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Home Surgical Tutorials General Surgery Tutorials Head Injury management guidelines for trainee general surgeons

Head Injury management guidelines for trainee general surgeons

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Written by Jeremy Ganz   
Monday, 25 June 2012 10:41

Background

This short set of guidelines is aimed at surgical trainees who will of necessity have to care for head injuries. The frequency of these injuries treated in emergency departments is roughly 1500/100000 patients per year in the UK. There are only 15/100000 referred to neurosurgical departments and of these 9/100000 die1. Thus while the course of the great majority of Traumatic Brain Injuries (TBIs) is benign, the frequency of the condition is such that it is the major cause of mortality between the ages of >1 and 44. It follows from the above that neurosurgical departments will be involved in between 5 to 15% of patients. Thus 85 to 95% of patients will be managed either by general practitioners or general or orthopaedic surgeons.

While the great majority of TBIs run a benign course requiring no special treatment there is the well-known risk of epidural bleeding with delayed clinical deterioration and concomitant threat to life. For this reason patients who have suffered a head injury with loss of consciousness are observed overnight. This involves a considerable effort and expense for a condition which occurs in 0.83/100000 of the UK population 7per year. However, these bleeds occur most frequently in people under 60 years of age. Since the injury is in principle curable and occurs in younger patients, the extra effort is considered worthwhile despite the expense.

 

Principles of Management

1. Avoid a second injury to the brain – potentially urgent 2. Optimise the outcome for injuries to all other tissues - Important but only very rarely urgent

The guiding principle for avoiding a second injury is observation of the intracranial pressure. Remember! A falling level of consciousness indicates an abnormal rise in intracranial pressure: at least until a high quality CT examination shows otherwise. This does NOT happen often.

Avoid a second injury to the brain

Patients who are in coma from the injury should all be sent to neurosurgical centres as their first port of call, so that these guidelines will only concern patients who can be awakened. Coma in this context is defined on the next page. In this group of patients there are two main causes of a secondary deterioration of consciousness; epilepsy which is not due to a raised intracranial pressure (ICP) and haemorrhage which is. They are easily distinguished from each other because one is profound sudden and usually improves after some minutes. The other is more slowly progressive accompanied often with increasing headache.

Other possible causes of raised ICP include hydrocephalus, oedema and vasodilatation. These are virtually unknown in this group of patients.

The great problem for the general surgeon receiving such patients is how to assess them in a way which best can guarantee their safety.

This produces much uncertainty and even anxiety because of lack of familiarity with the examination of the nervous system. The good news is that only the simplest examination is necessary. Such examinations as testing tendon reflexes, coordination tests or cutaneous sensation tests are inappropriate in this context and truth to tell even experienced neurologists can disagree about the interpretation of tendon reflexes. For each aspect of the management the clinical methods are explained. These explanations will be followed by a description of common causes of confusion in interpreting the findings

Aims of Management – Potentially Urgent – To prevent secondary injury Control the Intracranial Pressure

Two questions need to be asked

 

  1. Does the patient have raised intracranial pressure (ICP)?
    Raised intracranial pressure above certain levels can impede blood flow to the brain and if high and persistent can induce secondary brain damage over and above the damage from the original injury. Every attempt is made to avoid this. Raised ICP lowers the level of consciousness.
  2. If there is raised ICP is it at a dangerous level?
    If not is it stable, improving or deteriorating.
Table 1. Glasgow Coma Scale
Eye Opening Score
Spontaneous 4
To speech 3
To stimulus 2
None 1
Verbal Response
Orientated 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Motor Response ( best )
Obeys commands 6
Localizes Stimulus

5

Flexion withdrawal 4
Flexion abnormal 3
Extension 2
No response 1
GCS Score 3-15 / 15

 

 

Raised intracranial pressure can be assessed by a simple clinical examination. The tool used for this purpose is the Glasgow Coma Scale (GCS); see table 1.

A normal value is 15 and a minimum value is 3. Neurosurgical departments have GCS chart forms filled in by the nurses. These should be available in ever department caring for TBIs. They are filled in every hour by the nursing staff just like a pulse and BP charts. A falling value should always be considered to be due to a rising ICP and should result in immediate examination by the doctor .

For the general surgeon it could be helpful to know how the various responses are examined. This is shown in table 2.

If GCS <= 8 the patient should be sent to a neurosurgical department (Recommendations from NICE). This is a decent definition of COMA

 

 

 

 

 

 

 

Table 2. How to undertake a GCS examination
Eye Opening Score
Spontaneous 4 Observe by day. At night wake up. Eyes open spontaneously
To speech 3 Repeat patient’s name until eyes open
To stimulus 2 If eyes don’t open shake patient
None 1
Verbal Response Ask name, place, age of patient plus date
Orientated 5 Correct and swift
Confused 4 Tries to answer but incorrect
Inappropriate words 3 Speaks words which do not answer question
Incomprehensible sounds 2 Just makes sounds
None 1 Silent
Motor Response ( best ) If awake ask patient to open eyes and move limbs
Obeys commands 6 Does as asked
Localizes Stimulus

5


Flexion withdrawal 4 Patients with responses this poor should be sent to a neurosurgical unit. They are examined with a standard pain stimulus which is not appropriate outside special units
Flexion abnormal 3
Extension 2
No response 1

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sources of confusion in interpreting the ICP status using the GCS

The patient’s previous medical history and current medication help with interpretation.

