6.3 Head Injury

Question 1

A 25-year-old patient has been involved in a RTA and brought to A&E with GCS of 11.

Discuss the prevalence of head injury and its main causes.

Answer 1

Prevalence and causes
* 70%–80% male.

• 10%–20% aged more than 65 yrs,

40%–50% children.

• Death due to head injury is 6–10 per 100 000 per annum.

Minor injury
* Falls (22%–43%) and assaults (30%–50%) are
commonest cause of minor head injury,
followed by road traffic accident (25%).

Major injury
* Road traffic accident is the major cause of moderate to severe injury.

Question 2

How will you manage this patient?

Answer 2

• Principal of management of head injury is to

prevent secondary brain injury due to
hypoxia,
hyper/hypocarbia,
hypovolaemia,
hypotension,
increased ICP.

• Initial assessment and management as per ATLS guidelines.
• Primary survey and management of other life-threatening injury
  (tension pneumothorax,
  cardiac tamponade,
  airway obstruction, etc.).
• Secondary survey.

Question 3

can you tell me the criteria for a ct scan in adult trauma patient?

Answer 3

1. • GCS < 13 on presentation
2. • Suspected open or depressed skull fracture
3. • Signs of basal skull fracture
     (haemotympanum, CSF leak from ear or
     nose, battle’s sign, panda eyes)

4.* Focal neurological signs

___________________________________

others

1. • More than one episode of vomiting following head injury
2. • History of loss of consciousness following injury or more than 30 minutes
     of retrograde amnesia of events immediately prior to injury
3. • Mechanism of injury
     (e.g. cyclist or pedestrian struck by motor vehicle,
     occupant ejected from a motor vehicle)

Question 4

How will you rule out cervical spine injury in trauma patient?

Alert and awake

Answer 4

The cervical spine may be cleared clinically if the following preconditions
are met.

Alert and awake patient
* Fully orientated

• No head injury
• Not under influence of drugs or alcohol
• No neck pain
• No abnormal neurology
• No significant injury that may ‘distract’ the
  patient from complaining about a possible spinal injury

Provided these preconditions are met, the neck may then be examined.

If there is no bruising or deformity,
no tenderness and a pain-free range of
active movements,

the cervical spine can be cleared.

Radiographic studies of the cervical spine are not indicated.

Question 5

Unconscious, intubated patients

Answer 5

The standard radiological examinations of the cervical spine in the
unconscious, intubated patient are:

• Lateral cervical spine film.
• Antero-posterior cervical spine film.
• CT scan of occiput—C3.
• The open-mouth odontoid radiograph is inadequate in intubated patients
  and will miss up to 17% of injuries to the upper cervical spine.

Axial CT scanning with sagittal and coronal reconstruction should be used to
evaluate abnormal, suspicious, or poorly visualised areas on plain radiology.

With technically adequate studies and experienced interpretation, the
combination of plain radiology and directed CT scanning provides a false
negative rate of less than 0.1%.

Question 6

What are the indications for intubation in a head injury patient?

Answer 6

• GCS < 8 in adult and < 9 in paediatric patients
• Seizure after trauma
• Airway obstruction, airway injury
• Severe facial injury (Le Fort fracture, mandible fracture)
• Inability to maintain oxygenation/ventilation
  (PaO2 < 9 kPa on air
  or < 13 kPa with oxygen,
  PaCo2 < 4 kPa or > 6 kPa)
• To facilitate transfer of patient to tertiary centre
• Alcohol or other drug intoxication plus signs of head injury

Question 7

this patient has sustained an extradural haematoma and needs urgent transfer to a
neurosurgical centre. How will you manage this transfer?

Answer 7

ensure

Patient
* Airway is secured and the patient is ventilated as indicated.
* Any life-threatening injury is dealt with and patient is optimally
resuscitated.

Personnel
* Fully trained doctor and assistant who are experienced in transferring
critically ill patient.
* Receiving team is aware and awaiting.

equipment
* Monitoring equipment are all fully charged or replacement batteries taken.

Minimal monitor for transfer of patient with head injury are ECG, Spo2,
invasive arterial blood pressure, EtCo2, GCS, and pupillary reflex.

• Infusion pumps and ventilators are adequately charged and spare
  batteries are taken for transfer.
• Oxygen cylinders are full and spares available.
• Cannulation and intubation kits.

Drugs
* For intubation
* Emergency drugs in case of decompensation
* Anti-seizure drugs
* Drugs that decrease ICP
* Fluids, blood, and blood products (if deemed necessary)

notes
* Patient notes and CT scan report plus hard copy in place
* All available blood results

Question 8

Maintain

Answer 8

General
* 30–45 degree head up
* Neck is midline and free from any tight ties
* Cervical spine immobilisation

Ventilation
* Pao2 > 13 kPa and
PaCo2 around 4.5 kPa

circulation
* MAP > 90 mmHg
(to maintain CPP 60–70 mmHg,
assuming that ICP is 20 mmHg)

• Use vasopressor to maintain MAP others
• Treat hyperpyrexia
• Maintain blood glucose level

Question 9

How will you manage a sudden rise of icP if it occurs during transfer?

Answer 9

Steps to treat sudden increase in ICP
(dilated pupil and direct absent light reflex)

General
* Ensure that patient is 30 degree head up.

• Make sure that patient is adequately sedated and ventilated
  (bucking and coughing increases ICP).
• ETT is in place and taped properly but not obstructing any venous drainage.

Numbers
* PaO2 > 13 kPa and PaCo2 around 4.5 kPa

• MAP > 90 mmHg
• Temperature and blood glucose are within normal limits

Drugs
* Phenytoin if convulsion is present.
* Mannitol: 0.25–0.5 gm/kg bolus over 5–10 minutes and repeated once
again if indicated, but always communicate with neurosurgeon before
second dose.
Maximum 1 gm/kg, as above that it is not beneficial.

Hypertonic saline may also be used.

expert help
* Communicate with neurosurgeon in charge.

Question 10

can you tell me the role of hypothermia in a head injury patient?

Answer 10

Any hyperpyrexia increases cerebral metabolic rate of oxygen (CMRo2) and
should be aggressively treated.

Equally hypothermia reduces CMRo2,
which can be beneficial for neurological outcome but
hypothermia below 35°C affects enzyme systems
and can cause clotting abnormality.

This can result in further bleeding in injured patient,
which ultimately increases ICP; so, routinely there is no role of
active cooling of head injury patient