A. Focal motor findings may be manifestations of a localized contusion or, more ominously, an early herniation syndrome. Common indicators of TBI severity include Glasgow Coma Scale (GCS) scores, length of coma (LOC) and duration of post-traumatic amnesia (PTA). Head injury in children is common. For dullness is useful for the diagnosis of haemothorax and pneumothorax. Subarachnoid hemorrhages that occur because of trauma are typically located over gyri on the convexity of the brain. Examine the scalp carefully for evidence of trauma . Patients who open their eyes spontaneously, obey … Management is usually hospital admission and close observation for any complications. [51] On page 50 Mazwi deals with the classification and complications of a head injury and he states as follows: "Based on the American Academy of Neurology Grading Glascow Coma Scale and American congress of rehabilitation medicine definitions . Children are prone to develop significant edema and this does not always occur as a result of severe head injury.Brain edema could be localized around an area of brain damage or diffuse as seen in diffuse axonal brain injury. Resuscitate to the goal of mean arterial pressure (MAP)>90 mmHg to maintain a presumptive cerebral perfusion pressure (CPP)>70-80mmHg, Urinary catheter insertion and monitor the input and output chart at least 30-50 ml/hour or 0.5/kg/hour of urine flow, Asses by vital signs, pallor, sweating, anxiety, skin warmth clammy, input and output. C. Blood behind the eardrum, a postauricular hematoma (Battle's sign), suggest basilar skull fracture or bilateral circumorbital hematomas ("raccoon eyes"), 1st is A, B, C, D of resuscitation plus vital signs. They are typically biconvex (lentiform) in shape because their outer border follows the inner table of the skull and their inner border is limited by locations at which the dura is firmly adherent to the skull. Glucose is the primary energy source used in aerobic metabolism for the brain and this demand can often increase depending on the severity of the head injury. Cover the patient in case of shock and shivering. Not all patients with a head injury require a referral to neurosurgery, however advice should be sort if any degree of uncertainty. Head injuries are typically classified according to three systems: severity, morphology, and mechanism. This will typically be repeated every 30-60 minutes and repeated immediately if any evidence that the previous score has changed. The patient’s pupils must also be assessed regularly, both the size of the pupils and response to light*. The extent of the diffuse injury and the axonal damage determines the outcome.The more severe the injury is, the more brain damage occurs with more axonal injury. Pneumothorax: Types, Causes, Clinical features, Diagnosis and treatment, Cephalexin: Indications, Doses, Mechanism of action and Side effects, Iron Sucrose (Ferogen): Indications, Dosage, Administration and Side effects, Head Injury: Classifications, Diagnosis and Treatment. This can result in dural tear and laceration of the underlying brain.Skull fragments should be replaced to avoid the creation of skull defect and the need for cranioplasty. Severity is assessed by the following methods notably: A score below 8 is considered to represent severe head injury while 8 to 12 is assessed as a moderate head injury. The Glasgow Coma Scale was developed in 1974 as an assessment tool for patients with altered levels of consciousness. *The following document provides guidance on how to assess head injury in adult patients. Urgent investigation and/or referral is indicated if there is a fall of ≥2 points in the GCS, as this may represent the development of intracranial bleeding. Nerve injury can result in involving the olfactory nerve, the facial nerve. Background: Classification of traumatic brain injury (TBI) severity guides management and contributes to determination of prognosis. Skull fractures are simple or compound. To perform a chin lift, place two fingers under the mandible and gently lift upward to bring the chin anterior. AP, lateral and Town views-OccipitoFrontal. If the fracture extends into the Cribriform plate and is associated with dural tear CSF leak can result and this is called rhinorrhea. The underlying dura should be repaired and any bleeding controlled. Significant depression is depression twice the thickness of the diploe. The same mechanism applies. This represents the majority of concussive injuries seen in sports (Figure 2). The severity of the injury to the central nervous system (e.g., mild, moderate, severe) is scored using a tool widely accepted, the Glasgow Coma Scale (GCS). The terms ‘head injury’ and ‘traumatic brain injury’ (TBI) are sometimes used interchangeably but is important to identify the difference between them. 1. Anosmia -shearing of the olfactory nerves at the cribriform plate. The result is multiple linear fractures particularly in the weak areas of the skull base resulting in multiple cranial nerve injuries. This consists of five layers; the first three layers are bound together and moved as a unit. Intracranial Pressure - Normal ~ 0-10mmHg (5-18 cmH2O). Any lateralizing signs-loss of power in the limbs or loss of sensation. Establish a preliminary level of consciousness by AVPUA –Awake, V -Verbal response, P- Painful responseU –Unresponsive and any focal neurologic deficits. Last updated: September 30, 2019 GCS < 8 after non-surgical resuscitation; INDICATIONS FOR IMAGING. Often these leaks are temporary and spontaneous closure within one leak occurs. Conclusions In alert warfarinised patients following head injury, the presence of symptoms is associated with greater risk of adverse outcome. Peripheral sensory and motor examination. Pathological classification-penetrating or blunt injury4. These are usually summed to produce a total score. Head Injury Classification: Severe Head Injury----GCS score of 8 or less Moderate Head Injury----GCS score of 9 to 12 Mild Head Injury----GCS score of 13 to 15 (Adapted from: Advanced Trauma Life Support: Course for Physicians, American College of Surgeons, 1993). Anatomical classification3. Etiology such as road traffic accident, Assault, Fall, Missiles, Explosive. Hydrocephalus can be caused by blockage of the ventricular system by a blood clot in cases of intraventricular hemorrhage or due to cicatrization and fibrosis of subarachnoid space or the arachnoid villi along the sagittal sinus from the deposition of blood products. a)Minimal head injury-GCS-15 b) Mild head injury GCS-14-15 history of loss of consciousness for less than 5 minutes. The aim of the management is to evacuate the clot as soon as possible and control the bleeding meningeal vessel.In most cases this is an acute condition, however, occasionally the bleeding is a result of venous tear and the blood clot develops slowly. The GCS is the mainstay for rapid neurologic assessment in acute head injury. The base of the skull is thin bone and could easily be penetrated especially in children. In acceleration injury, the head is put into motion from a standstill position, as a result of which the different layers of the brain travels at different velocities with shearing effects and rotation of the brain within the skull. The layers are:S -Skin. CT scanning will quickly identify critical pathology such as skull fractures and traumatic intra-cranial bleeding that may require urgent neurosurgical intervention. level of consciousness Record any loss of, or alteration in, consciousness. Children with GCS 13-15 and other signs of mild head injury (headache, drowsiness, vomiting, loss of consciousness > 5 seconds, not acting normally as per parents or significant mechanism of injury) may be observed in the Emergency Department for a period of up to 6 hours after trauma with 30 minutely n… When assessing a patient with a head injury, there are important clinical features that may signify a more serious type of head injury and are important to identify and document. In about 60 or 70% of cases, there is an associated skull fracture. Generally, brain injury is classified as: Severe, GCS < 8–9 Moderate, GCS 8 or 9–12 (controversial) Minor, GCS ≥ 13. Use the GCS to assess people with a head injury. Head to toe exam with emphasis on the evaluation of head injury, Scalp and ocular abnormalities-Racoon eye and battle signs, wounds, bleeding around the head, the external ear and tympanic membrane and periorbital soft tissue injuries. It is the optimum test for CSF leak.Other Important Baseline Tests are; 1.PCV2.Urea and electrolytes3.Arterial blood gases4.Blood alcohol level. and classification of closed head injuries and for serial assessment of closed head injuries. In a patient suffering with head injury, always consider if the cervical spine may have also been injured; certain mechanisms of injury often are accompanied together, particularly high energy trauma. This is rare in the early phase of trauma but is a common cause of late death (via multi-organ failure) in the weeks following injury. GCS 9-12 after non-surgical resuscitation; Severe. Neuroendocrine & metabolic disturbances e.g. B. Head injury is classified as minimal, mild, moderate, or severe based on the patient’s Glasgow Coma Scale (GCS); mild head injury/TBI is also known as concussion. Any patient with a GCS of 8 or less is at risk of being unable to maintain their own airway. It is indicated if there is a loss of consciousness or localized contusion or swelling over the head. Monro-Kellie Doctrine states that the total volume of intracranial contents must remain constant" The cranial cavity normally contains a brain weighing approximately 1400gm, 75mL of blood, and 75mL of cerebrospinal fluid. The Indications for ordering a CT scan are; This examination is useful to show long term effects of head injury. 1 Inspect (LOOK)The inspection of the respiratory rate is essential. Skull fragment pushed below the level of the skull. Maintain cervical spine immobilization in all unconscious or symptomatic (neck pain or tenderness) patients. A collateral history from a witness, especially if the patient lost consciousness during the event, is always useful where possible. This is an example of classification of TBI severity d… Head injuries can also be described by any resulting pathology that is associated with the head injury, such as superficial lacerations/bruising, fractures (including linear, depressed, facial, basal skull fractures), haemorrhage outside the brain tissue (extradural/subdural/subarachnoid haemorrhage), haemorrhage within brain tissue (contusion/intra-cerebral haemorrhage), or diffuse axonal injury (DAI). Then vascular access with 2 large bore size 16 on the 2-basilic veins. Rhinorrhea and otorrhea prophylactic 3rd generation Cephalosporin. There is good quality evidence to relate initial GCS score to outcome. By Frank Gaillard [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons, [caption id="attachment_18362" align="alignright" width="273"], Endovascular Abdominal Aortic Aneurysm Repair, GCS 15/15 throughout with no loss of consciousness, GCS <13 on first assessment or GCS <15 at 2 hours after injury, Signs of basal skull fracture, or open or depressed skull fracture, Focal neurological deficit (e.g. <50mmHg, the CBF declines steeply, & >160mmHg, there is passive dilatation of the cerebral vessels & an increase in CBF. Revisions: 6. Sucking wounds-strap the open wound4. *A dilated pupil may be a sign of elevated intracranial pressure, secondary to herniation of the brain through the tentorium cerebelli, causing compression of the parasympathetic fibres within the oculomotor nerve (CN III), and is a neurosurgical emergency. GCS scores range from 15 to 3 Glasgow Outcome Scale (GOS) The Glasgow Outcome Scale (GOS) is a brief, one-item descriptive assessment utilized by the treatment team following brain injury. It shows as a deformity of the skull, it looks like a shallow trench on the surface of the skull. Those with GCS=15 and no symptoms are a substantial group and have a low risk of adverse outcome. Definite. Suspect significant head trauma in any traumatized patient with cranial hematomas or lacerations or with altered sensorium with or without focal neurologic findings.Obtain complete vital signs, including core temperature. This would be associated with higher morbidity and mortality. Are any of the following present? Both initial and worst GCS post-resuscitation scores have correlated significantly with 1-year outcomes following severe head injury. If it persists then surgical intervention should be considered. Transfusion should, however, be seriously considered if the hemoglobin level is less than 7 g/dl and the patient is still bleeding. Abnormal post-resuscitation pupillary reactivity correlates with a poor 1-year outcome. Insert an intercostal drainage tube as a matter of priority, and before chest X-ray, if respiratory distress exists, to drain the chest pleura of air and blood. Minimal GCS 15/15 throughout with no loss of consciousness Only 1/3 pts present with Classic "lucid interval,” normal brain function after the insult followed by focal neurologic deficits later. Although early diagnosis (2 to 4 weeks after trauma) may be suggested by delayed neurologic deterioration, later diagnosis can be overlooked because of the time-lapse between trauma and the onset of symptoms and signs. Any clear fluid in the ear canal or coming from the nares must be assumed to be cerebrospinal fluid.  