Delay
in the early assessment of head-injured patients can have
devastating consequence in terms of survival and patient
outcome. Hypoxia and hypotension double the mortality of head-injured
patients.
The following conditions are potentially life-threatening,
but difficult to treat in district hospitals. It is important
to treat what you can, within your expertise and resources,
and to triage casualties carefully.
ACUTE EXTRADURAL
Classically, the signs consist of:
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Loss
of consciousness following a lucid interval, with rapid
deterioration |
| :: |
Middle
meningeal artery bleeding with rapid raising of intracranial pressure |
| :: |
Development
of hemiparesis on the opposite side of the impact area
with a dilating pupil on the same side, with rapid deterioration. |
ACUTE
SUBDURAL HAEMATOMA
Acute subdural haematoma (clotted blood in the subdural space accompanied by
severe contusion of the underlying brain) occurs from the tearing of bridging veins
between the cortex and the dura.
Management is surgical and every effort should be made to do burr hole decompressions.
The diagnosis can be made on history and examination.
The conditions below should be treated with more conservative medical management,
as neurosurgery usually does not improve the outcome.
BASE-OF-SKULL FRACTURES
Bruising of the eyelids (Racoon eyes) or over the mastoid process (Battle’s sign);
cerebrospinal fluid (CSF) leak from ears and/or nose.
CEREBRAL CONCUSSION
Cerebral concussion with temporary altered consciousness.
DEPRESSED SKULL FRACTURE
A depressed skull fracture is an impaction of fragmented skull that may result in
penetration of the underlying dura and brain.
INTRACEREBRAL HAEMATOMA
Intracerebral haematoma may result from acute injury or progressive damage secondary
to contusion.
Alteration of consciousness
is the hallmark of brain injury.
COMMON ERRORS
The most common errors in head injury evaluation and resuscitation are:
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Failure
to perform ABC and prioritize management |
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Failure
to look beyond the obvious head injury |
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Failure
to assess the baseline neurological examination |
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Failure
to re-evaluate a patient who deteriorates. |
MANAGEMENT
Stabilize the Airway, Breathing and Circulation and immobilize the cervical
spine, if possible. Vital signs of important indicators in the patient’s
neurological status must be monitored and recorded frequently. Undertake
a Glasgow Coma Scale (GCS) evaluation.
Never assume that alcohol is the cause of
drowsiness in a confused patient.
Remember:
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Severe
head injury: GCS of 8 or less |
| :: |
Moderate
head injury: GCS between 9 and 12 |
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Minor
head injury: GCS between 13 and 15. |
Deterioration
may occur due to bleeding:
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Unequal
or dilated pupils may indicate an increase in intracranial
pressure |
| :: |
Head
or brain injury is never the cause of hypotension in
the adult
trauma patient |
| :: |
Sedation
should be avoided as it not only interferes with the
state of
consciousness, but will promote hypercarbia (slow breathing with
retention of CO2) |
| :: |
The
Cushing response is a specific response to a lethal rise
in intracranial pressure. This is a late and poor prognostic
sign. The hallmarks are:
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Bradycardia |
| • |
Hypertension |
| • |
Decreased
respiratory rate. |
|
Basic
medical management
Basic medical management for severe head injuries includes:
| :: |
Intubation
and moderate hyperventilation, producing moderate hypocapnia
(PCO2 to 4.5–5 Kpa)
| • |
This
will temporarily reduce both intracranial blood
volume and
intracranial pressure |
| • |
Hypoxia
and hypoventilation may kill patients |
|
| :: |
Sedation
with possible paralysis |
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Moderate
IV fluid input with diuresis: i.e. do not overload |
| :: |
Nurse
head up 20%
|
| :: |
Prevent
hyperthermia. |
Caution:
Never transport a patient with a suspected cervical spine
injury in the sitting or prone position; always make sure
the patient is stabilized before transferring.
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