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Head Injury |
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Any patient who has sustained an injury to the face or jaws should be suspected of having an associated head injury. A history of a significant period of loss of consciousness, confusion, vomiting and a falling Glasgow coma score should lead the clinician to the possibility of the intra-cranial injury.
Any patient with a suspected head injury who requires admission is normally under the Medical team on-call.
The PRIMARY brain injury such as contusions occurs at the time of injury. The priority in such a patient is to prevent the evolution of SECONDARY brain injury such as intra / extra-dural haematoma and from anoxia. Close observation is therefore needed to assess the development of such pathology.
Neurological examination must include: ¨ Pupillary reflexes—direct and consensual ¨ Glasgow Coma Scale—GCS (max score is 15) ¨ Cranial nerve assessment ¨ Pulse and blood pressure ¨ Radiographic investigation after discussion with the A&E staff may include: ¨ Skull AP and lateral ¨ Cervical spine +/- odontoid peg views Management of the minor head injury patient on the ward includes observation for 24 hours or until the GCS returns to 15. Neurological observations should be performed half hourly for 6 hours, 1 hourly for 6 hours and then 2 hourly until the patient is fully conscious. Any changes in pulse +/- 20 bpm or in BP +/- 20mmHg should be reported to the medical staff on call (watch for a falling pulse rate and rising blood pressure as a warning of rising intra-cranial pressure).
Patients with a skull fracture should stay in hospital for 48 hours and those with a CFS leak should stay until the leak has stopped. Headaches/ acute pain should be treated with simple analgesia such as paracetomol. Do not use opioids as this may cause pupil constriction and mask the effects of rising intracranial pressure. Patients with persistent nausea and vomiting should be kept under observation until this settles.
The head injury patient, after the appropriate period of observation, should only be discharged into the care of a responsible adult. They should be given a ‘head injury card’ and warned of possible sequelae with a contact number in case of need.
Compound fractures of the skull base are often associated with a dural tear. This is associated with the escape of cranial contents—e.g. blood or CSF, and injury to cranial nerves. Thus features such as CSF rhinorrhea, orbital haematoma and injury to cranial nerves I—IV suggest a fracture of the anterior cranial fossa. The middle and posterior cranial fossae may also be involved.
CSF is clear and has a high sugar (clinistix) and low protein content (electrophoresis) compared to nasal or lacrimal fluid. The patient may complain of a persistent salty taste in the mouth.
Patients with such leaks are more at risk of bacterial meningitis either at an early stage (highest risk within 14 days) or occasionally many years later.
The administration of prophylactic antibiotics in the case of proven CSF leak is controversial. However, if there are associated facial/ oral lacerations and fractures, a course of e.g. Ampicillin to cover the pneumococcus is advisable. Should the leak not subside spontaneously then a formal dural repair may be necessary. |
