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.
Imaging
• 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.
•
Seizure.
•
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.
Examination
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.
Other investigations
•
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.
Common Diagnoses
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.
Subdural haematoma
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.
