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Head trauma

Clinical Discipline(s)/Organ System(s)
Emergency Medicine, Nervous System, Neurosurgery
Progress Test Topic(s)
Seriously ill patient
Description
A 26 year old NZ European male presents to the Emergency Department having received a head-high tackle in a rugby game one hour previously. He was knocked out at the scene and now has ongoing headache. He is repetitively questioning and has a reduced level of consciousness. He has no other injuries.
Applied Science for Medicine 
   - Anatomy of the head and neck
   - Brain structures responsible for maintaining consciousness
   - Physiology of cerebral perfusion and Cushing's response
   - Differing characteristics of an extradural, subdural, subarachnoid and intracerebral bleed
   - Microbiology of infection post cranial vault fracture
   - Pharmacology of paracetamol, non-steroidal anti-inflammatory drugs, metoclopramide, ondansetron
Clinical and Communication Skills 
   - History from a patient with head trauma and/or take the history from a witness; recognise symptoms that are important in determining the severity of head trauma
   - Examination of a patient with head trauma; recognise the signs of raised intracranial pressure, including papilloedema, and base of skull fracture. Perform neurological examination to detect focal abnormalities
   - Perform an assessment of airway, breathing and circulation, recognise signs of life, assess the level of consciousness using Glasgow Coma Scale (GCS) and Alert, Voice, Pain, Unresponsive (AVPU) Scale, neurological observations and fundoscopy
   - Differential diagnosis of head trauma
   - Identify the appearance and outline the management of an auricular haematoma
   - Define a coup and contre-coup injury
   - Precautions needed when a base of skull fracture is present
   - Indications for CT, MRI, MR angiography, cervical spine X-ray
   - Interpret chest X-ray, arterial blood gas, coagulation screen, CSF analysis, blood glucose level
   - Management of head trauma; surgery, neuroprotective regimens, conservative
   - Criteria for admission or discharge from Emergency Department
   - Complications of head trauma
   - Prognosis post-head trauma
   - Role of the neurosurgical and medical teams
Personal and Professional Skills 
   - Consent; competence
   - Decision-making for others
   - Discuss concussion with patient and family/whānau
   - Discuss potential for long-term disability
   - Role of the Accident Compensation Corporation
Population Health 
   - Health benefits and risks of participation in organised sports
   - How to reduce risk of serious injury in contact sports
   - Long-term sequelae: impairment, disability and handicap
   - Health and social services for care of those who have suffered severe head injury
Conditions to be considered relating to this scenario
Common
concussion, post-concussion syndrome, skin laceration and contusion, base of skull fracture, cerebral contusion, skull fracture, auricular haematoma
Less common but 'important not to miss'
brain herniation from raised intracranial pressure, diffuse axonal injury, intracerebral haemorrhage, subdural haemorrhage, extradural haemorrhage
Uncommon
hydrocephalus