Introduction
Head trauma is one of the commonest causes of death and disability in young adults and a core emergency topic in special surgery. The exam expects you to classify injuries of the scalp, skull and brain, to recognise a patient who is deteriorating, to know which lesions need urgent neurosurgical evacuation, and to explain the basic principles of initial management.
Classification of head injury
Injuries are grouped by the structure damaged and by the mechanism, which may be closed or open, blunt or penetrating. The main types you should know are:
Assessment at presentation
Begin with the primary survey (ABCDE, as in ATLS), because hypoxia and hypotension worsen brain injury. The Glasgow Coma Scale (GCS) scores eye, verbal and motor responses from 3 to 15: mild injury is 13 to 15, moderate 9 to 12, severe 8 or less.
- Protect the cervical spine until injury is excluded while securing the airway
- Keep oxygen saturation and systolic pressure within target; hypotension suggests bleeding outside the skull
- Check pupil size and reaction; an enlarging pupil on one side suggests a mass lesion on that side
- Look for the Cushing response: rising blood pressure, bradycardia and irregular breathing, a sign of raised intracranial pressure
- Look for signs of basal skull fracture: periorbital bruising (raccoon eyes), mastoid bruising (Battle sign), CSF rhinorrhoea or otorrhoea, haemotympanum
- Track the GCS over time; a fall of 2 or more points is a reason for urgent imaging