Head Injury Flashcards
Within what timeframe should patients presenting with head injury be assessed?
Within 15 minutes of arrival to A&E, to determine if TBI or spine injury. Assess C-spine then ABCDE
What is the primary goal of treating someone with suspected TBI?
To prevent 2ndry brain injury
First stuff you’d do when presented with head injury BEFORE properly assessing them?
- put out trauma call on 2222
- move pt to resus bay
Airway/C-spine assessement?
- Triple immobilize cervical spine until formally cleared
- Ensure airway patency
Breathing assessment
- Administer high flow O2 (15 L via non-rebreather mask)
- Gain observations: oxygen saturations, respiratory rate.
- Inspect/ palpate thorax for equal chest movements and signs of trauma
- Auscultate and percuss chest, responding to abnormalities
- ABG
C - Circulation and Control of haemorrhage:
- Assess haemodynamic stability with blood pressure, heart rate, ECG and peripheral circulation
- Assess for any bleeding source
- IV access with 2 wide bore cannulae
- Send off blood including FBC, U&E, LFT, clotting, G&S and X-match
- If hypotensive start IV fluids (normal saline is best) or O- blood, as indicated
D - Disability
- Assess conscious level (GCS or AVPU)
- Assess for lateralizing sign
- Temperature
- BM/ blood glucose
- Pupil reaction
E - exposure:
- Completely expose patient to assess for any missed injuries whilst avoiding hypothermia.
- Based on the history it would be particularly pertinent to assess the head for signs of trauma.
Revise GCS assessment
EYES
1. No response
2. Opens to pain
3. Opens to voice
4. Opens spontaneously
VOICE
1. No response
2. Incomprehensible sounds
3. Inappropriate words
4. Confused
5. Orientated
MOVEMENT
1. No response
2. Extends to pain
3. Flexes to pain
4. Withdraws to pain
5. Localises to pain
6. Obeys commands
How would you manage GCS of 8/15 or less?
Needs definitive airway
Call on-call anaesthetics team
What is a definitive airway
Cuffed tube below the level of the vocal cords used to allow airway access.
What are the indications of a CT head?
Perform CT head scan:
Within 1 hour if:
- GCS 12 or less on initial assessment in the ED
- GCS < 15 at 2 hours after the injury on assessment in the ED
- Suspected open or depressed skull fracture
- Any signs of basal skull fracture
- Posttraumatic seizure
- Focal neurological deficit
- More than 1 episode of vomiting
Within 8 hours if:
- Age >65
- History of bleeding or clotting disorders
- Dangerous mechanism of injury (pedestrian or cyclist struck by motor vehicle, an occupant ejected from motor vehicle or fall from a height greater than 1 meter or 5 stairs)
- More than 30 minutes retrograde amnesia of events immediately before the head injury.
https://www.nice.org.uk/guidance/ng232
A candidate in a previous interview was pressed on naming as many of these as possible. Try to learn guidelines for 1-hour criteria as an absolute minimum.
How can GCS determine severity of head injury?
GCS 13-15 = mild
GCS 9-12 = moderate (CT within 1 hour)
GCS 3-8 = severe (definitive airway needed)
What are some signs of basilar skull fractures?
- haemotympanum (blood behind ear drum)
- raccoon eyes
- CSF otorrhoea or rhinorrhoea
- Battle’s sign (bruising behind ear, over mastoid)
What factors can increase mortality or risk of secondary brian injury?
Hypotension and hypoxia
What do you do if BP isn’t rising above 100mmHg?
Neurological exam is not a priority if BP <100. Need to establish cause of hypotenison (intracranial haemorrhage cannot cause haemorrhagic shock, so likely other cause)
Perform FAST scan, consider if pt needs urgent theatre for laparotomy
What are some significant findings on CT head?
- Scalp swelling
- subgaleal haemorrhage at region of impact
Crucial findings:
- intracranial bleeding
- contusions
- mass effect, midline shift
Shift of 5mm or more needs surgery
