QuestionSBA
QuestionChoice
There is little high quality evidence for therapeutic hypothermia, and some evidence of harm. Normothermia should be promoted.
10017365
e
Cool the head (therapeutic hypothermia)
QuestionChoice
A higher blood pressure should be maintained to ensure the brain is adequately perfused.
10017364
d
Reduce systolic blood pressure to <100mmHg
QuestionChoice
Patients with brain injuries should be deeply sedated to reduce metabolic demands and reduce distress, which helps lower intracranial pressure and thus the risk of brain herniation.
10017362
b
Use as little sedation as possible
QuestionChoice
This is the correct answer. This position helps to reduce intracranial pressure, and thus the risk of brain herniation.
10017361
a
Position head up at 30 degrees
QuestionChoice
A lower PaCO2 is usually achieved through hyperventilation. A lower PaCO2 causes vasoconstriction in the cerebral arterioles, moderately reducing cerebral perfusion, and thus ICP.
10017363
c
Aim for a PaCO2 of 6 mmHg
QuestionComment
Can someone explain why is the first one not correct if controlled hyperventilation can lower ICP please? 
52696
QuestionComment
the PaCO2 is 6 here which is at the upper end of normal; to produce the cerebral vasoconstriction you would have to aim for a pCO2 at the lower end of normal :)
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Bilibalibu 
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# Summary
 
Head injury is a common emergency presentation that ranges in severity from mild trauma with no brain injury to life-threatening intracranial bleeds. NICE has clear criteria for who should be assessed in hospital and what scenarios warrant a CT head. The guidance states in what circumstances this should be done within an hour (e.g. Glasgow Coma Scale 12 or less on initial assessment) and when this should be done within 8 hours (e.g. anyone aged 65 or over with a head injury). Management depends on the severity of injury identified and may be conservative (e.g. observation alone), medical (e.g. management of raised intracranial pressure) and/or surgical (e.g. evacuation of an intracranial haemorrhage).

# Epidemiology
 
Head injury is the commonest cause of death and disability in people aged 1 to 40 years old in the UK. However, 90% of head injuries that present to A&E are minor, with 0.2% of patients dying as a result of the injury (most of whom have low Glasgow Coma Scale (GCS) scores).

# Aetiology
 
Many forms of trauma can lead to a head injury, including:

- Road traffic accidents
- Falls (considered a dangerous mechanism of injury if height greater than 1 metre or 5 steps) 
- Assault (including non-accidental injury in babies and children)
- Sports injuries
- Accidents at work

# Classification

Not all head injuries lead to **traumatic brain injury** (when neurological function is impacted by the injury).

Traumatic brain injuries can be categorised as mild (also known as concussion), moderate and severe depending on the patient's GCS as follows:

- Mild - GCS 14-15
- Moderate - GCS 9-13
- Severe - GCS 3-8
 
# Signs and Symptoms

Symptoms of head injury include:

- Pain in the head or neck
- Loss of consciousness or drowsiness
- Confusion or amnesia
- Seizures
- Vomiting
- Changes to vision or hearing
- Neurological symptoms such as weakness, sensory changes, ataxia or difficulty speaking

Signs include:

- External injuries e.g. scalp lacerations or haematoma
- Retinal haemorrhages or papilloedema on fundoscopy
- Unequal or unreactive pupils 
- Cranial nerve palsies (e.g. down and out pupil deviation in a oculomotor nerve palsy)
- Signs of **basal skull fracture:**
    - Haemotympanum (blood behind the eardrum)
    - Periorbital haematomas
    - Cerebrospinal fluid otorrhea or rhinorrhea
    - Battle's sign (bruising over the mastoid process)
- Cushing's triad of raised intracranial pressure:
    - Hypertension
    - Bradycardia
    - Irregular breathing
- Decreased GCS
- Cognitive impairment
- Focal neurological signs
 

# Differential Diagnosis
 
There is a wide range of injuries that can occur after head trauma:

- **Concussion** i.e. mild traumatic brain injury which causes transient disturbance in brain functioning with symptoms of headache, dizziness, difficulty concentrating and confusion
- **Intracranial haemorrhage** which can take multiple forms including extradural, subdural, subarachnoid or intracerebral haemorrhages (see separate chapters for details)
- **Skull fracture:** which may be displaced or non-displaced, and may be detected clinically if there is obvious deformity or other signs (e.g. of basal skull fracture) or on imaging
- **Vascular injuries** e.g. arterial dissection secondary to skull base fracture, traumatic fistula formation or venous thrombosis
- **Brain contusion** i.e. a bruise of the brain caused by its collision against the inner surface of the skull, causing haemorrhage, oedema and inflammation
- **Secondary brain injuries** which is indirect injury to the parenchyma following the initial insult e.g. cerebral oedema or hypoxia

 
# Investigations

## CT Head Guidelines

The key investigation in head injury is a CT head - this is not required in every case but there are clear NICE guidelines on who requires imaging of what urgency as follows:

**CT head should be done within 1 hour of presentation:**

-  GCS of 12 or less on initial assessment in the Emergency Department
-  GCS less than 15 2 hours after injury
-  Suspected open or depressed skull fracture
-  Signs of basal skull fracture as above
-  New focal neurology
-  More than 1 episode of vomiting
-  Post-traumatic seizure
 

**CT head should be done within 8 hours of the injury (or within 1 hour if presenting later than this) in patients with any loss of consciousness or amnesia and one of:**
 
-  Aged 65 or older
-  Bleeding or clotting disorder
-  Dangerous mechanism of injury (e.g. hit by a car, fall down more than 5 steps)
-  More than 30 minutes of amnesia for events prior to the injury

**Consider** a CT head within 8 hours of the injury in patients without any of the above but who are on anticoagulant or antiplatelet medications (except if taking aspirin alone).

