The management of head injuries in A&E departments

Background

Head injury is the most common cause of death and disability in people up to the age of 40. Each year it is thought that almost 1.5 million people go to their local A&E department with a recently sustained head injury. 200,000 are admitted to hospital with their injuries. Of these people, around 1 in 5 will have features suggesting skull fracture or have evidence of brain damage.

Most patients recover without specific or specialist intervention but others experience long-term disabilities or even die from the effects of complications that could potentially be minimised or avoided with early detection and appropriate treatment.

95% of people who have sustained a head injury present to A&E with normal or minimally impaired conscious levels measured in accordance with the Glasgow Coma Scale (‘GCS’). The GCS is essentially an objective way of recording a person’s level of consciousness and gives a patient a score of between 3 (indicating deep unconsciousness) and 15 (indicating normal consciousness).

The majority of fatal outcomes are in the moderate (GCS 9-12) or severe (GCS 8 or less) head injury groups which account for only 5% of attendees. Therefore, Emergency Departments see a large number of patients with minor or mild head injuries and need to quickly identify the very small number who will go on to have serious acute intracranial complications.

Initial assessment in the Emergency Department 

A trained member of staff should assess all patients presenting to an Emergency Department with a head injury within a maximum of 15 minutes of arrival at hospital. Part of this assessment should establish whether the patient is at ‘high’ risk or ‘low’ risk of a clinically important brain injury and/or cervical spine injury.

Some patients with head injuries will arrive at A&E having been injured whilst on a night out with friends, for example, as a result of a fall or an assault. In these circumstances it is often ‘easy’ to ascribe any reduction in a person’s level of consciousness to intoxication. However, the NICE guidelines make it clear that intoxication should only be considered as a potential reason for a reduced level of consciousness after a significant brain injury has been excluded.

For adults who have sustained a head injury and have a GCS of less than 13 at the time of their initial assessment in the Emergency Department a CT scan should be carried out within 1 hour of the assessment being carried out.

Observations

Observations should be performed and recorded on a half hourly basis until the GCS has returned to 15. Any evidence of neurological deterioration or a fall in the GCS should prompt urgent re-appraisal by the supervising doctor.

A case study

We are currently dealing with a case on behalf of a young man who was admitted to an A&E department with obvious signs of a head injury after being assaulted in a town centre following a night out with friends.

His GCS was initially assessed at the scene by paramedics as 12/15.

He was taken to hospital where his GCS was recorded as 11/15. Despite this a referral for a CT scan was not made as it was felt that his reduced level of consciousness was due to him having had ‘too much to drink’.

Some two and a half hours after his arrival at hospital he was found collapsed in his cubicle. By this time his GCS had fallen to 3/15. An urgent CT scan was carried out which confirmed the presence of a large extradural haematoma (essentially a build up of blood between the outer membrane of the brain and the skull). The build up of blood often increases the pressure in the intracranial space, compresses delicate brain tissues and causes the brain to physically ‘shift’ within the skull. If this isn’t treated promptly, it can be fatal.

He subsequently underwent neurosurgery to evacuate the haematoma. However, whilst the surgery was successful he has been left with a number of physical and cognitive deficits including left sided weakness, impaired vision and behavioural problems which could all potentially have been avoided.

The prognosis for patients with extradural haematomas is better the earlier the diagnosis is made and treatment instigated. Indeed, in those patients who are treated before any significant deterioration in their condition occurs, they can often be expected to make a very good recovery.

How can we help?

At Novum Law we offer free initial advice on claims of this kind. If you believe that you or any member of your family have a potential claim then let us assess your case. You can rest assured that we will deal with your enquiry without any initial cost or obligation.