seizures). Clinical evidence of a skull fracture (cerebrospinal \202 uid leak, peri-orbital haematoma). Signi \201 cant extracranial injuries. \200 Worrying mechanism (high energy, possible no n-accidental injury, possible penetrating injury). Continuing uncertainty about the diagnosis after \201 rst assessment. \200 Medical co-m orbidity (anticoagulant use, alcohol abuse). \200 Adverse social factors (eg alone at hom e). The following are highly recommended: \200 The SIGN (Scottish Intercollegiate Guideli nes Network) guideline on head injury is accessible at www.sign.ac.uk The NICE (National Institute for Health and Clinical Excellence) clinical guidelines on hea d injury published in 2007 and accessible at www.nice. org.uk e r u s s e r p l a n a r c a r t n i I Intracranial blood volume Fig. 8.6 ICP according to intracranial blood volume. 356 CHAPTER 8 Major trauma Head injury: triage and monitoring Triage Every ED requires a system for the rapid initial assessment of head-injured patients. The exact system will depend upon local policy, expert ise and facilities. It must enable patients with signi \201 cant injuries to receive immed iate resuscitation and ensure urgent treatment of those patients liable to complications. E xperienced nursing staff can quickly identify those patients in need of urgent attention, b ased upon: \200 The mechanism of injury. \200 History from the ambulance crew. \200 A n assessment of vital signs. \200 Conscious level according to the Glasgow Coma Scale ( b p.361). \200 Limb power. \200 Pupil responses. \200 BMG. For patients who are haemod ynamically stable, alert and orientated , with no neurological de \201 cit and an apparent ly minor head injury, it is appropriate to proceed to obtaining a full history, as outlined on b p.358. For patients with multiple injuries and/or a serious head injury , there will be no time initially to obtain a full history. Instead, proceed rapidly to initial assessme nt and resuscitation. During the \201 rst few seconds, it is useful to obtain an impressi on of the severity of the head injury. One simple method (AVPU) classi \201 es patients ac cording to their response to stimulation: \200 A lert. \200 Responsive to V oice. \200 Responsive only to P ain. \200 U nresponsive. If a patient is unresponsive or responds only to pain, call for senior ED help and an ICU specialist or anesthetist, since expert ai rway care (RSI, tracheal intubation and IPPV) will be needed. Monitoring Every head-injured patient requires regular neurological observations. These sho uld include measurements of GCS, pupil response, limb power, pulse, BP and respiratory rate on a standard chart, such as the one shown in Fig. 8.7 . This monitoring is critical if co mplications such as intracranial haematomas, \201 ts and hypovolaemia from other injuries are to be detected and treated at an early stage. Any deterioration in GCS is an emergency : re-examine the patient and correct identi \201 able problems promptly whilst obtaining u rgent senior help. 357 HEAD INJURY: TRIAGE AND MONITORING NAME UNIT No D. of B. WARD NEUROLOGICAL OBSERVATION CHART TIME DATE 4 3 2 1 5 4 3 2 1 6 5 4 3 2 Spontaneously To speech To pain None Oriented Confused Inappropriate Words Incomprehensible Sounds None Obey commends Localize pain Normal Flexion Abnormal Flexion Extension to pain None Eyes closed by swelling =C Eyes Open C O Endotracheal tube or Tracheostomy =T M Best verbal response A S C Usually records the best arm response A L E Best motor response 1 240 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 26 22 18 1 4 1 40 39 38 37 36 35 34 33 32 31 30 2 T e m p e r a t u r e 3 C 4 5 Blood pressure and Pulse rate 6 7 8 Respiration Pupil scale (m.m.) 10 6 Size Reaction Size Reaction + reacts \200\223 no reaction c. eye closed right PUPILS left L I M B Normal power Mild weakness Severe weakness Spastic flexion Extension No response A R M S Record right (R) and left (L) separately if there is a difference between the two sides. M O V E M E N T Normal power Mild weakness Severe weakness Extension No response L E G S Fig. 8.7 An example of a neurological observation chart. 358 CHAPTER 8 Major trauma Head injury: history It may be impossible to obtain a complete history from the patient, pa rticularly if there was loss of consciousness and/or amnesia. Use all available sources of information, including friends and family, other witnesses, and the ambulance crew. Cover t he following areas: Mechanism of injury Eliciting the exact mechanism of injury will provide an impression of t he nature of the forces involved and the risk of subsequent complications. Consider the pos sibility that the head injury may have been preceded and caused by another medical problem (eg arrhythmia, epilepsy, diabetes). Time of injury This information is useful, but may not be known. Loss of consciousness/amnesia A period of