Head and C-spine injury

Question 1

Head injury.

a) Neuro obs - what to assess?
b) Neuro obs - how often to assess?
c) Who to CT?
d) Previously normal CT - when to repeat?

Answer 1

a) Neuro obs:
- GCS;
- pupil size and reactivity;
- limb movements;
- SpO2, RR, HR, BP, Temp

b) For GCS 15*: (if remaining in hospital)
- Half-hourly for 2 hours.
- Then 1-hourly for 4 hours.
- Then 2-hourly thereafter.

*If at any stage GCS drops below 15, restart half-hourly neuro obs

c) - High-energy mechanism of injury
- Symptoms: LOC, amnesia, progressive/severe headache, vomiting, neck pain (C-spine CT)
- Signs: reduced GCS, focal neurology, signs of basilar skull fracture
- Other factors: anticoagulation, intoxication/drug use

d) Normal CT scan but not achieved GCS equal to 15 after 24 hours’ observation (or deterioration)

Question 2

Head injury: history

a) Mechanism - high-energy examples
b) Worrying symptoms at/since injury
c) Factors in DHx/SHx increasing the level of risk

Answer 2

a) - Fall from a height > 1 metre or 5 stairs.
- Diving accident.
- High-speed motor vehicle collision, either as a pedestrian, cyclist, or vehicle occupant.
- Rollover motor accident or ejection from vehicle.

b) - LOC, amnesia, progressive/severe headache, vomiting, neck pain

c) - Recent alcohol or drug intake.
- Current anticoagulation

Question 3

Head injury: examination

a) Initial A-E assessment
b) Gross inspection of head
c) Worrying signs on neuro examination
d) Other examination to perform (*contraindicated in who?)

Answer 3

a) A-E assessment:
- Airway - GCS < 8?
- Breathing - hypoxia, abnormal breathing
- Circulation - shock, Cushing reflex, etc.
- Disability - GCS, glucose, pupils, focal neurology
- Exposure - bleeding, rashes

b) - Signs of visible trauma to the scalp, skull and neck
- Basilar skull fracture: periorbital / mastoid ecchymosis, CSF rhinorrhoea / otorrhoea, haemotympanum, new deafness

c) - Pupillary abnormality
- Cranial nerve palsy
- Any focal neurological deficit, such as: dysphasia,
ataxia, reduced power or abnormal sensation,

d) C-spine exam* - signs of a possible C-spine injury:
- Midline cervical spine tenderness
- Lateral rotation restricted to < 45 degrees to left + right

• contraindicated if:
• High-energy vehicle collision.
• Neck uncomfortable/painful in a sitting position.
• Non-ambulatory at any time since the injury.
• No midline cervical spine tenderness.

Question 4

Head injury in children: when to consider NAI

a) Site and character of bruise/injury
b) Child age/demographic
c) Other injuries/clinical signs
d) Other factors in the presentation

Answer 4

a) The injury or bruise is:
- On any non-bony part of the face (including eyes/ ears)
- On both sides of the face or head.
- Disproportionate to the explanation of injury
- Present in multiple sites or in clusters.
- Of a similar shape and size.

b) The child is not yet independently mobile (crawling, cruising, walking).

c) - Retinal haemorrhages
- Rib fractures

d) - The explanation for the injury is implausible, inadequate, or inconsistent (eg. between parents or carers; between accounts over time)
- There is a delay in presentation.

Question 5

Head injury: safety netting advice for discharge

Answer 5

• Responsible adult with them for first 24 hours