Head Injury
The Problem:
Head injuries can be trivial, minor (GCS 13 - 15), moderate (GCS 9 - 12), or severe (GCS 8 or below). Some cause bleeding or other problems that can add to the initial damages and we need to identify and control those events before new damage is done.  (See Bleeds.) Repetitive clinical examination and CT scans are the basic tools used to identify patients at  high risk for herniation. Remember that the C-spine may be unstable in anyone with a head injury. (see Clearing the C-spine.)

Patients with high GCS but imaging showing cerebral contusions and/or skull fractures often need observation in hospital for a few days. Reliable vital signs are needed Q 1 or 2 hours. Careful documentation of GCS and eye signs are crucial for reliable inter-observer detection of change. 

The big thing with skull fractures is sorting out the type and knowing which ones need to go to the OR. Open skull fractures (including ones involving the frontal sinuses) may need to be debrided. Depressed skull fractures that need operative management are usually depressed a distance equal to the thickness of the skull at the site of fracture.

 What We Do:
Patients with acute brain injury are usually started on Dilantin. Evidence suggests this to be of value for 2 weeks but not longer. In the short term, the main concern with contusions or diffuse axonal injury is the risk for delayed hemorrhage or dangerous swelling, shifts, and herniation. Prediction of ultimate cognitive and behavioural changes for an individual patient is not very accurate, but families usually keep asking anyway.

Alcohol is often a contributing factor to injuries. It can confounds the neurological assessment. Anticoagulants need to be identified as an extra risk factor in head injury patients and coagulopathies corrected ASAP. Strokes can occasionally cause MVA or fall with head injury. A good general assessment is needed in ER.

Basal skull fractures are common. Those with an associated CSF leak may need to be followed for meningitis. Rarely, elective surgery is needed to close the dural tear.  Be sure to document the cranial nerve exam well and to look in both ears. Check visual field acuity before their eyes are swollen shut.  If the patient is not improving in 24 hours get another CT.

Links:
For adults, there is a lot of good information at the Coma Recovery Association. For children, there is an especially good source from the Childrens Hospital in Los Angeles.

Evidence Footnotes:
1. reference

Authorship: Dr Valerie Taylor Last Revised: 29 May 2002
 
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