Head injury defined as any trauma to the head other than superficial injuries to the face
Assessment
Examination
Management
Complications
Cognitive
Pyschological
Metabolic
Physical
Reference
commonest cause of death and disability in people aged 1–40 years in the UK
concussion- disturbance in brain function caused by force, resulting in acute impairment, resolves spontaneous
post concussion syndrome- headaches, dizziness, nausea
intracranial haemorrhage-increased risk in people taking anticoagulants
Open or depressed skull fracture; basal skull fracture
seizures
problems with gait, muscles, weakness
Hypopituitarism--symptoms non specific. Rare life-threatening complications include sodium dysregulation and adrenal crisis.
depression and anxiety
PTSD
Challenging behaviour may include inappropriate vocalisation, disinhibited or sexualized behaviour
memory, attention and concentration, planning, problem-solving, language, and perception problems
Hx of symptoms, DHx- anticoagulants, affects on systems
Mechanism of injury- fall/height/speed and nature
Hx of injury- how,, when and why injury occurred
Examination- GCS to assess level of consciousness. Note in dementia may be altered prior to injury
Observations- BP, TPR, SpO2, CR- for signs of hypoxia/shock
Assessment before during and after fall
Evidence of trauma to scalp, skull, head and neck
CNS examination -PEARL, focal neurological deficit e.g. visual, speech , balance, walking, muscle disturbances
Observe for signs of basal skull fracture-clear fluid draining from ears or nose/bleeding from ears or nose/bruising behind ears/periorbital haematomas
Assess neck tenderness - range of neck movements
Suspect non accidental injury as a contributory factor or cause of head injury in children when explanation does not match injuries (see Child protection)
Referral
Refer any patient with red flags/risk factors to A&E, accompanied with a competent adult. Clinical judgement would determine level of urgency
written and verbal information on details, nature and severity of injury and risk of complications following a head injury
offer support if any issues alcohol/drug abuse
Assess affect on ADLs and offer support, sign post or refer
Risk Factors /Red Flags
A Glasgow Coma Scale (GCS) score of less than 15 on initial assessment.
Evidence of shock, or other injuries suggesting chest or abdominal trauma, limb or pelvic trauma, or significant vascular injury.
Dangerous mechanism of injury or high-energy head injury.
A history of bleeding or coagulation disorders, or current anticoagulant medication.
Current alcohol or drug intoxication.
Any loss of consciousness after the injury (even if they are fully alert on presentation).
Any post-traumatic seizure.
Any previous brain surgery.
Amnesia (antegrade or retrograde) lasting more than 5 minutes. Note: assessment of amnesia is unlikely to be possible in a child aged under 5 years.
Persistent headache since the injury.
Vomiting since the injury — particularly more than one episode in an adult or three or more episodes in a child, using clinical judgement.
Any focal neurological deficit since the injury.
A suspected open or depressed skull fracture, or tense fontanelle in a child.
A suspected basal skull fracture.
Signs of a penetrating injury or visible trauma to the scalp or skull — in children under 1 year of age, a bruise, swelling, or laceration of more than 5 cm on the head.
Suspected cervical spine injury following assessment of the neck.
Concern about the diagnosis of head injury.
Risk Factors/Red Flags
offer support and self care advice e.g work, driving, sports, reassure symptoms resolve usually within 3 months.
analgesia if indicated
Safety netting- if symptoms worsen, dont improve, or delayed affects eg anxiety to return to GP
click to edit
neurology or neuroendocrinology, neuropsychology or psychiatry, neurosurgery, or a specialist in rehabilitation medicine, depending on clinical judgement, if:
Persistent non-specific symptoms for more than three months suggesting possible post-concussion syndrome.
Another complication or cause of head injury is suspected, for example, if there are new-onset focal neurological signs.
There are concerns or uncertainty about the nature or severity of symptoms