Download Head Injury - Aberdeen Emergency Medicine

Head Injuries in the
Emergency Department
August 2015
Emergency Department
Aberdeen Royal Infirmary
Agenda
 Background
 Management
 Clinical
 XRay
principles
features
appearances
Emergency Department
Aberdeen Royal Infirmary
Head Injury

Trauma is the leading cause of death before
the age 45
 50% of traumatic deaths are due to head injury
 In Scotland, every year, head injury results in




100,000 hospital attendances
20,000 hospital admissions
9000 patients with residual neurological disability
640 deaths
Emergency Department
Aberdeen Royal Infirmary
Primary Brain Injury
 Injury
to, or irreversible death of, neurones
at the time of injury
 Direct
result of the force of injury
 Role
of accident prevention and devices to
limit force of injury

e.g. bicycle helmets
Emergency Department
Aberdeen Royal Infirmary
Secondary Brain Injury
 Ongoing
insults after the moment of injury
extend the damage to neurones
 Prevention
of these is the focus of
treatment
Emergency Department
Aberdeen Royal Infirmary
Key Management Principles


Identify at risk groups
Prevent, or limit, the causes of secondary
brain injury







Hypoxia
Hypercarbia
Hypotension
Hypo- or Hyper-glycaemia
Hyperthermia
Convulsions
Raised Intracranial Pressure
Emergency Department
Aberdeen Royal Infirmary
Treatment
Emergency Department
Aberdeen Royal Infirmary
Treatment - ATLS

Airway + Oxygen + C-spine protection

Breathing + ventilation

Circulation + haemorrhage control



Disability


Monitor…
IV access +/- fluids
AVPU/GCS, pupils, focal/lateralizing signs
Exposure/Environment

Other injuries + co-morbidities
Emergency Department
Aberdeen Royal Infirmary
At Risk Groups
 Indications
for referral to hospital
 Indications
for admission
 Indications
for imaging
 Indications
for neurosurgical referral
Emergency Department
Aberdeen Royal Infirmary
Referral to Hospital
 NHS










24, GP, Minor injuries Unit
GCS<15 at any time after injury
Loss of consciousness
Focal neurological deficit
Suspicion of skull fracture or penetrating injury
Headache, vomiting, seizure since injury
Amnesia
High energy injury
Hx of clotting disorder on anti-coagulant therapy
Drug or alcohol intoxication
Concerns of NAI
Emergency Department
Aberdeen Royal Infirmary
History
Emergency Department
Aberdeen Royal Infirmary
History

LoC ?

Vomited?

Mechanism ?




High speed
Penetrating
Lateral blow
Other injuries
Examination
Emergency Department
Aberdeen Royal Infirmary
Examination

GCS

Pupils

Cranial nerves

Focal deficits

Lateralising signs
Examination
Emergency Department
Aberdeen Royal Infirmary
Examination


Explore the wound

Full thickness ?

Boggy haematoma ?

Palpable skull # ?

Foreign Body?
Closure…
Admission or Discharge ?
 GCS
<15/15 at any time e.g. LoC
 GCS
15/15 but “risk factors” present
 Medical
 Social
problems (e.g. warfarin, alcohol)
problems (e.g. no supervision)
Emergency Department
Aberdeen Royal Infirmary
“Risk Factors”
 Amnesia
for > 5 min
 Neurological


symptoms
Headache (severe) / Nausea / vomiting
Irritability / focal signs / seizure
 Skull
# (clinically or radiologically)
 Abnormal
CT
Emergency Department
Aberdeen Royal Infirmary
Discharge
 If
no LoC and no risk factors
or medical / social co-morbidity
 Verbal
& written advice to patient & carers
 Contact
number for ED
 DISCUSS
WITH A SENIOR IF UNSURE
Emergency Department
Aberdeen Royal Infirmary
Written Discharge Advice
Emergency Department
Aberdeen Royal Infirmary
CT head







GCS 13 at any point since injury, 13 or 14 2 hours post
injury
Focal neurological deficit
Suspected skull fracture
Post traumatic seizure
LOC or amnesic in >65 yrs or coagulopathy
Dangerous mechanism of injury
Amnesia >30 minutes prior to injury
Emergency Department
Aberdeen Royal Infirmary
+ CT neck

GCS <15
 Focal neurological deficit
 Parasthaesia in extremities

Dangerous mechanism of injury –
fall from hieight
>1m, fall >5 stairs, axial load to head, RTC >65mph, rollover or
ejection.
Emergency Department
Aberdeen Royal Infirmary
Base of Skull #
Emergency Department
Aberdeen Royal Infirmary
Base of Skull #
Emergency Department
Aberdeen Royal Infirmary
Base of Skull #

Panda eyes

Raccoon eyes

Rhinorrhoea

Otorrhoea

Battle’s sign

Cranial nerve palsies
Panda Eyes
Raccoon Eyes
Emergency Department
Aberdeen Royal Infirmary
Otorrhoea
Emergency Department
Aberdeen Royal Infirmary
Battle’s Sign
Emergency Department
Aberdeen Royal Infirmary
Cranial Nerve Palsies
Emergency Department
Aberdeen Royal Infirmary
?
Emergency Department
Aberdeen Royal Infirmary
IF IN DOUBT…
ASK!
Emergency Department
Aberdeen Royal Infirmary