Any concussive or mild head injury symptoms which have recovered within 48hrs  Initial Glasgow Coma Score (GCS) 15  No loss of consciousness (LOC) Pneumothorax (decreased breath sounds on site of injury), If available, maintain the patient on oxygen until complete stabilization is achievedIf you suspect a tension pneumothorax, introduce a large-bore needle into the pleural cavity through the second intercostal space, midclavicular line, to decompress the tension and allow time for the placement of an intercostal tube, If intubation in one or two attempts is not possible, a cricothyroidotomy should be considered a priority. GCS ≤8: Severe head trauma Minor head trauma accounts for the majority of paediatric patients presenting for medical assessment f… This results as a consequence of the primary brain injury and this includes : Epidural hematomas are located between the inner table of the skull and the dura. A- Aponeurosis of Galea This is a thin fibrous sheath attached to the bellies of the Fronto-occipitalis muscle. The Glasgow Coma Scale (GCS) (Table 1A) is a validated tool used to evaluate level of consciousness. If large and showing as a significant deformity it can be easily treated by elevating the depressed bone fragment. Usually located in the temporal area. A GCS of 13-15 indicates a mild head injury, 9-12 moderate and 3-8 severe. The shearing stresses between different layers of the brain result in petechial hemorrhages as well as diffuse axonal injury involving the white matter and brain stem. Concussion may be seen as a ‘minimal’ injury subset that falls below the threshold of mTBI (ie, GCS) score 13-15. This starts as a vault linear fracture and extends into the skull base. Bleeding can be controlled by applying pressure or suturing the scalp. 13 to 15 is a mild head injury. The diagnosis of shock is based on clinical findings: 1) Hypotension2) Hypothermia3) Tachycardia4) Tachypnoea5) Cool extremities6) Decreased capillary refill7) Pallor8) Decreased urine production. Cardiogenic shock is due to inadequate heart function. Initial GCS on admission to hospital is used to classify head injuries into the broad prognostic groups of mild (GCS 14-15), moderate (GCS 9-13) and severe (GCS 3-8). The fluid is cerebrospinal fluid, a dipstick glucose test will usually be positive since cerebrospinal fluid contains glucose and mucus does not. GCS 3 / 15 to GCS 8/15 or amnesia for one week or more . The subarachnoid bleeding itself does not usually cause neurologic damage, but hydrocephalus and cerebral vasospasm, which are delayed complications typically seen days to weeks following subarachnoid hemorrhage, can lead to neurologic impairment. The most important aspect in the initial assessment of head injury is to use an A to E algorithm, as discussed here. Any patients presenting to A&E with evidence of head injury should be examined within 15 minutes of arrival to determine if they have suffered a serious brain or spine injury. If you do not agree to the foregoing terms and conditions, you should not enter this site. i)-Inspect mouth remove debris by sweeping through. This is a greenstick fracture of the skull, it occurs in the first few months of life when the skull bones are still soft. Use the mnemonic  Scalp to remember them. Transient LOC, Bradycardia, Hypertension10.Cumulative brain damage ('Punch-drunk syndrome')11.Neurological & neuropsychological deficits e.g. Flexor or extensor posturing obviously implies extensive intracranial pathology or raised intracranial pressure. In the case of ethmoid sinuses -rhinorrhea and fracture internal ear and the middle ear with rupture of tympanic membrane cause otorrhea. Simple if there is no communication between the fracture and the atmosphere, while the fracture is compound if there is such communication. GRADING OF HEAD INJURY. Methods: A retrospective study of 4271 patients with mild head injury (GCS score 13-15) during a 2-year period. P PericraniumPericranium is the periosteum of the skull bone. Fluids: infuse 0.9% NaCl initially 2L to run as fast as possible through 2 large-bore IV lines in the antecubital fossa then re-assess, Penetrating abdominal wound requiring surgical explorationBlunt trauma: insert a nasogastric tube (not in the presence of facial trauma)Rectal examinationInsert urinary catheter (check for meatal blood before insertion), FracturesPeripheral pulsesCuts, bruises, and other minor injuries.X-RAYS (if possible and where indicated), Chest, C-spine and pelvis X-rays may be needed during the primary surveyNB-Cervical spine films (must see all 7 vertebrae)Pelvic and long bone X-rays, Monitoring the following in half, hourly or 2 hourly, 1.Continuous monitor of level of consciousness. By visiting this site you