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Table of Contents
Head injury is defined as any trauma to the head regardless of mechanism or presence of neurological symptoms.1
This guide provides an overview of the recognition and immediate management of a traumatic head injury using an ABCDE approach.
The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.
This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care.
Basic principles & pathophysiology
The severity of head injuries can vary from minor head injuries to life-threatening traumatic brain injury (TBI) and/or intracranial haemorrhage.
Traumatic head injuries are a common presentation, with 1.4 million patients attending emergency departments in the United Kingdom every year.1
Although the incidence of death from head injuries overall is low (0.2%), the consequences of missing major pathology can be catastrophic. Head injuries are the most common cause of death and disability in those under the age of 40 in the UK.1
The Monro-Kellie doctrine
The Monro-Kellie hypothesis describes the relationship between the contents of the skull and intracranial pressure (ICP).
The skull is a closed rigid box with a fixed capacity (after the sutures have closed).
Within the skull there are three main substances:
- Brain tissue,
- Cerebrospinal fluid (CSF)
- Blood
If the volume of one of these substances increases, to maintain a constant ICP, the volume of one of the others must decrease. Initially, this can be achieved through a process referred to as compliance.
An increase in the amount of blood in the skull leads to a compensatory decrease in the amount of CSF and normal ICP is maintained (Figure 1).
Once the compensatory compliance mechanism is overwhelmed, small increases in the volume of any one of the three substances will lead to dramatic increases in ICP (Figure 2). In head injuries, the volume of brain tissue or blood within the skull can increase secondary to swelling (i.e. oedema) or haemorrhage. If left untreated, rising ICP leads to a progressive reduction in cerebral perfusion, herniation of the brainstem and ultimately death.
Clinical features of raised ICP
Clinical features of raised ICP can include:
- Headache
- Nausea and vomiting
- Restlessness, agitation or drowsiness
- Slow slurred speech
- Papilloedema
- Ipsilateral sluggish dilated pupil which then becomes fixed (βblown pupilβ)
- Cranial nerve palsy (e.g. CN III palsy with ‘down and out’ pupil)
- Seizures
- Reduced GCS
- Abnormal respiratory pattern
- Abnormal posturing, initially decorticate and then decerebrate
Cushingβs reflex is a physiological response to raised ICP which attempts to improve perfusion. It leads to a triad of hypertension, bradycardia, and an irregular breathing pattern (Figure 3).Β
Cerebral Perfusion Pressure (CPP)
Cerebral perfusion pressure is the pressure driving blood through the brain tissue, allowing the delivery of oxygen and nutrients. CPP can be calculated using the equation below:
CPP = Mean Arterial Pressure (MAP) β ICP
A rise in ICP will reduce CPP. If CPP drops too low for a significant amount of time, ischaemia occurs.
Herniation
Herniation can be defined as the movement of brain structures from one cranial compartment to another. Herniation of different brain structures leads to different clinical features.
Herniation of the cerebellar tonsils through the foramen magnum leads to compression of the brainstem and respiratory arrest. This is often referred to as βconingβ.
Herniation of the uncus of the temporal lobe through the tentorial notch often leads to compression of cranial nerve three (oculomotor nerve) leading to the classical βblown pupilβ that is often assessed for in TBI patients.
Primary and secondary brain injury
Primary brain injury is the initial injury caused to brain tissue from the forces of the traumatic event itself. This may be focal (e.g. skull fractures, blood vessel injury and haematoma formation) or diffuse (e.g. contusion).
Secondary brain injury is indirect damage to brain tissue that that occurs after the primary insult, worsening the original injury. Common causes include inadequate perfusion of the brain causing cerebral hypoxia, acidosis, hypoglycaemia and cerebral oedema leading to raised ICP.
Primary brain injury has already occurred in patients who present with a head injury. A key part of head injury management is to minimise secondary brain injury.
Table 1. Factors that may contribute to secondary brain injury, and the interventions to try to limit them.