unconsciousness implies a head injury of at least moderate severity. It can be dif \201 cult to establish exactly how long unconsciousness lasted, particularly if there is associated amnesia. Document the length of amnesia (both b efore and after injury), but remember that the full extent of the amnesia may not become ap parent until much later. Subsequent symptoms Some symptoms are relatively common after head injury (eg headache and vomiting) \200\224 many patients will complain of these without being directly asked. Ther e are a number of other symptoms, however, which the patient may not mention unless speci \201 cally asked. Enquire about the following symptoms: \200 Headache. \200 Nausea and vomiting. \200 Limb weakness. \200 Paraesthesiae. \200 Diplopia. \200 Rhinorrhoea. \200 Otorrhoea. Past medical history Document pre-existing illnesses and symptoms, particularly those that may have caused the head injury (eg cardiac arrhythmias, epilepsy, diabetes), or might make the consequences more severe (eg bleeding tendency). Enquire about previous head injury (a n old skull fracture visible on new X-rays may otherwise be confusing). Drug history Ask particularly about recent alcohol and other drug ingestion and whether or not the patient is taking anticoagulant drugs (eg warfarin). This is very important, since patients with bleeding disorders and/or on anticoagulants have a much higher risk of intrac ranial problems after head injury, often require CT and must be admitted to hospital ( b p. 366). 359 HEAD INJURY: HISTORY Social history Before contemplating discharge of any head-injured patient, \201 nd out if there is a responsible adult at home, or if there is someone else with whom the patient co uld go and stay. Tetanus status If there are any wounds, consider the need for tetanus prophylaxis. 360 CHAPTER 8 Major trauma Head injury: examination Resuscitation proceeds with examination, according to problems ide nti- \201 ed in the primary survey. Follow initial brief neurological examination (GCS, p upil reactions, limb weakness) by de \201 nitive complete examination: Cervical spine injury Consider this possibility in all cases (see b p.320). Glasgow Coma Scale Determining the conscious level is a crucial part of the neurological ex amin- ation. The adult score ranges from a minimum of 3 to a maximum of 15 and is calculate d as shown in Table 8.2 . Repeated GCS recordings are a crucial part of monitoring the head injured patient. A fall in GCS indicates a poten- tially serious deterioration and mandate s a search for correctable conditions. Vital signs Record pulse, BP, and respiratory rate. BMG This is essential in all patients with altered conscious level. Alcohol Record if the patient smells of alcoholic drinks but never assume d GCS is due to a lcohol. Eye signs Document pupil size (in mm) and reaction to light. Unilateral pupillary dilatatio n may re \202 ect orbital injury or oculomotor nerve compression due to i ICP ( b p.354). Check for a full range of eye movements and the presence of diplopia or nystagmus. Look in the fundi, although papilloedema is a late sign of i ICP. If there is any suspicion of eye injury, measure VA ( b p.534). In infants, check for retinal hemorrhages ( b p.731). Scalp, face, and head Examine the cranial nerves and search for abnormal cerebellar signs ( nystagmus, hypotonia, intention tremor, dysdiadochokinesia). Carefully record scalp, ear or facial injury. Examination of facial injuries is on b p.370. The limbs Check limb tone, power, sensation and re \202 exes. Abnormalities (eg hemiparesi s) may result from the primary brain insult or be a consequence of a developing intracrania l haematoma requiring urgent intervention. A stroke can cause a fall resulting in a head in jury. Other injuries The presence of a head injury can render identi \201 cation of non-cranial injuries dif \201 cult. Intra-abdominal injuries often co-exist with serious head injuries and are dif \201 cult to detect; have a low threshold for FAST CT. In particular, rela tively minor non-life-threatening orthopedic injuries (eg \201 nger dislocations, wrist f ractures) are easily missed. Ensure full examination, including palpation of all limbs for possible injury. 