Head Injury
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Introduction
Over 60% of trauma admissions have head injuries, and 60% of MVA-related deaths are due to head injury. Head injuries suggests C-spine injury until proven otherwise, both radiologically and clinically.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis. To get students thinking.
Causes and Risk Factors
Pathophysiology
Layers of scalp spell SCALP:
- skin
- connective tissue (dense)
- aponeurosis (galea)
- loose connective tissue
- periosteum
Signs and Symptoms
- history
- physical exam
History
Inquire into mechanism of injury.
Ask about
- any loss of consciousness
- nausea/vomiting
- headache
- post-traumatic amnesia
- loss os sensation or function
Physical Exam
Neurological exam (record and regularly repeat)
- Glascow coma scale (GCS)
- eyes: pupillary size and reactivity
- brainstem (respiration, CN palsies)
- CN exam
- motor, sensory exam, reflexes
- sphincter tone
Head and Neck
- lacerations, bruises
- basal skull fracture (bruised mastoid process, hemotympanum, racoon eyes, CSF otorrhea/rhinorrhea
- facial fractures, foreign bodies
- spine: palpable deformity, midline pain/tenderness
- missing teeth (potential for aspiration)
Other
- BP: low suggests injury elsewhere
Investigations
Red Flags
Severe head injury should be suspected if:
- GCS<8
- deteriorating GCS
- unequal pupils
- lateralizing signs
- lab investigations
- diagnostic imaging
Lab Investigations
- CBC
- lytes
- glucose
- INR, PTT
ABG
type and cross-match
drug screen
NEVER do a lumbar puncture
Diagnostic Imaging
C,T,L-spine X-rays
- AP, lateral, odontoid views to ensure full viewing
- oblique views assessing pars interarticularis fracture
CT head and upper C-spine
- fractures
- loss of mastoid/sinus air spaces
- blod in cisterns
- pneumocephalus
The Canadian CT head rule suggests CT is only indicated with minor head injuries with any of the following:
- GCS score <15 2h after injury
- suspected skull fracture
- any sign of basal skull fracture
- vomiting x2 or more
- age >65
- amnesia >30 min
- dangerous mechanism (pedestrian MVC, fall from >3 feet or >5 stairs, etc)
chest/pelvic X ray as indicated
Differential Diagnosis
Treatments
Minor injury
Observe for 24-48 hours, waking every hour. Use sedatives or analgesics selectively while monitoring.
Severe injury
ABCs are always the priority; intubate if necessary
secure C-spine
maintain BP
monitor to detect complications
manage increased ICP if present
- elevate head of bed
- mannitol
- hyperventilate
- paralyzing agents
pharmacotherapy:
- anticonvulsants x7 days
- calcium channel blockers in adults
Spinal injury
- reduce dislocation by traction or surgery
- stabilize spine
- MRI if neurological deficit present to rule out compression
Consequences and Course
The Case of...
Case #2 - a small story wrapping it all up and asking about esp management.
Additional Resources
Topic Development
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