Head Injury

Background

  • Defined as any traumatic injury to the head other than superficial facial injuries.
  • The commonest cause of death and disability in people age 1-40 in the UK.
  • Account for 1.4 million ED attendances each year, 95% of these are minor head injuries that can be managed in the ED.

Assessment

History:

  • Establish Mechanism of Injury
  • Symptoms and onset in relation to injury
  • Past Medical history (specifically disorders of clotting)
  • Medication (any anticoagulants/antiplatelets)

Examination:

  • Any focal neurology
  • Any signs of basal skull # (battles sign, panda eyes, haemotypanum, oto/rhinorrhea
  • Any depressed skull fracture (boggy haematoma, palpable dent)
  • Any other injuries (specifically C spine injuries)

 

Investigations – Adults

Note: If anti-coagulated, haematology happy to reverse prior to scan if we are concerned

Immediate CT Head (within 1 hour) ANY of: 

  • GCS <13/15 on arrival in ED
  • GCS<15 2 hours or more post injury
  • Any signs of and open or depressed skull fracture
  • Any signs of a base of skull fracture – Haemotympanium,  Panda Eyes, CSF leak from nose or ears, Battle’s Sign
  • Post-traumatic seizure
  • Any new focal neurological deficit
  • More than 1 episode of vomiting

Delayed CT (within 8 hours) if any LoC or amnesia plus one of:

  • Age more than 65
  • Bleeding or clotting disorder
  • Dangerous mechanism of injury (Pedestrian or Cyclist hit by motor vehicle, Ejection from motor vehicle, fall greater than 1M or 5 steps)
  • More than 30 minutes retrograde amnesia

 NICE Guidance: CT Head/Neck in adults

 

Investigations – Children

Immediate CT Head (within 1 hour) if ANY of:

  • Suspicion of Non-accidental Injury
  • Post-traumatic seizure
  • Initial GCS in ED less than 14 or less than 15 in under 1’s
  • GCS less than 15 2 hours after injury
  • Any suspicion of an open or depressed skull fracture or a tense fontanelle
  • Any signs of a base of skull fracture – Haemotypanium, Panda Eyes, CSF leak from nose or ears, Battle’s sign
  • Any new focal neurological deficit
  • Bruising/swelling or laceration more than 5cm on the head

Immediate CT Head (within 1 hour) if 2 or more of:

  • Loss of consciousness witnessed for greater than 5 minutes
  • Abnormal drowsiness
  • 3 or more discrete episodes of vomiting
  • More then 5 minutes of amnesia
  • Any dangerous mechanism of injury – pedestrian or cyclist hit by motor vehicle, ejection from a motor vehicle, fall more than 1m or 5 steps

If only 1 of the above

  • Observe for at least 4 hours post head injury
  • Scan within 1 hour if:
    • GCS <15
    • Further vomiting
    • Further episode of abnormal drowsiness

NICE Guidance: CT Head/Neck in Children

Discharge

Adults who do not fulfil the requirements for CT Head can be discharged provided they have a responsible adults at home with a discharge advice leaflet Adult Head Injury Advice Leaflet

Adults with a normal CT head who have returned to their normal self can be safely discharged provided they have a responsible adult at home and are given a written discharge advice leaflet.  Adult head Injury Advice Leaflet   

Patients with abnormalities on CT scanning should referred to the Neurosurgeons via Neurosurgical Website

Children who do not require a CT Head and do not have any features suggesting a need for observation can be discharged with a responsible adult and a discharge advice leaflet. Paediatric Head Injury Advice Leaflet

Adults who do not fulfil the discharge criteria or who require a period of observation after Neurosurgical advice should the admitted to CDU on Head injury Pathway CDU Head Injury Pathway

Children who require admission for observation should be referred to the Paediatric registrar (CRH) or PNP (HRI). Any safeguarding or Non-accidental injury concerns should be referred to Paediatric Consultant on call for safeguarding.

DVLA Advice

References

NICE 2017 Head Injury Assessment and Early Management Guidelines https://pathways.nice.org.uk/pathways/head-injury

Head Injury in Sport

 

Search: paeds head injury paeds, headinjury, head inj, head injury PAEDIATRICS

 

 

 

 

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