Minor Head And Neck Injury
Minor head and neck injuries are extremely common reasons to attend the Emergency Department. Within this group of patients there is a very small number who have sustained serious damage: the challenge is to accurately and efficiently identify these. This task is complicated by the fact that alcohol is involved in more than half of these cases. Minor head injury is defined as Glasgow Coma Scale (GCS) 13 or above, and may be associated with a period of loss of consciousness (LOC), and/or amnesia.
Guidelines use clinical features to identify low-risk patients who can safely be discharged and high-risk patients who need further investigation.
• Skull radiography (5 CXR) is not helpful as it cannot exclude significant brain injury: only CT brain (100 CXR) can do this.
• Radiography of cervical spine (5 CXR) is appropriate in patients with a low to moderate probability of injury. X-ray of cervical spine comprises three views: AP, lateral and (odontoid) peg.
• In patients with a high likelihood of neck injury or when the X-ray of cervical spine is not of adequate diagnostic quality or if a CT brain scan is indicated as well, then a CT cervical spine scan (100 CXR) is preferable.
Head injury: clinical assessment
This should include details about mechanism of injury, previous medical history, loss of consciousness and symptoms since. The key points to establish are:
• Mechanism of injury: pedestrian or cyclist vs vehicle, or ejected from vehicle, or fall 1 metre.
• Age ≥ 65 years.
• Vomiting > 1 episode.
• Pre-traumatic amnesia >30 minutes.
• Warfarin or coagulopathy.
• GCS < 15 after 2 hours in Emergency Department.
• Suspected skull fracture (open or depressed or skull base).
• Focal neurological deficit.
If any of the above factors is present, it is likely that the patient will need a CT brain scan (100 CXR).
Neck injury: clinical assessment
History: high-risk factors
• GCS < 15, unstable physiologically.
• Age > 65 years.
• Prior neck problems, neurology.
• Fall > 1 metre.
• Axial load to head, e.g. diving, rollover crash.
• Motor vehicle crash involving high speed, ejection from vehicle, bicycle, motorcycle or recreational vehicle.
If a patient has neck pain and any of these features, arrange imaging.
Look Look for fixed flexion deformity of the neck.
Feel While a clinician stabilises the head, take the collar off and feel for midline tenderness over the spinous processes.
Tenderness over the trapezius muscles is common but does not necessitate imaging.
If either Look or Feel is abnormal, arrange imaging, otherwise test movement:
Move Ask the patient to rotate their head 45° left and right.
If this is possible without pain and the above tests have been performed by a doctor with the appropriate training and experi- ence, the neck is ‘cleared’.
If any of the findings are abnormal, arrange imaging.
• Investigations indicated as per Chapters 8 and 9.
• Blood glucose.
• Alcohol testing, whether breath or blood, is only useful if it is negative. If positive, it is dangerous to assume that all symptoms are due to the alcohol.
Concussion: mild traumatic brain injury
After ruling out significant brain injury, the patient may be discharged to the care of another adult with written head injury instructions. These should express clearly the reasons to return to the Emergency Department, e.g. vomiting or drowsiness.
The patient should be warned about common symptoms following a mild head injury (e.g. poor concentration, labile mood): psychological follow-up may be helpful.
Acute neck sprain
Patients should be warned that pain and stiffness is likely to be worse the following day and that it is important to use sufficient analgesia, e.g. NSAID ± codeine, to keep the neck mobile. The term ‘whiplash’ is best avoided as it has medicolegal implications. It is interesting that in countries without a compensation culture, acute neck sprains do not cause long-term disability.
Soft foam collars discourage neck movement, preventing recovery and encouraging psychological dependence, so should not be used. Semi-rigid collars (e.g. Philadelphia) are sometimes used for patients with a stable neck injury on expert advice.
Diagnoses not to miss
Reason for fall or injury
Elderly patients who present with a fall may have been on the floor for a prolonged period: look for hypothermia, pressure sores, rhabdomyolysis (Chapter 29). Think about possible causes (e.g. urinary tract infection, postural hypotension or arrhythmia), and keep an open mind about possible elder abuse or domestic violence.
Occult cervical spine fracture
Elderly patients with facial injuries may have fallen so fast they have not been able to protect their face, and therefore are at high risk of cervical spine fractures, especially of the odontoid peg. Have a low threshold for requesting CT, as plain radiographs are usually uninterpretable.
Extradural (epidural) haematoma
A fracture of the temporal bone overlying the middle meningeal artery may cause a large bleed. The classical presentation is of deterioration following a lucid interval; if diagnosis and surgery are rapid, a good outcome is common.
Patients at high risk of subdural haematoma (SDH) include the elderly with recurrent falls, alcoholics and those on anticoagu- lants. SDH may present following an acute injury, or as a chronic deterioration, and often has a poor prognosis whether surgery is performed or not, due to the underlying conditions.
Cervical spine fracture
C2 and C5/6 injuries are most common. Document and monitor neurological and respiratory function carefully. Insertion of a catheter, pressure area care, and correction of spinal shock using intravenous fluids are essential basic treatments.