K. Trauma

K. Trauma

Head: General

Head Injury:

Protocols for management of head injuries are constantly under review and will vary according to local availability of CT, distances involved in transportation to neurosurgical centres, etc. The recommendations given here may need to be adapted following consultation with the neurosurgical centre for your area in the light of local circumstances and policies.

The key management and clinical questions in head injury are:

Clinical:

Is there evidence of brain injury?
Is there evidence of intracranial haemorrhage or raised intracranial pressure?
Is there clinical evidence of a skull fracture and, if so, is it depressed?
Are other systems/areas involved?

Management:

Does the patient need admission to hospital for observation?
Is CT required?
Is a neurosurgical opinion required?

These questions underline key policies concerning management of patients. Decisions about imaging requirements cannot be separated from non-imaging issues such as admission.

The usual indications for admission include: confusion or depressed consciousness; fracture on SXR; neurological symptoms or signs; seizures; CSF or blood from nose or ear; coagulation disorders; lack of adult supervision at home; patient difficult to assess (?non-accidental injury (NAI), drugs, alcohol, etc.). If a decision is made to admit for observation, imaging becomes less urgent, and the patient will be better examined when sober and more co-operative. CT is increasingly being used as the first investigation in those where there is a medium risk of intracranial injury, in which case SXR is usually unnecessary. Difficulties with image interpretation or the management of the patient may be resolved by referrals via image transfer systems to designated neuroscience centres.

Intracranial abnormalities suggesting need for urgent neurosurgical management include:

High or mixed attenuation intracranial lesion
Shift of mid line structures (e.g. third ventricle)
Obliteration of third ventricle
Relative dilatation of a lateral ventricle(s)
Obliteration of basal cisterns
Intracranial air
Sub arachnoid or intraventricular haemorrhage.

Children

Head injuries are relatively common in children; in the majority of cases, there is no serious injury: imaging and hospitalisation are unnecessary. If there is a history of loss of consciousness, neurological signs or symptoms (excluding a single vomit) or an inadequate or inconsistent history, imaging is required. CT is the simplest way of excluding significant brain injury. If non-accidental injury is suspected, a skull SXR as part of a skeletal survey is required. In addition, MRI of the brain may be required later to further document timing of the injury.

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