Contributing factors |
Interventions |
Hypoxia and hypercapnia |
Oxygen to maintain saturations of 94-98% Intubation in patients unable to protect their airway or with poor respiratory effort |
Hypovolaemia and hypotension |
Resuscitate with intravenous fluids or blood products Vasopressors |
Cerebral oedema and raised ICP |
Avoid tight C-spine collars Position the patient at 30Β° to aid venous drainage Mannitol or hypertonic saline to reduce ICP Intubation and hyperventilation strategies |
Expanding haematoma |
Reverse clotting abnormalities Consider the use of tranexamic acid if < 3 hours since injury Neurosurgical intervention |
Hypoglycaemia or hyperglycaemia |
Maintain blood glucose within normal range with insulin or dextrose as required |
Increased metabolic demand (e.g. hyperthermia or seizures) |
Maintain normothermia Anti-convulsant medications if seizure activity Neuroprotective anaesthesia |
Clinical features
History
Patients who have sustained a head injury may not be able to provide an accurate history as a result of the injury itself (e.g. due to reduced consciousness).
Where possible, obtain a collateral history. If the patient was bought in by ambulance, try to gather a detailed history and description of the scene from the paramedics.
In the context of acute severe head trauma, taking a history should not delay performing an urgent ABCDE assessment to identify and address serious pathology.
A more detailed history can be obtained once the patient is stable.
Typical symptoms of a traumatic head injury include:
- Pain localised to the area of trauma
- Headache
- Drowsiness or loss of consciousness
- Nausea and vomiting
- Confusion or irritability
- Changes in hearing (ringing in ears, hearing loss) or vision (double vision, blurring, visual field loss)
- Memory loss (amnesia) or concentration difficulties
- Weakness or sensory changes such as numbness or paraesthesia
- Difficulties with speech (e.g. slurring)
- Dizziness or issues with balance
Other important areas to cover in the history include:
- A detailed account of the event. This includes when the head injury occurred, how it occurred, and which part of the head took the impact. Find out if the patient was intoxicated or taking any illicit drugs at the time.
- Establishing if the patient has any neurological symptoms. This includes seizure activity, weakness, sensory or visual changes.
- Whether there was any loss of consciousness after the injury and establishing if the patient has any amnesia.
- Whether the patient has any symptoms that may be due to raised ICP (covered previously).Β
- Drug history: establish whether the patient is taking any anticoagulants and if they have any drug allergies.
- A focused past medical history: establish if the patient has a bleeding disorder; has previously had brain surgery or sustained a significant head injury.
- A focused social history: establish the patient’s baseline functioning and what their home situation is. Take a brief alcohol and drug history.
- Whether the patient has sustained any other injures. Specifically, ask about pain in the cervical spine. NICE have guidelines on when c-spine immobilisation should be performed.3
If the head injury was due to a fall, then this should be explored further, and the cause of the fall should be sought. See our article on falls assessment and management.
Clinical signs
Typical clinical signs associated with a traumatic head injury include:
- Lacerations, abrasions, bruising and swelling over the area of the head that has sustained trauma
- Decreased consciousness (GCS) or drowsiness
- Confusion
- Irritability
- Focal neurological signs such as weakness or sensory loss
- Abnormal findings on cranial nerve examination such as visual field loss; abnormally shaped or sized pupils; and speech difficulties
- Impaired coordination on examination
- Signs of basal skull fracture: this includes CSF tracking from the nose or ears and bruising around the eyes or behind the ears
- Impairments in memory
Tips before you begin
GeneralΒ tipsΒ for applying anΒ ABCDEΒ approachΒ in an emergency setting include:
- Treat all problems as you discover them.
- Re-assess regularly and after every intervention to monitor a patientβs response to treatment.
- Make use of the team around you byΒ delegating tasks where appropriate.
- All critically unwell patients should haveΒ continuous monitoring equipment attached for accurateΒ observations.
- Clearly communicate how often would you like the patientβs observations relayed to you by other staff members.
