This is a summary of a talk given at Northampton General Hospital on the 11th December 2018 as part of a Pre-hospital & Transfer medicine-themed series. You can find out about future events by following them on Twitter @NGHPTM

The phrase ‘head injury’, to me covers a multitude of different conditions / scenarios and is a catch-all term for a spectrum of disease. At one end we have the true ‘minor head injury’ where you hit your head on a low tree branch / door frame / drip stand and continue with no injuries / consequence. At the other end you have catastrophic life-changing injuries which can, on occasion, be fatal. Within this blog I want to focus on three different entities:

Minor head injury

Concussion

Serious head injury

Statistics

But first, a few statistics taken from NICE:

Head injury is the commonest cause of death and disability in people aged 1-40 years.

Each year, ~1.4 million people attend Emergency Departments in England & Wales with a head injury, which is about 7% of attendances.

33-50% of these are children under 15 years of age.

Around 200,000 people are admitted to hospital / year as a result of a head injury, to put this into a more local context, Northampton has ~500 beds, that’s 400x the capacity of Northampton / year. Leicester Royal Infirmary has ~1000 beds, that’s 200x the capacity / year.

Despite a considerable morbidity, the mortality of patients attending the ED with a head injury is ~0.2%

95% of patients with a head injury present with a normal, or minimally impaired, conscious level (GCS >12).

So, my take home from this is that Head Injury is extremely common and we need to be good at assessing it, but the serious stuff we train most for isn’t that common. That’s not to say we shouldn’t train for serious head injuries, we should, but they’re not as common as you might perceive.

Assessment

Patient assessment should focus on the life threatening issues and follow the usual stepwise <C>AcBCDE approach. If you’ve not seen it then the Glasgow Coma Scale website provides a fascinating background into the GCS score, alongside potential future developments. It’s worth noting the simplified language used on the site, and I think that we sometimes over complicate things.

It’s also important to remember to address any analgesic requirements the patient may have, NICE recommend IV opiates but each case would need to be assessed on its merits. The key thing is to make sure you go back and reassess a patient’s pain and don’t simply assume that a single administration will be sufficient. We also need to think about safeguarding, and decide if there are any concerns in this regard.

Once a holistic assessment of the patient has been completed we can then make a decision about what to do next.

CT Brain

NICE has a very clear algorithm on when we should be thinking about doing a CT Brain / Head on a patient, it’s important to remember that this is an unenhanced (i.e. non-contrast) scan and is designed to look for bleeding / fractures. It won’t pick up things in the same detail as an MRI will, but it’s much quicker and for the purposes of identifying a clinically significant brain injury it will suffice.