Head Injury

Question 1

What do we mean by secondary brain injury?

Answer 1

When complications such as cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates original brain injury

Question 2

What medication can you use if there is life threatening rising ICP whilst waiting for transfer to specialist unit or for theatre to be prepared?

Answer 2

IV mannitol

Question 3

Discuss when ICP monitoring is:

• Appropriate
• Mandatory

Answer 3

• Appropriate= GCS 3-8 and normal CT scan
• Mandatory= GCS 3-8 AND abnormal CT scan

Question 4

NICE has clear, strict guidance regarding which adults should have CT heads. Of the adults who need a CT head, some of them will need it immediately and some within 8hrs of head injury.

State the NICE criteria for immediate head CT following head injury

Answer 4

• GCS <13 on initial assessment
• GCS <15 2hrs post injury
• Any signs of basal skull fracture (panda eyes, battle’s sign, CSF leakage from ear or nose, haemotypanum)
• Post-traumatic seizure
• Focal neurological deficit
• >1 episode of vomiting
• Suspected open or depressed skull fracture

Question 5

NICE has clear, strict guidance regarding which adults should have CT heads. Of the adults who need a CT head, some of them will need it immediately and some within 8hrs of head injury.

State the NICE criteria for CT head within 8hrs of injury

Answer 5

For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury, perform a CT head scan within 8 hours of the head injury:

• ≥65yrs
• Hx of bleeding, clotting disorders or on anticoagulants
• Dangerous mechanism of injury (e.g. pedestrian hit by car, ejection from motor vehicle, fall from >1m)
• >30 mins of retrograde amnesia of events before head injury

Question 6

State some key questions to ask in a head injury history

Answer 6

• When
• Mechanism
• Symptoms:
  
  • LOC
  • Confusion
  • Amnesia
  • Seizure
  • Vomiting (how many episodes)
  • Headache
  • Neck pain
  • Visual disturbances
• Drug or alcohol intake
• Anticoagulants
• PMH
  
  • Bleeding disorders
  • Surgery
  • Previous head traumas

Question 7

State some key things to examine for in patient with head injury

Answer 7

• GCS
• Vital signs
• Visible trauma
• Cranial nerves (including fundoscopy)
• Focal neurological deficit
  
  • Speech
  • Balance/walking
  • Muscle power
  • Sensation
  • Reflexes
• Signs basal skull fracture
  
  • Battle’s sign
  • Periorbital haematoma
  • CSF from ears or nose
  • Hemotympanum
• Neck tenderness & range of motion

Question 8

Remind yourself of GCS

Answer 8

Question 9

Describe the difference between decorticate and decerebrate posturing

Answer 9

Question 10

Discuss the immediate management of raised ICP

Answer 10