HEAD INJURIES

HEAD INJURIES

The goal of head injury management is to prevent or reverse secondary insult to the injured brain and provide the best environment for the recovery of the dysfunctional or damaged brain tissues.

Initial assessment

Follow the format of Primary survey and resuscitation, secondary survey and definitive management of any trauma patient. The detection of previous extracranial injuries e.g. hypovolaemic shock and tension pneumothorax will takes priority over the management of head injury.

Assess:

A: Airway with cervical spine control

B: Breathing. Acceptable ABG PaO2 > 100mmHg, PaCo2 < 40 mmHg

C: Circulation. Maintain BP. If hypovolaemic shockwas present on the arrival of the patient, it is very unlikely due to head injury and other cause must be ruled out.

D: Dysfunctional of CNS. Check GCS, pupils, limb movement, gag reflex, and ventilator pattern.

E: Exposure and X-ray

The extent of investigation and management of patients suffering from head injuries depend on the severity of the head injuries, as assessed by GCS and associated injuries.

Citeria for skull X-ray after recent head injury:

SXR can be helpful but clinical judgement is necessary and the following criteria will be refined by further experience. The presence of one or more of the following indicates the need for SXR in patient with a history of recent head injury.

1.       Loss of consciousness or amnesia at any time

2.       Neurological symptoms and signs

3.       CSF or blood from nose or ear

4.       Suspected penetrating injury or scalp bruising or swelling

5.       Alcohol intoxication

6.       Difficulty in assessing the patient (e.g. the young, epileptic)

Note: Simple laceration is not a criterion for SXR

Risk of intracranial clot:

No fracture and conscious           1:5900

No fracture & unconscious          1:300

Fracture and conscious                  1:32

Fracture and unconscious            1:4

A fracture is present in 90% of extradural (EDH) and 75% of intradural haematoma

Indications of CT Brain in Head Injuries:

In first 6 hours

-          Focal signs (conscious and unconscious)

-          Deteriorating level of consciousness

-          Fluctuating level of consciousness

-          Coma (differential diagnosis)

-          Epilepsy (focal or general)

-          Penetrating injury

-          Depressive fracture

-          Combined head and facial injury

In first week

-          Repeat scan at 3 days may be needed for all the above condition

-          Post operative

-          In CSF leak

-          Intracranial infection

In first month

-          Chronic subdural haematoma

-          Hydrocephalus

-          CSF fistula

-          Intracranial infection

-          Aerocele

On admission 30% of severely head injured patients are hypovolaemic and 15% are hypotensive. These need to be rectified to prevent secondary brain damage.

If deterioration of conscious level is apparent the following possibilities should be investigated.

Secondary deterioration in conscious level:

Extracranial causes:

-          Hypoxia e.g. airway obstruction, hypoventilation

-          Hypotension e.g. bleeding

-          Metabolic derangement e.g. dehydration, hypoglycaemia, fluid overload, hyponatraemia

-          Fever

Intracranial causes:

-          Brain oedema

-          Intracranial haematoma

-          Epilepsy

-          Meningitis, brain abscess

-          Aerocele

Check respiratory rate, pulse rate, blood pressure

Full blood count, BUSE, RBS, ABG, CXR, ECG

Consider CT scan

Management of Head Injuries

For minor head injuries where patient is conscious, ambulant and without major associated injuries and without neurological symptoms, the patient is allowed light food or nourishing fluid. Intravenous drip is not required. However, head chart hourly is required for the first 24 hours.

For severely injured head injured patient, the principle of management are outlined as followed:

1)      Constant observation

o   Glasgow coma scale chart hourly for at least the first 24 hours

2)      Patient position

o   Propped up position 30 degree with head in neutral position

3)      Nasogastric tube and urinary catheterization

o   Nil orally initially but enteral feeding subsequently

4)      Prophylaxis against gastric ulcer

o   IV ranitidine 50 mg tds

5)      Fluid balance

o   In adult, 1000 mls 0.9% NS and 500 mls dextrose 5% over 24 hours

o   However, fluid restriction should not be pursued at the expense of cardiovascular stability or renal function

o   Check electrolytes

6)      Nursing care

o   In preventing of pressure sore, Ducolax suppositories for constipation

Physiotherapy

Chest and limbs physiotherapy

Respiratory rate

Oxygen therapy

If respiratory distress, find and treat the cause.

