Guidelines for Management of Head Injuries

 Cross River State Ministry of Health

Clinical Guidelines & Audit Unit

June 2004

PREAMBLE

Trauma involving head injury is an important cause of morbidity and mortality in our environment. Most of these injuries are from road traffic accidents (RTA). Most often, head injury is associated with injuries to other parts of the body like the chest, the abdomen, the limbs, etc. These accidents are usually caused by excessive speeding, alcohol intoxication, and failure to use restraining seat belts, crash helmets, absence of, or poor implementation of traffic legislation. Other reasons for the high incidence of severe RTA on our roads are; the poor state of our roads and vehicles, the high illiteracy level and indiscipline of the drivers. The increasing use of motorbikes as a means of transportation without helmets has further worsened the situation.

The prognosis of a head injury depends on the primary injury to the brain as well as the secondary insults to the injured brain. These include; intracranial haematomas, raised intracranial pressure, brain oedema, infection, epilepsy, hypoxia, etc. These must be prevented or urgently treated.

AIM

The aim of this guideline, therefore, is to reduce morbidity and mortality from head injury through early and effective resuscitation, assessment, and appropriate referral; monitoring, and effective treatment of complications.  Some aspects of this guideline have been adapted from the “SIGN guideline for head injury.”¹

SEARCH STRATEGY: The MEDLINE (1966 – March 2004), and the Cochrane Library (Issue 2, 2004) were searched for Randomised Control Trials and Systemic Reviews on efficacy and effectiveness of interventions. We also visited “NICE” website for evidence based guidelines – www.NICE.org
 

At any health facility

1                    Receive

2                    Resuscitate

Assess the patient

Breathing – ensure the airway is patent by sunctioning

Circulation – ensure circulation

Disability – immmobilise fractures

External bleeding – arrest all external bleeding

3                    Decide to keep or refer

Indications for referral at 1^st level of care

i)                    Impaired consciousness (Glasgow Coma Score less than 15)

ii)                   Multiple injuries

iii)                 Lateralizing/localizing signs (neurological symptoms e.g severe headache, nausea and vomiting , irritability or altered behaviour, or a seizure

iv)                Amnesia for the incident or subsequent events.

v)                  Clinical evidence of a skull fracture e.g. CSF leak, periorbital haematoma.

vi)                Significant extracranial injuries.

vii)               A possible penetrating brain injury or possible non-accidental injury in a child.

viii)             Continuing uncertainty about the diagnosis after first assessment.

At the Casualty/Accident & Emergency department of the Hospital

The attending physician should carry out the following and clearly record same in the case note:

-          A quick assessment of vital functions i.e. airway, breathing, bleeding and level of  consciousness

-          An unconscious patient should have an endotracheal tube   inserted and ventilation assisted by giving oxygen

-          Pulse, BP and pallor should be assessed for evidence of bleeding or shock

-          If there is evidence of bleeding or shock immediate intravenous infusion is started with any crystalloid solution. ^2[A1]

-          Blood is taken for grouping and X-matching, and blood transfusion is given as necessary

-          Avoid the use of colloids for resuscitation^2[A1]

-          Insert an indwelling urethral catheter

-          A nasogastric tube is passed to empty the stomach, and thereby reduce the risk of aspiration

Initial Assessment

-          Cause and time of head injury

-          Level of consciousness using the GlasgowCcoma Scale (GCS)

GCS

Total Coma Score 3/15 – 15/15

-          Any loss of consciousness following head injury, followed by recovery.

-          Pupilary size and reaction to light, comparing left and right.

-          Limb movement, power, deep tendon reflexes and planter responses, focal neurological signs, pulse rate, blood pressure, respiratory rate, temperature.

-          Total injury inventory.

-          Urine examination for blood and abdominal paracentesis/peritoneal lavage for intra-abdominal bleeding if appropriate.

Monitoring

The following should be monitored every 15 to 30 minutes:

§        Level of consciousness using GCS

§        Pupilary size and reaction to light

§        Blood Pressure

§        Temperature

§        Pulse

§        Respiratory rate

Indicators of neurological deterioration:¹

§        Development of agitation or abnormal behaviour.

§        Sustained decrease in conscious level of at least 1point in motor or verbal response or 2 points in eye opening response of the GCS.

§        Development of severe or increasing headache or persisting vomiting.

