Head Injury

 

Head injury is defined as any trauma to the head other than superficial injuries to the face.  Each year, 1.4 million people attend emergency departments in England and Wales with a recent head injury, and 33–50% of these are children aged under 15 years.  The annual incidence at UK emergency departments of people with a head injury is about 6.6%.  About 90% of people attending emergency departments with a head injury have a minor head injury.  The majority of people who have minor head injuries recover without specific or specialist intervention.  Delayed presentation of intracranial complications is rare after mild traumatic brain injury, and usually occurs within 24 hours of the injury.  Most people who have persistent symptoms of mild traumatic brain injury recover within 2–3 months of the injury.  Factors which may increase the risk of a poor prognosis following mild traumatic brain injury include female sex, age over 40 years, persistent physical illness and/or a pre-existing neurological condition, previous head injuries, co-morbid mental health problems, such as anxiety and depression, and lack of social support

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Assessment

Ask about:

  1. How and when the head injury occurred
  2. The mechanism of injury — a dangerous mechanism of injury or high-energy head injury is defined as:
    1. Fall from a height of greater than 1 metre or 5 stairs
    2. High-speed motor vehicle collision either as a pedestrian, cyclist, or vehicle occupant
    3. Rollover motor accident or ejection from a motor vehicle
    4. Accident involving motorized recreational vehicles or bicycle collision
    5. Diving accident
  3. Current symptoms since the injury, such as:
    1. Loss of consciousness
    2. Amnesia
    3. Vomiting
    4. Headache
    5. Neck pain
  4. Recent alcohol or drug intake
  5. Current anticoagulant medication
  6. Pre-injury level of consciousness and functioning

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Examination

Examine the person to assess:

  1. The person's level of consciousness using the Glasgow Coma Scale (see Diagnostics & Assessments tab)
  2. For hypoxia or signs of shock (such as tachycardia, hypotension, reduced capillary refill time)
  3. Signs of visible trauma to the scalp, skull, head, and neck
  4. Cranial nerves including pupil size and reactivity
  5. Any focal neurological deficit, such as:
    1. Problems with visual or speech disturbance, understanding speech, reading or writing
    2. Problems with balance or walking
    3. Loss of muscle power
    4. Paraesthesia in the upper or lower limbs or abnormal reflexes
  6. For a suspected basal skull fracture, which may present with:
    1. Clear fluid (possible cerebrospinal fluid) leaking from the ear(s) or nose
    2. Periorbital haematoma(s) with no associated damage around the eyes
    3. Bleeding from one or both ears; blood behind the ear drum (haemotympanum); new deafness in one or both ears
    4. Battle's sign — bruising behind one or both ears over the mastoid process, suggesting fracture of the middle cranial fossa
  7. For any neck tenderness — midline cervical spine tenderness may indicate cervical spine injury
  8. Range of neck movements — an inability to rotate the neck 45 degrees to the left and right may indicate cervical spine injury

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NOTE safe examination of the neck should only be performed using clinical judgement if the person:

  • Was involved in a simple rear-end motor vehicle collision
  • Is comfortable in a sitting position
  • Has been ambulatory at any time since the injury
  • Has no midline cervical spine tenderness
  • Presents with delayed onset neck pain

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When to suspect non-accidental injury

Suspect non-accidental injury as a contributory factor or cause of head injury in a child if:

  1. The child is not yet independently mobile (crawling, cruising, walking)
  2. The injury or bruise is:
    1. On any non-bony part of the face (including the eyes or ears)
    2. On both sides of the face or head
  3. Any bruises are:
    1. Disproportionate to the explanation of injury sustained
    2. Present in multiple sites or in clusters
    3. Of a similar shape and size
  4. The child has retinal haemorrhages or injury to the eye (in the absence of major confirmed accidental trauma or a known medical explanation)
  5. The explanation for the injury is implausible, inadequate, or inconsistent:
    1. With the child's presentation, normal activities, existing medical conditions, age or developmental stage, or account — compared with that given by parents or carers
    2. Between parents or carers
    3. Between accounts over time
  6. There is a delay in presentation

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For more information, see sections on Bruising and Safeguarding Children

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Follow up

Arrange to re-assess the person if they have ongoing symptoms or signs after a mild traumatic head injury

  1. Refer the person immediately to the hospital emergency department, to be accompanied by a competent adult (if they are a child), if there are persistent or worsening clinical features relating to the initial head injury, such as vomiting or headaches, which may indicate a possible complication
  2. Refer the person for specialist assessment and management of possible complications of a head injury to neurology or neuroendocrinology, neuropsychology or psychiatry, neurosurgery, or a specialist in rehabilitation medicine, depending on clinical judgement, if:
    1. There are persistent non-specific symptoms for more than three months suggesting possible post-concussion syndrome
    2. Another complication or cause of head injury is suspected, for example, if there are new-onset focal neurological signs
    3. There are concerns or uncertainty about the nature or severity of symptoms

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Initial management and referral

Refer an adult or child immediately to the hospital emergency department, accompanied by a competent adult, if there are any of the following risk factors, which may indicate an intracranial complication or cervical spine injury: 

