See the following
medical link information discussed symptoms of a significant closed
head injury, and some of the fatal or devastating medical conditions
that can follow a brain trauma episode.
General Approach to Head Injury
The presence of significant
intracranial injury should be obvious from the mini-neurological
exam of the initial survey. The secondary survey may reveal a
decreasing level of responsiveness or localized neurological deficits.
When you find evidence of neurological injury, detailed testing
such as Doll's eyes and caloric testing can be left to the neurosurgical
The hallmark of cerebral injury
is decreased level of consciousness. The differential diagnosis
of decreased consciousness is "TIPPS on the VOWELS:"
T = Trauma
I = Infection
P = Psychological
P = Poisons
S = Shock
A = Alcohol
E = Epilepsy
I = Insulin
O = Opiates
U = Urea (metabolic)
Careful examination of the skull and facial bones may reveal evidence
of an impact that makes intracranial injury more likely. Any patient
who has some degree of minor head injury, who you do not x-ray
or CT scan, should be reexamined before leaving the emergency
department. Mastoid swelling and discoloration, widespread scalp
hematoma, periorbital ecchymosis, and other "classic" signs of
skull fracture often do not develop for hours.
Vital signs may reflect intracranial
pathology. Increased intracranial pressure (ICP) often causes
a slowing of respiration, then an increase with further elevation
of ICP. The combination of systolic hypertension (widened pulse
pressure), with slowed pulse is called the "Cushing response"
to increased ICP. It often indicates a surgical lesion. Elevated
temperature is common with cerebral injury. Tachycardia in the
presence of head injury, unless due to some other injury, is a
bad prognostic sign.
"Fancy" reflexes such as eyelid
reflex, corneal reflex, Doll's eyes, and calorics are of little
value acutely, and are best left to the neurosurgical consultant.
The patient is best followed using pupil signs and a general scale
of responsiveness such as the Glascow Coma Scale.