§        New or evolving neurological symptoms or signs e.g. pupil inequality or asymmetry of limb or facial movement.¹

Criteria for Skull X-ray:

a.      Loss of consciousness or amnesia at any time.

b.      Neurological symptoms & signs.

c.      CSF or blood from nose or ear.

d.      Suspected penetrating injury, scalp bruising and swelling

e.      Alcohol intoxication.

f.    Difficulties in assessing patients e.g. the very young and epileptic. (Local consensus)

The risks associated with combinations of neurological and skull findings are shown on the table below:

Risk of an Operable Intracranial Haematoma in Head-injured patients¹

Skull X-ray may show foreign body

Unilateral intracranial pressure increase may result in a shift of calcified peneal body from the mid-line on skull X-ray.

In comatose patients lateral films of the cervical spine should be taken.

CT scanning

Where CT scanning is available it is the yardstick for screening intracranial damage, as even mild head injury may be followed by clinically silent but potentially important CT abnormalities.¹

Exploratory Burr-holes

Indicated where there is rapid neurological deterioration due to suspected intracranial haematoma and when CT scan is unavailable (local consensus of senior doctors).

Blood gas analysis

Should be done in unconscious patients if possible as it may give indication for endotracheal intubation and controlled ventilation.

Indication for admission¹

Patient should be admitted to hospital if:

i).  Level of unconsciousness is impaired (GCS < 15/15).

ii). The patient is fully conscious but any of the following risk factors are present:

-          amnesia after injury,

-           continuing nausea and vomiting

-          a seizure at any time after injury

-          focal neurological signs

-          irritability or abnormal behaviour

-          clinical or radiological evidence of skull fracture or pineal shifts

-          an abnormal CT scan

-          severe headache or other neurological symptoms

-          patient has significant medical co-morbidity e.g. anti-coagulant use

Children should be admitted if any of the following risk factors apply: ¹

1.      History of loss of consciousness.

2.      Neurological abnormality, persisting headache or vomiting.

3.      Clinical or radiological evidence of skull fracture or penetrating injury.

4.      Difficulty in making a full assessment.

5.      Suspicion of non-accidental injury.

6.      Other significant medical problems.

7.      Not accompanied by responsible adults or social circumstances considered unsatisfactory.

Management of the Unconscious patient

The unconscious patient should never be left unattended.

§        If cervical injury is excluded, nurse patient head-up inclined at 30 to 40 degrees.

§        If cervical injury is suspected spinal movement must be avoided,^3[D]

§        Immobilization can be accomplished by placing patient in a semi-rigid cervical collar on spine board,^3[D]

§        The head and neck are further immobilized using sand bags or linen rolls^3[D] and tapes,

§        Orotracheal tube is required in coma but cervical spine must be immobilized if injury is suspected and cricoid pressure may facilitate the process,^3[D]

§        Turn patient from side to side every 2 hours to avoid hypostatic pneumonia and pressure sores,

§        Also the use of foam and shipskin helps to prevent pressure sores^3[D],

§        Hyperpyrexia promotes brain swelling and raises the intracranial pressure.^4[D] This can be controlled by surface cooling with fans, wet sheets, ice packs, and by administration of antihistamine e.g. promethazine.

§        Bladder catheterization with indwelling Foleys’ catheter and continuous drainage prevents urinary retention, keeps patient dry and allows accurate monitoring of fluid balance.

§        A nasogastric tube keeps stomach empty initially and could be used for feeding and giving fluids after 48 hours.^5[A1] Early enteral feeding is beneficial.

§        Maintain fluid balance by using crystalloids.^2[A1]

§        Strict input-output chart is maintained to avoid overhydration.

§        Group/cross-match and transfuse when necessary

§        Urea and electrolyte estimation is done twice weekly as brain swelling is frequent when the serum sodium falls below 120mmol/L.^4[D]

§        Patient should be protected from extremes of temperature

§        If daefecation is not spontaneous, bowel motion can be controlled by enema given every 2 to 3 days.

§        Early seizures can be reduced by prophylactitic anti-epileptic drugs e.g. Phenytoin, Tegretol and Phenobarbitone. ^7[A1]

Management of raised intracranial pressure (ICP)

-          Manitol 20%,  250ml I.V in 30 mins X 2 doses given rapidly—this lowers intracranial pressure^6[A1]

-          Barbiturates have been shown to cause hypotension and are, therefore, not recommended^8[A1]

-          Corticosteroids are not recommended for lowering ICP^9[A1]

-          Controlled ventilation in expert hands is effective in lowering ICP.^4[D]

Extradural haematoma

 In extreme emergencies, and where there is no neuro-surgical opinion the surgeon/ surgical resident should do a bore-hole on the side of the dilated pupil; if no help from eye signs, on the side of the fracture of the temporal bone in the region of the middle meningeal artery

Scalp laceration

–        suturing under local anesthesia after wound debridement

–        Antibiotics 

–        Tetanus toxoid

Basal fracture of the skull with Rhinorohea or Otorrhea

–        Hospital observation

–        Antibiotics

–        Refer to a neuro-surgeon for fascial graft if CSF discharge continues after 2 weeks.

