within 1 hr of arrival)
- GCS < 13 on initial assessment in the ED.
- GCS < 15 at 2 hours after the injury on assessment in ED.
- Suspected open or depressed skull fracture.
- Sign of basal skull fracture (haemotympanum, 'panda' eyes, CSF leakage from the ear or nose, Battle's sign).
- Post-traumatic seizure.
- Focal neurological deficit.
- More than 1 episode of vomiting.
For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury should get a CT head within 8 hrs
- Age 65 years or older.
- Any history of bleeding or clotting disorders and on anticoagulation
- Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
- More than 30 minutes' retrograde amnesia of events immediately before the head injury.
- Presence of new, surgically significant abnormalities on imaging
- GCS < 9 after initial resuscitation
- Unexplained confusion lasting > 4 hours
- Deterioration in GCS after admission
- Progressive focal neurological signs
- Seizure without full recovery
- Definite or suspected penetrating injury
- CSF leak
- ABC: Get IV access. Protect neck until no injury proven. Airway patency should be assessed and the cervical spine immobilised.
- If GCS < 9 then immediately call an anaesthetist and get airway protected. The airway should be secured, by tracheal intubation, in patients who do not have a patent airway or who are significantly obtunded (GCS = 8).
- The anaesthetist can expertly manage the ABC whilst you can sort out the neurology and other issues. In major trauma the chest should be examined and any life-threatening injuries (e.g. tension pneumothorax, open pneumothorax, massive haemothorax, flail chest, cardiac tamponade) promptly treated
- Get urgent CT head and neck to determine the extent of injury and need for ITU and/or neurosurgical input.
- Reverse any anticoagulation if any signs of SAH/SDH/EDH/ICH
- Discuss any structural issues on CT - bleeding, oedema, hydrocephalus discuss with neurosurgery and if GCS low discuss Neuro ITU and observation
- Avoid NG tube if base of skull fracture
Head injury and admit: following should stay
- New, clinically significant abnormalities on CT
- GCS < 15
- Persistent vomiting, severe headaches
- Other issues : drugs/alcohol which can cloud clinicla picture and full assessment
- Other injuries, shock, suspected non-accidental injury
- Meningism, cerebrospinal fluid leak
- Going to be alone for next 24 hours
- On anticoagulation
- Sober and not affected by drugs
- Poor social support
- Cause not understood and need telemetry
- Patients may have concussion symptoms for months after a head injury
- Symptoms : headaches, dizziness, tiredness, depression, memory problems.
Factors that worsen outcome
- Raised intracranial pressure (ICP)
Indications for Intubation Post-Head Injury
- Airway: Loss of airway reflexes or Significant bleeding into the airway
- Hypoxia - PaO2 < 13kPa (98mmHg) on oxygen
- Hypercarbia - PaCO2 > 6kPa (45mmHg)
- Spontaneous hyperventilation causing PaCO2 < 4kPa (30mmHg)
- Irregular respirations
- Disability: GCS < 9
- Before transfer to neurosurgical unit
- Bilateral fractured mandible
- Deteriorating conscious level (Motor component falls by 1 in GCS)
Summary of Therapeutic Targets in Managing Severe Head Injury
- PaO2 > 13kPa (98mmHg)
- PaCO2 of 4.5 - 5.0kPa (34- 38mmHg)
- A lower PaCO2 , = 4kPa (30mmHg), should be targeted with clinical or radiological signs of intracranial hypertension
- MAP = 80 mmHg (in the absence of ICP monitoring)
- Glucose 4-8 mmol/l
- Temperature < 37 C
- If ICP monitoring in situ : CPP 50 - 70mmHg , ICP < 20mmHg
Management of Raised ICP
- ICP above 20mmHg requires urgent treatment.
- IN absence of ICP monitoring Look for signs : dilated pupils and low GCS
- Targets PaCO2 ~ 4.5kPa (34mmHg)
- Target PaO2 > 13kPa (98mmHg)
- Target temperature < 37 C).
- Mannitol (0.25 - 0.5g / kg) or hypertonic saline (e.g. 100mls 5% saline)
- Consider Moderate Hyperventilation which is ventilation to achieve a target PaCO2 of approximately 4kPa (30mmHg) with the aim of further reducing ICP through reducing cerebral blood flow. However this can worsen perfusion.
- Therapeutic hypothermia, cooling to 34 C, can be induced. This reduces cerebral metabolic rate and cerebral oxygen consumption. A neuromuscular blocker is required to prevent shivering. Side effects include immunosuppression, coagulopathy and pancreatitis.
- Thiopentone can also be used to suppress cerebral metabolism.
- Decompressive crainectomy. In this procedure a bone flap is removed from the skull in an attempt to decompress cerebral swelling.