Head Injury

History

• Mechanism: Detailed account of injury including height, speed, force, and use of protective equipment (e.g., helmet)

• Loss of consciousness: Duration and associated seizure activity are critical

• Amnesia: Document both anterograde and retrograde memory loss

• Associated symptoms: Multiple episodes of vomiting, persistent headache, confusion, drowsiness, or focal neurological deficits

• Other injuries: Presence of external injuries or signs of non-accidental injury

• Past medical history: Bleeding disorders, anticoagulant use, prior head injuries, neurodevelopmental conditions, VP shunt status

Examination

• General: Observe for visible injuries, signs of shock, and overall appearance

• Glasgow Coma Scale: Assess eye, verbal, and motor responses to gauge level of consciousness

• Neurological: Check for focal deficits, abnormal posturing, and signs of raised intracranial pressure (e.g., unequal pupils, posturing)

• Skull assessment: Palpate for step-off deformities, swelling, or tenderness

• Basal skull fracture signs: Look for haemotympanum, Battle’s sign, raccoon eyes, and any CSF rhinorrhoea or otorrhoea

• Vital signs: Monitor blood pressure, heart rate, and respiratory rate as indicators of systemic stability

Investigations

• CT Brain (+/- C-spine): Gold standard for moderate to severe injuries or when red flags are present (GCS ≤13, focal deficits, suspected NAI, signs of basal skull fracture)

• Indications for CT: Persistent altered mental status, history of loss of consciousness, post-traumatic seizure, severe mechanism, scalp haematoma

• MRI: Consider if specific lesions are suspected and CT is inconclusive

• Other tests: Urgent imaging for suspected non-accidental injury; plain skull X-ray rarely used in acute head trauma

Management

• Mild Head Injury (GCS 15 without risk factors):

  • Discharge with head injury advice if stable with no red flags

  • Advise rest, gradual return to normal activities, and monitoring for symptom change

• Mild Head Injury (with risk factors, GCS 14–15):

  • Observe for up to 4 hours with neurological checks every 30 minutes

  • Discharge if returning to baseline and tolerating oral intake

• Moderate Head Injury (GCS 9–13):

  • Require urgent CT brain (+/- C-spine) and neurosurgical consultation

  • Continuous monitoring and early involvement of a senior clinician

• Severe Head Injury (GCS ≤8):

  • Activate trauma protocol with airway protection, possible intubation

  • Urgent neuroimaging and neurosurgical involvement

  • Initiate measures to reduce raised intracranial pressure (e.g., elevate head, hyperosmolar therapy with mannitol or hypertonic saline)

Discharge Advice

• Provide caregivers with clear instructions on red flag symptoms (worsening headache, confusion, persistent vomiting, new neurological deficits)

• Advise on gradual return to cognitive and physical activities, especially following concussion

• Arrange follow-up to reassess neurological status and recovery progress

Red Flags

• Deteriorating or persistently low GCS (<13)

• Signs of basal skull fracture (haemotympanum, Battle’s sign, raccoon eyes, CSF leak)

• Focal neurological deficits or post-traumatic seizures

• Evidence of raised intracranial pressure (unequal pupils, abnormal posturing)

• Suspected non-accidental injury or severe mechanism of injury (high-impact MVC, significant fall)

Additional Notes

• Children under 6 months, those with neurodevelopmental disorders, or special conditions (e.g., VP shunt, bleeding disorders) require lower thresholds for neuroimaging and careful evaluation

• In remote or rural settings, stabilise airway, breathing, and circulation while arranging prompt transfer

• Continuous monitoring post-injury is critical to detect delayed complications such as intracranial bleeding or raised ICP