Head Injury
History
Mechanism: Detailed account of injury including height, speed, force, and use of protective equipment (e.g., helmet)
Loss of consciousness: Duration and associated seizure activity are critical
Amnesia: Document both anterograde and retrograde memory loss
Associated symptoms: Multiple episodes of vomiting, persistent headache, confusion, drowsiness, or focal neurological deficits
Other injuries: Presence of external injuries or signs of non-accidental injury
Past medical history: Bleeding disorders, anticoagulant use, prior head injuries, neurodevelopmental conditions, VP shunt status
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Examination
General: Observe for visible injuries, signs of shock, and overall appearance
Glasgow Coma Scale: Assess eye, verbal, and motor responses to gauge level of consciousness
Neurological: Check for focal deficits, abnormal posturing, and signs of raised intracranial pressure (e.g., unequal pupils, posturing)
Skull assessment: Palpate for step-off deformities, swelling, or tenderness
Basal skull fracture signs: Look for haemotympanum, Battle’s sign, raccoon eyes, and any CSF rhinorrhoea or otorrhoea
Vital signs: Monitor blood pressure, heart rate, and respiratory rate as indicators of systemic stability
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Investigations
CT Brain (+/- C-spine): Gold standard for moderate to severe injuries or when red flags are present (GCS ≤13, focal deficits, suspected NAI, signs of basal skull fracture)
Indications for CT: Persistent altered mental status, history of loss of consciousness, post-traumatic seizure, severe mechanism, scalp haematoma
MRI: Consider if specific lesions are suspected and CT is inconclusive
Other tests: Urgent imaging for suspected non-accidental injury; plain skull X-ray rarely used in acute head trauma
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Management
Mild Head Injury (GCS 15 without risk factors):
Discharge with head injury advice if stable with no red flags
Advise rest, gradual return to normal activities, and monitoring for symptom change
Mild Head Injury (with risk factors, GCS 14–15):
Moderate Head Injury (GCS 9–13):
Severe Head Injury (GCS ≤8):
Activate trauma protocol with airway protection, possible intubation
Urgent neuroimaging and neurosurgical involvement
Initiate measures to reduce raised intracranial pressure (e.g., elevate head, hyperosmolar therapy with mannitol or hypertonic saline)
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Discharge Advice
Provide caregivers with clear instructions on red flag symptoms (worsening headache, confusion, persistent vomiting, new neurological deficits)
Advise on gradual return to cognitive and physical activities, especially following concussion
Arrange follow-up to reassess neurological status and recovery progress
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Red Flags
Deteriorating or persistently low GCS (<13)
Signs of basal skull fracture (haemotympanum, Battle’s sign, raccoon eyes, CSF leak)
Focal neurological deficits or post-traumatic seizures
Evidence of raised intracranial pressure (unequal pupils, abnormal posturing)
Suspected non-accidental injury or severe mechanism of injury (high-impact MVC, significant fall)
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Additional Notes
Children under 6 months, those with neurodevelopmental disorders, or special conditions (e.g., VP shunt, bleeding disorders) require lower thresholds for neuroimaging and careful evaluation
In remote or rural settings, stabilise airway, breathing, and circulation while arranging prompt transfer
Continuous monitoring post-injury is critical to detect delayed complications such as intracranial bleeding or raised ICP
