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Head and Neck Injury
Last updated 3rd December 2020
Last updated on 8th January 2014 by Calum Murray
Overview
- Head injury accounts for 1% of Emergency Department admissions.
- 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.
- Additionally falls on the wards are by far the most numerous incidents reported and investigated (over one per day in Dumfries).
History
- 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.
- Ask patient and witnesses about LOC/Amnesia/Vomiting/Headache.
- Drug Hx – Anticoagulants, Antiplatelets & Alcohol all increase risk.
Examination
- Should follow ABCD approach – in trauma A=Airway and Cervical Spine
- 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.
- 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.
- BM – essential in all patients with decreased conscious level.
- Eyes – Document pupil size and reaction to light (unequal pupils are physiological in 20% of the population). Assess eye movements inc diplopia and nystagmus.
- 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
- 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
- For the majority, i.e. minor head injury, this will simply be observation and simple analgesia.
- 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
- 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 .
- Have the casenotes, bloods and a “current” neuro assessment (GCS in words) to hand.
- THINK and explain why you are referring?
- advice on management @ DGRI?
- consideration of transfer for intervention?
- would patient benefit from care in Neurosurgical ICU?
Patients with Head and Neck Injuries on the Wards
- 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.
- If requesting CT also refer to oncall orthopaedic surgeon unless expert in assessing necks e.g. ED Consultant.
- 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.