Head injury

Question 1

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

Answer 1

Impression
This is a major trauma, and such a patient should be assessed and managed as such, with consideration for all serious head and C-Spine injuries during initial work-up to be ruled out, and any acute pathology emergently managed. In this setting I would be concerned about;

Bony pathology;
- base of skull fractures
- C-spine fractures
- facial fractures
- depressed skull fractures
Vascular pathology
- extradural hb (arterial)
- subdural hb (venous)
- sub-arachnoid
- intra-parenchymal bleed
Brain injury
- concussion
- diffuse axonal injury
- coup/contra-coup contusion
- TBI

Management priorities

• Conduct primary survey after assembling appropriate trauma team involving senior clinicians, setting should be in ED resus bay.
• Priorities are to conduct full survey, including appropriate imaging such as CT Brain according to clinical indications and instituting any short-term stabilising measures
• definitive management through orth referral, or retrieval to tertiary trauma centre and neurosurgeon involvement as necessary according to injuries.

Question 2

Head trauma - History

Answer 2

History
- mist ample, collateral history where relevant

Other relevant

• recent head injury/stroke/vascular accident
• CVD risk factors
• anticoagulation medication
• PSHx

Question 3

Head trauma - Assessment

Answer 3

Assessment
Would call for senior assistance, move to ED and begin primary survey

A - patent, maintaining, tube pending GCS
B - RR, SP02, assess for evidence of fractures, auscultate for breath sounds, etc
C - IVC access, initial bloods (VBG, FBC, UEC, G+H), ECG, fluids, if significant blood loss consider like-with-like replacement, treat any episodes of hypotension immediately, consider need for vasopressors (under guidance of senior colleague)
D - GCS, C-Spine assessment (Canadian C spine rule), CT Brain, CT Spine, CT facial bones, trauma series X-Ray, otherwise clear C-Spine clinically if
E - Temp, secondary survey, log roll for other injuries
F - IDC insertion, UO monitoring
G - BSL

• involve neurosurgeon early if Red flag injury is identified
• retrieval/transfer to tertiary centre

Question 4

Head Trauma - History

Answer 4

History

• collateral: witnessed LOC?, alcohol?, neurological deficits (walking, talking, etc)
• sx: pain - SOCRATES,
• MIST AMPLE
• utilise NEXUS criteria, Canadian C-Spine, Canadian CT head rules

Question 5

Head Trauma - Examination

Answer 5

Examination

• general appearance
• neuro exam: pupils, focal deficits, lateralising weakness
• base of skull fracture: battles sign, racoon eyes, CSF rhinorrhoea/otorrhoea, haemotympanum, cranial nerve palsy
• ICP: cushings reflex, papilloedema, anisicoria,

Question 6

Head Trauma - Investigations

Answer 6

Investigations
as per A to E assessment
- Bedside: eFAST scan, BSL, ECG, VBG
- Bloods: G+H, coags, FBC, UEC, LFT
- Imaging: