Injuries — head

All people with a head injury must be treated as though they also have a neck injury

• If person has any red flags they may have a serious head injury and/or increased risk of deterioration — see Management
• You must know your responsibility under the laws in your jurisdiction relating to violence against adults, children and mandatory reporting

Assessment

Do not

• Do not assume altered consciousness is due to alcohol. If unconscious person has been drinking — always treat as head injury and do medical consult
• If possible intoxicated person should be observed until clinically not intoxicated  
• Do not give sedating medication to drowsy, confused or agitated persons with a head injury 

Ask

• Mechanism of injury — what happened, when it happened
• Has person had any alcohol or other drugs

Check

Person must always be woken up for all head injury assessments. If unable to wake them — urgent medical consult

Do quick initial check for level of consciousness using AVPU. If only P or U — may need airway protection

• Alert — eyes open, understanding, following commands, talking
• Tell person not to move their head
• Voice — not alert but responds to your voice
• Pain — responds only to pain. Squeeze muscle at top of shoulder (trapezius squeeze) — Figure 2.21
  
• If only small response — low groan without opening eyes, treat as unresponsive
• Unresponsive — unconscious, not responding

• U/A, pregnancy test
• Coma scale score (Table 2.11,Table 2.12)
• Pupil reactions — record time in file notes
• Head-to-toe exam — with attention to signs of skull fracture
• Laceration or haematoma (blood filled swelling) on scalp
• Bruising around eyes (raccoon eyes) or behind ears (Battle's sign)
• Clear or blood-stained fluid (CSF) from ears or nose
• Blood in ear canal or behind eardrum
• Bleeding into white of eye AND can’t see back edge of bleed
• Feel for skull fractures/bogginess under cuts and bruises on head or face
• Limb weakness, lack of movement
• Immunisation status — tetanus

Glasgow Coma Scale

Child Coma Scale

Use for children under 5 years

* Child over 2 years can often follow commands

Scoring coma scale

• Do not record amnesia as confusion
• If in doubt between 2 levels — score at lower level
• Report scores of component parts (E3, V2, M5) as well as total score
• Motor score (M) most useful

Interpreting score

• 3–8 — Severe head injury
• 9–13 — Moderate head injury
• 14–15 — Minor head injury

A score of 15 doesn't mean 'normal'. Can still have altered cognitive function

• If coma scale score falling — medical consult
• Drop of 2 or more points in score is very serious
• May be problems other than head injury — shock
• May be due to rising intracranial pressure

Pupil reactions

• Pupils should be the same size. Dilated pupils are a late sign of deterioration
• Both should constrict (get smaller) when a light is shone into either eye

Check

• Move out of direct sunlight or have someone shade person's eyes so you can see pupils clearly
• Look at both pupils with a bright light
• Are pupils the same size
• Does size change when bright light shone into them
• Is reaction time fast or slow
• If pupils are dilated, sluggish or unequal — Figure 2.22. May be due to
• Eye or head injury
• Increased intracranial pressure (bleeding into brain)
• Some eye drops
• Some toxins, chemicals

• Difference in pupil size of 0.5–1mm may be anisocoria (normal for person). Check carefully for difference in reaction

Management

Medical consult after initial assessment and stabilisation if person has any of the risk factors below

Moderate or severe head injury

Moderate — coma scale score 9–13
Severe — coma scale score 3–8

Do

• Medical consult
• 15 minutes observation including coma scale, pupil assessment or as directed by medical consult
• Tilt head of bed up 15–30°. If concern about spinal injury — tilt whole bed
• Keep cervical spine (neck) still — use cervical collar (per organisation guidelines) OR cushioning/padding to keep head and neck in position
• Monitor airway
• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%
• Put in IV cannula, largest possible
• POC Test — lactate
• In head injury, too much IV fluid can cause swelling on the brain
• If bleeding from other injuries causes fast pulse or shock (low BP) — give IV fluids in 250–500mL boluses to keep systolic BP 90–100mmHg
• If low BGL — see hypoglycaemia
• Keep temp normal — warm up if temp less than 34°C and cool if temp more than 38°C
• If fitting — give midazolam
• Medical consult

Do also — if severe

• Medical consult — may need to
• Give antiemetic to stop vomiting — non-sedating preferred (eg ondansetron)
• Manage fitting — load with levetiracetam IV infusion over 15 minutes — 20mg/kg/dose up to 3,000mg — doses
• If getting worse despite resuscitation (eg deteriorating level of consciousness, unilateral/one-sided paralysis, unequal pupils) — may need mannitol or hypertonic saline. Medical consult, doctor should talk with retrieval team
• If scalp skin broken — give cefazolin IV or intraosseous — adult 2g, child 50mg/kg/dose up to 2g — doses — every 8 hours (tds) until evacuated. Can give IM if needed but painful
• If allergy to penicillin or cephalosporins — give clindamycin IV — adult 600mg, child 15mg/kg/dose up to 600mg — doses — every 8 hours (tds) until evacuated
  

Follow-up

Send to hospital for CT scan, further assessment and management if

• Severe or moderate head injury
• Possible skull fracture — high risk of bleeding in/around brain, CT scan needed
• Minor head injury with other serious injury/instability

Minor head injuries

Coma scale score 14–15

Do

• Half hourly observations including coma scale score and pupils assessment in clinic for at least 2 hours after injury, if score deteriorates — medical consult
• If over 65 years — medical consult, CT scan if available
• Can be sent home with responsible carer at 2 hours after injury if all the below are OK
• Unconscious for less than 5 minutes
• Coma scale score 15
• Improving clinically
• No weakness, numbness, tingling anywhere
• No ongoing drowsiness, confusion, headache, vomiting, memory loss
• No known bleeding disorder (eg warfarin use), bad liver disease, dialysis
• No evidence of being under the influence of alcohol or drugs
• Carer is able to check person is not showing any signs of deterioration for next 2 hours (ie person is observed for a total of 4 hours post injury)
• Carer understands signs of deterioration and is able to contact clinic
• Give verbal and written advice (in appropriate language if available) to person or carer
• If during night time hours, carer must wake person at least once for assessment

Follow-up

• Tell them to come back to clinic if any of these things happen
• Confusion, drowsiness, slurred speech, memory impairment, poor concentration
• Vomiting, headaches, fitting, dizziness
• Fatigue, sleep disturbance
• Unusual clumsiness
• Acting strange, change in behaviour, mood swings
• Bleeding or fluid loss from ears or nose

Bleeding scalp wound

Check

• Head injury assessment
• Immunisation status — tetanus

Do

• Stop bleeding — apply firm direct pressure using hands or pad
• If artery spurting blood — clamp with artery forceps or suture
• Most bleeding stops after adequate suturing or stapling
• Clean wound using large amounts of normal saline 
• Remove dirt and hair — clip or shave hair with consent
• If pieces of bone — leave in place
• IV antibiotics as for compound fracture
• Medical consult
• Close wound — suture with 3.0 monofilament or silk or staple
• Local anaesthetic — use lidocaine (lignocaine) 1% + adrenaline (epinephrine) 1:100,000 if available