With the high number of road traffic accidents and assaults, this is a fairly common injury. Early and proper management is critical in order to avoid death and long-term morbidity.
Radiological information of CT scan is usually more informative than simple skull radiograph.
- Initiate resuscitation measures.
- Document accurately the neurological status with Glasgow Coma Scale or other reliable scale.
- Ensure adequate oxygenation and monitor fluid balance. Avoid over hydration.
- Review regul;arly every 15-30 minutes while awaiting transportation if at level 4 and are not able to manage.
- Arrange immediate referral to a specialized unit, and provide appropriate transportation and personnel top accompany the patient during transportation.
If at level 5 to 6:
- Admit patient for hourly neurological observation iof:
- Depressed conscious level is observed anytime after injury.
- Skull fracture.
- Focal neurological signs elicited.
- Elderly patients
- Record hourly neurological observations, to include:
- Glasgow Coma Scale
- Blood pressure, pulse, and respiratory rate
- Pupil size and reaction
- Limb movements (normal, mild weakness, severe weakness, spastic flexion, extension, no resp[onse)
- Check for peripheral deep tendon reflexes
- Carry out appropriate investigations.
- Carry out surgical intervention as needed
- Rehabilitate as appropriate: Physiotherapy, occupational therapy, and counseling.
IMPORTANT: Regular neurological assessment performed less often than hourly are of no use for interpretation.
- If there are signs of an intracranial hematoma developing(declining conscious level, pupil signs, onset of confusion):
- Cross-match and arrange for burr hole surgery as an emergency.
- Compound skull fractures:
- Through wound toileting and haemostasis as an emergency.
- Crystalline penicillin 2 mega units intravenous QDS and current antibiotic regime for 7 days
- Depressed skull fractures
- Through more than one table, require elevation.
- Basal skull fracture:
- Bloody CSF coming from the error nose is indicative of a basal skull fracture unless other external source of bleeding is seen.
- Do not give narcotic analgesics to head injury patients
- Use paracetamol
- Convulsions must be rigorously controlled.
- Diazepam 10-20mg intravenous and phenobarbitone 5mg IM daily.