361 HEAD INJURY: EXAMINATION Signs of base of skull fracture This is often a clinical diagnosis. One or more of the foll owing may be seen: \200 Bilateral orbital bruising con \201 ned to the orbital margin ( \200\230panda eyes \200\231). \200 Subconjunctival hemorrhage (no posterior margin of ble eding seen). \200 Haemotympanum or bleeding from the auditory meatus. \200 CSF otorrhoe a or rhinorrhoea ( anosmia). Fluid mixtures containing relatively similar quantities of blood and CSF will separate into a \200\230double ring \200\231 when dropped onto blotting paper. Battle \200\231s sign: bruising over the mastoid process without local direct trauma follow s petrous temporal bone fracture, but takes several days to appear. Glasgow Coma Scale (adults) The GCS assesses the level of consciousness by scoring three as pects of the patient \200\231s response and adding up the scores to reach a \201 nal scor e. Table 8.2 Glasgow Coma Scale Eye response open spontaneously 4 open to verbal command 3 open to pain 2 no response 1 Verbal response talking and orientated 5 confused/disorientated 4 inappropriate words 3 incomprehensible sounds 2 no response 1 Motor response obeys commands 6 localizes pain 5 \202 exion/withdrawal 4 abnormal \202 exion 3 extension 2 no response 1 Total (GCS) Range 3 \200\22315 Notes \200 Record GCS in shorthand showing its component parts (for example, GCS 10/15 (E 3, V2, M5) means that the patient opens eyes to verbal commands, speaks incomprehensible so unds, localizes a painful stimulus). Similarly, when communicating with other health profes sionals describe the total score (GCS) and list its components. Unconsciousness is generally taken to mean no eye response and GCS \211 8. \200 \200 \230Abnormal \202 exion \200\231 implies decorticate rigidity; and \200\230abnormal exte nsion \200\231 implies decerebrate rigidity. The GCS is dif \201 cult to apply to small children, but may be modi \201 ed as outlined on b p.717. 362 CHAPTER 8 Major trauma Head injury: imaging Traditional use of X-rays has largely been replaced by CT scanning; ED s in some countries have abandoned skull X-rays altogether, so be aware of local policies a nd protocols. In the UK, Scottish Intercollegiate Guidelines Network (SIGN) guidelines on t he early management of patients with a head injury ( www.sign.ac.uk ) were updated in 2009. In England and Wales, National Institute for Health and Clinical Excellence (NICE) guidanc e, published in 2007, is available at www.nice.org.uk The role of CT scanning CT scanning is used to identify and de \201 ne the brain injury, e specially intracranial haematomas amenable to surgical treatment. Ensure adequate resuscita tion before transferring for CT scan. In many cases, this will include RSI, tracheal intuba tion, and IPPV. Always arrange for appropri- ately trained staff to accompany the patient t o the CT scanner. When clinical features point strongly to an intracranial haematoma (eg th e emergence of focal signs or a deteriorating GCS), discuss promptly with a neurosurgeon th e bene \201 ts of transferring the patient to a center that has both CT scanning facilitie s and an emergency neurosurgical service. Indications for CT scan Request CT scan for any of the following (see www.nice.org.uk ): \200 GCS < 13 / 15 at any point since injury. \200 GCS 13 \200\22314 / 15 at 2hr post-in jury. \200 Suspected open or depressed skull fracture. \200 Any sign of basal skull fra cture. \200 Post-traumatic seizure. \200 Focal neurological de \201 cit. \200 > 1 ep isode of vomiting (except in children <12 years, where clinical judgment is required). Amnesia for > 30min of events before impact * . \200 Loss of consciousness and/or amnesia combined with one of: age > 65 years, coagulopathy (including clotting disorder, anticoagu lant drug treatment) or dangerous mechanism * (eg pedestrian hit by car, fall > 1m or 5 ste ps). Most requests will be urgent (scan performed and interpreted within an hour), except for th e two indications marked with an asterisk * , which if isolated, may allow CT scan to be ob tained less urgently (within 8hr), depending upon locally agreed policy. Interpretation of CT scan CT scans must be assessed by someone with appropriate expertise. \200 Skull fractures are obvious, as is the degree of depression of fragments. \200 Int racranial haematomas may cause midline shift and take several forms: extradural haematomas ( b p.365) appears as a high density (white) lens-shaped lesions. Subdurals conform more to the surface of the brain ( b p.365). Extradural and subdural haematomas can co-exist. Cerebral contusions appear as patches of low or mixed attenuation. \200 Cerebral swelling may take some time to develop, causing the ventricles to appear smaller than normal. 363 HEAD INJURY: IMAGING Skull X-rays: rationale Skull X-rays are quick, cheap, and easy to obtain but they should o nly be used when CT scanning is not available in adult patients with minor head injury who do not need an immediate CT scan. Standard views are: antero- posterior (AP), lateral and T owne \200\231s. They are useful to detect skull vault fractures, but do not de \201 ne any intracranial lesion. Identi \201 cation of skull fractures has been traditionally held to be important because of the i risk of intracranial haematoma, particularly if the consciou s level is impaired (see Table 8.3 ). If CT is planned, do not waste time doing skull X-ray s. Table 8.3 Risks of operable intracranial haematoma after head injury GCS 15 / 15 GCS 15 / 15 GCS 15 / 15 