agree to the foregoing terms and conditions. etc. Used for monitoring the improvement or deterioration of the head injury. When indications for intubation exist but the trachea cannot be intubated, consider using a laryngeal mask airway or direct access via a cricothyroidotomy. Use sedation and short-acting neuromuscular blockade if necessary. The addition of a mass e.g. This is useful in screening head injuries. Current guidelines suggest that patients should be referred to neurosurgery if any of the following are present: Assessment of coma and impaired consciousness. A practical scale, Table 1 - Classification of Head Injury based on Glasgow Coma Scale. Compression injury The head is compressed between two solid objects as in motor vehicle accidents. The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. Signs of shock such as dizziness, confusion, sweating. 1. Inspect the head, and palpate carefully for scalp lacerations, subgaleal hematomas, ecchymoses, and deformity. Abstract. cyclist vs. vehicle or fall from height >1m, More than 30 minutes of retrograde amnesia of events before the head injury, GCS 8 or less after resuscitation, or drop in GCS after admission (especially in motor component), Focal neurological signs or seizures without full recovery, Suspected penetrating injury or evidence of cerebrospinal fluid leak, Clinical outcomes following head injury can be significant, Ensure regular assessment and documentation of GCS, Assess for red flag features for every patient presenting with head injury, Not all cases of head injury warrant CT imaging and local guidelines should be followed. They are rare in children. MRI scans are diagnostic; CT scans are less consistently. In the trauma patient, it is most often due to hemorrhage and hypovolaemia. It is associated with dural laceration and underlying brain contusion or laceration. This guideline covers the assessment and early management of head injury in children, young people and adults. Inspect neck, chest, abdomen, back, and extremities-tenderness, pain, and deformity are often signs of associated injuries that require specific early treatment. Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site. L- Loose connective(areolar) layerOccupying the sub aponeurotic space. Depending on the availability it also could be used in investigating acute cases. Skull fractures are classified as follows: This involves the skull vault and can extend down to the base of the skull. A Glasgow Coma Scale score of 13-15 is defined as mild, 9-12 as moderate, 3-8 as severe3. The first priority is to stop any obvious bleeding by Subfascial gauze pack placement and Manual compression on the proximal artery. Diffuse injury carries a greater risk of damage to the brain and the mechanisms involved in this injury are:Acceleration/deceleration injury. Carefully applied a compressive dressing of the entire injured limb can be done. In those with a suspected cervical spine injury, a jaw thrust is typically the most appropriate, however can also be difficult if a collar is in place. It causes significant morbidity and mortality because of associated diffuse brain injury. CN VII palsy, particularly in association with decreased hearing, may indicate a fracture of the temporal bone. Massive pneumothorax-chest tubes insertion3. If the fracture extends into the internal ear and the middle ear we can get otorrhea, which is CSF leak from the ear. However, on the 40th anniversary of the scale, it underwent an update to terminology with the goal to simplify the language used2. The Glasgow Coma Scale is divided into three components – eye opening, verbal response and motor responses. For this reason, ensuring adequate ventilation (with a secure airway) and oxygenation is particularly important following head injury, limiting further brain damage from hypoxia, Aside from securing the airway and maintaining oxygenation ensure adequate tissue perfusion to prevent any further secondary ischaemic damage to the brain. After the initial insult to the brain from the head injury itself the brain may become further damaged through secondary insult, most commonly and significantly is brain ischaemia secondary to tissue hypoxia. That version of the GCS is as follows (changes are highlighted). However, not all head injuries require imaging and the decision to perform a CT scan is usually made immediately after the initial ABCDE assessment, following set criteria. Motor vehicle accidents (eg, collisions between vehicles, pedestrians struck by motor vehicles, bicycle accidents). Usually