Assessment of head injury

The most important points to assess in a head injury are:

• history of events preceding and following the injury
• external evidence of injury
• basal skull fracture
• conscious level - Glasgow Coma Scale or equivalent
• pupillary abnormalities - cranial nerves II and III
• limb movements - hemiparesis or hemiplegia may occur, either contralateral or ipsilateral to the side of the lesion, but are of little value in localising the site of the damage.

These guide the need for further investigation and provide a baseline from which to assess progress.

Notes (1):

• in patients considered to be at high risk for clinically important brain injury and/or cervical spine injury, assessment should be extended to full clinical examination to establish the need to request CT imaging of the head and/or imaging of the cervical spine
• patients who, on initial assessment, are considered to be at low risk for clinically important brain injury and/or cervical spine injury should be re-examined within a further hour by an emergency department clinician
• pain should be managed effectively because it can lead to a rise in intracranial pressure. Reassurance and splintage of limb fractures are helpful; catheterisation of a full bladder will reduce irritability. Significant pain should be treated with small doses of intravenous opioids titrated against clinical response and baseline cardiorespiratory measurements
• throughout the hospital episode, all healthcare professionals should use a standard head injury proforma in their documentation when assessing and observing patients with head injury. This form should be of a consistent format across all clinical departments and hospitals in which a patient might be treated. A separate proforma for those under 16 years should be used. Areas to allow extra documentation should be included (for example, in cases of non-accidental injury)
• it is recommended that in-hospital observation of patients with a head injury, including all emergency department observations, should only be conducted by professionals competent in the assessment of head injury
• patients who returned to an emergency department within 48 hours of discharge with any persistent complaint relating to the initial head injury should be seen by or discussed with a senior clinician experienced in head injuries, and considered for a CT scan
• current primary investigation of choice for the detection of acute clinically important brain injuries is CT imaging of the head

Reference:

1. NICE (September 2007). Triage, assessment, investigation and early management of head injury in infants, children and adults