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Tuesday, August 12, 2025

Head injury and concussion


1. Definition

  • Head injury: Any trauma to the scalp, skull, or brain. May be classified as mild, moderate, or severe based on clinical assessment, often using the Glasgow Coma Scale (GCS).

  • Concussion: A type of mild traumatic brain injury (mTBI) characterized by transient alteration in brain function without structural damage detectable on standard imaging.

2. Causes and Mechanisms

  • Falls (most common cause overall)

  • Road traffic accidents

  • Sports-related impacts (e.g., contact sports, cycling)

  • Assaults

  • Occupational accidents

Mechanisms include:

  • Direct blow to the head

  • Acceleration–deceleration forces (brain moves within skull)

  • Blast injury in military or industrial settings

3. Classification of Head Injury Severity (GCS)

  • Mild: GCS 13–15

  • Moderate: GCS 9–12

  • Severe: GCS ≤8

4. Concussion Pathophysiology

  • Functional disturbance of the brain due to mechanical forces → changes in neuronal membrane permeability, ionic shifts, metabolic dysfunction, and impaired neurotransmission.

  • No macroscopic structural injury on conventional imaging (CT/MRI).

5. Clinical Features

General Head Injury Symptoms

  • Scalp laceration, swelling, or bruising

  • Loss of consciousness (variable duration)

  • Headache, dizziness

  • Nausea, vomiting

  • Seizures

  • Focal neurological deficits (weakness, numbness, vision loss)

Concussion-Specific Features

  • Transient confusion or disorientation

  • Amnesia (retrograde or anterograde)

  • No focal neurological deficits on exam

  • Fatigue, irritability, difficulty concentrating

  • Photophobia or phonophobia

  • Symptoms usually resolve within 7–14 days in adults (longer in children)

6. Red Flag Symptoms Requiring Urgent Imaging and Specialist Review

  • GCS <15 two hours after injury

  • Suspected open or depressed skull fracture

  • Signs of basal skull fracture (periorbital ecchymosis, Battle’s sign, CSF rhinorrhea/otorrhea)

  • Seizure post-injury

  • Focal neurological deficit

  • More than one episode of vomiting

  • Severe, worsening headache

  • Suspected penetrating injury

  • Coagulopathy or current anticoagulant use

  • High-risk mechanism (high-speed collision, fall >1 m in child / >2 m in adult)

7. Diagnosis

Primary assessment:

  • Follow ABCDE trauma approach (Airway, Breathing, Circulation, Disability, Exposure)

  • Assess GCS and pupil response

Investigations:

  • CT head (within 1 hour for high-risk features, within 8 hours for moderate risk)

  • CT cervical spine if indicated

  • Blood tests: FBC, coagulation profile, electrolytes if severe

  • MRI brain in selected cases (persistent symptoms, suspected diffuse axonal injury)

8. Management

A. Mild Head Injury / Concussion (GCS 13–15, no red flags)

  • Observation for 4–6 hours in ED; if stable, discharge with head injury advice

  • Physical and cognitive rest for 24–48 hours

  • Gradual return to normal activities over days to weeks

  • Avoid alcohol, sedatives, and driving until fully recovered

  • Pain relief: Paracetamol preferred; avoid NSAIDs in first 24 hours unless bleeding risk excluded

B. Moderate to Severe Head Injury

  • Immediate resuscitation and stabilization (ABCDE)

  • Oxygen to maintain SpO₂ >94%

  • Maintain systolic BP ≥100–110 mmHg to ensure cerebral perfusion

  • Elevate head of bed to 30° to reduce intracranial pressure (ICP)

  • Control seizures if present (Lorazepam 4 mg IV, then consider Levetiracetam or Phenytoin for prophylaxis in high-risk patients)

  • Early neurosurgical consultation

  • ICP monitoring if GCS ≤8 with abnormal CT or high risk of intracranial hypertension

C. Surgical Indications

  • Extradural hematoma with mass effect

  • Large acute subdural hematoma (>10 mm thick or causing >5 mm midline shift)

  • Depressed skull fracture > skull thickness or with dural penetration

  • Intracerebral hemorrhage with neurological deterioration

  • Penetrating brain injury

9. Concussion Return-to-Play / Return-to-Work Protocol

  • Step 1: 24–48 hrs physical and cognitive rest

  • Step 2: Light aerobic exercise (e.g., walking, stationary cycling)

  • Step 3: Sport-specific exercise without contact

  • Step 4: Non-contact training drills with progressive resistance

  • Step 5: Full-contact practice after medical clearance

  • Step 6: Return to competition/work

  • Each step takes at least 24 hrs; if symptoms recur, return to previous step after 24 hrs symptom-free

10. Complications

  • Intracranial hemorrhage (epidural, subdural, intracerebral)

  • Post-concussion syndrome (persistent headache, dizziness, cognitive issues >3 months)

  • Second-impact syndrome (rare but catastrophic cerebral edema after a second head injury before recovery from first)

  • Chronic traumatic encephalopathy (CTE) after repeated concussions

  • Seizures

11. Prognosis

  • Mild head injuries and concussion usually resolve fully within 1–2 weeks (adults) or up to 4 weeks (children)

  • Severe head injury prognosis depends on initial GCS, age, associated injuries, and time to definitive treatment

  • Early recognition of complications greatly improves outcomes




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