HEAD INJURIES

Trauma to the head resulting in brain injuries due to:

  • Direct damage to the brain (contusion, concussion, penetrating injury, diffuse axonal damage)
  • Haemorrhage from rupture of blood vessels around and in the brain
  • Severe swelling of the cerebral tissue (cerebral oedema)

Causes

  • Road traffic accident
  • Assault, fall or a blow to the head

Clinical features

  • May be closed (without a cut) or open (with a cut)
  • Swelling on the head (scalp hematoma)
  • Fracture of the skull, e.g., depressed area of the skull, open fracture (brain matter may be exposed)
  • Racoon eyes (haematoma around the eyes), bleeding and/ or leaking of CSF through nose, ears – signs of possible skull base fracture

Severe head injury

  • Altered level of consciousness, agitation, coma (see GCS below)
  • Seizures, focal neurological deficits, pupil abnormalities

Minor head injury (concussion)

  • Transient and short lived loss of mental function, e.g., loss of consciousness (<5 minutes), transient amnesia, headache, disorientation, dizziness, drowsiness, vomiting
    • symptoms should improve by 4 hours after the trauma

Severity classification of head injuries

Head injuries are classified based on Glasgow Coma Scale (GCS) score as:

  • Severe (GCS 3-8)
  • Moderate ( GCS 9-13)
  • Mild (GCS > 13)

Glasgow Coma Scale (GCS)

EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
1 = No response 1 = No response 1 = No response
2 = Open in response to pain 2 =
Incomprehensible sounds (grunting
in children)
2= Extension to painful stimuli
(decerebrate)
3 = Open in
response to voice
3 = Inappropriate words (cries and screams/cries inappropriately in children) 3 = Abnormal
flexion to painful stimuli (decorticate)
4 = Open
spontaneously
4 = Disoriented able to converse
(use words inappropriately / cries in children)
4 = Flexion/ withdrawal from
painful stimuli
NA 5 = Oriented able to converse (use words
appropriately/ cries appropriately
in children)
5 = Localize pain
NA 6 = Obeys
command
(NA in children
<1 yr)

For infants and children use AVPU

A Alert GCS >13
V Responds to voice GCS 13
P Responds to pain GCS 8
U Unresponsive GCS <8

Note

Mild injuries can still be associated with significant brain damage and can be divided into low and high risk according to the following criteria:

LOW RISK MILD HEAD INJURY HIGH RISK MILD HEAD INJURY
  • GCS 15 at 2 hours
  • No focal neurological
    deficits
  • No signs/symptoms of
    skull fracture
  • No recurrent vomiting
  • No risk factors (age >65
    years, bleeding disorders,
    dangerous mechanism)
  • Brief LOC (<5 minutes)
    and post traumatic
    amnesia (<30 minutes)
  • No persistent headache
  • No large haematoma/
    laceration
  • Isolated head injury
  • No risk of wrong
    information
  • GCS <15 at 2 hours
  • Deterioration of GCS
  • Focal neurological deficits
  • Clinical suspicion of skull
    fracture
  • Recurrent vomiting
  • Known bleeding disorder
  • Age >65 years
  • Post traumatic seizure
  • LOC >5 minutes
  • Persistent amnesia
  • Persistent abnormal
    behaviour
  • Persistent severe
    headache
  • Large scalp haematoma
  • Polytrauma
  • Dangerous mechanism
    (fall from height, car
    crash etc.)
  • Unclear information

Investigations

  • Skull X ray useful only to detect fracture
  • CT scan is the gold standard for detection of head injury

Differential diagnosis

  • Alcoholic coma – may occur together with a head injury
  • Hypoglycaemia
  • Meningitis
  • Poisoning
  • Other cause of coma

Management (general principles)

Management depends on:

  • GCS and clinical features at first assessment
  • Risk factors (mechanism of trauma, age, baseline conditions)
  • GCS and clinical features at follow up

TREATMENT

  • Assess mechanism of injury to assess risks of severe injury (which may not be apparent at the beginning)
  • Assess medical history to assess risk of complication (e.g., elderly, anticoagulant treatment etc.)
  • Assess level of consciousness using GCS or AVPU
  • Perform general (including ears) and neurological examination (pupils, motor and sensory examination, reflexes)
    • Assess other possible trauma especially if road traffic accident, e.g., abdominal or chest trauma
  • DO NOT SEDATE. Do NOT give opioids
  • Do NOT give NSAIDs (risk of bleeding)

Management of mild traumatic head injury

  • First aid if necessary
  • Mild analgesia if necessary e.g. paracetamol
  • Observe for at least 4-6 hours, monitor GCS and neurological symptoms
If low risk (see above)
  • Discharge on paracetamol
  • Advise home observation and return to the facility in case of any change
If high risk
  • Monitor for 24 hours
  • Refer immediately if GCS worsens or other clinical signs appear/persist
  • If patient is fine at the end of observation period, send home with instructions to come back in case of any problem (severe headache, seizures,
    alteration of consciousness, lethargy, change in behaviour etc.)

Note

  • Headaches and dizziness following mild traumatic brain injury may persist for weeks/months

Management of moderate traumatic head injury

  • Refer to hospital for appropriate management
  • Careful positioning (head 300 up)
  • Use fluids with caution
  • Keep oxygen saturation >90% and systolic BP >90 mmHg
  • Monitor GCS, pupils and neurological signs
  • Early CT if available, otherwise observe and refer immediately if not improving in the following hours

Management of severe traumatic head injury

  • Refer immediately for specialist management
  • Supportive care as per moderate head injury
  • If open head injury, give first dose of antibiotic prereferral
    • Ceftriaxone 2 g IV
      Child: 100 mg/kg

Prevention

  • Careful (defensive) driving to avoid accidents
  • Use of safety belts by motorists
  • Wearing of helmets by cyclists, motor-cyclists and people working in hazardous environments
  • Avoid dangerous activities (e.g., climbing trees)