Damage to the head tissue causing swelling ± wound ± fracture

Cause

• Road traffic accident
• Assault, fall or a bang on the head

Clinical feature

• May be closed (without a cut) or open (with a cut)

• Headache pain

• Swelling or cut wound on the head

• Fracture of the skull, eg. depressed area of the skull, brain matter may be exposed

• Altered level of consciousness if brain tissue is involved, including coma

• Haematoma

Differential diagnosis

• Poisoning
• Meningitis
• Alcoholic coma - may occur together with a head injury
• Hypoglycaemia
• Other cause of coma

Management

This is based on classification of the head injury using the Glasgow Coma Score (GCS) as follows:

a) Simple: no loss of conciousness (LOC), GCS = 15

Give any necessary first aid
Monitor level of conciousness and GCS
If satisfactory, send patient home with analgesics

b) Concussion: LOC <6 hours, GCS = 13-15

Give necessary first aid

Keep under observation for 24 hours

If no deterioration, send patient home

If condition deteriorates, refer to hospital immediately for specialist management

c) Contusion: LOC >6 hours, GCS = 8-12

Treat as for cerebral oedema below

d) Haemorrhage: lucid intervals - GCS may be up to 15 but drops off with increasing LOC

Treat as for cerebral oedema below

In all cases:

Give any necessary first aid

If patient able to swallow, give analgesic for the pain, see p343

avoid narcotic analgesics because of sedative effects

If there are signs of cerebral oedema:
HC4

Give supportive treatment:

- nurse in a semi-prone position

- keep a head injury chart to record the Glasgow Coma Score, pupil size and neurological signs

- withhold IV fluids or use with caution

Give oxygen if available

Refer to hospital as soon as possible for specialist management

Open head injury
Ref

Refer immediately to a specialist after giving first aid and an initial dose of antibiotic (see 5.1, p110)

- if at HC3 level or higher give antibiotic as in Meningitis, p10 prior to referral

Closed head injury Ref

Treat as for cerebral oedema above

Prevention

• Careful (defensive) driving to avoid accidents

• Use of safety belts by motorists

• Wearing of helmets by cyclists, motor-cyclists and people working in hazardous environments

• Avoiding climbing trees