- If you require senior input,Β call for help early using an appropriateΒ SBARR handover
- Review resultsΒ as they become availableΒ (e.g.Β laboratory investigations).
- Make use of your localΒ guidelinesΒ and algorithmsΒ in managing specific scenarios (e.g.Β acute asthma).
- AnyΒ medications orΒ fluidsΒ will need to beΒ prescribedΒ at the time (in some cases you may be able to delegate this to another member of staff).
- Your assessment and management should beΒ documented clearly in the notes, however, this shouldΒ not delayΒ initial clinical assessment, investigations and interventions.
Initial steps
Acute scenarios typically begin with aΒ briefΒ handoverΒ from a member of theΒ nursing staffΒ including theΒ patientβs name,Β age,Β backgroundΒ and theΒ reasonΒ theΒ reviewΒ has been requested.
You may be asked to review a patient with a traumatic head injury in the emergency department or following a fall on the wards.
Introduction
IntroduceΒ yourselfΒ to whoever has requested a review of the patient andΒ listenΒ carefullyΒ to their handover.
Interaction
IntroduceΒ yourselfΒ to theΒ patientΒ including yourΒ nameΒ andΒ role.
AskΒ how the patient is feelingΒ as this may provide some useful information about their currentΒ symptoms.
In the context of a head injury, this may not be possibleΒ due to impaired consciousness.
Preparation
Make sure theΒ patientβsΒ notes,Β observationΒ chartΒ andΒ prescriptionΒ chartΒ are easily accessible.
Ask for anotherΒ clinicalΒ memberΒ ofΒ staffΒ toΒ assistΒ you if possible.
If the patient isΒ unconsciousΒ orΒ unresponsive, start theΒ basic life supportΒ (BLS)Β algorithmΒ as per resuscitation guidelines
Airway
In patients with head injuries, the airway may be compromised due to a number of factors such as:
- Blood or swelling in the airway
- Vomit or secretions
- Reduced consciousness (from the head injury itself or other factors e.g. intoxication)
Clinical assessment
Can the patient talk?Β
Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No:
- Look for signs ofΒ airwayΒ compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
- Open the mouthΒ andΒ inspect: look for anything obstructing the airway such as secretions or a foreign object.
Interventions
Regardless of the underlying cause of airway obstruction, seekΒ immediate expert supportΒ from an anaesthetist and the emergency medical team (often referred to as the βcrash teamβ). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
The head tilt-chin lift manoeuvre should be avoided if there is any concern of a spinal injury.
Jaw thrust
If the patient is suspected to have sufferedΒ significantΒ traumaΒ with potential spinal involvement, perform aΒ jaw-thrustΒ rather than a head-tilt chin-lift manoeuvre:
1.Β Identify the angle of the mandible.
2.Β With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.
3.Β Using your thumbs, slightly open the mouth by downward displacement of the chin.
Oropharyngeal airway (Guedel)
Airway adjuncts are often helpful and, in some cases, essential to maintain a patientβs airway. They should be used in conjunction with the manoeuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.
An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.
ToΒ insertΒ anΒ oropharyngealΒ airway:
1.Β Open the patientβs mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.
2.Β Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180Β°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.
3.Β Advance the airway until it lies within the pharynx.
4.Β Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patientβs airway by looking, listening and feeling for signs of breathing.
Nasopharyngeal airway (NPA)
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways.
The use of nasopharyngeal airways in head injury is controversial. They are generally better tolerated than oropharyngeal airways in patients who are partially or fully conscious and may be the only option in severe facial fractures or trismus. However, the general consensus is that they should not be used if there is any concern that the patient may have a basal skull fracture.
Basal skull fracture
Signs suggestive of a basal skull fracture include:
- CSF (clear fluid) leaking from nose or ear
- Raccoon eyes: bruising around the eyes
- Battle sign: bruising behind the ear over the mastoid process
- Haemotympanum: blood noted behind the tympanic membrane on otoscopy
CPR
If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.
