Emergency Medicine

Critical Care Emergencies 29

Severe Head Injury

(ii) Lie the patient flat and or elevate the legs.

(iii) Give a bolus of normal saline 20–40 mL/kg i.v.

(iv) If rapid deterioration occurs, change to 1 in 10 000 or 1 in 100

000 adrenaline (epinephrine) 0.75–1.5 μg/kg i.v.; i.e. 50–100 μg or

0.5–1.0 mL of 1 in 10 000, or 5–10 mL of 1 in 100 000 adrenaline

(epinephrine) over 5 min i.v. The ECG must be monitored.

4 Second-line measures only used after achieving cardiorespiratory stability
include:
(i) Promethazine 12.5–25 mg i.v. or chlorphenamine 10–20 mg
slowly i.v. plus ranitidine 50 mg i.v.
(ii) Hydrocortisone 200 mg i.v. (if not given already).
(iii) Glucagon 1–2 mg i.v. repeated as necessary, for patients on
-blockers resistant to the above treatment.

5 Admit any patient receiving adrenaline (epinephrine) for 6–8 h observation
as late deterioration may occur in up to 5%, known as biphasic anaphylaxis.

6 Then discharge home on prednisolone 50 mg once daily, loratadine 10 mg
once daily plus ranitidine 150 mg b.d., all orally for 3 days.
(i) Inform the GP by fax or letter.
(ii) Refer all significant or recurrent attacks to the allergy clinic,
especially if the cause is unavoidable or unknown.

DIAGNOSIS

1 The head injury may be obvious from the history or on immediate examina-
tion.

2 The possibility of a head injury must also be considered in every instance of
coma or abnormal behaviour, in at-risk groups such as alcohol intoxication
and epileptics, non-accidental injury in children, and in falls in the elderly.

3 Confirm a history from the ambulance crew, police or any witnesses as to the
circumstances and nature of the injury, period of loss of consciousness or
subsequent seizures.

4 Obtain other medical details, if a relative or friend is available, of current
medical or surgical conditions, drug therapy, allergies and any previous
head injury or epilepsy.

5 Check the temperature, pulse, blood pressure, respiratory rate, and attach an
ECG monitor and pulse oximeter to the patient. Record the level of
consciousness using the GCS score (Table 1.1).

SEVERE HEAD INJURY