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About head injury
Injury to the head. If you couldn't figure that out, give up medicine.
Getting hit in the head by a donkey kick. Having a small anvil dropped on your skull. Receiving a legitimate tombstone piledriver from WWE Superstar, The Undertaker. (This would also have an effect on the cervical spine.)
OK, I'll stop - it's all trauma to the head.
- Call neurosurgeons in comatose patients or those with raised ICP
- Examine CNS
- Chart - pulse, blood pressure, temperature, respiratory rate and pupils every 15 minutes
- Anterograde amnesia (memory loss from point of event)
- Retrograde amnesia (memory loss from before the event) - this directly correlates with severity of injury
The key to eliciting the salient clinical features in head injury is to figure out three things. Do they need a) a CT scan; b) ventilation; or finally c) admission?
Criteria for a CT scan
An immediate CT scan is required if any of the following are true. I've split it into a few categories:
- GCS <13 at any point
- GCS <14, >2 hours after injury
- Focal neurological deficit
- Loss of consciousness WITH any of:
- Age >65
- Dangerous mechanism of injury i.e. RTA, fall from a great height
- Antegrade amnesia >30 minutes
- Suspected open/depressed skull fracture or signs of basal skull fracture
- 2 or more discrete episodes of vomiting
Criteria for ventilation
- PaO2 <9kPa in air/13<kPa in O2 or PaCO2 >6kPa
- Spontaneous hyperventilation (PaCO2 <3.5kPa)
- Respiratory irregularity
Wow this page is boring. It's just a list of boring criteria you have to learn. To break it up, here's a quote from W.H. Auden
Here is a story all about how my life got flipped, turned upside down
And I'd like to take a minute just sit right there,
I'll tell you how I became the Prince of town called Bel-air
Auden was ahead of his time. The lyrics were used in popular late 80s/early 90s American TV show The Fresh Prince Of Bel-air.
Ventilation in neurosurgery
Here are some more really interesting criteria regarding ventilation when referring to neurosurgery:
- Deteriorating level of consciousness
- Bilateral fractured mandible
- Bleeding into mouth
- Difficult to assess (kids, post-ictal, alcohol intoxication)
- CNS signs
- Severe headache
- Loss of consciousness when patient either unwell or no responsible adult is able to attend to patient.
Intracranial haematoma (in adults)
The risks of a haematoma developing are as follows. In a:
- Fully conscious, no skull fracture - <1:1000
- Confused, no skull fracture - 1:100
- Fully conscious, skull fracture - 1:30
- Confused, skull fracture - 1:4