GCS 15 / 15 GCS 15 / 15 GCS 9 \200\22314 / 15 GCS 9 \200\22314 / 15 GCS 9 \200\22314 / 15 GCS 3 \200\2238 / 15 GCS 3 \200\2238 / 15 GCS 3 \200 \2238 / 15 Overall 1 in 6000 With no other features 1 in 31,300 With post traumatic amnesia 1 in 6,700 With skull fracture 1 in 81 With skull fracture and amnesia 1 in 29 Overall 1 in 51 With no skull fracture 1 in 180 With skull fracture 1 in 5 Overall 1 in 7 With no skull fracture 1 in 27 With skull fracture 1 in 4 Adapted from Teasdale et al . Indications for skull X-rays Skull X-rays should no longer be used when CT scanning is imme diately available. If CT is not available, it can be used to identify adult patients with s kull vault fractures, who will then require transfer for CT scanning. They have virtually n o role now in the assessment of head injuries. Interpretation of skull X-rays It can be dif \201 cult to distinguish fractures from vascu lar markings and suture lines. If in doubt, examine the relevant part of the head for sign of injury and seek a senior opinion. Linear fractures appear as sharp-edged lucent lines, w hich have a different appearance from vascular markings. Depressed fractures take various f orms, but tangential views may demon- strate the depressed bone. Base of skull fractures ar e often not visible, but there may be indirect evidence in the form of an intracranial aero coele or \202 uid (air/blood) level in a sinus. Check each of the main sinuses (frontal, sphenoidal, maxillary) in turn, remembering that the lateral skull X-ray is usually obtaine d with the patient lying supine ( \200\230horizontal beam \200\231, ie occiput downwards). This will affect the orientation of the \202 uid level. 364 CHAPTER 8 Major trauma Management of serious head injury Tailor management according to the needs of each individu al patient. Initial management \200 Clear, establish and maintain the airway, provide O 2 and protect the cervical spine ( b p.320). Check breathing \200\224 provide support with bag/valve/mask device as necessary. Examine for and treat any serious chest injury. \200 Check BMG and treat hypog lycaemia if present ( b p.322). \200 Insert two large IV cannulae and send blood for X-ma tching, FBC, clotting screen, U&E, and glucose. Correct hypovolaemia, resuscitate, and treat other injuries. \200 If GCS \211 8 / 15 , the patient will require urgent airway protection with RSI, tracheal intubation and IPPV (s ee b p.312). Call for senior ED help and request help from ICU and/or anesthesia. Check ABG and ventilate to p CO 2 of \211\210 4.5kPa. Liaise early with an anesthetist, ICU and a neurosurgeon (see below). \200 Contact a radi ologist early to arrange a CT scan with minimum delay. \200 In the multiply or seriously injured patient who will require a CT scan, concerns of opioid drugs masking pupillary sign s are less important than ensuring adequate analgesia. Give titrated IV opioid analgesia ( b p.320), after recording GCS, pupil reactions, and basic neurological examination. Give IV antibiotics for patients with compound skull fractures. Cefuroxime 1.5g IV is a sui table choice, but be guided by local policy. Regional neurosurgical centers vary as to whet her or not they advise prophylactic antibiotics for clinical base of skull fracture (there is no compelling evidence that they prevent meningitis): follow local policy. \200 Clean and close scalp wounds to control scalp bleeding (use simple interrupted silk sutures for r apid closure), but do not allow this to unduly delay CT scan or neurosurgical transfer. Insert a urinary catheter. \200 Consider the need for an orogastric tube. Avoid using NG tubes in facial injury or any possibility of base of skull fracture. Consider the need for tetanus immunization. Indications for neurosurgical referral \200 CT shows a recent intracranial lesion. \200 Patient ful \201 ls the criteria for CT scan, but this cannot be done within an appropriate period of time. Persisting coma (GCS < 9 / 15 ) after initial resuscitation. \200 Confusion which persist s > 4hrs. \200 Deterioration in conscious level after admission (a sustained drop of one point on the motor or verbal subscales, or two points on the eye opening subscale of the GC S). \200 Progressive focal neurological signs. \200 Seizure without full recovery. \200 Depressed skull fracture. \200 De \201 nite or suspected penetrating injury. \200 CSF leak or other sign of a basal fracture. 