Diagnosis

• High energy impact: fall > 1 m; ejected from motor vehicle; High speed motor vehicle; bicycle
• Open or depressed skull fracture signs:
• Basal of skull, open or depressed fracture signs: Mastoid ecchymosis (bruising); Panda eyes w/o associated damage around eye; Bleeding from one or both ears
• Telephone referral: Unconscious; Focal neurology; Seizure; High energy; Suspicion of head injury
• Primary referral: Above + GCS < 15; Amnesia; Persistent headache; Vomiting; Anti-coagulation; NAI

Investigation

• GCS, state denominator and whether learning / neuro disability baseline
• CT imaging of choice to detect acute clinically significant brain injury
• CT head within 1 hr if:
  • GCS < 13 on initial assessment (< 14 children)
  • GCS < 15 after 2 hours of presentation
  • Suspect open or depressed skull facture
  • Focal neurology
  • Post traumatic seizure
  • > 1 episode of vomiting
• CT head within 8 hrs:
  • > 65 yrs
  • Clotting disorder
  • Warfarinised
  • High energy
  • > 30 retrograde amnesia before event
• CT cervical spine:
  • GCS < 13 on initial assessment
  • Intubated
  • Plain x-ray inadequate or suspicious
  • Definitive diagnosis required i.e. before surgery
  • Alert stable but: > 65; High energy impact; Paraesthesia in limbs; Focal neuropathy
• Assess range of movement only if none of above applies and one of the following:
  • Ambulatory and sitting comfortably
  • No midline cervical tenderness
  • Involved in simple rear end MVC
• X-ray cervical spine (3 planes): if neck pain but no indication as above for CT
• CT imaging of brain / cervical involve radiology department, reassess if initially considered low risk
• CT should cover any areas of concern on X-ray or clinical grounds including cervical spine
• If patient returns within 48 hrs then senior review +/- CT scan
• MRI (angiography) if injury referable to cervical spine especially is vascular injury due to vertebral misalignment, fracture of foramina tranversaria, lateral processes
• MRI has a role in ligamentous and disc injuries highlighted by CT / X-ray
• Discuss w/ neurosurgeon new ‘surgically significant’ imaging abnormality: ‘significant’ agree locally
• Discuss with neurosurgeon: Persistent GCS < 8 (coma); Deteriorating GCS; Progressive neurological signs; CSF leak; Seizure w/o recovery; Suspected penetrating injury

Management

• ATLS, ITLS, APLS
• Neck immobilisation if: GCS < 15; Neck pain; Focal Neurology; Paraesthesia in extremities; Suspicion
• Manage pain as can lead to rise in ICP
• If GCS < 8 involve an anaesthetist
• Transfer to Neurosurgical unit:
  • Consider occult injury
  • Designated consultant to establish transfer arrangements
  • Accompanied by doctor with adequate training and means of communication
  • Complete resuscitation and stabilisation before transfer
  • Intubate and ventilate if GCS < 8
• Admit if:
  • New imaged abnormality; GCS not returned to 15; Continued worrying signs; CT not done
• Observation: ½ hrly until GCS back to 15, then ½ hrly for 2 hrs, 1 hrly for 4 hrs, 2 hrly thereafter
• Urgent reappraisal if 1 point dropped for > 30 mins
• Discharge only once GCS = 15 and suitable supervision at home (24 hrs), but explain risk factors that means should return per referral guidelines in diagnosis above

NICE Source: CG176 Head injury: assessment and early management. Summary compiled by Dr D P Sheppard MBBS.