THE GENERAL METHOD FOR AN UNCONSCIOUS PATIENT WITH A HEAD INJURY

This extends Section 51.3 on the care of a severely injured patient. It applies to all patients who have lost consciousness after an injury, ever if their most obvious injury is a fractured femur.

CAUTION! Admit all patients, especially children, who have been unconscious with a head injury even for a moment. Observe them carefully for 24 to 48 hours.

THE IMMEDIATE CARE OF AHEAD INJURY

AIRWAY This is critically important. (1) Place the patient in the recovery position (51-2). (2) Clear his mouth and pharynx (3) Insert an oral airway.

If his consciousness is much impaired, so that he has no cough reflex, intubate him before you pass a stomach or a nasogastric tube. If his consciousness is not so deeply impaired, a tracheal tube is less essential. As soon as his con sciousness improves he will reject a tracheal tube.

If he is deeply unconscious and intubation is impossible, or he fails to maintain an adequate airway, do a tracheostomy He may need one if he is in coma for a long time.

EMPTY THE PATIENT’S STOMACH Many patients vomit and aspirate their stomach contents after admission to hospital. If a patient’s stomach was full when he was injured, it will still be full now. If it is obviously distended, pass an oral stomach tube, and when it is empty, pass a nasogastric tube. Otherwise, pass a nasogastric tube to begin with.

CAUTION! If you decide to pass a stomach tube do so: (1) After you have intubated a patient, or you may drown him in his own gastric contents. (2) Pass it while he is in the recovery position.

THE HISTORY OF A PATIENT WITH A HEAD INJURY

What exactly happened? As far as possible, try to assess the patient’s level of consciousness, from the moment of his accident. Now, or later, enquire how much loss of memory he has for the events following the injury. The duration of pre– and post–traumatic amnesia are good indications of the severity of a head injury.

Question witnesses. Did the patient have a lucid interval (a period of consciousness before becoming comatose) following the injury?

THE EXAMINATION OF A HEAD INJURY

GENERAL EXAMINATION Look at the patient in a good light, examine his body and limbs first, and then his head and neck. Smell his breath for alcohol and acetone, and don’t forget the other causes of coma, including epilepsy, diabetes, liver failure, meningitis, drugs, malaria, and trypanosomiasis.

CAUTION! (1) However strongly he smells of alcohol, don’t assume that this is the cause of his impaired consciousness. (2) Always admit an alcoholic who has sustained a head injury.

NEUROLOGICAL EXAMINATION If the patient is sufficiently conscious, test the motor power of all his four limbs. Look especially for signs of weakness on one side of his body. Recognizing this requires practice in a patient who is not fully cooperative.

If he is restless, observe how he moves each side of his body. Rub his chest over his sternum with your closed fist and see how he responds. Press firmly with your nail above his orbits. His grimace may be weaker on one side than the other. Lift his arms and legs, release them and see how they fall away.

See how his limbs respond when you pinch them firmly. The signs may only be minimal. For example, a child may not be able to move his limbs quite so well on one side as on the other.

Examine his knee and ankle jerks, and his abdominal and plantar reflexes. Test for neck stiffness, and examine for Kernig’s sign.

CAUTION! Don’t do a diagnostic lumbar puncture early on, because it will give you no information that you cannot get more safely in other ways. If a patient’s CSF pressure is raised, lowering it suddenly may kill him. However, if you suspect meningitis (63.13) or subarachnoid haemorrhage, proceed to do one.

EXAMINE THE PATIENT’S EYES Record the size and equality of his pupils, and whether they react to light. You may have to use a very bright light. Examine his eyes now before they are closed by swelling, and frequently later, even if they become severely swollen. Don’t give him atropine, because this will destroy the great diagnostic value of a unilateral dilating pupil.

Examine his nervous system often, because unequal pupils and unequal reflexes are important signs as to which side of his brain is being compressed. The inequality may disappear later. If you don’t examine a patient often this important information will be lost.

Look for papilloedema. It is a rare but certain sign of raised intracranial pressure.