Re-assessment
Make sure to re-assess the patient following any intervention.
Breathing
Ventilation must be sufficient to prevent secondary brain injury from cerebral hypoxia and hypercapnia. Abnormalities in the patient’s respiratory pattern may indicate raised ICP.
Clinical assessment
Observations
Review the patientβsΒ respiratoryΒ rate:
- AΒ normalΒ respiratory rate is betweenΒ 12-20 breaths per minute.
- Bradypnoea may be secondary to raised ICP and is seen as part of the Cushingβs reflex. Consider other causes of a reduced RR such as opioid toxicity.
- Tachypnoea may be due to pain or agitation, acidosis or due to the presence of respiratory pathology.
Review the patientβs oxygen saturations (SpO2):
- AΒ normal SpO2Β rangeΒ isΒ 94-98%Β in healthy individuals andΒ 88-92%Β in patients withΒ COPDΒ who are at high-risk ofΒ CO2Β retention.
- Hypoxaemia may occur due to associated injuries or respiratory issues and can contribute to secondary brain injury.
See our guide to performingΒ observations/vital signsΒ for more details.
Inspection
Look for signs of cyanosis, respiratory distress, use of accessory muscles, and abnormal breathing patterns.
Deep irregular breathing can be caused by raised ICP.
Assess for equal chest expansion with respiration and for any obvious chest wall trauma.
Palpation
Palpate the position of the patientβs trachea and assess chest expansion.
Assess for any chest wall tenderness that may signify chest wall trauma.
Auscultation
Auscultate both lungs:
- Assess for good air entry throughout the chest
- Assess for any added sounds such as crackles and wheeze
Investigations and procedures
Arterial blood gas
Take anΒ ABGΒ ifΒ indicatedΒ (e.g. low SpO2) to quantify the degree of hypoxia.
Chest X-ray
A chest x-ray may be needed if examination suggests other respiratory pathology.
Intubation and ventilation
Indications for intubation and ventilation are:
- pO2 < 13kPa on supplemental oxygen
- pCO2 > 6kPa
- Spontaneous hyperventilation causing pCO2 < 3.5kPa
Interventions
Oxygen
Administer oxygen to all critically unwell patients during yourΒ initialΒ assessment. This typically involves the use of aΒ non-rebreathe maskΒ with an oxygen flow rate ofΒ 15L. You can then trial titrating oxygen levels downwards after your initial assessment.4
If the patient has COPD and a history of CO2Β retention you should switch to aΒ venturi maskΒ as soon as possible andΒ titrate oxygen appropriately.
Assisted ventilation
If your patient is unconscious and their respiratory rate is inadequate (too slow or irregular with big pauses), you can provide assisted ventilation through aΒ bag-valve-maskΒ (BVM): ventilate at a rate of 12-15 breaths per minute (roughly one every 4 seconds).
Other interventions
Other interventions may be appropriate depending on examination findings (e.g., aspiration of tension pneumothorax).
Re-assessment
Make sure to re-assess the patient following any intervention.
Circulation
In patients with TBI, it is important to maintain an adequate mean arterial pressure to ensure adequate cerebral perfusion.
Mortality is significantly increased in patients with TBI who have periods in which their systolic blood pressure is less than 90mmHg.Β
Aim for a MAP > 90mmHg or systolic BP > 110mmHg. A lower BP may sometimes be permitted in patients with multiple injuries or major haemorrhage.
Clinical assessment
Observations
Review the patient’s heart rate:
- Causes ofΒ tachycardia (HR>99) in the context of head injury include hypovolaemia, arrhythmia, pain or drugs.
- Causes ofΒ bradycardia (HR<60) in the context of head injury include Cushing’s reflex and opioid use.
Review the patientβsΒ bloodΒ pressure:
- A normal blood pressure (BP) range is between 90/60mmHg and 140/90mmHg but you should review previous readings to gauge the patientβs usual baseline BP.