**Note - these guidelines apply to patients aged 16 and over; see references below for full NICE guidance including in paediatric patients**

## Other Investigations

**Bedside tests:**

- **Capillary blood glucose** to rule out hypoglycaemia as a cause of reduced GCS
- **Blood gas** especially if other traumatic injuries to look at haemoglobin and lactate
- **ECG** as some intracranial injuries (e.g. subarachnoid haemorrhage) can cause cardiac abnormalities
- **Toxicology screen** if drug intoxication is suspected

**Blood tests:**

- **Full blood count** for anaemia
- **U&Es and LFTs** as a baseline prior to treatment
- **Coagulation screen** to look for any bleeding diathesis
- **Group and save** +/- crossmatch in case a blood transfusion is required

**Imaging:**

- Other imaging may be warranted for suspected injuries (e.g. a chest X-ray if suspecting traumatic pneumothorax)
- **MRI head** is sometimes used after CT or in subacute presentations of head injury (e.g. if normal CT but ongoing clinical suspicions of traumatic brain injury)

# Management
 
**Conservative Management:**

- Patients with mild head injuries who are GCS 15 with no concerning symptoms, signs or risk factors can be managed in the community with observation by a responsible adult for 24 hours and careful safety-netting regarding when to seek medical advice
- Follow trauma algorithms (see ATLS chapter for more details) and ensure other injuries are assessed and managed appropriately
- Intubation and ventilation may be required e.g. in patients with a GCS of 8 or less or irregular breathing  
- Assess for cervical spine injury and immobilise if needed (see spinal injury chapter for more details) 
- Consider safeguarding e.g. in suspected abuse or neglect and refer to appropriate teams
- Regular neurological observations (half-hourly until GCS is 15)
- Patients with significant injuries may need to be transferred to a specialist neurosurgical centre
- In the longer term, multidisciplinary neurorehabilitation and social support are crucial for patients with ongoing disability as a result of traumatic brain injury

**Medical Management:**

- Resuscitation with IV fluids if hypotensive, oxygen if low saturations
- Analgesia is crucial and helps with raised intracranial pressure 
- Consider tranexamic acid (2 grams IV bolus) in patients with a head injury and a GCS of 12 or less
- Consider reversal of anticoagulation e.g. in  intracranial haemorrhage (with haematology input as needed)
- Medical treatment of seizures may be required (e.g. benzodiazepines)
- Maintain normoglycaemia with insulin or dextrose
- Monitor intracranial pressure and treat with hypertonic saline or mannitol, nurse with head elevated at 30 degrees

**Surgical Management:**

- Discuss the following patients with neurosurgery:
     - Significant injuries identified on CT head
     - GCS less than 8 despite resuscitation
     - Deterioration in GCS as an inpatient
     - Progressive focal neurology
     - Seizure without full recovery
     - Penetrating injury (e.g. a knife or gun wound)
     - Cerebrospinal fluid leak
     - Unexplained confusion for over 4 hours
- Neurosurgical management depends on the nature of the injury identified (e.g. a craniectomy or craniotomy to facilitate evacuation of a large extradural or subdural haematoma)

 
# Complications

- **Herniation** occurs due to raised intracranial pressure and mass effect e.g. from a large intracranial bleed.
    - "Coning" is used to describe herniation of the cerebellar tonsils through the foramen magnum; this puts pressure on the brainstem causing respiratory arrest and death
    - The uncus of the temporal lobe can herniate through the tentorial notch - this causes compression of the oculomotor nerve leading to a unilateral "blown pupil"
- **Hypopituitarism** occurs in 33-50% of people with traumatic brain injuries, especially moderate and severe injuries. This can present months after the initial injury and should be suspected in patients with hypotension or hyponatraemia.
- **Post-traumatic seizures** are common especially after moderate or severe traumatic brain injury
- **Permanent neurological deficits** include weakness, spasticity, contractures, dysarthria and dysphasia
- **Mental health problems** including depression, anxiety and post-traumatic stress disorder are very common after traumatic brain injuries and can occur even if there is amnesia regarding the event.
- **Cognitive impairment** is also common and ranges in severity; difficulties may be seen with memory, concentration, language, planning and challenging behaviours such as disinhibition.
 
# NICE Guidelines

[NICE - Head injury: assessment and early management](https://www.nice.org.uk/guidance/ng232)

[NICE CKS - Head Injury](https://cks.nice.org.uk/topics/head-injury/)

# References
 
[Radiopaedia - Traumatic Brain Injury](https://radiopaedia.org/articles/traumatic-brain-injury?lang=gb)

[Headway - The Brain Injury Association](https://www.headway.org.uk/)
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Management of head trauma
Topic
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Anaesthetics and Intensive Care Medicine
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Elevating the head to 30 degrees in traumatic brain injury patients reduces intracranial pressure and lowers the risk of brain herniation.
A patient who has sustained a traumatic brain injury is intubated and ventilated on the intensive care unit, awaiting a neurosurgical opinion.

What is the most appropriate management?
a