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Home | Articles | Neurology | Head and Neck Injury

Head and Neck Injury

Last updated 3rd December 2020

Last updated on 8th January 2014 by Calum Murray

Overview

  1. Head injury accounts for 1% of Emergency Department admissions.
  2. Although fatality is not high, trauma is the leading cause of death in those under 45 and 50% of these deaths are because of head injury.
  3. Additionally falls on the wards are by far the most numerous incidents reported and investigated (over one per day in Dumfries).

History

  1. Mechanism of Injury will provide an idea of the forces involved. Consider that a head injury often is preceded by a medical issue e.g. hypoglycaemia.
  2. Ask patient and witnesses about LOC/Amnesia/Vomiting/Headache.
  3. Drug Hx – Anticoagulants, Antiplatelets & Alcohol all increase risk.

Examination

  1. Should follow ABCD approach – in trauma A=Airway and Cervical Spine
  2. Neck Injury – 5 to 14% of patients with a decreased conscious level and blunt trauma will have an associated cervical spine injury – your assessment should be guided by mechanism of injury (dangerous or not?) and presenting clinical features (see cervical spine flow chart) – If GCS <15 & head injury then best to immobilise neck and seek advice.
  3. Glasgow Coma Scale – Click here for Online GCS Calculator. It is best to record this as separate components (E/M/V) in words as this is the format a Neurosurgeon will ask for.
  4. BM – essential in all patients with decreased conscious level.
  5. Eyes – Document pupil size and reaction to light (unequal pupils are physiological in 20% of the population). Assess eye movements inc diplopia and nystagmus.
  6. Scalp/Face/Head – Battle’s sign (bruising over the mastoid process), Panda eyes (purplish discolouration around the eyes) and CSF leaks from nose or ears all suggest fractures of base of skull
  7. Limbs – Tone/Power/Sensation and Reflexes

Selection of Adults for CT Head Scan

(From NICE CG 176)

Selection of Adults for Imaging of Cervical Spine

(From NICE CG 176)

Management

  1. For the majority, i.e. minor head injury, this will simply be observation and simple analgesia.
  2. Frequency of observation should relate to clinical risk – risk of rapid deterioration is highest in the first 6 hours. SIGN recommend 30min neuro obs for 2 hours then hourly for the next 4 hours with decreasing frequency following this.

How to Make a Neurosurgical Referral

  1. Will need patient’s name, age, CHI number and responsible Consultant You should also provide your name and contact number AND record their name & grade in the notes .
  2. Have the casenotes, bloods and a “current” neuro assessment (GCS in words) to hand.
  3. THINK and explain why you are referring?
    1. advice on management @ DGRI?
    2. consideration of transfer for intervention?
    3. would patient benefit from care in Neurosurgical ICU?

Patients with Head and Neck Injuries on the Wards

  1. If neck imaging is required the patient should be placed in hard cervical collar and immobilised (phone Emergency Department if unavailable on ward). If agitated just apply a collar (do NOT restrain) and seek help.
  2. If requesting CT also refer to oncall orthopaedic surgeon unless expert in assessing necks e.g. ED Consultant.
  3. If plain xray is normal and the patient can rotate their neck laterally to 45 degrees bilaterally without severe pain or neurology then the collar can be removed. If not D/W oncall Orthopaedics.

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