Head Injury and Traumatic Brain Head Injury (TBI)

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🧠 Head injury is the most common cause of death and disability in people aged 1–40 in the UK. Refer to NICE guidance (all ages). Red flag triggers for CT: GCS < 15, LOC, focal neurology, suspected skull fracture, amnesia, persistent headache, vomiting, seizures, anticoagulant use (except aspirin alone), high-energy mechanism, or safeguarding concerns.

ℹ️ About

• 💥 Trauma to scalp, skull, or brain (excludes superficial face injuries).
• 🚗 Common causes: RTAs, falls, assaults (age & geography dependent).
• 🔒 Classified as closed (no fracture) or penetrating (with fracture).
• 📊 Accounts for ~7% of major trauma; ~5% mortality.
• ⚡ Early neuroprotective care significantly improves outcome.

Epidemiology

• 🏥 10% of A&E attendances; 25% admitted.
• Only 1% referred to neurosurgery.
• 👨 Young men highest risk; bimodal peaks in young adults and elderly.
• Head injuries = 50% of trauma deaths; 60% from RTAs.

Patterns of Brain Bleeds

Mechanism of Injury

• ⚡ Direct trauma → axonal shearing, contusions, haemorrhage.
• 🧩 Primary injury: occurs at time of impact (contusions, DAI, lacerations).
• ♻️ Secondary injury: hypoxia, raised ICP, oedema, haematoma, seizures, infection.
• High-risk events: high-speed RTA, fall ≥3m, elderly fall, alcohol, altered GCS.

Risk Factors & Concerns

• 🧑‍🤝‍🧑 Groups: young men (15–29), elderly, RTAs, falls, assaults.
• By bleed type:
  • 🩸 Subdural haematoma → elderly, bridging vein rupture.
  • 🩸 Extradural haematoma → young, MMA rupture, lucid interval.
  • 🩸 Traumatic ICH / SAH → diffuse, often with contusions.

Clinical Assessment (ABCDE + Neuro)

• 📍 Mechanism, LOC, amnesia, seizure, vomiting.
• 🧍 Full GCS & neuro exam (limbs, pupils, vision, speech).
• 👁️ Pupil dilatation + coma = brainstem compression until proven otherwise.
• 💧 CSF leak from nose/ear = base of skull fracture (check for “panda eyes” or Battle’s sign).
• 🔎 Always assess for associated trauma (C-spine, chest, long bones).

Investigations (NICE CT Criteria)

• 🕐 CT Head within 1h if:
  • GCS < 13 initially or < 15 at 2h
  • Open/depressed skull fracture
  • Signs of base of skull fracture
  • Seizure, focal deficit
  • ≥1 vomiting episode
• 🕗 CT Head within 8h if:
  • Age ≥ 65
  • Bleeding/clotting disorder or anticoagulant/antiplatelet (except aspirin alone)
  • Dangerous mechanism (ejected, fall ≥1m)
  • Retrograde amnesia > 30 mins

Complications of Head Injury

Infographic

💊 Management

• 🩺 ABCDE first: oxygen (SpO₂ 94–98%), 2x IV access, C-spine precautions.
• 💤 GCS ≤ 8 → intubate (call anaesthetist, RSI with neuroprotective sequence).
• 🧾 Urgent CT head/neck if indicated.
• 💉 Reverse anticoagulation (target platelets ≥100).
• 👀 Obs: GCS, pupils, vitals - half-hourly ×2h → hourly ×4h → 2-hourly if stable.
• 📌 Neurosurgical referral if: GCS ≤8, deteriorating GCS, new focal signs, abnormal CT.
• 💊 Seizure prophylaxis: Levetiracetam 1g BD IV → NG/PO when possible.
• 🤝 Long-term: early neuro-rehabilitation (OT, physio, psychology).

🌟 Exam tip: - Extradural = lucid interval, young patient, MMA tear. - Subdural = elderly, bridging veins, gradual decline. - DAI = normal CT but low GCS.

References

• BSUH Traumatic Brain Injury Guidelines
• North Bristol NHS – Severe TBI Management

🧾 Clinical Case Examples

Case 1 – Extradural haematoma ⚡
A 21-year-old motorcyclist, not wearing a helmet, falls off his bike. He loses consciousness briefly, then is lucid for 1 hour before suddenly collapsing. On exam: right fixed dilated pupil, left-sided weakness. 👉 Diagnosis: Extradural haematoma (middle meningeal artery rupture). 👉 Management: Urgent CT head, neurosurgical referral for craniotomy.

Case 2 – Subdural haematoma 🩸
An 80-year-old woman on warfarin trips at home and strikes her head. Over the next 2 days she becomes confused and drowsy. GCS drops from 15 → 12. 👉 Diagnosis: Acute-on-chronic subdural haematoma (bridging vein rupture). 👉 Management: CT head, reverse anticoagulation, neurosurgical discussion.

Case 3 – Diffuse axonal injury 🧩
A 19-year-old student is involved in a high-speed RTA. At the scene his GCS is 6. In ED: intubated, CT head appears normal. 👉 Diagnosis: Diffuse axonal injury. 👉 Management: Admit to ICU, ICP monitoring, supportive neurocritical care, later rehabilitation.

Case 4 – Base of skull fracture 💧
A 35-year-old man is assaulted. He presents with periorbital bruising (“raccoon eyes”) and clear fluid leaking from the ear. 👉 Diagnosis: Basilar skull fracture with CSF leak. 👉 Management: CT head + temporal bones, neurosurgical review, prophylactic antibiotics not routinely given (unless advised by specialist), monitor for meningitis.

Case 5 – Post-concussion syndrome 🌀
A 28-year-old woman presents 2 weeks after a minor head injury. She complains of persistent headaches, poor concentration, irritability, and disturbed sleep. GCS was 15 at the time of injury, CT normal. 👉 Diagnosis: Post-concussion syndrome. 👉 Management: Reassurance, symptom control (analgesia, sleep hygiene), occupational health/psychology support if prolonged.

Case 6 – Anticoagulated head injury 💊
A 72-year-old man on apixaban falls in the bathroom, striking his head. He is GCS 15 with no focal neurology. 👉 Diagnosis: High-risk head injury on anticoagulation. 👉 Management: CT head within 1h (NICE), consider reversal if bleed, admit for observation even if initial CT normal.