1. Emergency Department Aberdeen Royal Infirmary Head Injuries in the Emergency Department August 2015

2. Emergency Department Aberdeen Royal Infirmary Agenda  Background  Management principles  Clinical features  XRay appearances

3. Emergency Department Aberdeen Royal Infirmary Head Injury  Trauma is the leading cause of death before the age 45  50% of traumatic deaths are due to head injury  In Scotland, every year, head injury results in 100,000 hospital attendances 100,000 hospital attendances 20,000 hospital admissions 20,000 hospital admissions 9000 patients with residual neurological disability 9000 patients with residual neurological disability 640 deaths 640 deaths

4. Emergency Department Aberdeen Royal Infirmary Primary Brain Injury  Injury to, or irreversible death of, neurones at the time of injury  Direct result of the force of injury  Role of accident prevention and devices to limit force of injury e.g. bicycle helmets e.g. bicycle helmets

5. Emergency Department Aberdeen Royal Infirmary Secondary Brain Injury  Ongoing insults after the moment of injury extend the damage to neurones  Prevention of these is the focus of treatment

6. Emergency Department Aberdeen Royal Infirmary Key Management Principles  Identify at risk groups  Prevent, or limit, the causes of secondary brain injury Hypoxia Hypoxia Hypercarbia Hypercarbia Hypotension Hypotension Hypo- or Hyper-glycaemia Hypo- or Hyper-glycaemia Hyperthermia Hyperthermia Convulsions Convulsions Raised Intracranial Pressure Raised Intracranial Pressure

7. Emergency Department Aberdeen Royal Infirmary Treatment

8. Treatment - ATLS  Airway + Oxygen + C-spine protection  Breathing + ventilation  Circulation + haemorrhage control Monitor… Monitor… IV access +/- fluids IV access +/- fluids  Disability AVPU/GCS, pupils, focal/lateralizing signs AVPU/GCS, pupils, focal/lateralizing signs  Exposure/Environment Other injuries + co-morbidities Other injuries + co-morbidities

9. Emergency Department Aberdeen Royal Infirmary At Risk Groups  Indications for referral to hospital  Indications for admission  Indications for imaging  Indications for neurosurgical referral

10. Referral to Hospital  NHS 24, GP, Minor injuries Unit GCS<15 at any time after injury GCS<15 at any time after injury Loss of consciousness Loss of consciousness Focal neurological deficit Focal neurological deficit Suspicion of skull fracture or penetrating injury Suspicion of skull fracture or penetrating injury Headache, vomiting, seizure since injury Headache, vomiting, seizure since injury Amnesia Amnesia High energy injury High energy injury Hx of clotting disorder on anti-coagulant therapy Hx of clotting disorder on anti-coagulant therapy Drug or alcohol intoxication Drug or alcohol intoxication Concerns of NAI Concerns of NAI Emergency Department Aberdeen Royal Infirmary

11. History

12. History  LoC ?  Vomited?  Mechanism ? High speed High speed Penetrating Penetrating Lateral blow Lateral blow Other injuries Other injuries

13. Emergency Department Aberdeen Royal Infirmary Examination

14. Examination  GCS  Pupils  Cranial nerves  Focal deficits  Lateralising signs

15. Emergency Department Aberdeen Royal Infirmary Examination

16. Examination  Explore the wound Full thickness ? Full thickness ? Boggy haematoma ? Boggy haematoma ? Palpable skull # ? Palpable skull # ? Foreign Body? Foreign Body?  Closure…

17. Emergency Department Aberdeen Royal Infirmary Admission or Discharge ?  GCS <15/15 at any time e.g. LoC  GCS 15/15 but “risk factors” present  Medical problems (e.g. warfarin, alcohol)  Social problems (e.g. no supervision)

18. Emergency Department Aberdeen Royal Infirmary “Risk Factors”  Amnesia for > 5 min  Neurological symptoms Headache (severe) / Nausea / vomiting Headache (severe) / Nausea / vomiting Irritability / focal signs / seizure Irritability / focal signs / seizure  Skull # (clinically or radiologically)  Abnormal CT

19. Emergency Department Aberdeen Royal Infirmary Discharge  If no LoC and no risk factors or medical / social co-morbidity  Verbal & written advice to patient & carers  Contact number for ED  DISCUSS WITH A SENIOR IF UNSURE

20. Emergency Department Aberdeen Royal Infirmary Written Discharge Advice

21. CT head  GCS 13 at any point since injury, 13 or 14 2 hours post injury  Focal neurological deficit  Suspected skull fracture  Post traumatic seizure  LOC or amnesic in >65 yrs or coagulopathy  Dangerous mechanism of injury  Amnesia >30 minutes prior to injury Emergency Department Aberdeen Royal Infirmary

22. + CT neck  GCS <15  Focal neurological deficit  Parasthaesia in extremities  Dangerous mechanism of injury – fall from hieight >1m, fall >5 stairs, axial load to head, RTC >65mph, rollover or ejection. Emergency Department Aberdeen Royal Infirmary

23. Base of Skull #

24. Emergency Department Aberdeen Royal Infirmary Base of Skull #

25.  Panda eyes  Raccoon eyes  Rhinorrhoea  Otorrhoea  Battle’s sign  Cranial nerve palsies

26. Panda Eyes

27. Emergency Department Aberdeen Royal Infirmary Raccoon Eyes

28. Emergency Department Aberdeen Royal Infirmary Otorrhoea

29. Battle’s Sign

30. Emergency Department Aberdeen Royal Infirmary Cranial Nerve Palsies

31. Emergency Department Aberdeen Royal Infirmary ?

32. IF IN DOUBT… ASK!