This clinical update on head injuries includes initial assessment and examination of people presenting with head injury. It also explains the concepts of ‘red flags’ and potential complications of head injuries. 

Head injury is defined as any trauma to the head other than superficial injuries to the face.¹ Most head injuries are caused by falls, sports-related incidents and motor vehicle collisions. Approximately 10,000 new head injuries occur in Ireland each year.²

The majority of people who attend emergency departments with head injury will have a minor injury, although approximately 20% of these will be admitted to hospital.³ The majority of people with a minor head injury will recover without specific or specialist intervention.¹

However, trauma is the leading cause of death in people under the age of 45 years, and up to 50% of these deaths are as a result of a head injury.³ The majority of deaths from head injury are in people who present with a moderately or severely impaired consciousness level.¹

Assessment

The assessment of a person with a head injury consists of taking a history and an examination, including a Glasgow Coma Scale score. When assessing a person who has a head injury you should ask how and when the head injury occurred. If possible you should ask about recent alcohol or drug intake, current anticoagulant medication, pre-injury level of consciousness and functioning.^1,3 People who have dementia, for example, may have different levels of pre-injury cognitive functioning to those without dementia.

It is important to note that people who present with loss of consciousness, amnesia, vomiting, headache or neck pain are more likely to have a serious head injury. The following circumstances are more likely to cause serious head injury:

• Falls from a height of greater than one metre or five stairs

• High-speed motor vehicle collisions, either as a pedestrian, cyclist or vehicle occupant

• Rollover motor accidents or ejection from a motor vehicle

• Accidents involving motorised recreational vehicles or bicycle collision

• Diving accidents.

In children you should consider the possibility of non-accidental injury if: 

• The child is not yet independently mobile (crawling, cruising, walking) 

• The bruise is on any non-bony part of the face (including eyes or ears)

• The injury is to both sides of the face or head 

• The bruises are at variance to the explanation given by the parents or carers

• Retinal haemorrhages or injury to the eye (in the absence of major confirmed accidental trauma or a known medical explanation) should also be considered a ‘red flag’ for non-accidental injury.⁵

Examination

Examine the person to assess their level of consciousness, using the Glasgow Coma Score (see Tables 1 and 2). Look for signs of breathing difficulties or shock such as increased heart rate, low blood pressure or reduced capillary refill time. 

Examine the patient for signs of visible trauma to the scalp, skull, head and neck. Check pupil size and that pupils are reacting normally to light. Look for any problems with vision or speech disturbance, understanding speech, reading or writing. 

If the person has been standing check for any problems with balance or walking. Ask about and test for any numbness in the upper or lower limbs. Test reflexes and look for any loss of muscle power. If appropriate, assess the person’s neck for tenderness and movement ability. Safe examination of the neck should only be performed if the person was not involved in a high-energy injury, is comfortable in a sitting position, has been walking at any time since the injury, has no tenderness along the spine, or describes a problem with delayed onset neck pain.

Signs of very serious injury include:

• Clear fluid (possible cerebrospinal fluid) leaking from the ear(s) or nose

• Bruising around the eyes (with no associated damage around the eyes)

• Bleeding from one or both ears

• Blood behind the ear drum

• New deafness in one or both ears

• Bruising behind one or both ears.¹

Glasgow Coma Scale

The Glasgow Coma Scale (GCS)³ is used internationally in clinical practice to assess the depth and duration of impaired consciousness and coma. 

It is used to assess the level of consciousness in all people who have received a head injury (including people who appear intoxicated). People are scored on three different aspects of behavioural response: eye opening, verbal and motor responses. Each area of assessment is evaluated independently of the other and graded, with the lowest possible score being 3 (deep coma or death) and the highest being 15 (fully awake).

For example, a person with a best score of 4 for eye response, 5 for verbal response, and 5 for motor response should be recorded as E4, V5, M5 and the total score of 14/15 given.

People with dementia, chronic neurological disorders or learning difficulties may have a pre-injury baseline GCS score of <15, which should be taken into account during clinical assessment.