- Causes ofΒ hypertension in the context of acute head injury include pain and Cushing’s reflex.Β
- Causes ofΒ hypotension in the context of acute head injury include haemorrhage from other injuries, and drugs (e.g. opiates).
See our guide to performingΒ observations/vital signsΒ for more details.
General inspection
Inspect the patient from theΒ end of the bedΒ whilst at rest, looking for clinical signs suggestive of underlying pathology:
- Pallor or mottled skin: commonly associated with hypovolaemic shock (e.g. haemorrhage).
Palpation
Place theΒ dorsal aspectΒ of your hand onto the patientβs to assessΒ temperature:
- In healthy individuals, the hands should beΒ symmetrically warm, indicating adequate perfusion.
- Cool handsΒ indicateΒ poor peripheral perfusion (e.g. hypovolaemic shock).
MeasureΒ capillary refill timeΒ (CRT):
- In healthy individuals, the initial pallor of the area you compressed shouldΒ return to its normal colourΒ inΒ less than two seconds.
- A CRT that isΒ greater than two secondsΒ suggestsΒ poor peripheral perfusion (e.g. hypovolaemia) and the need to assess central capillary refill time.
Pulses and blood pressure
Assess the patientβsΒ radialΒ andΒ brachialΒ pulseΒ to assessΒ rate,Β rhythm,Β volumeΒ andΒ character:
- AnΒ irregularΒ pulse is associated withΒ arrhythmiasΒ such asΒ atrial fibrillation.
- AΒ threadyΒ pulse is associated withΒ intravascular hypovolaemia (e.g. haemorrhage).
Auscultation
AuscultateΒ the patientβs precordium to assessΒ heart sounds, listening for evidence of murmurs.
Investigations and procedures
Intravenous cannulation
Insert at least oneΒ wide-bore intravenous cannulaΒ (14G or 16G) and take blood tests as discussed below.
See ourΒ intravenous cannulation guideΒ for more details.
Blood tests
Request the following blood tests:
- FBC
- U&Es
- LFTs
- Coagulation screen
- Group & save (+/- crossmatch)
- Toxicology screen (if you suspect drug overdose)
- Lactate (to assess for evidence of inadequate end-organ perfusion)
See ourΒ blood culture,Β blood bottleΒ andΒ investigation panel guides for more details.
ECG
Perform an ECG if to identify any abnormal rhythms which may be contributing to poor perfusion.
Attach 3-leadΒ continuous ECG monitoringΒ if available.
See our guides toΒ recordingΒ andΒ interpretingΒ an ECG for more details.
Interventions
Hypovolaemia
Hypovolaemic patients requireΒ fluidΒ resuscitationΒ (the below guidelines are for adults):
- Administer a 500ml bolus Hartmannβs solution or 0.9% sodium chloride (warmed if available) over 15 mins.
- Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).
After each fluid bolus,Β reassessΒ for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).
Repeat administrationΒ of fluid boluses up toΒ four timesΒ (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.
Seek senior inputΒ if the patient has a negative response (e.g. increased chest crackles) or if the patient isnβt responding adequately to repeated boluses (e.g. persistent hypotension).
See ourΒ fluid prescribing guideΒ for more details onΒ resuscitation fluids.
Hypertension
Hypertension in traumatic head injury is generally left alone unless it is dangerously elevated, as it is often a homeostatic response to ensure there is adequate cerebral perfusion.
Coagulation abnormalities
If a patient is found to have coagulation abnormalities in the context of acute head injury (e.g. raised PT or INR) they will likely require treatment to reduce their risk of further bleeding.Β
Correction of coagulation abnormalities is typically lead by the on-call haematologist.
CPR
If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.
Re-assessment
Make sure to re-assess the patient following any intervention.
Disability
Clinical assessment
Consciousness
Assess the patientβs level of consciousness by using the Glasgow Coma Scale (GCS).
A summary of the Glasgow coma scale is shown below. For a more detailed explanation, see the Geeky Medics guide to the Glasgow Coma Scale.Β
Table 2. An overview of the Glasgow Coma Scale.
