Head Injury Investigation And Admission Criteria


X-ray the skull if:

(plus cervical spine, chest, abdomen, pelvis and limbs if required)

conscious level is impaired at the time of examination or if the patient has lost consciousness at any time since the injury neurological symptoms or signs are present

CSF leak from the nose (rhinorrhoea) or ear (otorrhoea)

penetrating injury is suspect significant scalp bruising or swelling patient assessment is difficult (e.g. alcohol intoxication).

lateral lateral


Fluid level in sphenoidV r,r sinus (basal #) x J' -

'Brow up' positioning for the lateral view aids identification of intracranial air (pneumocele) and fluid levels in the sphenoid sinus


(basal # with dural tear)

Note 'double density' appearance - confirms suspicion of depressed # on other view

Linear # (note whether it crosses the middle meningeal grooves with subsequent risk of extradural haematoma)


Note fluid level in frontal sinus

A Towne's view is essential, otherwise occipital # will be missed

towne's Pineal shift is occasionally observed, indicating the presence of a mass (but beware, a rotated film is misleading)

Risk of intracranial haematoma (requiring removal) in adults attending A & E departments after head injury. No skull # - orientated 1 in 6000

No skull # - not orientated 1 in 120 Skull # - orientated 1 in 32

Skull # - not orientated 1 in 4

Adapted with permission Mendelow et al 1983 ii: 1173-1176 British Medical Journal


ADMIT patients at risk of developing secondary complications e.g.

ADMIT patients at risk of developing secondary complications e.g.

Transfer to the neurosurgical unit

Prior to the transfer, ensure that resuscitation is complete, and that more immediate problems have been dealt with (see page 217). Insert an oropharyngeal airway. Intubate and ventilate if the patient is in coma or if the blood gases are inadequate (P02 < (kPa on air, 13k/>a on 02 or C02>6kPa). If the patient's conscious level is deteriorating, an intravenous bolus infusion of 100 ml of 20% mannitol should 'buy time' by temporarily reducing the intracranial pressure.

NOTE: for comatose patients with an unstable systemic state from multiple injuries, a negative CT scan in the local hospital may avoid a dangerous transfer to the neurosurgical unit.

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