Head injury is one of the most common emergencies encountered in the ED (Emergency Department). It ranges from mild concussion to severe traumatic brain injury (TBI), skull fractures, intracranial hemorrhage, and cervical spine injury.
Early recognition of danger signs, appropriate imaging, airway protection, and neurological monitoring can be life-saving.
This guide is based on the clinical framework shown in your uploaded chart (featuring red flags, Canadian CT rules, GCS scoring, and management principles).
Introduction to Head Injury
Head injuries occur due to:
- Road traffic accidents
- Falls
- Sports trauma
- Assault
- Alcohol-related injuries
The goal of ED evaluation is to determine:
- Is the brain injured?
- Is the C-spine injured?
- Does the patient need a CT scan, neurosurgical consult, or ICU?
Even subtle symptoms can indicate serious underlying pathology.
Red Flags in Head Injury
According to the chart, the following symptoms must always be treated as emergencies:
Major Red Flags
Loss of Consciousness (LOC)→ Examination is unreliable.
→ Other injuries may mask pain.
Physical Red Flags
These strongly suggest skull fracture or intracranial bleeding:
- Battle’s sign (bruising behind ears)
- Raccoon eyes
- Hemotympanum (blood behind eardrum)
- Nasal CSF leak
- Pupils asymmetrical
Any of the above → CT scan + neurosurgical evaluation required immediately.
Brain vs. C-Spine Evaluation
Head injuries often coexist with neck (cervical spine) injuries.
Two validated clinical decision rules are used.
A. Brain Injury Evaluation
Canadian CT Head Rule
(Preferred rule—high sensitivity)
This rule identifies patients who need an urgent CT scan.
Using only major criteria captures ~100% of patients requiring intervention.
CT is needed if any of the following:
- Age ≥ 65
- Vomiting ≥ 2 episodes
- Suspected open/depressed skull fracture
- Signs of basal skull fracture
- GCS < 15 at 2 hours
- Retrograde amnesia > 30 min
- Dangerous mechanism (e.g., pedestrian struck, fall > 3 ft, high-speed MVC)
B. C-Spine Evaluation
Canadian C-Spine Rule (CCR)
More sensitive and specific than NEXUS.
C-spine injury must be suspected in:
- Elderly
- High-energy trauma
- Neurological symptoms
- Intoxicated patients
- Pain/tenderness on neck movement
If CCR is positive → immobilize the neck + CT C-spine.
Serious Brain Injuries You Must Not Miss
Your chart highlights several life-threatening conditions:
1. Subarachnoid Hemorrhage (SAH)
- Sudden, severe headache
- Possible LOC or syncope
- Often due to ruptured aneurysm
2. Subdural Hematoma
- More common in elderly & alcoholics
- Slow venous bleed
- Confusion, drowsiness → coma
- Delayed presentation common
3. Epidural Hematoma
- Often young patients
- Lucid interval classic finding
- Middle meningeal artery bleed
4. Intracerebral Hemorrhage (ICH)
- Neurological deficits
- Sudden deterioration
5. Skull Fracture
- Battle’s sign
- Raccoon eyes
- CSF leak
All require neurosurgery consultation, close neuro monitoring, ± ICU admission.
Facial Fractures (From Chart)
Nasal Fracture
- Follow-up with ENT / Primary care
- Pain management
Orbital Fracture
- Concern for muscle entrapment
- Ophthalmology or OMFS consultation needed
Other Facial Fractures
- Consider OMFS (Oral & Maxillofacial Surgery) consult
Glasgow Coma Scale (GCS)
The GCS is used universally to assess neurological status.
| Component | 1 | 2 | 3 | 4 | 5 | 6 |
|---|---|---|---|---|---|---|
| Eyes | Closed | Opens to pain | Opens to voice | Spontaneous | — | — |
| Verbal | No sounds | No words | Inappropriate words | Confused | Normal | — |
| Motor | None | Abnormal extension | Abnormal flexion | Withdraws to pain | Localizes pain | Obeys commands |
Interpretation
- GCS 13–15 → Mild Head Injury
- GCS 9–12 → Moderate
- GCS ≤ 8 → Severe → Intubate
GCS must be recorded at arrival, after intervention, and before transfer/discharge.
Emergency Management of Head Injury
Step 1: Primary Survey (ABCDE)
- Airway with cervical spine protection
- Breathing assessment
- Circulation—control bleeding
- Disability—GCS, pupils
- Exposure—look for other injuries
Step 2: Stabilize
- Oxygen
- IV access + fluids
- Cervical collar if C-spine risk
- Control seizures
- Prepare for CT imaging
Step 3: Imaging
- Non-contrast CT head is the test of choice
- CT C-spine if CCR positive
- Avoid delaying imaging in severe cases
Step 4: Neurosurgical Consultation
For:
- Intracranial bleeding
- Skull fractures
- GCS < 13
- Deteriorating neurological status
Step 5: Consider Medications
- Antiseizure medications (phenytoin/levetiracetam)
- ICP management (head elevation, hypertonic saline, mannitol)
- Avoid anticoagulants unless cleared by neurosurgery
Step 6: Observation
Mild head injury patients require:
- Regular GCS monitoring
- Repeat neuro exams
- Watching for vomiting, confusion, pupil changes
Special attention:
- Elderly
- Intoxicated
- Anticoagulated patients
Pearls & Pitfalls (From Chart)
1. Elderly or alcoholic? → Think subdural hematoma.
Slow venous bleeds often present late.
2. Lucid interval = Epidural hematoma.
3. Always check the ears for:
- Hemotympanum
- CSF leak
- Mastoid bruising
4. Anticoagulants increase risk of delayed bleeding.
Even if initial CT is normal → observe longer.
5. Distracting injuries can hide neck pain.
Maintain C-spine precautions.
6. Intoxicated patients cannot be clinically cleared.
Their exam is unreliable.
Documentation Essentials
Your chart emphasizes good documentation:
General
- LOC
- Nausea/vomiting
- Seizure
- Elderly/alcoholic
- Blood thinner use
- Distracting injuries
Head Exam
- Deformities
- Mastoid bruising
- Nasal septum deviation
- Tympanic membranes
- Pupils
- Lacerations/abrasions
Neurological Exam
- Full cranial nerve and limb exam
- Strength, sensation
- Cerebellar tests
Mechanism of Injury
- MVC: belted/unbelted, airbags, vehicle totaled
- Fall height
- Object struck
This helps with diagnosis, medico-legal safety, and safe discharge.
Disposition: When to Admit vs. Discharge
Admit to hospital/ICU if:
- GCS < 15
- Abnormal CT
- Seizure
- Anticoagulated
- Elderly with any concerning symptoms
- Persistent vomiting
- Persistent headache or neurological changes
Safe Discharge if:
- Normal CT
- GCS 15
- No red flags
- Reliable supervision at home
- Clear discharge instructions given
FAQs About Head Injury
1. What is the most important first step in head injury?
Maintaining airway while protecting the cervical spine.
2. Do all head injuries need a CT scan?
No. Use the Canadian CT Head Rule to decide.
3. When should you suspect a skull fracture?
Battle’s sign, raccoon eyes, CSF leak, hemotympanum.
4. Which patients are highest risk?
Elderly, alcoholics, anticoagulated patients.
5. What GCS indicates severe head injury?
GCS ≤ 8 → intubation and ICU required.
6. Why are intoxicated patients tricky?
Their neurological exam is unreliable; bleeding can be missed.
7. What is the danger of delayed bleeding?
Anticoagulant users can develop intracranial hemorrhage hours later.