Behaviour/domain | Response | Score |
Eye-opening response |
Eyes opening spontaneously |
4 |
Eyes opening to sound |
3 |
|
Eyes open to pain |
2 |
|
No eye opening |
1 |
|
Verbal response |
Orientated to time, place and person |
5 |
Confused |
4 |
|
Inappropriate sounds |
3 |
|
Incomprehensible sounds (e.g. groaning) |
2 |
|
No response |
1 |
|
Motor response |
Obeys commands for movement |
6 |
Moves towards pain/localises to pain |
5 |
|
Withdraws away from pain |
4 |
|
Abnormal flexion/decorticate posturing |
3 |
|
Abnormal extension/decerebrate posturing |
2 |
|
No motor response |
1 |
Head injuries are classified as mild, moderate, or severe based on the patientβs GCS following the injury:
- Mild head injury: GCS of 14/15
- Moderate head injury: GCS 9-13
- Severe head injury: GCS <8
Assess if the patient is orientated to person, place and time.
Pupils
Assess the patientβs pupils:
- Assess the size and shape of the patientβs pupils. A normal pupil diameter ranges from two to five millimetres.
- Assess the pupils for both direct and consensual response to light using a pen torch.
- An oval-shaped pupil, sluggish reaction to light, βblown pupilβ or deviated pupil suggests raised ICP or herniation.
- Bilaterally small or βpinpointβ pupils may be due to opioid toxicity.
Neurological examination
Perform a neurological examination in patients who are able to follow commands, assessing:
- Cranial nerves
- Power in each limb (see our upper limb and lower limb neurological examination guides)
- Sensation in each limb
- Cerebellar function
A new neurological deficit suggests intracranial injury.
Investigations
Blood glucose
Measure the patientβsΒ capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia).Β
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
TheΒ normalΒ reference rangeΒ for fasting plasma glucose isΒ 4.0 β 5.8 mmol/l.
HypoglycaemiaΒ is defined as a plasma glucose ofΒ less thanΒ 3.0 mmol/l. InΒ hospitalised patients, a blood glucoseΒ β€4.0 mmol/LΒ should be treated if the patient isΒ symptomatic.
See ourΒ blood glucose measurement and hypoglycaemia guides for more details.
Imaging
In the UK, NICE has produced guidance on head injuries including when to perform a CT head scan.
Typical pathologies which may be shown on the CT scan include:
- Intracranial bleeds: extradural haemorrhage, subdural haemorrhage, subarachnoid haemorrhage and intracerebral haemorrhage
- Brain contusions
- Skull fractures
- Cerebral oedema
Any injuries identified on CT should be discussed with the neurosurgical team.
See our CT head interpretation guide for more details.
Interventions
Maintain the airway
Alert aΒ seniorΒ immediately if you have any concerns about the consciousness level of a patient. A GCS ofΒ 8 or belowΒ warrantsΒ urgent expert helpΒ from anΒ anaesthetist. In the meantime, you shouldΒ re-assessΒ andΒ maintain the patientβs airwayΒ as explained in the airway section of this guide.
Opioid toxicity
If opioid toxicity is suspected as the cause for the patientβs reduced level of consciousness (e.g. pinpoint pupils) interventions such asΒ naloxoneΒ should be considered.
See ourΒ opioid toxicity guideΒ for more details.
Hypoglycaemia
The management of hypoglycaemia involves the administration ofΒ glucoseΒ (e.g. oral or intravenous).
See ourΒ hypoglycaemiaΒ guide for more details.
Re-assessment
Make sure to re-assess the patient following any intervention.
Exposure
It may be necessary toΒ exposeΒ the patient during your assessment: remember to prioritise patient dignity and conservation of body heat.
Clinical assessment
Begin by asking the patient if they haveΒ painΒ anywhere, which may be helpful to guide your assessment.
Other injuries +/- bleeding
Fully expose the patient looking for evidence of other injuries or bleeding.
