Head Injury: Assessment, Diagnosis and Treatment

Head Injury: Assessment And Early Management

Discuss the management of head injury.

Answer. Initial assessment of head injuries must follow advanced trauma and life support (ATLS) guidelines with an initial primary survey, then *resuscitation followed by secondary survey then defiite management like: airway, breathing, circulation, disability and exposure.

Important Histories Of Head injury

• Period of loss of unconsciousness
• Period of post-traumatic amnesia
• Cause and circumstances of injury
• Presence of headache and vomiting.

Head injury Physical examination includes

• Thorough general examination.
• Local examination for evidence of injury, skull fractures.
• Determination of conscious level by Glasgow coma scale.

Head injury Investigations

• X-ray skull: To look for fracture, relative position ofcalcifid pineal gland, presence of intracranial air.
• Serum electrolyte measurement is done
• Blood grouping and cross matching of blood is done.
• CT scan: Plain (not contrast) to look for cerebral edema,hematoma, midline shift, fractures, ventricles, brainstem injury.
• Carotid arteriography
• Investigations for other injuries such as ultrasound of abdomen.
• Monitoring of intracranial pressure.

Head Injury Glasgow Coma Scale

Eye-opening

• Spontaneous    4
• To speech         3
• To pain              2
• Nil                     1

Best Motor response

• Obeys command     6
• Localizes pain         5
• Withdrawal to pain  4
• Flexion to pain        3
• Extension to pain    2
• Nil                           1

Verbal response

• Oriented                   5
• Confused                 4
• Inappropriate words 3
• Incomprehensible   2
• Nil                           1

Total score is 15
Mild head injury score 13 to 15
Moderate head injury score 9 to 12
Severe head injury score less than 8 (3 to 8)
Any patient who has a coma score of 7 or less than 7 is said to be in coma.
Pupillary response should be elicitated to determine whether there is incipient transtentorial habitat, with Oculomotorpalsy and responses recorded.

Head Injury General Management

• Management ofhead injuries includes ventilation, surgery,
  ICU management of intracranial pressure, cerebral perfusion pressure and oxygenation.
• Management of patients having head injury is based on
  Glasgow coma scale following the resuscitation.
• Patients with mild injury, i.e. having Glasgow comma scale of 14 to 15 should be admittd to the ward where thorough neurological examinations are performed.
• If patient with mild head injury subsequently deteriorate neurologically, CT scan of patient’s head should be done and local neurosurgical unit should be contacted.
• Mild head injury patients should remain under observation until complete neurological recovery occur. Such patients are discharged to the responsible adult which can take good care of such patient at home for few days.
• Patients with Glasgow comma scale of 13 or less should undergo for CT scan of their head. If there is presence of acute lesion on CT scan or there is presence of diffse cerebral edema should referred to local neurosurgical unit.
  CT scan should also be sent to the unit. A provisional radiography report should also be sent to referring hospital.
• If there is presence of compound depressed skull fracture,severely depressed fracture, CSF otorrhea and rhinorrhea patient should be referred to neurosurgical unit.
• Airways are protected by using mouth gag, endotracheal intubation or tracheostomy whenever required.
• Throat suction, bladder and bowel care as well as good nursing is essential.
• After evacuation of hematoma patient should be admittd to ICU and ventilated to a PCO 2 of 4 to 4.5 Kpa.
• A central line, arterial line and urinary catheter should be inserted.
• Head of bed should be positioned 40 degrees up and patient is given analgesia (Fentanyl)
• IV fluids are administered should be isotonic. It is administered till nasogastric tube is inserted for feeding.
• ICP monitor should be inserted intraparenchymally to measure ICP and CPP (ideally should be < 25 mm Hg and CPP should be about 70 mm Hg) If CPP is low, ionotropic agent should be used.
• Mannitol or frusemide could lower the ICP if it is not controlled by these agents then EEG burst suppression therapy with a barbiturates, ventriculator or lumber CSF drainage to be considered.
• Antibiotics like penicillin, ampicillin are given to prevent risk of meningitis.

Surgical Management

• Burr hole is made and hematoma is evacuated.
• Surgery is done in case when:
  • Consciousness is decreasing continuously.
  • Pupil becomes fied or dilated.
  • Pulse rate becomes less than 60/minute.

Surgical Management

• Craniotomy is done and cranial flp is raised. Clot is evacuated applying hitch stitches between dural layer and scalp.