Head Injury
NICE guideline - head injury (HI) is defined as any trauma to the head other than superficial injuries to the face.
Adults
For adults with head injury, any 1 of the following risk factors indicates the need for a CT head scan ≤1/24 of the risk factor being identified:
- GCS < 13 on initial assessment in the ED.
- GCS < 15 at 2/24 post injury on assessment in the ED.
- Suspected open or depressed skull fracture.
- Any sign of basal skull fracture (haemotympanum, 'panda' eyes, CSF leakage from ear, nose, and Battle's sign).
- Post‑traumatic seizure.
- Focal neurological deficit.
- >1 episode of vomiting.
In HI adults, CT cervical spine should also be performed ≤1/24 if any of:
- GCS <13 on initial assessment.
- The patient has been intubated.
- Plain X-rays are technically inadequate (for example, the desired view is unavailable).
- Plain X-rays are suspicious or definitely abnormal.
- A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
- The patient is having other body areas scanned for head injury or multi-region trauma.
- The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply:
- age 65 years or older
- dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision)
- focal peripheral neurological deficit
- paraesthesia in the upper or lower limbs.
If there are no indications for C spine CT as above, but there is suspicion of C spine injury, ROM of neck can be assessed unless:
- patient can not actively rotate the neck 45O to left and right.
- midline tenderness
Children/young people
any 1 of the following risk factors indicates the need for a CT head scan ≤1/24 of the risk factor being identified:
- Suspicion of non‑accidental injury.
- Post‑traumatic seizure but no history of epilepsy.
- On initial ED assessment, GCS <14, or for children under 1 year, GCS (paediatric) <15.
- At 2 hours after the injury, GCS less than 15.Suspected open or depressed skull fracture or tense fontanelle.
- Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
- Focal neurological deficit.
- For children under 1 year, presence of bruising, swelling or laceration of more than 5 cm on the head.
In addition, children and young people with head injury and more than 1 of the following risk factors should have a CT head scan ≤1/24 of the risk factors being identified:
- Loss of consciousness lasting more than 5 minutes (witnessed).
- Abnormal drowsiness.
- Three or more discrete episodes of vomiting.
- Dangerous mechanism of injury (high‑speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of >3m, high‑speed injury from a projectile or other object).
- Amnesia (antegrade or retrograde) lasting >5mins.
If only 1 of these latter risk factors, observe for 4/24 post HI. If any of the following occur, CT ≤1/24:
- GCS<15
- further vomiting
- abnormal drowsiness
'For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having anticoagulant treatment, perform a CT head scan ≤8/24 of the injury.' (NICE)
In HI children, CT cervical spine should also be performed ≤1/24 if any of:
- GCS <13 on initial assessment.
- The patient has been intubated.
- Focal peripheral neurological signs.
- Paraesthesia in the upper or lower limbs.
- A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
- The patient is having other body areas scanned for head injury or multi-region trauma.
- There is strong clinical suspicion of injury despite normal X-rays.
- Plain X-rays are technically difficult or inadequate.
- Plain X-rays identify a significant bony injury.
Subdural Haematoma
Classified into:
- acute (within 3 days of trauma)
- subacute (4−20 days)
- chronic (after 20 days)
- cases with no history of trauma are classified according to the total duration of symptoms
As a general rule, asymptomatic CSDHs are considered nonsurgical. In the same way, asymptomatic recollections of haematoma, detected by imaging methods and showing no signs of cerebral compression, are not subjected to new surgical drainage. The decision to operate or to re-operate is based on the presence of symptoms and clinical or imaging signs of cerebral compression
- An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score.
- A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg.
- It is generally accepted that a patient presenting with neurologic symptoms and a radiologically proven cSDH, should undergo immediate surgical evacuation.
- Widely used cutoffs for the indication of surgical evacuation (even in asymptomatic patients) are:
- cSDH with maximum hematoma thickness exceeding that of the skull; or greater than 1cm.
- An evidence-based hematoma cutoff size for the indication of operative treatment does not exist.
References include:
https://www.nice.org.uk/guidance/qs74/chapter/Quality-statement-2-CT-head-scans-for-people-taking-anticoagulants
Surgical Mx of acute subdural
Evidence based Rx Chronic Subdural 2014