When ventilation or ABG or both are too poor to allow spontaneous ventilation, consider endotracheal intubation (referral for ICU management)

PaO2 < 65 mmHg breathing air

          < 100 mmHg receiving supplemental O2

PaCO2 > 40 mmHg

Prevention of factors causing secondary deterioration in conscious level.

Antibiotics.

Indicated investigations: Compound vault fracture

                                             Basal fracture- with CSF leak: absolute

                                             Without CSF leak: relative

                                             Suspected or proven meningitis

For prophylactic

i)                    Iv benzylpenicillin 1 mega unit qid OR

ii)                   Iv bactrim 10mls bd or oral bactrim 2bd OR

iii)                 Iv sulphadamide  500mg qid OR

iv)                 Iv cloxacillin 500mg qid OR

v)                  A combination of the above

Duration of treatment 1 week

In meningitis, high dose antibiotics should be used

       Iv benzylpenicillin 2-4 mega unit qid

       Iv chloramphenicol 1000mg qid

Treatment of epilepsy

Phenytoin- loading dose 250-500 mg slow iv, followed by maintenance 100 mg tds

Indication: Compound skull fracture with dural penetration

                    Acute subdural hematoma

                   Early epilepsy (24h to 1 week)

Mannitol

A powerful osmotic diuretic and may be life saving but it carries danger. Consult surgeon before using it,

Dose: 0.5-1 g/kg body weight, given as iv bolus over 10-30 mins. Usually 200 ml of a 20% solution.

Make sure a urinary catheter is inserted before giving.

Mannitol may be give together with iv frusemide.

Indications for controlled ventilation:

      Emergency reduction of ICP (cerebral resuscitation)

     Cranial gunshot wound

     Associated chest injury

     Aspiration pnemonitis

     Control of epilepsy

     Diffuse brain swelling especially in children

Indications for neurological consultations of patient with recent head injury

i)                    Skull fracture with confusion or impairment of consciousness, focal neurological signs, fits or any other neurological signs and symptoms.

ii)                   Coma, continuing after resuscitation (GCS < 8)

iii)                 Deterioration in level of consciousness

iv)                 Confusion or other neurological disturbances persisting more than 6-8 hours even if there is no skull fracture

v)                  Compound depressed fracture of the vault of skull

vi)                 Suspected fracture of the base of skull (CSF rhinorrhoe or otorrhoea, bilateral orbital haematoma, mastoid haematoma) or other penetrating injury (eg. Gunshot etc)

Notes: Patient in categories i) to iii) should refer urgently. In all cases the diagnosis and initial treatment of serious extracranial injuries take priority over the transfer of patient to the neurosurgical unit.

Preparation for interhospital transfer of severely head injured pt

1. Consult the neurosurgical unit
2. Send notes on clear description of all injuries, GCS, pupils size and reponse, BP, results of investigations, drugs and iv fluid given and x rays
3. Transport pt only after complete resuscitation. Consider endotracheal intubation and ventilation prior transfer.
4. Ensure ambulance is fully equipped and with trained staff. Personnel should be able to insert or to reposition ET tune and to initiate or maintain ventilation.
5. Smooth and slow journey

Patient discharged from ward should be taken care of by a responsible adult. They should be warned. If the patient develops any of the following problems he or she should be brought back to the hospital without delay:

1. Drowsiness or excessive sleepiness
2. Confusion or disorientation
3. Severe headache, vomiting or fever
4. Weakness of any limbs or double vision
5. Convulsion, seizure or passing out
6. Discharge of blood or fluid from ears or nose