HEAD INJURYSurgical Emergencies 249MANAGEMENT
1 Avoid giving patients with suspected head injury excessive parenteral
analgesia until fully assessed, to allow an appropriate measure of conscious-
ness and to look for other neurological signs.
2 Clean scalp lacerations thoroughly, trim the edges and remove any foreign
bodies. Then suture in layers using a monofilament synthetic non-
absorbable material such as nylon or polypropylene.
3 Give tetanus prophylaxis according to the patient’s immune status.
4 Admission
(i) Admit patients with a minor head injury and any of the following
features to the surgical team for neurological observation:
(a) confusion or any other decreased level of consciousness
(b) neurological symptoms or signs, including persistent
headache or vomiting
(c) abnormal CT head scan
(d) skull fracture
(e) difficulty assessing, e.g. alcohol, drugs, epilepsy
(f) other medical condition, e.g. warfarin, coagulation defect
(g) significant associated injuries requiring inpatient care.
(ii) Make certain all of the above have had radiological imaging,
ideally with a CT head scan. Some will be discussed with the
neurosurgery team.
5 Discharge
(i) Send the following patients with a minor head injury home, provided
there is someone with them and home circumstances are suitable:
(a) fully conscious and oriented
(b) normal CT head scan
(c) normal skull X-ray (when CT unavailable)
(d) no other significant injuries
(e) no seizures or focal neurological signs
(f) no persistent headache or vomiting.
(ii) Give each patient a standard head injury advice card
(a) these cards advise patients to return if complications such as
confusion, drowsiness, seizure, visual disturbance, vomiting or
persistent headache occur in the subsequent 24 h after discharge.
(iii) This still leaves some patients with a minor head injury yet to
be dealt with. Admit the following patients to the ED short-stay
ward for observation:
(a) no one to accompany them
(b) poor home circumstances
(c) an unreliable history, particularly if they were under the
influence of alcohol or drugs
(d) other painful injuries, e.g. to the face or nose, etc.