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
HEAD INJURY IN CHILDREN
Skull fracture
- Open, closed, depressed
Brain injury
- Concussion: variable, temporary alteration of neurological function
- Contusion: brain bruise
- Compression: swelling or haemorrhage
Diagnosis
- History
- Diminished level of consciousness, seizure
Treatment
- 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