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
- Consult
the neurosurgical unit
- 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
- Transport
pt only after complete resuscitation. Consider endotracheal intubation and
ventilation prior transfer.
- 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.
- 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:
- Drowsiness
or excessive sleepiness
- Confusion
or disorientation
- Severe
headache, vomiting or fever
- Weakness
of any limbs or double vision
- Convulsion,
seizure or passing out
- Discharge
of blood or fluid from ears or nose