365 MANAGEMENT OF SERIOUS HEAD INJURY Treating complications Early recognition and treatment of complications is essential to pre vent secondary brain damage. It is crucially important to prevent hypoxia and hypovolaemia adding to the primary cerebral insult. Seizures Check BMG, glucose, and ABG. Treat with IV lorazepam 4mg. Repeat this once if not initially effective. Start an IV phenytoin infusion (loading dose 10 \200\22315mg/kg IV over 30min with ECG monitoring) to prevent further \201 ts. Fits which continue for \211 10 \210\222 15min or recur despite this treatment require senior ED and ICU help, RSI, tracheal intubation, and IPPV. Deteriorating conscious level Having corrected hypoxia, hypercapnia and hypovolaemia, a diminishing conscious leve l is likely to re \202 ect intracranial pathology, leading to i ICP, requiring urgent inve stigation and treatment. Bradycardia, hypertension, and a dilating pupil are very late sign s of i ICP. Speed is of the essence. Liaise with a neurosurgeon who will advise on use of a gents to d ICP (eg a bolus of 0.5g/kg IV mannitol \200\224 typically 200mL of 20 % for an adult). Mannitol is an osmotic diuretic which may temporarily d ICP and \200\230buy time \200\231 to get the patient to theater for drainage of an intracranial haematoma. Other examples of deterioration requiring urgent reassessment \200 The development of agi tation or abnormal behavior. \200 The development of severe or increasing headache or per sistent vomiting. \200 New or evolving neurological symptoms/signs (eg limb weakness). Intracranial haematoma Causes of neurological deterioration after head injury include hypox ia, hypovolaemia, seizures, cerebral swelling, and intracranial haematomas. Intracranial ha ematomas are important, as prompt surgery may save lives. Patients with bleeding disorders or on anticoagulants have a greatly i risk of developing an intracranial haematoma after he ad injury. Extradural haematoma Classically, extradural haematoma follows bleeding from the middle men ingeal artery \200\231s anterior branch after temporal bone fracture. Texts describe head i njury with initial loss of consciousness, then return to full consciousness, before neurolo gical deterioration as intracranial bleeding continues and ICP i . However, many patients d eviate from classical \200\230talk and die \200\231 descriptions: extradural hemorrhage ma y occur in non-temporal areas, with no skull fracture and no initial loss of consciousness. Subdural haematoma Bridging vein bleeding between brain and dura causes subdural haematoma. Unlike extradural haematoma (which is separated from brain surface by the dura), subdural haematoma conforms to the brain surface. This helps distinguish extradural from subdural ha ematoma on CT. Subdural haematoma may be acute or chronic. Acute subdural haematoma is asso ciated with a severe brain insult. Chronic subdural haematoma often occurs in elderly and a lcoholics ( i risk perhaps due to cerebral atrophy). Chronic subdural haematoma develops ov er several days, often presenting with \202 uctuating conscious level, sometimes with an obscure (or even no) history of head injury. 366 CHAPTER 8 Major trauma Minor head injury Introduction Assessment and management of patients who have sustained rel atively minor primary brain insults can be dif \201 cult. This is especially true when ass essment is rendered awkward by virtue of age, epilepsy, drug, or alcohol ingestion. In thes e circumstances, adopt a cautious approach and admit the patient for observation until the picture becomes clearer. Golden rules for managing head injury are : \200 Never attribute a d GCS to alcohol alone . \200 Never discharge a head-injured patient to go home alone. \200 Admit patients wit h head injury and coexisting bleeding tendency (including those taking anticoagulant drugs). Differential diagnosis Consider whether another condition could be principally responsible for the patient \200\231s symptoms. For example, small children who vomit after head injury may be suffering from otitis media or a throat infection. Otitis media may be responsible for both the vomiting (with fever) and for the head injury (by causing unsteadiness of gait , resulting in a fall). Indications for admission \200 d GCS (ie < 15 / 15 ), neurological de \201 cit or post-t raumatic seizure. \200 Signi \201 cant neurological symptoms (severe headache, vomiting, irrita- bility or abnormal behavior, continuing amnesia > 5min after injury). \200 Signi \201 cant medical problems, particularly bleeding tendency (including inherited diseases and anticoagulant drugs). Inability to assess due to epilepsy, consumption of alcohol or drugs. \200 Clinical or ra diological evidence of skull fracture. \200 No one available at home or no safe home to g o to (including suspected NAI and domestic violence). Observation of those admitted All patients require regular neurological observations (see b p.356). Act promptly if conscious level d or neurological de \201 cit develops. Remember that one of the principal reasons for admitting patients with apparently minor head injurie s is to monitor for the development of intracranial problems. In these cases, resuscitate, liaise with a neurosurgeon and obtain an urgent CT scan. If after 12 \200\22324hr of observation, the patient is symptom-free, haemo- dynamically st