  1. Alcohol: Produces confusion drowsiness and lack of cooperation
    a. There is no simple way to assessing the degree of effect alcohol has on the level of consciousness in a given patient. However, a tendency to improvement over hours indicates that the effects of alcohol are significant while a tendency to deteriorate should always be attributed to increasing ICP
    b. Narcotics may be similarly confusing
  2. Post traumatic periorbital/periocular bleeding or swelling - Patient cannot open eyes
  3. Patient had deficient mental function prior to TBI - Commonest causes are:
    a. Dementia – Alzheimer etc.
    b. Congenital deficiencies
    c. Psychiatric patient on medication.
  4. Trauma/Fracture to a limb or joint may prevent motor response assessment for that limb.
  5. Post traumatic epilepsy with post epileptic loss of consciousness.
    a. In general the commonest form of epilepsy in these patients is a single fit of short duration followed by speedy reawakening. If epilepsy is persistent or goes into status the patient should be sent to the neurosurgical centre
    b. For a single fit give no medication and expect the patient to wake up over several minutes to an hour. Failure to wake after one hour is an emergency requiring transfer to a neurosurgical unit.
    c. After a second fit start oral anti-epileptic medication (Epanutin) 100 mg twice a day) for example.
  6. Medication with opiates
    a. Patients with head injuries who receive opiate analgesics may suffer a falling GCS because of the drugs. Wherever possible sedative opiates should be avoided. The preferred analgesic is codeine phosphate 60 mg im up to 4 times a day.
    b. Opiate medication also depresses respiration which can lead to a rise in CO2 in the blood which in turn can dilate the intra-cerebral blood vessels which can raise the ICP.
    c. If opiate medication is unavoidable the patient is better managed in an intensive care unit in a hospital with a neurosurgical department.

 

Aims of Management – Important but not urgent

So long as the patient is awake and responsive there is NO urgency. If the patient is received outside normal working hours, definitive neurosurgical consultation and management can be deferred until normal working hours the next day.

Assessing the patient for focal neurological deficit

Again no sophisticated neurological examination is required. The patient is asked to move all limbs. Movements on both sides should be symmetrical. The plantar responses should be tested. The thumbnail is scraped up the lateral aspect of the foot where the skin is thickest (avoiding tickling) and then is directed medially under the thickened skin at the base of the toes. An abnormal response is extension of the big toe and spreading of the small toes. This indicates a contralateral upper motor neurone lesion if the damage is in the brain.

Focal neurological deficit can occur without loss of consciousness in injuries which have produced focal damage to the brain. These are typically depressed fractures to which

we shall return. As a simple rule, injuries inducing loss of consciousness are caused by trauma from objects bigger than the head (like the ground or parts of a vehicle). These injuries shake up the entire brain producing unconsciousness. Injuries producing only focal damage are caused by objects smaller then the skull (such as a stone or the bottom of a beer mug) and loss of consciousness may not occur at all.

Look at the face. Ask the patient to show teeth and screw up eyes. Note lack of symmetry. Most facial nerve paralyses in patients who are awake will be due to damage to the facial nerve rather than the brain.

Sources of confusion in interpreting focal neurological deficit

 

  1. Limb trauma preventing normal neurological function
  2. Patient has a previous neurological deficit as from a stroke

 

Assessing the patient for skull and scalp injury

Scalp Lacerations

Shaving should be minimal, just adequate to identify the margins of the cut. The wound is cleaned and washed with saline not antiseptics. It is not a good idea to let powerful cytotoxic agents seep beneath the skull through visible or unseen fractures. Where contused the edges should be trimmed; a skin hook can be more use than toothed forceps in this situation. The scalp should be sewn in two layers. Inverted 2.0 Vicryl to the galea and interrupted 3.0 non absorbable sutures to the skin. This is important as it secures reliable haemostasis. After suturing, the hair should be cleaned of blood with cold water and a comb. Dressings may then be applied.

Scalp contusions

These require no treatment. However, occasionally it is possible to feel a swelling with an indurated margin and a central cavity. This is almost invariably lying over a fissure and NOT a depressed fracture. Swellings over depressed fractures are usually boggy or soft. They should only be palpated gently.

Skull Fractures

There are three main types. Fissure, depressed and skull base.

 

  1. Fissure fracture
    These require no specific treatment. However, their presence indicates a more serious level of trauma.
  2. Depressed fractures
    These may be suspected clinically and diagnosed on imaging. They will often require neurosurgical management but seldom as a matter of urgency in patients who are awake. Their presence requires consultation with the neurosurgical department at the time of admission.
  3. Skull base fractures
    These are indicated by the presence of bleeding or CSF leakage from the ears or nose. They are open fractures and therefore many neurosurgeons use a short course of prophylactic antibiotics, usually cephalosporins. However, this is an area where there is no clear cut agreement about which agents to give and for how long. This being so general surgeons should take advice from the neurosurgical centre to which they refer.

