Emergency Management of Head Injury - A Detailed Review

Introduction:

Head injuries are one of the leading causes of a visit to the emergency department. Accidental falls, assaults, sports mishaps, road traffic accidents, and crashes are the common causes of head injury. The brain is protected by the skull (hard bone in the head) and cushioned by the tissue layers (meninges) with cerebrospinal fluid. As a result, most bumps or injuries to the head are minor and do not affect the brain.

However, minor head injuries can lead to dizziness or headaches. People with severe head injuries may sustain life-threatening traumatic brain injuries, leading to unconsciousness, brain dysfunction, disability, or even death. A quick assessment, initiating prompt medical treatment, and emergency care can help save lives. The primary goal of emergency management of a head injury is ensuring sufficient oxygenation to the brain and maintaining normal pressure in and around the brain.

How Are Head Injuries Diagnosed?

Injuries to the head and brain are diagnosed using the following:

1. Neurological evaluation tests are performed to check the brain’s function, including memory, reflexes, coordination, balance, hearing, vision, and other sensory and motor functions.

2. Imaging tests such as skull X-rays, computed tomography (CT) scan, and magnetic resonance imaging (MRI) are performed to check for internal bleeding and swelling in the brain.

3. Various blood tests, including the banyan brain trauma indicator test (BTI), are performed to check for proteins indicating concussion or mild brain injury.

How Are Minor Head Injuries Managed?

In minor injuries, the patient might have a bump on the head or profuse bleeding (a scalp injury) that appear more serious than they are. In addition, headaches, lightheadedness, nausea, and vomiting can occur after a minor head injury. Minor head injuries are diagnosed based on the patient’s symptoms and neurological evaluation. Some minor head injuries can lead to concussions (temporary loss of consciousness) that requires a detailed examination of the patient to check if there is an injury to the brain.

There is no need to rush to the emergency department for minor head injuries. Instead, one can recover from home but check for new or worsening symptoms. The following steps can help manage minor injuries to the head.

1. Stay with the injured person for the first 48 hours after the injury.

2. Stay within easy reach of a telephone and be prepared to call for emergency help.

3. If children have a minor head injury, comfort them and ensure that they rest.

4. A bag of ice or frozen peas can be used to give a cold compress to the injured part of the head.

5. The patient must avoid stressful situations, alcohol, and recreational drugs.

6. The patient must not take any medications such as sedatives, sleeping pills, or tranquilizers unless prescribed.

7. Medications such as Paracetamol can be used to treat headaches. Drugs such as Ibuprofen and Aspirin must be avoided unless prescribed by a doctor.

8. The patient must not resume contact sports (for at least three weeks) without a doctor’s advice.

9. The patient should not return to school or work without complete recovery.

10. The patient should avoid driving if the symptoms persist.

11. If the symptoms worsen, immediately seek medical attention.

12. Consult a doctor if the symptoms persist for more than two weeks.

13. Rush to the emergency department or call for emergency medical services in case of the following (as these could indicate brain injury):

• Concussion.

• Unconsciousness.

• Seizures.

• Trouble hearing.

• Vision loss or double vision.

• Frequent vomiting.

• Loss of memory.

• Unequal pupils.

• Clear fluid or blood oozing out from the nose or ears.

How Are Severe Head Injuries Managed?

Severe head injuries affecting brain function are diagnosed and treated at the same time as it is life-threatening. The emergency medical services and ambulance must be called for multiple injuries, unconsciousness, critical illnesses, or injuries in other body parts (motor accidents). When the patient reaches the hospital, the emergency team checks the patient and assesses the severity of the injury. The following steps are initiated to manage the patients:

• Assessment of the airway (passage to the lungs) is done immediately on first contact with the patient. The airway is made clear to ensure sufficient oxygen-rich air reaches the lungs.
• The breathing is assessed (including the breathing pattern and oxygen saturation).The circulation and vital signs (blood pressure, heart rate) are assessed.
• The heart function is checked to ensure sufficient blood flow and oxygen supply to all body parts and organs. Cardiopulmonary resuscitation and defibrillation are initiated if required.Oxygen supplementation is done whenever required.
• Depending on the patient's condition, there are various ways to provide oxygen to the body. These include bag-mask ventilation, in which oxygen is pumped through a bag attached to the mask, and noninvasive positive pressure ventilation (NPPV), in which tubes or masks are used to blow mild air into the airway to keep it open.
• In case of airway obstruction, invasive emergency techniques such as tracheostomy (a hole is made in the windpipe to facilitate breathing) and ventilators may be used. Access into veins (intravenous access) is obtained to give medications if needed.

The healthcare professional then checks the following:

1. The ability of the patient to respond to commands.

2. The patient's requirement for stimulation (shouting, speaking, squeezing) to open their eyes.

3. The basic brain function is assessed:

• Is the size of their pupils normal?

• How does the patient (pupillary response) react to light?

• Is the patient able to move their arms and legs?

• Is the patient able to speak normally?

• How are the patient’s coordination and reflexes?

• Once the patient is out of immediate danger and stabilized, a complete neurological examination is performed to assess the severity and location of the injury.

• The patients are checked for internal bleeding and managed accordingly.

• The patient is monitored periodically to check if the symptoms are resolved or worsening.

• Computed tomography and magnetic resonance imaging are done to check for brain damage. In addition, the patient’s skull and neck may be X-rayed if a fracture is suspected.

• Special imaging, such as angiography (along with computed tomography and magnetic resonance imaging), is done if blood vessel damage is suspected.

• Measures are taken to maintain normal pressure in and around the brain.

• Invasive medical interventions and surgeries may be performed to treat the patient (depending on the type and severity of the injury).

Conclusion:

A head injury can be innocuous (a little slip and a bump to the head). However, severe injuries to the head can cause brain injury that varies in severity. Most people with minor head injuries recover within a few hours at home. However, some may show worsening symptoms requiring prompt medical treatment. Severe head injuries require emergency management at the hospital as these can cause permanent brain injury, disability, or even death.