Head Injury

• Combined traumatic brain injury (TBI) and maxillofacial fractures present significant morbidity and mortality, with risks of functional, cosmetic, and psychological consequences.

Epidemiology

• ♂ > ♀ (79% of cases are male)
• Mechanisms of Injury:
  • Traffic accidents (53.4%)
  • Falls (22.7%)
  • Assaults (11.2%)
• Common Maxillo-Facial Fracture Patterns:
  • Middle third fractures (52.4%)
  • Lower third fractures (20.6%)
  • Upper third fractures (14.5%)

Clinical Features

• Neurological symptoms (e.g., altered consciousness, focal deficits).
• Signs of maxillofacial fractures:
• Signs of basal of skull injury (Racoon Eye's, Battle's Sign, Cerebrospinal fluid rhinorrhea, haemotympanum)
• High likelihood of concurrent injuries (e.g., cervical spine)

Investigations

CT Imaging in head injury

Criteria on when to get a CT head are set out in NICE guidelines

Adults (16 and over)

1. CT within 1 hour if any of the following:
   • GCS ≤ 12 on initial assessment.
   • GCS < 15 two hours post-injury.
   • Suspected open or depressed skull fracture.
   • Signs of basal skull fracture:
     • Haemotympanum, 'panda/racoon' eyes, CSF leakage, or Battle’s sign.
   • Post-traumatic seizure.
   • Focal neurological deficit.
   • >1 episode of vomiting.
2. CT within 8 hours for those with loss of consciousness or amnesia, or within 1 hour if presenting >8 hours post-injury, and any of these risk factors:
   • Age ≥ 65.
   • Bleeding/clotting disorders.
   • Dangerous mechanism (e.g., struck by a vehicle, ejected from one, fall >1m or >5 stairs).
   • >30 minutes retrograde amnesia of events immediately before the head injury.

Children (Under 16)

1. CT within 1 hour if any of the following:
   • Suspected non-accidental injury.
   • Post-traumatic seizure.
   • GCS < 14 (or < 15 for babies under 1 year) on initial assessment.
   • GCS < 15 two hours post-injury.
   • Suspected open/depressed skull fracture or tense fontanelle.
   • Signs of basal skull fracture (e.g., haemotympanum, 'panda' eyes, CSF leakage, Battle’s sign).
   • Focal neurological deficit.
   • For babies under 1 year: scalp bruise/swelling/laceration > 5 cm.
2. CT within 1 hour if >1 of these risk factors:
   • Loss of consciousness > 5 minutes.
   • Abnormal drowsiness.
   • ≥3 episodes of vomiting.
   • Dangerous mechanism (e.g., high-speed traffic accidents, falls >3m, projectile injuries).
   • Amnesia lasting >5 minutes (anterograde or retrograde).
   • Current bleeding/clotting disorders.
3. Observation for 4 hours if only 1 risk factor from above, with CT indicated within 1 hour if:
   • GCS < 15 during observation.
   • Further vomiting or abnormal drowsiness.

People on Anticoagulant/Antiplatelet Therapy

• CT within 8 hours for head injury with no other risk factors.
• CT within 1 hour if presenting >8 hours post-injury.

Radiology Reporting

• Provisional written radiology report should be available within 1 hour of CT scan.

Management

Initial Rapid Assessment

Head injuries are initially assessed using the AVPU scale, which provides a rapid evaluation of consciousness:

• A: Alert.
• V: Responds to voice.
• P: Responds to pain.
• U: Unresponsive.

For a more detailed assessment, the Glasgow Coma Scale (GCS) is used to evaluate the level of consciousness.

Priorities

The primary goal in managing head injuries is to prevent secondary brain injury by maintaining adequate cerebral circulation. This is achieved by addressing the following:

• Airway:
  • Administer 100% oxygen.
  • Intubation should be considered in cases of hypoxia, hypercapnia, respiratory distress, or when the patient cannot protect their airway.
• Breathing:
  • Assess and manage chest injuries such as pneumothorax or hemothorax.
• Circulation:
  • Evaluate and treat hypovolaemia using isotonic fluids (e.g., 0.9% saline).
  • Consider the use of permissive hypotension, which has been shown to improve outcomes.
  • Identify and control sources of haemorrhage.

Glasgow Coma Scale (GCS)

The GCS is a tool used to assess the level of consciousness in patients with head injuries. It evaluates three aspects:

• Best Eye Response (E):
  1. No eye opening.
  2. Eye opening to pain.
  3. Eye opening to speech.
  4. Eyes open spontaneously.
• Best Verbal Response (V):
  1. No verbal response.
  2. Incomprehensible sounds.
  3. Inappropriate words.
  4. Confused responses.
  5. Oriented responses.
• Best Motor Response (M):
  1. No motor response.
  2. Extension to pain (decerebrate response).
  3. Abnormal flexion to pain (decorticate response).
  4. Flexion/withdrawal to pain.
  5. Localizes to pain.
  6. Obeys commands.

Scoring:

• A fully conscious patient scores 15.
• Patients scoring 8 or less are considered to be in a coma and are typically unable to protect their airway.
• The minimum score is 3.