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Although often dramatic in nature, soft tissue injuries of the head cause little long-term sequel and most can be easily managed in the emergency department. However, soft tissue injuries of the head can be an indicator of possible significant intracranial injury. For example, one study found that any sign of trauma above the clavicles is an independent predicator of possible intracranial abnormality on CT scan.
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Essentials of Diagnosis
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- Diagnosed through inspection and palpation
- May be significant source of blood loss
- Evaluate for underlying skull fracture
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Scalp lacerations are primarily diagnosed by palpation and a visual inspection of the patient's scalp. A complete and thorough examination of the scalp must be performed to find any evidence of laceration or hematoma. Once a laceration is located, palpate the area thoroughly to determine if any signs of skull fracture are present. Because the scalp has tremendous vascularity, scalp lacerations can be a source of significant blood loss.
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Most scalp lacerations can be easily closed with either staples or simple interrupted sutures. Clipping of the hair may facilitate easier closure. Alternatively, water-soluble lubricating jelly (eg, Surgilube) may be used to keep hair out of the laceration during closure. Shaving of the scalp may lead to increased risk of infection. The scalp is highly vascular and may be closed up to 12 hours after initial injury. Any patient with a scalp laceration and alteration of consciousness should undergo CT scanning prior to closure of the scalp laceration. The wound should be copiously irrigated with normal saline before closure. Occasionally, layered closure with absorbent sutures may be required (Chapter 30).
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Patients with scalp lacerations and no other complications may be discharged safely to home. Follow-up should occur in 3–5 days for recheck; the staples or sutures may be removed in 7–10 days.
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Essentials of Diagnosis
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- Diagnosed by inspection and palpation
- Strongly consider CT scan
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Scalp hematoma is diagnosed by palpation and visual inspection. In isolation a hematoma has little long-term significance but may be an indicator of more serious intracranial abnormality especially in children under 2 years of age when the hematoma is located in a nonfrontal scalp location. Patients with scalp hematoma and significant mechanism of injury or alteration in level of consciousness should undergo CT scanning.
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A scalp hematoma is treated primarily like a hematoma or contusion in any other part of the body. Ice, elevation, and nonsteroidal antiinflammatory drugs should be the mainstay of treatment. Aspiration of a scalp hematoma has little, if any, benefit and should rarely be attempted.
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Patients with only a scalp hematoma may be safely discharged home and referred for standard follow-up.
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Skull fracture is strongly associated with other more serious intracranial abnormalities. Studies have shown that 40–100% of all intracranial abnormalities are associated with skull fracture. Unless open and or depressed, the skull fracture itself, however, is typically of little clinical consequence to the patient.
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Closed Skull Fractures
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Essentials of Diagnosis
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- Use CT scan for diagnosis because CT shows fractures and other associated injuries
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Closed fractures of the skull are detected primarily on noncontrast CT scan. Because these fractures are often associated with more serious injury, it is prudent to evaluate the injury with CT scan rather than plain skull X-rays.
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There is no specific treatment for linear skull fractures. Close observation is recommended to detect the development of an epidural hematoma after an initially negative CT scan.
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Consider admission or extended observation for patients with isolated closed skull fractures and no evidence of brain injury.
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Essentials of Diagnosis
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- Use CT scan for diagnosis because CT shows fractures and other associated injuries
- Underlie scalp lacerations
- High risk of infection
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Open fractures underlie scalp lacerations and are often palpated during evaluation of the scalp laceration. These fractures have a serious risk of infection. Definitive diagnosis is made with noncontrast CT scan, and more serious intracranial abnormality should be ruled out. Open skull fracture is likely if pneumocephalus is noted on CT scan (Figure 22–1).
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Because the indications for antibiotics are controversial in patients with open skull fractures, discuss the decision to initiate antibiotics with the neurosurgeon who will be definitively managing the problem.
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Hospitalize all patients with open skull fracture.
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Depressed Skull Fractures
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Essentials of Diagnosis
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- Often found with inspection or palpation
- Use CT scan for diagnosis because CT shows fractures and other associated injuries
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Depressed skull fractures are often palpable or visible during examination. However, swelling around the area of the injury can mask a depressed skull fracture and make it appear to be a simple hematoma. Like all skull fractures, depressed skull fractures are often associated with more serious intracranial injury, and patients need to be evaluated accordingly. Noncontrast CT scan is the test of choice to determine whether the patient has intracranial injury or depressed skull fracture (Figure 22–2).
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Depressed skull fractures without intracranial injury represent a cosmetic situation. Open depressed skull fractures are at high risk of infection, similar to open nondepressed skull fractures.
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Patients should be admitted to the hospital for observation and referred to the appropriate surgical subspecialist for possible elevation of the depression and debridement if the fracture is open.