The Glasgow Coma Scale score can be translated into severity of the head injury:

• Mild – score of 13-15 

• Moderate – score of 9-12 

• Severe – score of 8 or less.

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Complications 

There are multiple possible physical, thinking (cognitive) and psychological complications following head injury, which may have an impact on a person’s ability to function and return to normal activities. 

Up to half of all adult inpatients with a head injury experience long-term psychological and/or physical disability.³

Complications of head injury include concussion, which is a disturbance in the function of the brain caused by a direct or indirect force to the head. It typically results in the rapid onset of short-lived impairment, which resolves spontaneously. 

Post-concussion syndrome can also occur and may include multiple physical symptoms such as headache, dizziness, nausea, balance and co-ordination problems, changes in appetite, sleep, vision, and hearing, and cognitive and behavioural symptoms such as fatigue, anxiety, depression, irritability, problems with memory, concentration and decision-making. 

Additional complications may include problems with walking (gait), mobility, muscle weakness, seizures, communication, swallowing, depression and anxiety, and signs of post-traumatic stress disorder. 

Some people experience cognitive impairment which may include problems with memory, attention and concentration, planning, problem-solving, language, and perception. People who have had a head injury may display challenging or disinhibited behaviour, which can include inappropriate vocalisation or sexualised behaviour. Delayed presentation of intracranial complications is rare after mild traumatic brain injury, and usually occurs within 24 hours of the injury.⁴

Prognosis

Most people who have persistent symptoms of mild traumatic brain injury recover within two to three months of the injury⁴ and most people with post-traumatic amnesia of less than 24 hours duration recover good cognitive function within three months of the injury.³

Factors which may increase the risk of a poor prognosis following mild traumatic brain injury include female sex, age over 40 years, persistent physical illness and/or a pre-existing neurological condition, previous head injuries, co-morbid mental health problems, such as anxiety and depression, and a lack of social support.⁴

Information and self-care advice

When discharging someone from hospital who has had a head injury, you should provide them with appropriate written ‘safety-netting’ information about their head injury. This should include advice on:

• Seeking medical advice if they have any ongoing or worsening symptoms, such as vomiting or headaches

• Taking appropriate pain relief if necessary, such as paracetamol or ibuprofen as appropriate

• Ensuring a gradual return to normal activities.

The Scottish Intercollegiate Guidelines Network provides several advice leaflets including advice for the person taking a patient home, advice for a patient allowed home after a head injury and advice for carers of children who have sustained a head injury. All these leaflets can be accessed at www.sign.ac.uk

Headway (Ireland) – Brain Injury Services and Support (www.headway.ie) is a charity that supports people affected by a head injury. It runs a telephone helpline, 1890 200278, a network of support groups and offers rehabilitation programmes, carer support, community outreach and respite care.

Clarity Informatics is contracted by the National Institute for Health and Care Excellence (NICE) to provide clinical content for the Clinical Knowledge Summaries service available through the Clarity Informatics Prodigy website at: prodigy.clarity.co.uk

References

1. National Institute for Health and Care Excellence. Head injury: assessment and early management [CG176]. Published 2014. Available from: https://www.nice.org.uk/guidance/cg176/resources [Accessed September 28, 2016]
2. Headway. The silent epidemic of acquired brain injury. Published 2010. Available from: http://www.headway.ie/information/silentepidemic.html [Accessed September 28, 2016]
3. SIGN. Early management of patients with a head injury. Published 2009. Available from: http://www.sign.ac.uk/guidelines/fulltext/110/index.html [Accessed September 28, 2016]
4. SIGN. Brain injury rehabilitation in adults. Published 2013. Available from: http://www.sign.ac.uk/guidelines/fulltext/130/index.html [Accessed September 28, 2016]
5. National Institute for Health and Care Excellence. When to suspect child maltreatment [CG89]. Published 2009. Available from: https://www.nice.org.uk/guidance/CG89 [Accessed September 28, 2016]