  1. A Glasgow Coma Scale (GCS) score of less than 15 on initial assessment
  2. Evidence of shock, or other injuries suggesting chest or abdominal trauma, limb or pelvic trauma, or significant vascular injury
  3. Dangerous mechanism of injury or high-energy head injury
  4. A history of bleeding or coagulation disorders, or current anticoagulant medication
  5. Current alcohol or drug intoxication
  6. Any loss of consciousness after the injury (even if they are fully alert on presentation)
  7. Any post-traumatic seizure
  8. Any previous brain surgery
  9. Amnesia (antegrade or retrograde) lasting more than 5 minutes
    1. NOTE assessment of amnesia is unlikely to be possible in a child aged under 5 years
  10. Persistent headache since the injury
  11. Vomiting since the injury — particularly more than one episode in an adult or three or more episodes in a child, using clinical judgement
  12. Any focal neurological deficit since the injury
  13. A suspected open or depressed skull fracture, or tense fontanelle in a child
  14. A suspected basal skull fracture
  15. Signs of a penetrating injury or visible trauma to the scalp or skull — in children under 1 year of age, a bruise, swelling, or laceration of more than 5 cm on the head
  16. Suspected cervical spine injury following assessment of the neck
    1. NOTEif there is any suspicion of cervical spine injury, full cervical spine immobilization should be arranged before transfer to hospital
  17. Concern about the diagnosis of head injury

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Refer an adult or child immediately to the hospital emergency department, accompanied by a competent adult, if there is:

  1. Possible non-accidental injury, safeguarding concerns, or a vulnerable person is affected

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Consider referral of an adult or child to the hospital emergency department, accompanied by a competent adult, if there are any of the following risk factors, depending on clinical judgement:

  1. Irritability or altered behaviour, particularly in infants and children aged under 5 years
  2. Other visible trauma to the scalp or skull
  3. A responsible adult is unable to stay with the person for the first 24 hours after the injury
  4. Ongoing concern by the person or their family/carers

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For all other children and adults who are at low risk of an intracranial complication or cervical spine injury:

  1. Advise that a responsible adult should stay with the person for the first 24 hours after the injury
  2. Give the person and/or family/carers verbal and written information and self-care advice

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Patients in East Kent can be referred to the Kent Clinical Neuropsychology Service, run by the Kent and Medway NHS and Social Care Partnership Trust (KMPT), if they have a brain injury  or long term neurological condition.  Please use the referral form below and email it to:  KAMNASCPT.neuropsych@nhs.net

  1. Kent Clinical Neuropsychology Service East Kent Referral Criteria
  2. Brain Injury Referral Form to Kent Clinical Neuropsychology Service (KMPT)

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Information and self-care advice

  1. Give verbal and written information and self-care advice to the person and/or family/carers following a head injury, including details of the nature and severity of the injury
  2. Give details of the expected recovery process and information on persistent, new, or delayed symptoms and signs which may indicate a possible complication, and when to immediately attend the hospital emergency department or seek urgent medical advice
  3. Give advice on a gradual return to normal activities, including school, work, sports, and driving
  4. Give advice on additional sources of support and information, such as the Brain and Spine Foundation, the Child Brain Injury Trust, and Headway (The Brain Injury Association)

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The following leaflets might be useful to give to patients:

  1. 'Brain injury - a guide for parents' fact sheet (Headway)
  2. 'Driving after brain injury' patient booklet (Headway)
  3. 'Management of acquired brain injury - a guide for GPs' fact sheet (Headway)
  4. 'Minor head injury and concussion' patient booklet (Headway)
  5. 'Rehabilitation after brain injury' fact sheet (Headway)
  6. 'Returning to education after brain injury' fact sheet (Headway)
  7. 'Returning to work after brain injury' fact sheet (Headway)

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The Glasgow Coma Scale
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The Glasgow Coma Scale (GCS) is used internationally in clinical practice to assess the depth and duration of impaired consciousness and coma
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Glasgow Coma Scale for adults and verbal children (usually 5 years of age and older)

  • Best eye response — does not open eyes, score 1; opens eyes in response to painful stimuli, score 2; opens eyes in response to voice, score 3; opens eyes spontaneously, score 4
  • Best verbal response — makes no sounds, score 1; incomprehensible sounds, score 2; inappropriate words, score 3; confused and disorientated, score 4; orientated and converses normally, score 5
  • Best motor response — makes no movement in response to pain, score 1; extension in response to painful stimuli, score 2; abnormal flexion in response to painful stimuli, score 3; flexion or withdrawal in response to painful stimuli, score 4; localizes painful stimuli, score 5; obeys simple commands, score 6

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Glasgow Coma Scale for preverbal children (usually less than 5 years of age)

  • Best eye response — no eye opening, score 1; eyes open in response to pain, score 2; eyes open in response to voice, score 3; eyes open spontaneously, score 4
  • Best verbal response — no vocal response, score 1; inconsolable or agitated, score 2; inconsistently consolable or moaning, score 3; cries but is consolable or inappropriate interactions, score 4; smiles and orients to sounds, follows objects, and interacts, score 5
  • Best motor response — no motor response to pain, score 1; extension in response to pain, score 2; flexion in response to pain, score 3; withdrawal from pain, score 4; localizing touch, score 5; spontaneous purposeful movement or obeys simple commands, score 6

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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