Head Injuries + Neurosurgery For the junior doctor

1. Head Injuries + NeurosurgeryFor the junior doctor Sean Martin

2. GCS • E4 • 1 – does not open eyes • 2 – opens to pain • 3 – opens to voice • 4 – open spontaneously • V5 • 1 – no sound • 2 – incomprehensible sounds • 3 – inappropriate words • 4 – confused • 5 – orientated • M6 • 1 – no response • 2 – extends to pain • 3 – abnormal flexion to pain • 4 – flexes to pain • 5 – localizes to pain • 6 – obeys commands

3. CT • High risk – for intervention • GCS <15 at 2h • Basal/depressed/open skull fracture • Vomiting more than twice • >65 • Medium risk – for injury on CT • >30 mins retrograde amnesia • Dangerous mechanism of injury

4. Discharge • GCS 15 • Responsible adult to observe 24h • Patient education • Telephone access • Access to further care • Transport home

5. Case 1 • 18 year old male presents to ED after being hit on the head with a bottle 3 hours previously • What would you do? • ABCDE • History: slightly drowsy after injury, but has resolved, no LoC • O/E: GCS 15, no focal neurology, large parietal haematoma • Deteriorates after another hour

7. Case 1 - Extradural • Laceration of MMA by fracture of temporal or parietal bones • Features: • Lucid interval followed by GCS • Deterioration is due to ICP • May get UMN signs • Management: • ABCDE  CT  Surgeons

8. Case 2 • 87 year old demented female has fallen out of bed that morning • What would you do? • ABCDE • History: headache, “more confused”, AF, vomited • O/E: GCS 13, drowsy, dysphasic

10. Case 2 – Acute Subdural • Shearing of veins crossing the subdural space • Associations: • Trauma, alcohol, anticoagulation • Features: • Progressively GCS • Signs of ICP • Management: • ABCDE  CT  Surgeons

12. Case 2b – Chronic Subdural • Similar to ASDH, but insidious • Fluctuating consciousness • Personality change • Sleepiness • Unsteadiness • Features of raised ICP • Almost always very old or very young

13. Case 3 • 48 year old male presents to the ED after a night out • What would you do? • ABCDE • History: friends says he collapsed, had been using cocaine • O/E: GCS 12, Babinski positive on the right, right hemi-paresis

15. Case 3 - Intracerebral • Rupture of small intracerebral vessels: • Spontaneous = “haemorrhagic stroke” • Traumatic = “burst lobe” (may have contusions and ASDH) • Features: • Neurology dependent on location • ICP (blood + oedema) • Associations: • Hypertension • AVM, bleeding disorders, drugs • Management: • ABCDE  CT  ?Surgeons

16. Case 4 • 48 year old female presents with “worst headache of my life” • What would you do? • ABCDE • History: instantaneous severe occipital headache, vomited 3 times, has polycystic kidneys • O/E: GCS 12, Kernig’s positive, hypertensive, pyrexial

18. Case 4 - Subarachnoid • 80% ruptured aneurysm, 5% AVM • Associations: • Smoking, alcohol, hypertension • Polycystic kidney disease, family history, bleeding disorders • Features: • Thunderclap headache, vomiting, GCS, neck stiffness, pyrexia, Kernig’s sign, BP • Management: • ABCDE  CT  Nimodipine  Surgeons

19. Question 1 • A 90-year-old woman is a resident in a nursing home. The duty doctor has referred her to the ED because of worsening confusion and fluctuating drowsiness over the last few days. She sustained a minor head injury when she fell out of bed 2 weeks ago. On examination she has AMT=2/10, but no focal neurology. She is not hypoxic, and metabolic and septic screens are negative.

20. Key point - old • A 90-year-old woman is a resident in a nursing home. The duty doctor has referred her to the ED because of worsening confusion and fluctuating drowsiness over the last few days. She sustained a minor head injury when she fell out of bed 2 weeks ago. On examination she has AMT=2/10, but no focal neurology. She is not hypoxic, and metabolic and septic screens are negative.

21. Key point - trauma • A 90-year-old woman is a resident in a nursing home. The duty doctor has referred her to the ED because of worsening confusion and fluctuating drowsiness over the last few days. She sustained a minor head injury when she fell out of bed 2 weeks ago. On examination she has AMT=2/10, but no focal neurology. She is not hypoxic, and metabolic and septic screens are negative.

22. Key point - insidious • A 90-year-old woman is a resident in a nursing home. The duty doctor has referred her to the ED because of worsening confusion and fluctuating drowsiness over the last few days. She sustained a minor head injury when she fell out of bed 2 weeks ago. On examination she has AMT=2/10, but no focal neurology. She is not hypoxic, and metabolic and septic screens are negative.

