Head Injury

You are the neurosurgery CT1 called to A&E to see a 45-year-old lady who has fallen down the stairs from top to bottom.  She initially was conscious, however has suddenly deteriorated and drop her GCS from 15 to 10. The ED team have arranged a CT scan, which they have asked you to look at. How would you proceed?

Example answer introduction

Given the mechanism of injury, there is potential for significant head injury and therefore I would attend immediately.  I would perform an initial assessment and stabilisation according to the Advanced Trauma Life Support Algorithm, take a history and perform a focused examination, then put in place an initial management plan and inform my registrar. 

Initial assessment + simultaneous resuscitation:

 

On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.

  • Airway with C-spine control

    • check that airway is patient 

    • If any signs of compromise they will need discussion and review by anaesthetics

  • Breathing

    • oxygen saturations, examine chest, examine work of breathing, breathing depth

    • if concerns give high flow oxygen through a non-rebreathe mask

  • Circulation

    • pulse, blood pressure, capillary refill time, skin turgor, fluid input/output

    • ensure IV access- 2 large bore etc- bloods as above, consider catheter (use clinical judgement as to if these are required if it is not a major trauma situation)

    • Give fluid challenge 250ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. 

  • Disability - GCS, pupils, blood sugar, temperature

  • Exposure-  systemic signs of shock, other injuries

Provide constant reassessment during this acute phase.

Focused history​

If the is drowsy I would obtain collateral history from a possible witness, discuss with paramedics and any relatives present for further information. 

 

  • Allergies

  • Medications – anti-epileptics, anticoagulants,  recent alcohol or drug intake

  • Past medical history – history of epilepsy, diabetes

  • Last meal

 

  • Events leading up to this point 

    • Details of mechanism of injury

    • NB: a dangerous mechanism of injury or high-energy head injury is defined as:

    • Fall from a height of greater than 1 metre or 5 stairs.

    • High-speed motor vehicle collision either as a pedestrian, cyclist, or vehicle occupant.

    • Rollover motor accident or ejection from a motor vehicle.

    • Accident involving motorised recreational vehicles or bicycle collision

    • Diving accident

  • Ask about current symptoms since the injury, e.g.

    • Loss of consciousness.

    • Amnesia

    • Vomiting

    • Headache

    • Neck pain

    • Pre-injury level of consciousness and functioning.

Focussed examination and investigations

Examination

  • Full neurological examination

    • Cranial nerve examination including pupillary response and size

    • Peripheral nerve examination

    • Cerebellar examination

    • Assess level of consciousness using Glasgow Coma Scale

    • Look for focal neurological deficit

  • Look for signs of shock e.g. tachycardia, hypotension

  • Look for signs of basal skull fracture

    • Periorbital haematoma

    • CSF leak from nose or ears

    • Battle’s sign

    • Haemotympanum

  • For any neck tenderness — midline cervical spine tenderness may indicate cervical spine injury

  • Assess for any associated injuries - this means FULL secondary survey - although in the interview do not go through this in detail

Investigations

 

I would then arrange further investigations following discussion with the neurosurgical registrar

 

  • Bloods - FBC, U&E, LFTs, clotting, Group & Save, lactate

  • X-rays and other imaging depending on secondary survey

  • CT brain 

Example questions to progress the station

Q1 Describe the findings of this CT scan

 

This is a non-contrast CT scan of the head. It shows a large right front-temporal area extradural haematoma. Urgent discussion with neurosurgery is required 

Q3 What are the components of the Glasgow Coma Score?

  • Best eye response

    • 1 - does not open eyes

    • 2 -  opens eyes in response to painful stimuli

    • 3 - opens eyes in response to voice

    • 4 - opens eyes spontaneously

  • Best verbal response

    • 1 - makes no sounds

    • 2 - incomprehensible sounds

    • 3 - inappropriate words

    • 4 - confused and disorientated

    • 5 - orientated and converses normally

  • Best motor response 

    • 1 - makes no movement in response to pain

    • 2 - extension in response to painful stimuli

    • 3 - abnormal flexion in response to painful stimuli

    • 4 -  flexion or withdrawal in response to painful stimuli

    • 5 - localizes painful stimuli

    • 6 - obeys simple commands

Q4 How does an extradural haematoma form?

  • Often results from a skull fracture which causes tearing of the meningeal vessel.

  • Most common is the middle fossa after temporal bone fracture and middle meningeal artery or vein tear

 

Patients with an extradural haematoma often have a ‘lucid’interval followed by rapid deterioration as the heamatoma expands.

On CT it will classically have a biconvex or lenticular appearance.

Q5 What would your initial management of a patient with the be?

Initial management

  • Maintenance IV fluids to maintain circulation and preserve cerebral perfusion

  • Analgesia

  • Anti-emetics

  • Laxative

  • Analgesia

  • Keep nil by mouth

  • Hourly neuro-observations

 

In an alert patient with a small haematoma, this may be treated conservatively with close observation in case of of sudden deterioration.

In this patient as their GCS has dropped to 10, the neurosurgical registrar should be contacted for review and also preparation for theatre:

  • Prep for theatre – may need burr hole

  • Senior review by neurosurgical registrar

  • Keep patient and any relatives informed 

  • Document, document, document!!!

 Escalation
  • Neurosurgical registrar

  • Theatres

  • Anaesthetist

  • Critical care

Note: 

 

  • In neurotrauma, mmanagement aims to minimise secondary brain injury

  • The primary brain injury results from the intial trauma, which may be diffuse or focal and of varying severity. This injury is essentially irreversible.

  • Secondary brain injury occurs after the primary injury and results from hypotension, hypoxia, ischaemic, pyrexia, infection or raised intracranial pressure. Secondary brain injury is potentially reversible and can potentially have devastating effects in in those with relatively minor injuries.

Useful Resources

NICE - Head injury: assessment and early management 

SIGN Guideline on early management of patients with a head injury

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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