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Head Injury and Unconsciousness

INTRODUCTION

The clinical terms used to describe brain injury of concussion, confusion and laceration indicate minor to major degrees of a similar injury. Life-threatening injuries include extradural and subdural haematomas (see Fig. H6). The Glasgow coma scale (see Table H5) can be used as a guide to the conscious state.

Figure H6

Illustration of sites of subdural and extradural haematomas in relation to the dura, skull and brain

An illustration of the skull shows the sites of subdural and extradural hematomas. The illustration shows the sites of subdural and extradural hematomas related to the dura, skull, and brain. Subdural hematoma is a type of bleeding that occurs within the skull of the head and outside the brain tissue. Extradural hematoma is a collection of blood in the extradural space between the skull bone and the outer protective lining that covers the dura. Bruise extends outside the skull bone.
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Table H5Glasgow coma scale
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Table H5 Glasgow coma scale

Score

Eye opening (E)

Spontaneous opening

4

To verbal command

3

To pain

2

No response

1

Verbal response (V)

Orientated and converses

5

Disoriented and converses

4

Inappropriate words

3

Incomprehensible sounds

2

No response

1

Motor response (M)

Obeys verbal command

6

Response to painful stimuli

Localises pain

5

Withdraws from pain stimuli

4

Abnormal flexion

3

Extensor response

2

No response

1

Coma score = E + V + M

Minimum 3

Maximum 15

If 8–10: take care—monitor the airway

Concussion (see image 141).

EXTRADURAL HAEMATOMA

Following head injury there may be a short lucid interval followed by loss of consciousness. The patient is restless, confused, irritable (Fig. H7), has severe headache and develops neurological signs.

Figure H7

Classic conscious states leading to extradural haematoma after injury

A graph represents the classic conscious states leading to extradural hematoma after injury. The vertical axis of the graph represents four states: alert, lucid, confused, and unconscious at the top of the axis. The graph shows a line representing injury that begins alert. The line decreases vertically and it passes through lucid, confused, and unconscious states. The line extends beyond the unconscious state. The line starts increasing steeply and it reaches the alert state and maintains for a little while. This region where the line moves from the unconscious state to lucid state is labelled lucid interval. The line then starts to decrease gradually and it represents a diagnosis of hematoma.
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Investigation Skull X-ray, CT scan. Lumbar puncture contraindicated

Management Urgent decompression of haematoma

SUBDURAL (EPIDURAL) HAEMATOMA

The responsible injury may seem trivial, esp. in elderly and the haematoma may be acute, subacute and chronic. Consider it in a person with personality change, headache, slow unsteady movements and fluctuating conscious level. Investigate and treat as above.

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