Emergency Medicine

HEAD INJURY

248 Surgical Emergencies

(iv) Associated alcohol or drug intoxication.

(v) Relevant medical conditions and drug therapy, including

warfarin.

2 Examination

(i) Record the temperature, pulse, blood pressure and respirations.

(ii) Assess higher mental functions, including the level of

consciousness, using the GCS score (see p. 30).

(iii) Check the pupil size and reactions, eye movements, cranial

nerves and the limbs for lateralizing neurological signs.

(iv) Examine the scalp for bruising, lacerations or palpable fractures

and haematomas.

(v) Exclude associated neck or other injuries.

3 Radiological imaging

(i) Request three-view cervical spine X-rays, if there is any

suggestion of an associated neck injury

(a) lateral cervical spine view, with an anteroposterior and open-

mouth odontoid view

(b) make sure C1–C7/T1 are visualized, if necessary by traction

on the shoulders (see p. 227).

(ii) CT head scan.

Request a CT scan of the head as the investigation of choice for the

detection of acute, clinically important brain injuries.

(iii) Indications for a CT head in the conscious GCS 15 head injury

patient following any loss of consciousness or significant

anterograde amnesia (PTA) include:

(a) drug or alcohol intoxication at time of trauma or evaluation

(b) headache or repeated vomiting ≥2 episodes

(c) age >60

(d) warfarin (or other bleeding tendency, e.g. chronic liver disease)

(e) dangerous mechanism, such as high-speed injury, injury

from a sharp or heavy object

(f) trauma above the clavicle such as a deep scalp laceration,

large haematoma, or skull fracture suspected on palpation

(g) seizure or focal neurological sign

(h) suspected open skull fracture

(i) signs of a basal skull fracture such as cerebrospinal fluid or

blood loss from the nose or ear.

(iv) Skull X-rays. These really now only have a limited role, if any:

(a) detection of non-accidental injury in children

(b) when CT scanning services are unavailable, in conjunction

with inpatient observation

• look for a linear fracture, the double shadow of a depressed
  fracture, suture diastasis, an air-fluid level in a sinus, a
  traumatic aerocoele, shift of the pineal or a foreign body.