able and is GCS 15 / 15 with no neurological de \201 cit, it is reasonable to consider dis charge. Patients who do not fall into this category (ie symptomatic, d GCS or neurological de \201 cit) require a CT scan. 367 MINOR HEAD INJURY Discharging patients Most of the patients who present with minor head injury can be safely discharged directly from the ED. Ensure that there is a responsible adult available to acco mpany them home and someone to stay with them for 24hr once they get home. Warn the patient and the accompanying adult of the potential problems following a head injury (Box 8.1 ) \200\224 and what to do if any of these problems are experienced. Give advice regarding ana lgesia. Most EDs have standard written instructions which are given to the patient and acco mpanying adult. Examples of head injury warning instructions are shown below. Box 8.1 An example of head injury warning instructions Adults \200 Ensure a responsible person is available to keep an eye on you for the next 24hr and show them this card. Rest for the next 24hr. \200 Do take painkillers such as paracetamol to relieve pain and headache. \200 DO N OT drink alcohol for the next 24hr. \200 DO take your normal medica tion, but DO NOT take sleeping tablets or tranquilizers without consulting your doctor \201 rst. If any of the following symptoms occur then you should return or be brought back to the hos pital or telephone the hospital immediately. Tel (01 * * * ) * * * * * * (24hr): \200 hea dache not relieved by painkillers such as paracetamol; \200 vomiting; \200 disturbance of vision; \200 problems with balance; \200 \201 ts; \200 patient becomes unrousabl e. Children \200 Your child has sustained a head injury and following a thorough examination we are satis \201 ed that the injury is not serious. Your child may be more tired than normal. \200 Allow him/her to sleep if he/she wants to. \200 Give Calpol or Disprol (pediatric paracetamol) for any pain or headache. Try to keep your child resting for 24hr. \200 If your child should develop any of the fol lowing: headache not relieved by pediatric paracetamol; \200 vomiting; \200 altered vision; \200 irritability; \200 \201 ts; \200 becomes unrousable. Bring him/her back to the hospital or telephone for advice immediately: Tel (01 * * * ) * * * * * * (24hr). Alternative suggested written advice is available from the National Institute for Clinical Excellence ( www.nice.org.uk ). 368 CHAPTER 8 Major trauma Post-concussion symptoms Presentation Post-concussion symptoms are common after head injury and cause much anxiety in patients and their relatives. The most frequent complaints are: \200 Headache. \200 Dizziness. \200 Lethargy. \200 Depression. \200 Inability to concentrate. Headaches occur in most patients admitted to hospital after head injuries: in \211\210 30 % the headaches persist for > 2 months. The headaches are usually intermittent and become worse during the day or on exertion. Some appear to be \200\230tension headach es \200\231 and are often not signi \201 cantly helped by analgesics. Migraine attacks may become more frequent or severe after a head injury. Headaches that do not \201 t these p atterns may re \202 ect serious intracranial pathology. Non-speci \201 c dizziness is common after concussion. Detailed questioning may distinguis h dizziness from vertigo due to disturbance of the vestibular mechanisms. Dizziness may be caused by postural hypotension or by drugs (eg co-codamol and other analgesics) or alcohol (to which patients are often more sensitive after a head injury). Diagnosis Post-concussion symptoms are diagnosed by exclusion of other problems or complica tions following head injury. Take a careful history, including questions about drowsiness, intellectual function, neck pain, photophobia, vomiting, and rhinorrhoea. Examine the patient for any speci \201 c cause of the symptoms and for any neurological de \201 cit. Look particularly for evidence of meningitis or an intracranial haematoma. Chec k for papilloedema. Elderly or alcoholic patients or those with a bleeding tendency are prone to develop chroni c subdural haematomas, which may cause confusion or intellectual deterioration, often witho ut localizing signs. Obtain a CT. Treatment After a careful history and examination, with appropriate investigations to exclu de other problems, reassure the patient and explain that the symptoms are likely to resolve gradually. Reduced short-term memory and impaired concentration may make it dif \201 cult for a patient to return to work and cause additional stress and anxiety: give suitable exp lanations and discuss the provision of a sick note with the GP. Follow-up Since symptoms may last for some time, arrange appropriate follow-up. This usuall y involves the GP, who needs to be kept fully informed of the clinical \201 ndings and di agnosis. This page intentionally left