IfΒ activeΒ bleeding is identified:
- Estimate the total blood loss and the rate of blood loss.
- Re-assess for signs of hypovolaemic shock (e.g. hypotension, tachycardia, pre-syncope, syncope).
Temperature
Measure the patientβsΒ temperature:
- Temperature >38Β°C may be due to infection. This may provide clues as to how the patient sustained the head injury (e.g. delirium secondary to infection in an elderly patient leading to a fall).
- Hypothermia (temperature < 36Β°C) may be seen in patients who have been immobilised by their injury for a prolonged period of time.
Interventions
Injuries
Treat other injuries identified and involve appropriate specialities (e.g. orthopaedics to reduce a fracture).
Explore any wounds and clean/close if confident to do so:
- Superficial lacerations may be closed with wound glue or wound closure strips
- Deeper or complex wounds may require sutures
Haemorrhage
If the patient isΒ activelyΒ bleedingΒ seekΒ urgent senior inputΒ (e.g. surgical registrar, anaesthetics) and consider the need forΒ bloodΒ productsΒ (e.g. packed red cells, platelets).
Large-bore intravenous accessΒ (x2) should be established and relevantΒ blood testsΒ should be sent (e.g. FBC, U&Es, coagulation studies, group and crossmatch) if not done so already.
InΒ severeΒ haemorrhage, consider initiating theΒ major haemorrhage protocolΒ (with senior approval).
See ourΒ blood transfusion guide for more details.
Warming
ConsiderΒ warmingΒ (e.g. Bair Huggerβ’) inΒ hypothermiaΒ (seek senior input).
CPR
If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.
Re-assessment
Make sure toΒ re-assessΒ the patient after anyΒ intervention.
Reassess ABCDE
Re-assessΒ the patient using theΒ ABCDE approachΒ to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.
DeteriorationΒ should be recognised quickly and acted upon immediately.
Seek senior helpΒ if the patient shows no signs of improvement or if you have any concerns.
Support
You should have another member of the clinical team aiding you in your ABCDE assessment, such as a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.
You may need further help or advice from a senior staff member and you shouldΒ not delay seeking help if you have concerns about your patient.
Use an effectiveΒ SBARR handoverΒ to communicate the key information effectively to other medical staff.
Next steps
Well done, youβve now stabilised the patient and theyβre doing much better. There are just a few more things to doβ¦
Take a history
Take aΒ thorough historyΒ to help narrow the differential diagnosis.
See ourΒ history taking guidesΒ for more details.
Review
Review theΒ patientβs notes,Β chartsΒ andΒ recent investigation results.
Review the patientβsΒ current medicationsΒ and check any regular medications areΒ prescribed appropriately.
Regular review
Ask the nursing staff to perform regular neurological observations. Frequency depends on the extent of the injury and the patientβs condition.
Make a regular clinical review of the patient so any deterioration is identified quickly and acted upon.
Document
ClearlyΒ document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patientβs response.
See ourΒ documentation guidesΒ for more details.
Discuss
Discuss the patientβs current clinical condition with aΒ seniorΒ clinicianΒ using anΒ SBARRΒ style handover.
QuestionsΒ which may need to be considered include:
- Are any further assessments or interventions required?
- Does the patient need a referral toΒ HDU/ICU?
- Does the patient need reviewing by a specialist (e.g. neurosurgery)?
- Should any changes be made to the current management of their underlying condition(s)?
Handover
The next team of doctors on shift should beΒ made awareΒ of any patient in their department who hasΒ recently deteriorated.
Reviewer
Dr Frances Balmer
ST4 in Emergency Medicine
Editor
Dr Chris Jefferies
References
- Head injury: assessment and early management. Published 2014, updated 2019. Available from: [LINK].
- Pixabay. Side on skull. License: [FFCU].
- Spinal injury: assessment and initial management. Published in 2016. Available from: [LINK].
- British Thoracic Society. BTS Guideline for oxygen use in adults in healthcare and emergency settings. Available from: [LINK].