A ’black eye’ is the result of bleeding into the eyelids and is of little significance’by itself. Conjunctival haemorrhages only indicate a fracture (usually of the orbital plate of the frontal bone) if: (1) They make the patient’s conjunctiva oedematous. (2) They are so large that you cannot see their posterior limit in any position of his eye. (3) They displace or restrict the movement of his eye. Otherwise, they are merely signs of local bruising.

EXAMINE HIS SCALP AND SKULL (1) Look for cuts and bruises. This is especially important if the patient is drunk, and you are not sure if he also has a head injury. Observe the site of the trauma accurately, before it becomes enlarged and oedematous. It is also a useful indication of the site of an intracranial haematoma. (2) Feel for: (a) The edges of a depressed fracture; this is not an easy sign and swelling of the scalp with blood in the tissues can give a similar feeling and be very deceptive. (b) Extensive boggy swelling of the patient’s scalp. (c) Thickening of his temporalis muscle. These are all signs of a fractured skull.

A pad and bandage will usually control bleeding from his scalp, but if it does not, sew it up temporarily. Don’t attempt to explore it until you have taken him to the theatre!

ASSOCIATED SKULL FRACTURES Surprisingly, a patient seldom has a depressed skull fracture and a compressing intracranial lesion at the same time. A plain or simple depressed fracture is usually an urgency rather than an emergency. If he does have a depressed skull fracture, this can, if necessary, wait 12 hours or longer. A compressing intracranial lesion will probably reveal itself before this, and if it does, you can deal with both lesions together.

The only emergencies are compound depressed fractures with open brain. Explore these early and close the patient’s skin before you refer him.

CAUTION! Remember that the only time that a fracture alters the management of an unconscious patient with a head injury, is when it is depressed. Otherwise, you can proceed as if it was not there.

EARS AND NOSE A bleeding nose may indicate a fractured base, and a bleeding ear almost always does. If a patient’s ear is bleeding, don’t examine it for fear of introducing infection. If it is not bleeding, examine the drum because blood behind it confirms a fractured base. If you see blood leave it.

Postmastoid bruising a few days after the injury also confirms a fractured base, but its absence does not exclude one.

Look also for leaking CSF.

INJURIES ELSEWHERE Look especially for injuries of a patient’s neck and back that may indicate fractures of his cervical spine (64.3). Carefully roll him onto his side while maintaining gentle head traction (64-4). Palpate every spinous process. Look for even a small kyphus or an abrupt misalignment.

If you suspect a fracture of his cervical spine, fit him with a cervical collar. He may also be paraplegic (64.13). If he is, make sure that he does not develop bed sores.

CAUTION! (1) If the patient is shocked, look for severe injuries in other places, especially in his thorax and abdomen. By themselves head injuries seldom cause shock, unless bleeding is very severe. There are several special tests for abdominal injuries which may help you (66.1). (2) If a patient has any serious abdominal or thoracic injuries, these take precedence over his head injury.

RECORDS FOR HEAD INJURIES

Assess the patient’s state of consciousness and start to fill in a coma chart (63-4). Careful notes are most important, especially if several people have to care for him. Note the exact times at which all observations are made.

X–RAYS FOR HEAD INJURIES

PLAIN X–RAYS are less important than regular assessment of the patient’s clinical state. Poor films are useless. Even good ones are difficult to interpret and may fail to show serious fractures. If possible, take an AP and a lateral of the patient’s cranial vault, especially if you suspect an extradural haematoma (impaired consciousness after a lucid interval). The position of the fracture line may tell you where to make your first burr hole. Most patients with an extradural haematoma have a fracture (but not vice versa). Fractures of the base are difficult or impossible to see on X-ray films. If litigation is no problem and films are scarce, keep them for more useful purposes.

If you X–ray the patient’s skull, take a lateral view of his cervical spine at the same time and an AP view of his chest.

CAUTION! While he is in the X–ray department his airway may obstruct, or he may vomit, or have a convulson, so send a responsible nurse to watch him.

If you have difficulty deciding what is a fracture and what is not, remember that:

Fracture lines have clean cut edges, run in all directions, may cross arterial and suture lines, change direction abruptly, and branch irregularly.

Suture lines are fine or dentate, are in constant positions, and may be widened by trauma.

Grooves for the meningeal vessels run in known directions, branch dichotomously, and get smaller from below upwards.

