Blunt head trauma

Question 1

A 65 year-old man presents after a fall onto his head from the roof of his house. There are no other injuries. What are the important management principles?

Answer 1

Impression
Significant head trauma secondary to fall from a height. Biggest concern is intracranial haemorrhage, C-spine injuries and base-of-skull fractures which may all represent surgical emergencies. Also concerned about traumatic brain injury, and would like to consider if there is a medical cause of the initial fall or if it is purely mechanical.

Priorities/key management principles
- Primary survey, exclude life-threatening injuries

Question 2

Blunt head trauma - Assessment

Answer 2

Assessment

• conduct AtoE assessment
• MIST AMPLE hand-over/initial history

A - patent, maintaining. avoid chin tilt due to ?C-spine injury
B - RR, sats - cushings response (sporadic breathing)
C - 2xIVC, BP and HR. Cushings response (bradycardia, HTN,
D - GCS, Canadian C-spine rule/CT-B rule/ NEXUS criteria
- Assess for evidence of raised ICP: pupils: anisocoria, fixed/dilated, papilloedema (elevate bed-head to 30degrees, Mannitol bolus
- decorticate posturing
- cushings triad (hypertension, bradycardia, irregular breathing)
E - secondary, temp, log roll

• arrange neurosurgeon consult for ?emergent neurosurgical intervention
• arrange retrieval as required

Question 3

Blunt head trauma - History

Answer 3

History

• MIST AMPLE initially
• Sx: time of injury, sx of TBI (confusion, amnesia, headache, disorganised speech)
• PMHx
• Medications: anticoagulation

Question 4

Blunt head trauma - Examination

Answer 4

Examination

• as per A to E assessment
• full neurological examination
• Post traumatic amnesia scoring for risk of traumatic brain injury; perform on the hour daily, stratifies risk of TBI [frequently missed, common cause of morbidity in the community]

Question 5

Blunt head trauma - Investigations

Answer 5

Investigations
- Key/diagnostic: CT B (?hb). Utilise NEXUS or Canadian head CT rules, C-spine imaging with CT spine

• Bedside: vitals
• Bloods: FBC, UEC, coags, group + xmatch, BSL

Question 6

Blunt head trauma - Management

Answer 6

Management
Supportive
- Head of bed up at 30-45 degrees
- cervical spine precautions (Miami collar)
- analgesia
- ICP management as per A to E (mannitol/hypertonic saline, tranexamic acid,
- VTE prophylaxis
- fluids
- neuro obs
- if for discharge, then send home with responsible adult

Definitive

• early involvement of neurosurgery, retrieval if necessary
• decompressive craniotomy, VP shunt insertion
• evacuation of intracranial haematoma’s