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Head injury History Taking

How does event happens which lead to injury? Details of exact mechanism of head injury.
Duration until reaching hospital? (may interfere management)
Site of trauma, any wounds
Complication of accident: LOC, amnesia, brain function
History of bleeding
Sign of shock: dizziness, confusion, sweating
History of otorrhea or rhinorhea (leak of CSF)
Increased ICP: blurred vision, headache, projectile vomiting
Seizure
Lateralizing signs- loss of power in the limbs or loss of sensation
History of alcohol or drugs, which may raise the risk of intracranial bleeding and cloud the
mental status assessment
History of previous head injuries or premorbid illness

Systemic review: (musculoskeletal) injuries over body parts, abrasion, fracture


GCS to assess overall severity and improvement or deterioration
LOC to assess mild head injury (no LOC= mild, <5 min = moderate, >5 min = severe)
Post- traumatic Amnesia retrograde amnesia = immediate loss of memory of the event, until can
recall back (<30 min = mild, >30 min = moderate, >24 hours = severe)
GCS:
i.
ii.

Conscious (15): conscious, alert, orientated


Drowsy (14): open eyes, but responds only to light stimulus, low responses, short
sustainability
Stuporus (9-13): responds only to vigorous stimulus (pinch, hit), not appropriate responds,
not able to sustain
Coma (0-8): cannot open eyes, may have sound but no word, may localize or feel but not
obey.

iii.
iv.

*GCS is not all important in every cases except trauma, as some cases may interrupt talking or
moving i.e. tracheostomy, pseudobulbar palsy.

Physical examination

complete vital signs

GCS

Blood behind eardrum, a post auricular hematoma (battles sign), suggest basilar skull
fracture or bilateral circum orbital hematomas (raccoon eyes)

Examine scalp. Inspect and palpate for laceration, hematoma, deformity


Inspect neck, chest, abdomen, back, extremities for injuries require specific early treatment.
Inspect clear fluid in ear canal or nasal nares. Test with dipstick glucose test as CSF contain
glucose but mucus does not, except in pt with hypoglycemia.

Neurological examination
1. Higher mental function: consciousness, handedness (dominant side),orientation, GCS,
speech, calculation, memory, intellectual, thinking
2. Cranial nerve
3. Motor: inspection, palpation, reflexes (according to myotome)
4. Sensory: crude, superficial, deep, vibration, position, tactile localization & discrimination
(higher cortical)
5. Cerebellar: peripheral (limbs), truncal, cerebellum
6. Skull & spine: palpate for deformities, tenderness, limitation of movement of spine.
7. Meningism (TRO infection / inflammation following head injury): photophobia, neck stiffness,
kernigs sign, brudzinskis sign

Investigation
1. CT scan (if <13, LOC or decreasing consciousness, post traumatic seizure, lateralizing signs,
penetrating injury or skull fracture, otorrhea and rhinorrhea.
2. X-ray of injury part
3. E-FAST (to rapidly identify fluid or blood in peritoneal, pericardial or pleural space.
4. Skull X-ray: normally not help much, less indicated, only when CT scan couldnt be
performed, or in cases of gun shot, fracture, localized contusion or swelling over the head. It
shows fractures and intracranial air.
5. Lab test: PCV, urea and electrolytes, arterial blood gases, blood alcohol level. no FBC.
6. Glycemic index: at A&E, TRO unconsciousness d/t hypoglycemia.

Management
I.
II.

Admission: any head injury even CT scan is normal. GCS <13.


Head injury observing chart (monitor half, hourly or 2 hourly)
a. GCS
b. Vital signs
c. Pupillary reflexes
d. Motor examination or response
e. Monitor danger signs: severe headache, vomiting, seizures, drainage of fluids form
ear or nose
Oxygen supply in moderate head injury
Drip: prevent secondary brain damage d/t hypoxia, HPT, hypoglycemia
Pain management
a. IV Tramadol
b. IM Voltaren
c. PCM
d. Cerebrex (X in risk of bleeding)
e. Morphine : interfere with pupil assessment. Avoid unless in severe pain.
Keep for observation for 6-8 hours (before giving orally): in case of delayed hematoma of
delayed expansion
Wound management

III.
IV.
V.

VI.
VII.

Criteria for discharge


-

GCS full
Asymptomatic
Not on drip
Injury on other sites are well
Social factor

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