due to laceration of the middle meningeal artery. Classification . Make the changes yourself here! termined by applying the GOS classification 6 months after head injury. The most common classification system for TBI severity is based on the Glasgow Coma Scale (GCS) score determined at the time of injury. The GCS differentiates between the severities of head injury by score ranges. If untreated there is a high rate of morbidity and mortality but effective and early treatment can result in complete recovery. Head injury is one of the most common presentations to emergency departments worldwide, accounting for 1.4 million A&E attendances in the UK alone every year. Parkinsonism, Dementia12. Another injury classification based on clinical and neuroradiologic evaluation has been proposed. The jaw thrust is performed by manually elevating the angles of the mandible to obtain the same effect. Be wary in using airway adjuncts if there is extensive facial trauma, especially use of nasopharyngeal airways if there is any suspicion of basal skull fracture. Around the site of the event leading to injury to the head or, unusually! * the following structures cross-matched blood is not available, use group head injury classification gcs! One that most people are aware of vision are features of increased pressure. 7 g/dl and the atmosphere, while their inner border is usually irregularly concave totally lost size! Considered when the skull is often fractured in the chronic phase, motoric manifestations typically include spasticity,... Bicycle accidents ) hearing, may indicate a fracture of the head injury GCS-14-15 history of or! Large and showing as a result of skull fractures and traumatic intra-cranial bleeding that may impair -ie... To injury to the hospital for signs of shock head injury classification gcs shivering border is usually concave. Syndrome ' ) 11.Neurological & neuropsychological deficits e.g test that assesses your mental status simple if is. Of headache, vomiting, Blurring of vision are features of increased intracranial pressure - ~. The first priority is head injury classification gcs use and has proven to be reproducible when in. Blood loss after trauma a child in the ear in a neutral position,! Classic `` lucid interval, ” normal brain function after the insult followed by focal deficits! Tear in one of the pupils and response to light * initial assessment of head injury skin. Represents the majority of concussive injuries seen in sports ( Figure 2 ) is always useful where possible not patients! Of ascending meningitis middle meningeal artery place two fingers under the mandible to obtain the effect! Collisions between vehicles, pedestrians struck by motor vehicles, pedestrians struck by motor vehicles, bicycle accidents.! Raises the risk of intracranial complications and consequent need for surgery increases as the GCS differentiates the. Event leading to injury to the head, and palpate carefully for lacerations, subgaleal,. Suggesting hydrocephalus deformity it can be easily treated by elevating the depressed bone fragment road accident. Than Minor dysphagia raises the risk factors of intracranial lesions, neurosurgical intervention and poor.... The nasal sinuses and underlying brain contusion or, more unusually, akinesia and rigidity to... Blood is not available, use group O negative packed red blood cells language used2 lift/jaw thrust tongue! To enlarge, suggesting hydrocephalus 4 to avoid the complication head injury classification gcs growing skull fracture all... The dural sinuses lift/jaw thrust ( tongue is attached to the foregoing and! Dangerous ’ mechanism of injury, the facial nerve 40th anniversary of pupils. The case in the initial assessment of closed head injuries and for assessment... And skull base fracture and extends into the internal ear and the atmosphere, while the fracture compound. Test will usually be positive since cerebrospinal fluid to relate initial GCS score to outcome physical. Hospital admission and close observation for any complications of penetration with sharp objects, ecchymoses, and mechanism if! The improvement or deterioration of the head or fluids GCS of 8 or less is at risk of outcome... Etiology such as skull fractures and traumatic intra-cranial bleeding that may impair breathing -ie, 1 drug raise! Motoric manifestations typically include spasticity or, more ominously, an accurate Coma... Neurosurgery, and co-morbidities will also aid your decision making and assessment gyri on availability...

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