 

In the event of bleeding or CSF leakage from the nose or ears, it is inappropriate to try to examine the interior of the nose. Otoscopy is also contraindicated as it carries a potential for increasing the risk of infection without providing any clinical benefit. In the event of pain or hearing loss but no leakage from the external auditory meatus, otoscopy to discover or exclude a hemotympanum is useful. If there is wax impeding a view then further examination of the ear should be deferred and the wax left undisturbed

There are additional signs of a skull base fracture. These are:

 

  1. Periorbital haematoma or ecchymosis, may be due to a skull base fracture
  2. Battle’s sign or ecchymosis over the mastoid bone is pathognomonic of a fracture of the middle cranial fossa base.

Management of Skull Base Fractures

 

 

  1. If there is blood leaking prophylactic antibiotics and consultation with the local ENT department should suffice.
  2. If there is CSF leakage then the local ENT department with or without cooperation with neurosurgeons will be required to plan treatment.
  3. Antibiotic policy should be co-ordinated with the treating departments.

 

Sources of confusion in managing skull base fractures

 

  1. Inadequate images
  2. Interpreting whether leakage from the nose is really CSF. This is very difficult and the use of glucostix to discover sugar is misleading and insufficient for a diagnosis. (The slightest contamination with blood will make the test valueless).
    Remember that localising these fractures can be very difficult and should only be attempted at hospitals with a neurosurgery service.

 

Imaging

Skull X-rays

Neurosurgeons generally advise that skull X-rays are not useful in the management of head injuries. This opinion reflects their practice in which the vast majority of patients have serious injuries which lie outside the scope of these guidelines.

However, for a hospital receiving patients without a neurosurgical facility, there is evidence that detecting a skull fracture indicates patients more at risk for the development of a haematoma3.

It is vital that at least 3 views are taken. The AP view the occipitomental view and a lateral view. If there is pain around the region of the temporomandibular joint a Town’s view should also be taken. It is also essential that the skull is orthogonal to the direction of the central beam of the X-ray. It is depressingly common that this simple rule is not followed. One reason for this is that patients may not co-operate. This being so, better images will be obtained if the surgeons confer with the radiologists on the best way to obtain optimal images.

CT

This is the investigation of choice. It is not necessary if the patient is awake. The procedure takes a little time so it is even more important that the patient is still when it is undertaken. Thus, it is probably of little relevance in a surgical department which is merely observing head injury patients overnight. This department should be aware of the advice from its neurosurgical department’s requirements. Since there are a variety of CT machines around, an examination from an inadequate machine in a peripheral hospital probably is not very helpful when a modern speedy spiral CT with 3D reconstruction is available at the tertiary referral centre.

MRI

This technique has no place in the acute assessment of TBIs. It can however be very useful later to assess the late end result of a serious injury.

Concluding Remarks

 

  1. The management of cervical injuries is not included. If suspected or diagnosed the patient should be transferred directly to the neurosurgical department. Moreover, while reasonably common in unconscious TBI patients they are less frequent and easy to detect in alert patients because of neck pain. They are thus considered outside the scope of these guidelines
  2. There is no mention made of the pathophysiology of raised intracranial pressure. It is not necessary to be familiar with this in detail to be able to manage awake TBI patients effectively. The interested surgical trainee will find an excellent, accurate and readable account in the Samandouras book on neurosurgery (1).
  3. While head injury patients require a relatively great amount of time and where that time is mainly spent in observation, this is still important because of their frequency and because of the potential dangers.
  4. Learning how to assess and record the GCS would make the trainee surgeon’s job much easier and remove much of the uncertainty around caring for these patients and communicating with the local neurosurgeons.
    a. These skills may be observed and even acquired by say a weekend, to a hospital with a neurosurgical department, together with the ICU and observation wards at that hospital. The observations are carried out by the nurses and are quickly learned.
    b. The ability to monitor the GCS is a major element in efficient ICP management.
  5. When to confer with the local neurosurgical department
    a. Deteriorating level of consciousness.
    b. Depressed or basal fracture
  6. How to confer: the necessary information is
    a. Time and nature of accident
    b. Course of GCS
    c. Presence of neurological deficit
    d. Basis for diagnosis of skull base or depressed fracture
    e. Other injuries, previous diseases and medication
    f. Imaging findings

 

REMEMBER – A Major TBI is one with GCS <9. Mortality is 50%

References

1. Introduction to traumatic brain injury. In The Neurosurgeon’s Handbook ed G. Samandouras, Oxford University Press, pp 207 - 208. 2010

2. Teasdale D, Jennett B, Assessment of coma and impaired consciousness. A practical scale. Lancet 13:2 (7872): 81- 84; 1974

3. Head Injury. Triage, assessment, investigation and early management of head injury in infants, children and adults. NICE. 2007.

http://www.nice.org.uk/nicemedia/live/11640/36255/36255.pdf

 

Comments  

 
# Hyun Bae 2016-06-14 07:58
Hey,

This is no doubt an excellent article. Trainees would definitely benefit from it, actually helps everyone.

The Spine Institute
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