Emergency Medicine

Critical Care Emergencies 31

SEVERE HEAD INJURY

(iii) Eye movements and fundoscopy:

(a) intact eye movements are one indicator of brainstem function

(b) fundoscopy may reveal papilloedema, subhyaloid

haemorrhage or retinal detachment.

(iv) Other cranial nerves: include examination of the corneal reflex,

facial movements and the cough and gag reflexes.

(v) Limb movements:

(a) assess for abnormal tone, weakness or loss of movement, or an

asymmetrical response to pain if the patient is unconscious

(b) check the limb reflexes, including the plantar responses.

9 Examine the scalp for bruising, lacerations and haematomas, and palpate for
a deformity indicating a depressed skull fracture.

10 Examine the face and mouth for signs of facial fracture or basal skull
fracture. A basal skull fracture is indicated by:
(i) Periorbital and subconjunctival haemorrhage.
(ii) Haemotympanum, external bleeding, or cerebrospinal fluid
(CSF) leak from the ear.
(iii) Haemorrhage or CSF leakage from the nose.
(iv) Nasopharyngeal haemorrhage, which may be profuse.
(v) Mastoid bruising (Battle’s sign), which may not appear for many
hours.

11 Perform a head-to-toe assessment for other injuries to the neck, chest,
abdomen and perineum including a rectal examination (loss of anal tone
may indicate spina l cord damage), back and limbs.

12 Request radiological examinations:
(i) CXR and pelvic X-ray in all multiply injured patients.
(ii) CT head scan with cervical spine scan.
The airway must be protected first, before a head CT is performed.
Indications for CT head scan include:
(a) GCS <13 at any point since injury
(b) GCS 14 or less 2 h post injury
(c) focal neurological signs including hemiparesis, diplopia
(d) neurological deterioration, i.e. 2 points or more on the GCS
(e) post-traumatic seizure
(f) coagulopathy (history of bleeding, clotting disorder, or
patient on warfarin)
(g) fracture known or suspected, including base of skull
(h) penetrating injury, known or suspected.
(iii) Skull X-rays are of no additional value in the early management of
a major head injury, when there is ready access to CT scanning
(a) only consider if CT scanning is not available. They may
demonstrate a radio-opaque foreign body or depressed skull
fracture, but cannot exclude serious injury if normal.