Head Injury/EDH

Stem: A 24-year-old young male brought to ED after RTA. On arrival, he had GCS 15, & then he vomited twice & after 20 minutes he become unconscious; now GCS decreased to 8. You have been called to see this patient. Considering this as critical care station, answer the following questions.

  • How will you manage this patient?
    — I will follow the A, B, C, D protocol
  • What will you expect in the CT scan?
    — biconvex, midline shift, & compression on the ventricle.
  • What is the normal ICP?
    — Its 7-15 mm Hg( supine) &
  • How will measure ICP? (Different methods?)
    —Invasive method:
    -Intraventricular catheter (EVD- external ventricular drain)
    -Extradural probe
    -Subarachnoid probe
    -Intraparenchymal probe
    -Lumbar CSF pressure
    Non-invasive method:
    -Transcranial Doppler
    -Tympanic membrane displacement
  • What body parts are injured?
  • What is GCS & what are its constituents?
  • Single test to confirm diagnosis? – CT head
  • When will you consider CT brain for trauma?
    High Risk Criteria:
    – GCS < 15 at 2 hours post-injury.
    – Suspected open or depressed skull fracture.
    – Any sign of basilar skull fracture:
    ->Racoon Eyes.
    ->Battle’s Sign.
    ->CSF oto-/rhinorrhea.
    – ≥ 2 episodes of vomiting.
    – Age ≥ 65.
    – Any head injury in anticoagulated patient.

    Medium Risk Criteria:
    – Retrograde Amnesia to the event ≥ 30 minutes.
    – “Dangerous” Mechanism:
    -Pedestrian struck by motor vehicle.
    -Occupant ejected from motor vehicle.
    -Fall from > 3 feet or > 5 stairs.
  • NICE guidelines: Criteria for performing a CT head scan. :
    —For adults who have sustained a head injury & have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
    –GCS < 13 on initial assessment in the emergency department.
    –GCS < 15 at 2 hours after the injury on assessment in the emergency department.
    –Suspected open/depressed skull fracture.
    –Any sign of basal skull fracture (hemotympanum, ‘panda’ eyes, CSF leakage from the ear or nose, Battle’s sign).
    –Post-traumatic seizure.
    –Focal neurological deficit.
    –More than 1 episode of vomiting.
    A provisional written radiology report should be made available within 1 hour of the scan being performed. 
  • Describe CT head. – lenticular/ biconvex lesion—extradural haematoma.
  • Management of raised ICP?
  • GCS drops – management?
  • Cause of secondary GCS drop?