Lesson Plan – Head Injury

As with any patient who has had a traumatic injury you should first assess their ‘ABC’: Airway, Breathing and Circulation.

This patient is talking (so his airway is clear) and you akthough there are no other injuries reported you should assess the breathing and criculation. In this patient’s case there is no abnormality.

Before going any further consider if the patient needs any analgesia: we have a duty to ensure that our patients have as little pain as possible (plus if there is a significant head injury then pain can cause a rise in intracranial pressure).

The Glasgow Coma Score is made up of three parts: Eyes (scored out of four); Verbal (scored out of 5) and Motor (scored out of 6).Therefore the highest score a patient can get is 15. As the lowest score for each is one the lowest total score possible is 3.

Eye response (E)

There are four grades starting with the most severe:

1. No opening of the eyes
2. Eye opening in response to pain stimulus.
3. Eye opening to speech. Not to be confused with the awakening of a sleeping person; such people receive a score of 4, not 3.
4. Eyes opening spontaneously

Verbal response (V)

There are five grades starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. Moaning but no words.
3. Inappropriate words. Random or exclamatory articulated speech, but no conversational exchange. Speaks words but no sentences.
4. Confused. The person responds to questions coherently but there is some disorientation and confusion.
5. Oriented. Person responds coherently and appropriately to questions such as the person’s name and age, where they are and why, the year, month, etc.

Motor response (M)

There are six grades:

1. No motor response
2. Decerebrate posturing accentuated by pain (extensor response: adduction of arm, internal rotation of shoulder, pronation of forearm and extension at elbow, flexion of wrist and fingers, leg extension, plantarflexion of foot)
3. Decorticate posturing accentuated by pain (flexor response: internal rotation of shoulder, flexion of forearm and wrist with clenched fist, leg extension, plantarflexion of foot)
4. Withdrawal from pain
5. Localizes to pain (purposeful movements towards painful stimuli)
6. Obeys commands (the person does simple things as asked)

Our patient confused (V=4), will localise to pain (M=5), and is opening his eyes to voice (E=3), so his GCS is 12/15

Yes! This patient fulfills one of the first criteria, which is a GCS of less than 13 on initial assessment in the Emergency Department.

From the description it doesn’t appear that she meets any of the criteria for CT brain scan.

Maddocks’ questions are part of a pitchside screening test that can be used for concussion.

When asking the Maddocks’ questions then the questions should be preceded with the preface: “I am going to ask you a few questions, please listen carefully and give your best effort.”

• What venue are we at today?
• Which half is it now?
• Who scored last in this match?
• What did you play last week?
• Did your team win the last game?

It is a relatively sensitive, but not specific test (players who answer all the questions correctly are unlikely to have concussion, wheras those who fail to answer one or two questions correctly may not have concussion).

The SCAT5 is the comprehensive assessment that incoporates the Maddocks’ questions, with the modified World Rugby Head Injury Assessment (HIA01) screening tool an example of a shortened version that can be used during a game.

The Headway discharge advice sheet is excellent. It lists some important “Dos and Donts”

Do…

• DO make sure you stay within reach of a telephone and medical help in the next few days
• DO have plenty of rest and avoid stressful situations
• DO show this factsheet to a friend or family member who can keep an eye on your condition
• DO take painkillers such as paracetamol for headaches

Don’t…

• DON’T stay at home alone for 48 hours after leaving hospital
• DON’T drink alcohol until you feel better
• DON’T take aspirin or sleeping tablets without consulting a doctor
• DON’T return to work until you feel ready
• DON’T play or train for any contact sport for at least three weeks without consulting your doctor
• DON’T return to driving until you feel you have recovered. If in doubt consult your doctor.

Patients can suffer some symptoms for weeks or even months after an injury:

• Headaches
• Irritability
• Feelings of dizziness
• Restlessness
• Nausea
• Impulsivity and self-control problems
• Sensitivity to light or noise
• Difficulties with concentration
• Sexual difficulties
• Feeling depressed, tearful or anxious
• Sleep disturbance
• Fatigue
• Memory problems
• Difficulties thinking and problem-solving

The ‘post concussion syndrome’ is a very real and potentially disabling spectrum of symptoms that can be cognitive, emotional, physical or a mixture of all of these.

Again, Headway have produced an excellent booklet describing all of these symptoms and some strategies to manage them, but they can be summed up by the phrase ‘be kind to yourself’. You should remind the patient to not rush their recovery and ask for help from friends if they need it.