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Traumatic injuries to the head 

Traumatic injuries to the head

Traumatic injuries to the head

Laurence Watkins

and David G.T. Thomas

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date: 27 April 2017

Head injuries cause 1% of all deaths, including 15 to 20% of those in people aged 5 to 35 years, with many survivors facing long-term disability.

Pathophysiology—brain injury may be (1) primary—axonal injury and focal contusions are caused at the moment of impact; or (2) secondary—causes are (a) extracranial—e.g. hypoxia and hypotension, and (b) intracranial—e.g. haematoma, brain swelling, and infection.


General aspects—rapid action in the ‘golden hour’ is often essential for success. Life-threatening extracranial injuries that affect the airway, breathing and circulation take priority, and all patients with head injuries should be assumed to have injury to the cervical spine—requiring immobilization—until this can be excluded.

Head injury—deterioration in conscious level, routinely assessed by serial recording of the Glasgow Coma Score (GCS), requires immediate action, with initial management depending on the severity of head injury. (1) Severe (GCS 3–8/15)—immediate referral to a neurosurgical unit is required; elective intubation and ventilation may be required prior to transfer; ventilation should maintain Pco2 4.0 to 4.5 kPa, and mean arterial pressure should be kept above 90 mmHg; CT scanning may be required. (2) Moderate (GCS 9–13/15)—an urgent CT scan is advisable, with urgent neurosurgical referral (and management as for severe head injury) if this reveals an intracranial abnormality. (3) Mild (GCS 14 or 15)—patients with GCS 15, no history of loss of consciousness, and none of a defined list of criteria for investigation, may be considered for discharge according to local head injury protocols. The availability of CT scanning at all times in centres receiving patients with acute head injury, together with neurological and neurointensive care facilities, is critical for the best outcomes.

Complications, prognosis, and prevention

(1) Acute subdural haematoma—rapid detection and surgical drainage is of proven value. (2) Infection—most neurosurgeons recommend early use of prophylactic antibiotics in penetrating injuries. (3) Cognitive symptoms—85% of adults with severe head injuries remain disabled at 1 year; long-term care requires multidisciplinary support in focused programmes of rehabilitation. Even ‘mild’ injuries can lead to significant ‘postconcussional symptoms’ including headache, dizziness, poor concentration, memory impairment, and personality change.

Prevention—this is a major concern for health and safety legislation, town planning and traffic laws, e.g. compulsory wearing of seat belts and crash helmets.

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