Head Injury: General Approach and Management

Remember: Spinal injuries (see Chapter 35) are strongly associated with head injury. Ensure head-injured patients are immobilised in a hard cervical collar and log-rolled until the spine is cleared clinically and/or radiologically when appropriate.

Pathology/Pathogenesis

The pathological changes in the brain arising as a result of a primary brain injury depend on a number of factors, including magnitude of force of impact, intracranial vectors of transmitted force (linear and rotational), skull thickness, impact site and secondary insults (e.g. bleeding from blood vessels giving rise to haematomas or hypoxic insults leading to secondary ischaemic damage).

Immediate Clincal Management

Stabilise airway, breathing and circulation and ensure cervical spine immobilised before attending to other injuries (including the head).
Establish Glasgow Coma Score (see Appendix 2).

History

Establish the following from patient or witnesses:

Mechanism and circumstances of accident. (Was there any preceding event that caused accident/fall such as a seizure?)
Timing of accident.
Associated injuries/symptoms, including history of headaches and vomiting.
Duration of any loss of consciousness (LOC).
Details of pre-hospital care—initial GCS, secondary insults (hypoxia, hypotension, cardiorespiratory arrest, blood loss and seizures).
Posttraumatic amnesia (PTA):

It is a transient state of altered cognition and behaviour following concussive type injuries. The characteristic deficiencies are anterograde amnesia (inability to lay down new memories following TBI) and disorientation. Recognition is important as a marker of injury severity.

Patients should not be discharged until out of PTA.

Examination

Pulse, blood pressure, respiratory rate and pattern.
Establish GCS.
Pupillary responses.
Focal limb weakness.
Signs of raised ICP (see Chapter 30).
Record external evidence of head injury such as scalp bruising, lacerations, palpable depressed skull fracture, CSF rhinorrhoea or otorrhoea and signs of basal skull fracture (see Chapter 33).