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Basilar Skull Fractures
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Essentials of Diagnosis
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- Use CT scan for diagnosis because CT shows fractures and other associated injuries; however, some basilar skull fractures may be missed on CT
- Associated with hemotympanum, Battle sign, raccoon's eyes, cerebrospinal fluid leaking from ear or nose, or hearing loss
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Basilar skull fractures are skull fractures at the base of the skull, typically at the petrous portion of the temporal bone. Clinical signs include hemotympanum, Battle sign (ecchymosis along the mastoid area of the skull), raccoon's eyes (periorbital ecchymosis), cerebrospinal fluid leak from the nose or ear, or hearing loss. Patients with any of these signs should undergo noncontrast CT evaluation for possible basilar skull fracture and to rule out more serious intracranial abnormality.
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Antibiotics are controversial and have unproven benefit in preventing meningitis in patients with basilar skull fracture. The decision to administer antibiotics should be made in consultation with the neurosurgeon to whom the patient is referred. If desired, an intravenous antibiotic such as cefazolin is a common choice.
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Patients with documented basilar skull fracture or significant signs of a basilar skull fracture should be admitted for observation. If a more serious intracranial abnormality is present, obtain neurosurgical consultation.
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Essentials of Diagnosis
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- Classic history of brief loss of consciousness followed by transient lucid interval
- Arterial bleeding source
- Diagnosis made by CT scan, which shows a biconvex hematoma
- Requires rapid neurologic evaluation for decompression
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An epidural hematoma is a collection of blood and clot between the dura mater and the bones of the skull. Sources of bleeding from epidural hematoma include the meningeal arteries (often the middle meningeal artery) or occasionally the dural venous sinuses. These bleeds generally have a lenticular (biconvex) shape. Patients with epidural hematoma may have an initial, brief loss of consciousness followed by a lucid interval during which they may be neurologically intact. This interval is then followed by rapid clinical deterioration. All patients with epidural hematoma typically require rapid intervention by a neurosurgical specialist. An epidural hematoma represents a space-occupying lesion to the brain, often from a high-pressure arterial source. Therefore, rapid expansion of this hematoma can lead to herniation of brain contents. Patient outcome is directly related to the patient's level of consciousness on presentation and to the time until decompression of potential space-occupying lesions (Figure 22–3).
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Essentials of Diagnosis
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- Venous bleeding source
- Diagnosis made by CT scan, which shows concave hematoma following the contour of the cortex
- May be chronic, acute, or acute on chronic
- Admit for neurosurgical evaluation
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A subdural hematoma also represents a space-occupying lesion. This lesion, however, lies in the space between the dura mater and the arachnoid mater and usually conforms to the contour of underlying cerebral cortex (Figure 22–4). The source of bleeding is often the bridging veins, which are more likely to tear in patients with significant brain atrophy (eg, elderly or alcoholic patients). These patients can develop large chronic subdural hematomas with minimal neurologic deficit. A subdural hematoma may or may not require surgical drainage. Acute bleeds can develop in areas of chronic subdural hematoma (often from new trauma) and cause neurologic deterioration (Figure 22–5). All patients with subdural hematoma should receive prompt neurosurgical evaluation.
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Essentials of Diagnosis
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- Diagnosis made by CT scan
- Associated edema may require intervention
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Cerebral contusion represents a non-space-occupying discrete lesion within the brain matter itself. These lesions are less likely to lead to herniation than are other types of intracranial lesions. Significant edema can occur around areas of cerebral contusion, which can lead to increased intracranial pressure and midline shift. Typically no surgical intervention is required for cerebral contusion. However, if the contusion is large enough and significant shift occurs, then intracranial pressure monitoring may be instituted by the neurosurgical specialist.
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Traumatic Subarachnoid Hemorrhage
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Essentials of Diagnosis
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- Diagnosis made by CT scan
- Can lead to elevated intracranial pressure owing to cerebrospinal fluid obstruction
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It was once thought that subarachnoid hemorrhage was relatively rare and had a poor outcome. However, it appears now that subarachnoid hemorrhage in a traumatic setting is much more common than previously believed. Traumatic subarachnoid hemorrhage is not a space-occupying lesion but can lead to increasing intracranial pressure, primarily by blocking the outflow of cerebrospinal fluid from the third and fourth ventricles in the brain. Patients with asymptomatic subarachnoid hemorrhage may be admitted for observation and no further intervention. Patients with altered level of consciousness or other neurologic findings may require intracranial pressure monitoring in the critical care unit setting (Figure 22–6).
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Diffuse Axonal Injury
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Essentials of Diagnosis
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- Diagnosis made by CT scan demonstrating blurring of gray- to white-matter margin, punctate cerebral hemorrhages, or cerebral edema
- Associated with posttraumatic coma
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Shearing forces from sudden deceleration during blunt trauma can cause severe intracranial injury. Diffuse axonal injury is a frequent cause of posttraumatic coma. This injury is typically manifested on noncontrast CT by a blurring the margin between the gray and white matter, punctate hemorrhages often in the internal capsule, and cerebral edema (Figure 22–7).
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