23. Question 2 • A 27-year-old disc jockey presents with a 12-hour history of severe headache which started suddenly the night before while he was at a party. He has mild photophobia and neck stiffness and feels nauseous. Neurological examination is otherwise normal, but a large ballotable mass is present in the right flank. On further questioning, he admits that the headache started during sexual intercourse after having taken a considerable quantity of cocaine.

24. Key point - thunderclap • A 27-year-old disc jockey presents with a 12-hour history of severe headache which started suddenly the night before while he was at a party. He has mild photophobia and neck stiffness and feels nauseous. Neurological examination is otherwise normal, but a large ballotable mass is present in the right flank. On further questioning, he admits that the headache started during sexual intercourse after having taken a considerable quantity of cocaine.

25. Key point - other features • A 27-year-old disc jockey presents with a 12-hour history of severe headache which started suddenly the night before while he was at a party. He has mild photophobia and neck stiffness and feels nauseous. Neurological examination is otherwise normal, but a large ballotable mass is present in the right flank. On further questioning, he admits that the headache started during sexual intercourse after having taken a considerable quantity of cocaine.

26. Key point - PKD • A 27-year-old disc jockey presents with a 12-hour history of severe headache which started suddenly the night before while he was at a party. He has mild photophobia and neck stiffness and feels nauseous. Neurological examination is otherwise normal, but a large ballotable mass is present in the right flank. On further questioning, he admits that the headache started during sexual intercourse after having taken a considerable quantity of cocaine.

27. Key point - exertion • A 27-year-old disc jockey presents with a 12-hour history of severe headache which started suddenly the night before while he was at a party. He has mild photophobia and neck stiffness and feels nauseous. Neurological examination is otherwise normal, but a large ballotable mass is present in the right flank. On further questioning, he admits that the headache started during sexual intercourse after having taken a considerable quantity of cocaine.

28. Question 3 • A 55-year-old hypertensive man with no previous history of neurological events presents with an abrupt onset of right-sided hemiparesis and hemisensory loss. He is also noted to have an expressive aphasia.

29. Key point - hypertension • A 55-year-old hypertensive man with no previous history of neurological events presents with an abrupt onset of right-sided hemiparesis and hemisensory loss. He is also noted to have an expressive aphasia.

30. Key point – vascular territory • A 55-year-old hypertensive man with no previous history of neurological events presents with an abrupt onset of right-sided hemiparesis and hemisensory loss. He is also noted to have an expressive aphasia.

31. Question 4 • A 23-year-old IVDA falls from a window while trying to evade the police. At the scene he was alert and orientated. On arrival in the ED he has a localized left fronto-parietal boggy swelling. About 1h later, he collapses. At this time his speech is confused, he has eye opening to speech, and he localizes to pain.

32. Key point - lucid interval • A 23-year old IVDA falls from a window while trying to evade the police. At the scene he was alert and orientated. On arrival in the ED he has a localized left fronto-parietal boggy swelling. About 1h later, he collapses. At this time his speech is confused, he has eye opening to speech, and he localizes to pain.

33. Key points - MMA • A 23-year old IVDA falls from a window while trying to evade the police. At the scene he was alert and orientated. On arrival in the ED he has a localized left fronto-parietal boggy swelling. About 1h later, he collapses. At this time his speech is confused, he has eye opening to speech, and he localizes to pain.

34. Question 5 • A 28-year-old professional boxer is brought to the ED immediately after a world heavyweight title fight. The paramedics in attendance at the event inform you that he collapsed in his corner at the end of the eighth round. At that time he was confused and drowsy. His condition has rapidly deteriorated on the way to hospital. At the time you assess him he has no verbal response or eye opening. Examination reveals a unilateral fixed dilated pupil on the right, and flexion to pain only on the left.

35. Key point - progressive • A 28-year-old professional boxer is brought to the ED immediately after a world heavyweight title fight. The paramedics in attendance at the event inform you that he collapsed in his corner at the end of the eighth round. At that time he was confused and drowsy. His condition has rapidly deteriorated on the way to hospital. At the time you assess him he has no verbal response or eye opening. Examination reveals a unilateral fixed dilated pupil on the right, and flexion to pain only on the left.

36. Key point - brain-shift • A 28-year-old professional boxer is brought to the ED immediately after a world heavyweight title fight. The paramedics in attendance at the event inform you that he collapsed in his corner at the end of the eighth round. At that time he was confused and drowsy. His condition has rapidly deteriorated on the way to hospital. At the time you assess him he has no verbal response or eye opening. Examination reveals a unilateral fixed dilated pupil on the right, and flexion to pain only on the left.

37. Key point - severe injury • A 28-year-old professional boxer is brought to the ED immediately after a world heavyweight title fight. The paramedics in attendance at the event inform you that he collapsed in his corner at the end of the eighth round. At that time he was confused and drowsy. His condition has rapidly deteriorated on the way to hospital. At the time you assess him he has no verbal response or eye opening. Examination reveals a unilateral fixed dilated pupil on the right, and flexion to pain only on the left.