Channels for the diploic veins run irregularly, and change course abruptly. They often start in lacunae near the superior sagittal sinus, and they vary in width.

Look carefully for a fracture line crossing a meningeal groove, and note which side it is, because it may indicate the site of an extradural haemorrhage. If you do see a fracture, make sure it does not date from a previous injury.

ARTERIOGRAMS Any X–ray machine that can take a skull X–ray can take an arteriogram. The only equipment you need is a 1.2 mm spinal needle. Arteriograms are usually not too difficult to interpret, and are very useful: (1) In an acute deteriorating head injury. (2) In the patient who is not improving after a week, and who may have a chronic clot.

NURSING A HEAD INJURY

POSITION Provided a patient has no other injuries which might prevent it, nurse him in the recovery position (51-2) and turn him 2 hourly. Raise the foot of his bed until his cough and swallowing reflexes have returned. This will raise his intracranial pressure, but his airway is more important.

If he is disturbed or violent and you have no proper cot in which to nurse him, put him on a mattress on the floor. This better than tying him to his bed, which may cause a wrist drop and other injuries. You may occasionally have to do this to prevent him soiling the dressings over his head wounds.

BED SORES Care for his skin from the start, as for paraplegia (64.13).

PAIN AND SEDATION If a patient is so violent on admission that he is a danger to himself and other people, give him chlorpromazine 25 to 50 mg, or diazepam 10 mg intramuscularly, or intravenously. Avoid stronger sedatives, especially morphine, because they interfere with the assessment of consciousness and depress his respiration.

Moderate restlessness is useful, because it is good physiotherapy for his lungs and prevents pressure sores. Make sure that his overactivity is not caused by a full bladder, or an uncomfortable position. If he is noisy, put him in a side ward.

TEMPERATURE If possible, take a patient’s rectal temperature every hour during the first 12 hours. Watch for hyperthermia and start cooling him if it reaches 39C.

CORNEA If his blinking or corneal reflexes are absent, take care that his cornea does not rub against his pillow, or the sheets, and ulcerate. If his eyes remain open, put adhesive strapping across his closed eyelids—this is critically important!

FOOD AND FLUIDS Start a fluid balance chart. While a patient is unconscious, give him fluids intravenously. At 24 to 48 hours, or earlier if his cough and swallowing reflexes return, give him food and fluids through a nasogastric tube. Pass a tube and start feeding him, even if his cough reflex has not returned at 24 to 48 hours, provided he has bowel sounds. He needs energy; about 12 MJ (3 000 kcal) in 3 litres of fluid (58.11). He may be unconscious for many days and eventually recover, so don’t let him starve meanwhile.

BLADDER Examine this to make sure it does not distend, and catheterize a patient when necessary to prevent overflow.

Bed wetting may require an indwelling catheter in a female, a Paul’s tube strapped to the penis of a male, or a polythene urinal in a child. If you pass a catheter, releasing it 4 hourly is better than letting it drain continuously.

OPEN HEAD INJURIES Give the patient benyzl penicillin and sulphadimidine intramuscularly, both 6 hourly.

ANTICONVULSANT THERAPY Give all patients phenobarbitone prophylactically while they are in hospital. 30 mg 8 hourly in an adult will not impair consciousness.

TETANUS PROPHYLAXIS Don’t forget to give a patient tetanus toxoid (54.11).

OTHER INJURIES If a patient with a head injury has fractures elsewere, at least splint them temporarily in the reduced position, even if you cannot treat them definitively.

THE FURTHER MANAGEMENT Of A PATIENT WITH A HEAD INJURY

Read on for: methods of monitoring a patient’s consciousness, pulse and blood pressure (63.2), patterns of head injury (63.3), the indications for burr holes (63.4), how to make a burr hole (63.5), open head wounds (63.6), fractures of the vault (63.7), ping-pong ball fractures in children (63.8), controlling bleeding (63.9), hyperthermia (63.10), convulsions (63.11), leaking CSF (63.12), meningitis (63.13), more difficulties with a head injury (63.14).

IF A PATIENT WITH A HEAD INJURY IS SHOCKED, LOOK FOR ANOTHER INJURY