Makindo Medical Notes

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Head injury is the most common cause of death and disability in people aged 1–40 years in the UK.

About

• A head injury refers to any trauma to the head, excluding superficial facial injuries.
• Common causes include road traffic accidents (RTA), falls, and assaults, varying with age and geography.
• This term is often used interchangeably with brain injury and traumatic brain injury (TBI).
• Most head injuries are minor and require minimal interventions.
• Head injuries can be classified as closed (no skull fracture) or penetrating (involving a skull fracture).
• Seen in approximately 7% of major trauma cases with a 5% mortality rate.
• Early neuroprotective measures can significantly improve patient outcomes.

Epidemiology

• Head injury refers to trauma affecting the scalp, skull, or brain.
• Accounts for 10% of A&E attendances, with 25% being admitted (UK).
• Only 1% of head injury cases are referred to neurosurgeons. Young males are at greater risk.
• Head injuries contribute to 50% of all trauma deaths, with 60% being from RTAs.

Patterns of Brain Bleeds

Mechanism of Injury

• Direct trauma can result in axonal shearing and micro/macro haemorrhages.
• Bleeding, oedema, and increased intracranial pressure (ICP) occur because the brain is confined within the rigid skull.
• Primary injuries occur at the time of trauma (cortical contusions, lacerations, diffuse axonal injury).
• Secondary injuries (potentially avoidable) include hypoxia, ischaemia (due to raised ICP and shock), oedema, intracranial haematoma, seizures, and infection.
• Specific Worrying Events:
  • High-speed motor vehicle accidents.
  • Falls from ≥ 3 m height.
  • Falls in elderly patients or those with alcohol involvement.
  • Altered Glasgow Coma Scale (GCS).

Risk Factors and Concerns

• Risk Groups:
  • Bimodal distribution: Young adults (15–29 years) and elderly individuals.
  • Men are twice as likely to suffer head injuries compared to women.
  • Main causes include RTAs, falls, and assaults.
• Concerns by Type of Injury:
  • Subdural haematoma: More common in older patients.
  • Extradural haematoma: More common in younger patients, often due to middle meningeal artery tears. Presents with a lucid interval followed by coma.
  • Traumatic intracerebral haemorrhage (ICH) and traumatic subarachnoid haemorrhage (SAH).

Clinical Assessment: Part of Full Trauma Workup

• Determine the mechanism of injury and assess if there was a loss of consciousness (LOC).
• Reduced GCS may suggest raised ICP—urgent CT and possible intubation required.
• Pupil dilation in a comatose patient suggests brainstem compression.
• Look for additional injuries (e.g., broken ribs, femur fractures).
• CSF leaks from the nose or ears suggest a skull fracture.
• Blood in ear canals or behind the ear drum also indicates a skull fracture.
• Signs of Skull Fracture: Battle's sign (bruising over mastoid), "panda eyes" (periorbital ecchymosis).
• If awake, perform a full neurological assessment for vision, weakness, or tingling. Assess for headache and vomiting.

Investigations

• CT Head (within 1 hour of arrival) is indicated for patients with:
  • GCS < 13 on initial assessment in the ED.
  • GCS < 15 at 2 hours post-injury.
  • Suspected open or depressed skull fracture.
  • Signs of basal skull fracture (e.g., haemotympanum, CSF leak, panda eyes).
  • Post-traumatic seizure or focal neurological deficits.
  • More than 1 episode of vomiting.
• CT Head (within 8 hours) for adults with:
  • Age ≥ 65 years.
  • Bleeding/clotting disorders or anticoagulant use.
  • Dangerous mechanisms of injury (e.g., ejected from vehicle, fall from ≥ 1 m).
  • More than 30 minutes' retrograde amnesia.

Complications of Head Injury

Sequelae	Type	Details and Pathophysiology	Clinical Management
Intracranial Haemorrhage	Acute	Includes epidural, subdural, subarachnoid, and intracerebral haemorrhages. Trauma leads to rupture of blood vessels, causing bleeding within or around the brain.	Urgent neuroimaging (CT/MRI), surgical intervention (e.g., craniotomy), and management of raised ICP.
Diffuse Axonal Injury (DAI)	Acute	Shearing forces cause widespread injury to white matter tracts, typically in high-velocity trauma.	ICU care, ICP monitoring, and neuro-rehabilitation. Prognosis is often poor in severe cases.
Skull Fractures	Acute	May be linear or depressed. Basilar fractures can cause cranial nerve damage and CSF leakage.	Imaging, surgical repair if necessary, monitor for CSF leaks, meningitis, or infection.
Post-Traumatic Seizures	Early/Delayed	Seizures may arise immediately after injury or later due to focal injury or cortical irritability.	Anticonvulsants (e.g., levetiracetam, phenytoin), may be given prophylactically.
Cerebral Oedema	Acute	Trauma leads to fluid accumulation and swelling in brain tissue.	Osmotic agents (mannitol, hypertonic saline), hyperventilation, corticosteroids for vasogenic oedema, decompressive craniectomy if severe.
Hydrocephalus	Acute/Chronic	Obstruction of CSF flow due to brain swelling or haemorrhage.	Ventriculostomy or ventricular shunt.
Post-Concussion Syndrome (PCS)	Chronic	Persistent symptoms after a concussion, including headaches, dizziness, cognitive dysfunction.	Symptomatic management and cognitive rehabilitation.
Chronic Traumatic Encephalopathy (CTE)	Chronic	Neurodegenerative condition due to repetitive head trauma, marked by tau protein accumulation.	Symptom management, including behavioral therapy and cognitive support.

Infographic

Management

• Initial ABCDE Management: IV access, oxygen therapy (target SpO₂ 94–98%), cervical spine protection until no injury is proven.
• For GCS < 9, immediate airway protection via tracheal intubation is required (call anaesthetist).
• Urgent CT head and neck to assess injury severity and determine need for neurosurgical input.
• Reverse any anticoagulation if there is a risk of intracranial bleeding (target platelets ≥ 100).
• Regular observations: GCS, pupils, limb movement, respiratory rate, heart rate, BP, temperature.
• Observation Frequency:
  • Half-hourly for 2 hours, then hourly for 4 hours, then 2-hourly thereafter.
  • If GCS deteriorates, revert to half-hourly checks.
• Criteria for neurosurgical intervention include: persistent coma (GCS ≤ 8), deteriorating GCS, new focal neurological signs, or abnormal neuroimaging.
• Levetiracetam (Keppra) is first-line anticonvulsant for significant head injuries. Start at 1g twice daily IV, followed by NG/PO if tolerated.
• Long-term rehabilitation is crucial, particularly for young men with behavioral and cognitive issues. Neuro-rehabilitation should involve occupational therapy, physiotherapy, and psychology.

References

• Guidelines for the Management of Traumatic Brain Injury
• Management of Severe Traumatic Brain Injury