Depressed fracture

 This is compound to the exterior in 90% of cases and should be referred to a neuro-surgeon

Indication for Neuro-surgical Opinion

-          CT shows recent intracranial lession

-          Persistent GCS score (8/15 or less) after initial resuscitation

-          Confusion persisting for more than 4 hours.

-          Deterioration of level of consciousness after admission

-          Progressive neurological signs

-          A seizure after recovery

-          Depressed fracture

-          efinite open / penetrating injury.

References

1.      Scottish Intercollegiate Guidelines Network (SIGN). www.sign.ac.uk. Guidelines designed to help doctors provide early and more effective treatment for patients with head injury. February 2001.

2.      Alderson P, Schierhout G, Roberts I, Bunn FI, Bunn F. Colloids versus Crystalloids for fluid resuscitation in critically ill patients (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.

3.      Lundberg GD. ALS For The Pediatric Trauma Victim. JAMA 1992; 268(16): 2271 – 2272.

4.      Forrest APM, Carter DC, Macleod IB. Head Injury in Principles and Practice of Surgery. Edinburgh Churchill Livingstone, 1985; pp 108 – 116.

5.      Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional support for head injured patients. (Cochrane Review) In: The Cochrane Library, 13 January 2000.

6.      Schierhout G, Roberts I. Mannitol for acute traumatic brain injury (Cochrane Library, Issue 2, 2002. Oxford: Update Software.

7.      Schierhout G, Roberts I, Anti-epileptic drugs for preventing seizure following anti-traumatic brain injury (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software

8.      Roberts I.  Barbiturates for acute traumatic brain injury (Cochrane Review).  In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software

9.      Alderson P, Roberts I. Corticosteroids for acute traumatic brain injury (Cochrane Review). In: The Cochrane Library, Issue 1, 2003.Oxford: Update software

APPENDIX 1

Levels of Evidence

A1       Systematic review of randomised controlled trials

A2       Individual RCTs with narrow confidence intervals and > 80% follow up

B          Systematic reviews of cohort or case-control studies with homogeneity, large individual cohort or case –control study, RCTs with <80% follow up.

C         Case-series and poor quality cohort or case-control studies.

D         Expert opinion without explicit critical appraisal.

SEARCH STRATEGY:

Evidence for practice was searched in the MEDLINE, Cochrane Library, and “NICE” website (www.NICE.org). The following search terms were used head injury, head trauma, accidents, randomised control trial, systematic reviews.
 

APPENDIX 2

HEAD INJURY MONITORING CHART

Name of patient: _____________________       Hospital Number: _____________

Date of admission: ____________________      Time of admission:_____________         

Monitoring should be every 15 to 30 minutes

ACKNOWLEDGEMENT

Guidelines Development Group

1.       Dr Angela Oyo-Ita                            Consultant, Community Physician, UCTH

2.       Dr Philip E. Bassey                         Asst. Director Public Health MOH

3.       Dr Esu Oyo-Ita                                Director of Medical Services MOH

4.       Dr Charles Iwara                             Assistant Director Medical Services MOH.

5.       Dr Victor Ansa                                 Consultant Physician, UCTH

6.       Dr A.E Offiong                                 Chief Medical Officer, MOH

7.       Dr Kuma P.                                     Senior Medical Officer, General Hospital, Calabar

8.       Dr Martin Meremikwu                       Associate Professor Paediatrics Unical (EHCAP Nigeria

Coordinator)

Consultant

Dr Cyprian Okoro of London School of Hygiene & Tropical Medicine and EHCAP, Liverpool School of Tropical Medicine.

Peer Review

This guideline (Management of Head Injuries) was peer-reviewed by Dr. I. A. Ikpeme Department of Surgery, Trauma Unit. University of Calabar, Calabar Nigeria.

Support

  The Cross River State Ministry of Health

  Effective Health Care Alliance Programme, Liverpool School of Tropical Medicine*

  The UK Department for International Development (DFID) supports EHCAP

  Institute of Tropical Diseases Research and Prevention