blank 370 CHAPTER 8 Major trauma Maxillofacial injuries: introduction These injuries often look dramatic and can be life-thr eatening as well as causing signi \201 cant long-term morbidity. Common causes are road traf \201 c collisions, assaults, and sport. Emergency resuscitative measures \200 Perform a rapid initial assessment to look for and treat airway obstruc- tion or major bleeding ( b p.320). Remember the possibility of an ass ociated neck injury. Blood may rapidly accumulate in the pharynx requiring anterior post erior nasal packing for control ( b p.552). \200 Management of airway obstruction is comp lex, intubation often dif \201 cult and occasionally a surgical airway is required: obtain experienced ED and anesthetic assistance early. Use jaw thrust, chin lift, and suction to establish a patent airway. With bilateral mandibular fractures, the tongue may fall backwards. Restore airway patency by pulling the fractured segment anteriorly or by inserting a large (0 silk) suture in the tongue and pulling anteriorly. \200 Maxillary fractures may be displaced far enough backw ards to compromise the airway by contact of the soft palate against the posterior pharyngea l wall. This can be relieved by hooking two \201 ngers behind the hard palate, and pullin g forwards and upwards, but this can produce considerable bleeding. History Important clues may be obtained from knowing the causative events both in relation to the facial injury itself and also of injury to the head, spine etc. Drug history (eg ant icoagulants or bleeding tendency) may be important. Examination Inspect the face from the front, side and above (by standing above and behind t he patient). Look for: \200 Asymmetry. \200 Flattening of the cheek (depressed zygomati c fracture). \200 \200\230Dish face \200\231 deformity ( \202 attened elongated face du e to posterior and downward displacement of the maxilla). Nasal deviation or saddle deformity. Measure the intercanthal distance: if > 3.5cm suspect naso-ethmoidal fracture \200\224 see below. \200 Uneven pupillary lev els (due to orbital \202 oor fracture). \200 CSF rhinorrhoea (causes \200\230tramline \200\231 effect with central CSF and blood either side). Subconjunctival hemorrhage without a posterior border (suggests an orbital wall or anterior cranial fossa fracture). Palpate the facial bones systematically. Start over the superior orbital margins. Work down feeling both sides at the same time checking for pain, deformity, crepitus and movement. F eel speci \201 cally for steps in the inferior orbital margin and zygoma. Subcutaneous emp hysema implies a compound fracture \200\224 often of the maxillary sinus. 371 MAXILLOFACIAL INJURIES: INTRODUCTION Check for hypo/anesthesia of the cheek, side of the nose and upper lip (infra-orbital nerve injury), and for numbness of the upper teeth (anterior superior alveolar nerve in the infr a-orbital canal), and lower teeth and lip (inferior dental nerve damage due to mandibular f racture). Examine inside the mouth, checking for dental malocclusion (ie the teeth do not meet togeth er properly when the mouth is closed), loose, or lost teeth (this may need CXR), bruising a nd bleeding. Examine the eyes carefully ( b p.536): assume any laceration below the medial canthus involves the lacrimal duct until proven otherwise. Investigations In patients with multiple injuries, imaging of the chest, pelvis and cervica l spine will take precedence. Even with \200\230isolated \200\231 facial injuries, perform imaging of the cervical spine and head, where indicated, before facial X-rays or CT scanni ng. Facial X-rays are often both dif \201 cult to perform (because of poor patient cooperation ) and dif \201 cult to interpret. Get maxillofacial specialist advice regarding the views required and their interpretation. CT scanning is often required prior to de \201 nitive m axillofacial surgery. The commonly required views include: \200 Occipitomental 10 , 30 , and 45 . \200 Lateral. \200 Orthopantomogram (for mandible). Treatment Treatment of speci \201 c facial fractures is considered in b p.372, b p.374, b p.376. Remember that even in the absence of a visible fracture on X-ray, patients in whom t here is clinical suspicion of facial fracture (swelling, tenderness, asymmetry, numbness, e tc.) require expert attention and/or follow-up. 372 CHAPTER 8 Major trauma Middle third facial fractures Dento-alveolar fractures These injuries involve only the teet h and their bony support. Look for deranged occlusion and stepped malalignment of teeth, br uising of gums, and palpable fracture in the buccal sulcus. Le Fort facial fractures (Fig. 8.8 ) These lie between the frontal bone, the skull base and mandible. They involve the upper jaw, teeth, nose, maxillary, and ethmoid air sinuses \200 Le Fort I involves the tooth-bearing portion of the maxilla. Look for lengthening of the face due