[EMed] Head Injury

Question 1

what are the signs of basal skull fracture?

Answer 1

• haemotypanum
• peri-orbital bruising “Racoon eyes”
• Battle’s sign (retro-orbital bruising)
• CSF leakage from ears/nose

Question 2

what are dangerous mechanism of injury (MOI)?

Answer 2

• pedestrian or cyclist struck by motor vehicle
• occupant ejected from motor vehicle
• high speed / rollover motor accident
• fall from >1m/5 stairs

Question 3

in an adult with head injury, what warrants a CT head <1 hour?

Answer 3

• GCS <13
• GCS <15 at 2 hours post-injury
• open / depressed skull #
• post-traumatic seizure
• focal neurological deficit
• > 1 vomit

Question 4

in an adult with head injury, what warrants a CT head <8 hours?

Answer 4

none of the <1 hour indications but risk factors:

• on anticoagulation
• > 65 years
• bleeding/clotting disorder
• dangerous MOI
• > 30 mins retrograde amnesia

Question 5

in an adult with head injury, what would would you do if they have no risk factors and have no LOC / amnesia?

Answer 5

no imaging

Question 6

when do you admit and observe a pt following head injury?

Answer 6

• new, clinically significant abnormalities on imaging
  AND / OR continued concerning features
• other injuries: shock, suspected NAI, CSF leak
• deterioration → immediate assessment +/- repeat imaging

Question 7

what are the examples of new, clinically significant abnormalities on imaging that warrants admission and observation?

Answer 7

• haematoma causing mass effect
• depressed skull #
• pneumocephalus
• cerebral oedema

will need d/w neurosurgery

Question 8

what are the examples of continued concerning features that warrants admission and observation?

Answer 8

• persistent vomiting
• severe headaches
• GCS <15 more than 2 hours following injury
• seizures

Question 9

what is the criteria for safe discharge?

Answer 9

1. no indication of CT head or normal imaging
2. GCS 15/15
3. supervision available at home
4. resolution of all significant sx and signs
5. pt + carers should be given written head injury advice card with red flags for deterioration e.g. reducing GCS as well as expected signs and sx following head injury

Question 10

what can traumatic brain injury (TBI) be divided into?

Answer 10

• primary brain injury

- secondary brain injury

Question 11

what is primary brain injury?

Answer 11

occurs during the initial trauma

• cortical contusions due to coup and contrecoup injuries
• diffuse axonal injury from shear and tear forces

Question 12

what is secondary brain injury?

Answer 12

occurs after initial insult

- potentially preventable via maintenance of normal physiological parameters

Question 13

what is a mild brain injury and what are the sx?

Answer 13

concussion

sx:

• headache
• nausea
• decreased concentration and memory problem
• difficulty sleeping
• disorientation

Question 14

how long are sx commonly present for in mild brain injury?

Answer 14

first 7-10 days

may take up to a month to resolve (post-concussion syndrome)

Question 15

7th (facial) nerve palsy following head injury. dx?

Answer 15

basal skull fracture

Question 16

what is mannitol or hypertonic saline used for?

Answer 16

osmotic diuretic used acutely to lower ICP

Question 17

unilateral ptosis + down and out eye + fixed dilated pupil. dx?

Answer 17

“surgical/traumatic” 3rd nerve palsy

Question 18

inability to abduct eye after head injury. dx?

Answer 18

6th nerve palsy - false localising sign with raised ICP

Question 19

what does a reduced GCS at >2 hours since assessment of head injury warrant?

Answer 19

CT head <1 hour

Question 20

what should also be assessed in all pts with head injury?

Answer 20

associated cervical spine injury