Clinical assessment of the head-injured patient: An anatomical approach

Introduction: The rapid and accurate clinical assessment of a head-injured patient is crucial. The initial management should be governed by attention to the airway, breathing and circulation according to the principles of the Advanced Trauma Life Support (ATLS) care system. This is vital not only to identify immediately life-threatening injuries but also to prevent secondary cerebral insults. The cervical spine should be immobilized, since patients with a head injury may also harbour a cervical spine injury. The level of consciousness and pupil size and reaction should be determined early and at regular intervals when managing patients with TBI. History: The clinical history should be obtained from the patient, witnesses and paramedical staff as appropriate. History-taking should include details of the mechanism of the injury and status of the patient at the accident scene in addition to the following: past medical history, medications, allergies, smoking, alcohol or drug use and social circumstances. Symptoms depend upon the severity of the injury. In conscious patients, headache due to somatic pain from a scalp injury is common. The headache caused by raised ICP is exacerbated by coughing, straining or bending and is associated with nausea, vomiting and impaired consciousness. Deterioration can be extremely rapid, highlighting the low threshold required to undertake imaging investigations looking for intracranial mass lesions. Amnesia, repetitive speech and disorientation are very common early features, even after relatively minor trauma. Focal neurological deficits affecting any part of the brain and cranial nerves can occur. Anosmia due to disruption of the olfactory pathways is perhaps the most common focal symptom. CSF rhinorrhoea and otorrhoea occasionally may be reported by the patient at this early stage. Witnessed seizures should be noted.