Head injury

Question 1

What should you diagnose if the pupils are uneven?

Answer 1

Rising intracranial pressure e.g. from extradural haemorrhage and get neurosurgical helo

Question 2

How can you exclude rising intracranial pressure?

Answer 2

Retinal vein pulsations at fundoscopy

Question 3

What is the immediate management plan for head injury? (ABC)

Answer 3

• ABC - stabilise airway, breathing, circulation
• Oxygen if sats <92% or hypoxic on ABG; intubate and hyperventilate if necessary. Immobilise neck until injury to cervical spine excluded
• Stop blood loss and support circulation; treat for shock if required

Question 4

How do you treat seziures due to head injury?

Answer 4

Give IV lorazepam +/- phenytoin

Question 5

When should you intubate a patient post head injury? What should you assess for in terms of memory?

Answer 5

• If GCS is 8 or less
• Get ICU involvement
• Assess anterograde amnesia (loss from the time of injury, ie post-traumatic) and retrograde amnesia (for events prior to injury)—extent of retrograde loss correlates with severity of injury, and never occurs without anterograde amnesia.

Question 6

When is it appropriate to perform a head CT in <8hr post admission?

Answer 6

Any LOC or amnesia AND any of:

• age >65yrs
• coagulopathy
• high-impact injury e.g. struck or ejected from vehicle: fall >1m or >5stairs
• retrograde amnesia of >30min

Question 7

When should you perform a head CT within 1hr in head injury?

Answer 7

• If GCS <13 on initial assessment or <15 at 2hr following injury
• Focal neurological deficit
• Suspected open or depressed skull fracture, or signs of basal skull fracture; periorbital ecchymoses (“panda” eyes/racoon sign), postauricular ecchymosis (Battle’s sign), CSF leak through nose/ears, haemotympanum
• Post-traumatic seizure
• Vomiting more than once

Question 8

List 4 signs of base of skull fractures.

Answer 8

• periorbital ecchymoses (“panda” eyes/racoon sign),
• postauricular ecchymosis (Battle’s sign),
• CSF leak through nose/ears,
• haemotympanum

Question 9

What is the management if you suspect cervical spine injury?

Answer 9

Perform CT spine <1hr if

• GCS<13 initially
• intubated
• definitive diagnosis of cervical spine injury needed
• other areas are getting scanned
• clinical suspicion of cervical spine fracture AND >65yrs/high-impact/focal neurology/paraesthesias in upper or lower limbs.

Question 10

Why should you not attribute low GCS to alcohol?

Answer 10

• Significant head injury may be present
• Alcohol is unlikely to cause coma if plasma alcohol is <44mmol/L

Estimate alcohol from osmolar gap if test unavailable - if blood alcohol ~40mmol/L then osmolar gao ~40mmol/L

Question 11

What are the indications of a bad prognosis in head injury?

Answer 11

• Old age
• Decerebrate rigidity
• Extensor spasms
• Prolonged coma
• High BP and low PaO2 on ABG
• Temperature >39oC
• 60% of those with LOC of >1month will survve 3-25yrs but may need daily nursing care