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Head injury

About head injury

Definition

Injury to the head. If you couldn't figure that out, give up medicine.

Aetiology

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.

Immediate management

Further management

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:

Consciousness

  • GCS <13 at any point
  • GCS <14, >2 hours after injury

Neurological abnormality

  • Focal neurological deficit
  • Seizure
  • Loss of consciousness WITH any of:
    • Age >65
    • Coagulopathy
    • Dangerous mechanism of injury i.e. RTA, fall from a great height
    • Antegrade amnesia >30 minutes

Other

  • Suspected open/depressed skull fracture or signs of basal skull fracture
  • 2 or more discrete episodes of vomiting

Criteria for ventilation

  • GCS<8
  • 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
  • Seizures

Admission

  • Difficult to assess (kids, post-ictal, alcohol intoxication)
  • CNS signs
  • Severe headache
  • Fracture
  • Loss of consciousness when patient either unwell or no responsible adult is able to attend to patient.

Complications

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