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Thursday, 23 December, 1999, 15:43 GMT
Heading for trouble
Hospitals scan some head injuries to check there is no bleeding
An injury which threatens the brain of the patient is among the most potentially serious the emergency team faces - and could lead to serious disability or even death.

Accident and Emergency
In accident and emergency, the brain injury could be as a result of an accident, possibility an impact which has cracked the skull, or result from problems affecting the blood supply to the brain, such as brain haemorrhages or strokes.

The area served by a typical district general hospital might throw up in a year some 6,000 head injuries in a year - of whom 20 would die at the scene.

On average, 80 patients would be admitted for observation, 20 would need a CT scan and need to be kept in the intensive care unit.

Of these,12 might be given neurosurgery to remove a blood clot - but only five would make a full recovery.

What happens at the scene of the accident is important, with the first aider checking the patients' airway, breathing and circulation.

Intubation - the insertion of a breathing tube - can prevent secondary brain damage due to lack of oxygen.

Cells in the brain control many of our vital functions
Some patients might find their problems manifested only as subtle symptoms, such as persistent headache, extreme physical fatigue, or even altered behaviours such as irritability or impatience.

A conscious patient arriving at A&E may have many reasons to be unsteady on their feet, complaining of a headache and slurring their words - many casualty customers have abused drugs or drink.

So it is difficult for even a trained casualty doctor or nurse to differentiate between the drunk and a brain-injured patient declining fast.

During a routine examination doctors should check the Glasgow Coma Score (GCS), which is generated by a combination of differing responses to various stimuli. Clues can also be gained by the reactiveness of the eye pupils.

Close observation

If a patient is relatively responsive, he may be placed under close observation while the results of an x-ray are awaited.

However, if the patient then goes into decline, or scores badly using the GCS system, the on-call neurosurgeon should be called, and an urgent CT scan taken to see if an operation is required.

Mr Nigel Brayley, a consultant in accident and emergency medicine at the Three Rivers Healthcare Trust in Essex, says: "The recent advances in head injury care are sadly all too few.

"The major changes are ensuring that a patient moves quickly through the initial first aid, trauma assessment including timely a CT scanner in the receiving hospital, and early intubation."

He said that neurosurgery should be carried out within a "golden four hour" limit.

Swift actions can limit damage

Modern emergency medicine has discovered that key actions taken swiftly after a traumatic brain injury can make a big difference to the outcome.

Studies have shown that keeping the patient's fluid levels high are vital - low blood pressure is associated with double the death rate.

One of the biggest threats is the pressure caused by the brain swelling, like a bruise, following an injury.

The human brain is very vulnerable to injury
There is only a limited amount of space within the skull, or cranium, and if all the available space is taken up, the pressure can contribute to the damage.

Some doctors choose to increase the ventilation of the patient, which narrows the blood vessels leading to the brain, and creates more room.

But there are concerns that this may contribute to the death of brain cells as their supply of oxygenated blood is reduced, and recommend this course is only taken if pressure on the skull is critical.

Intracranial Pressure (ICP) can be relieved by giving narcotic sedatives which reduce the metabolic demands on the brain - and the agitation of the patient. But these can also have unwelcome side effects.

Steroids are also given to reduce brain swelling by stopping extra fluid entering brain cells and increasing their volume.

But their side-effects can upset the function of the body's immune system, which could be crucial in a severely injured patient, who needs to fight potential infection.

Drugs on the horizon

Researchers have suggested that brain damage from injuries works like a chain reaction.

Damaging molecules called free radicals, they suggest, are released during trauma, and cannot be cleared away because interruption to normal flow of fluids around the injury, leading to more and more damage.

The brain is very vulnerable to injury
Some new treatments include so-called free radical "scavengers", which can make them less toxic to the brain.

And one of the most promising areas under investigation is the chilling of the brain, which has improved outcomes in animal experiments.

The body temperature is lowered to 32 to 33 degrees celsius, several degrees below normal.

See also:

29 Jun 99 | Health
Headache's secrets revealed
25 Jan 99 | Medical notes
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