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Head Injury

  • Altered level of consciousness is a hallmark of acute cerebral trauma
  • Never assume that substances (alcohol or drugs) are causes of drowsiness
  • Frequent clinical mistakes:
      - Incomplete ABC's, priority management
      - Incomplete primary, secondary surveys
      - Incomplete baseline neurologic examination
      - No reassessment of neurologic status

Basal skull fractures

    - Periorbital ecchymosis (racoon eyes)
    - Mastoid ecchymosis (Battle's sign)
    - Cerebrospinal fluid leak from ears or nose

Depressed skull fracture

    - Fragments of skull may penetrate dura, brain

Cerebral concussion

    - Variable temporary altered consciousness

Intracerebral hematoma

    - Caused by acute injury or delayed, progressive bleeding originating from contusion

Intracerebral hematoma

    - Decreased level of consciousness
    - Bradycardia
    - Unequal or dilated pupils
    - Seizures
    - Focal neurologic deficit

Basic medical management for severe head injury:

    - Intubation with supported ventilation, if available
    - Sedation
    - Moderate intravenous fluid input (euvolemia)—do not overload; use normal saline, avoid dextrose
    - Head of bed elevated 30 degrees
    - Prevent hyperthermia

Acute Extradural or Subdural Hematoma

Traumatic bleeding within epidural or subdural spaces (rarely both) increases intracranial pressure, causes neurological impairment, possibly death

Signs classically consist of:

    - Hemiparesis on opposite side as impact
    - Dilating pupil on same side as impact

Management is surgical: burr hole drainage of hematoma is an emergency, potentially life-saving procedure—the patient needs immediate referral


Skull fracture

    - Open, closed, depressed

Brain injury

    - Concussion: variable, temporary alteration of neurological function
    - Contusion: brain bruise
    - Compression: swelling or haemorrhage


    - History
    - Diminished level of consciousness, seizure


    - Give nothing orally
    - Protect airway
    - Limit fluid intake (2/3 maintenance)
    - Elevate head of bed to 30 degrees
    - Urgent review by paediatric or neurological surgeon
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