to the dropped maxillary segment. There may be movement or a split of the hard palate, a haematoma of the soft palate/buccal sulcus, and malocclusion. Le Fort II involves the maxilla, nasal bones and the medial aspects of the orbits. Look for a \200\230dished-in \200\231 face, a step in the infra-orbital margin, infra-orbital nerv e damage, malocclusion and surgical emphysema. The maxilla may be \202 oating \200\224 i f the upper teeth are pulled (gently!) the maxilla may move forward. Check for epistaxis, C SF rhinorrhoea, diplopia, and subconjunctival haematoma. Facial swelling occurs rapidly and is often severe. Later, bilateral peri-orbital bruising may be evident. \200 Le Fort III involves the maxilla, zygoma, nasal bones, ethmoid and the small bones of the base of the skull. The entire midface is fractured from the base of the skull. Features include those o f type II plus: \202 attened zygomatic bones (which may be mobile and tender), steps over the fronto-zygomatic sutures, movement and deformity of the zygomatic arch, and different pupillary levels. There is usually severe facial swelling and bruising. Pharyngeal bleeding may severely compromise the airway and cause hypovolaemic shock. Le Fort fractures may be asymmetrical (eg Le Fort II on the right and III on the left). Naso-ethmoidal fractures These produce a \202 attened nasal bridge with splaying of the n asal complex, saddle-shaped deformity of the nose, traumatic telecanthus, periorbital bruis ing, subconjunctival haematoma, epistaxis, CSF rhinorrhea, and supraorbital or supratrochle ar nerve paraesthesia. Management of middle third facial fractures \200 Resuscitate and establish a clear airway as described on b p.324. \200 Refer dentoalveolar fractures for repositioning and immobi lization with acrylic/metal splints wiring. Refer all patients with middle third or naso-ethmoidal fractures to the maxillofacial surge ons for admission. Any continuing hemorrhage requires packing \200\224 leave this to the s pecialist. Tell the patient not to blow the nose ( i subcutaneous emphysema and may drive b acteria into fracture sites and intracranially). Prophylactic antibiotics are often advised by maxillofacial surgeons. Ensure tetanus prophylaxis ( b p.410). Discuss patients with CSF leaks with the neurosurgeons. \200 Clean and dress compound fac ial lacerations, but do not close them (unless actively bleeding); they may need formal deb ridement and they provide access to fractures for open reduction and internal \201 xation . 373 MIDDLE THIRD FACIAL FRACTURES Le Fort III Le Fort II Le Fort I Fig. 8.8 Le Fort classi \201 cation of facial fractures. 374 CHAPTER 8 Major trauma Zygomatic, orbital and frontal sinus fractures Zygomatic (malar) fractures These injuries a re usually due to a direct blow and are frequently associated with severe eye injuries. \200\230Tripod fractures \200\231 involve fractures through the zygomatico-temporal and zyg omatico-frontal sutures, and the infra-orbital foramen. Examination Look for \202 attening of the cheek (often obscured later by swelling), a pal pable defect in the infra-orbital margin, infra-orbital nerve damage, diplopia, and subconj unctival hemorrhage (especially if no posterior margin is seen). Isolated fractures of the zygomatic arch may be accompanied by a palpable defect over the arch and limited or painful jaw movement resulting from interference with the normal movement of the coronoid process of the mandible. Orbital \200\230blow-out \200\231 fractures Caused by a direct blow to the globe of the ey e (commonly from a squash ball or shuttlecock) resulting in a fracture of the orbital \202 oor and prolapse of contents into the maxillary sinus. Examination Check for diplopia due to inferior rectus entrapment (the patient cannot look u p and medially), enophthalmos, and surgical emphysema. Carefully check the eye itself for i njury (hyphaema, retinal detachment, glaucoma, blindness). Record the visual acuity. Test i nfra- orbital nerve function. Fractures of the \202 oor of the orbit may not be easily vi sible on X-ray, but can often be inferred by the soft tissue mass in the roof of the maxill ary sinus ( \200\230tear drop \200\231 sign), clouding of the sinus and surgical emphysema. Management of zygomatic and orbital fractures \200 Tell the patient not to blow his/her n ose. \200 Refer all patients (including those in whom a fracture is clinically suspected but not evident on X-ray) to maxillofacial specialists who will advise regarding prophylact ic antibiotics and will arrange further investigation (usually CT scanning) and treatment. \200 Involve the ophthalmologists if the eye is also injured. Note: Patients with orbital emphysema who complain of sudden d in vision may be suffering from a build-up of air under pressure which is compromising retinal blood \202 ow. These patients need emergency deco mpression.