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11/13/24, 8\:10 PM Guide | Head injury history

Head injury history

Table of contents

Background

Head injuries are a common presentation, particularly in the emergency department and in general practice, and can have
severe and lifelong impacts on the lives of patients and their families.
Head injuries are the most common cause of death and disability in under 40-year-olds in the UK. 1
associated with head injuries, it is important to ensure a thorough history is taken.
Because of the risks
A head injury describes any trauma to the head which may result in damage to the skin, skull or underlying neurological
structures (e.g. brain, meninges) in more serious cases; this is known as a traumatic brain injury (TBI).
2-3
An example of a minor trauma is hitting the head on a doorframe or cupboard door. This may result in a bump, bruise, and/or
small scalp laceration.
An example of major trauma is the head colliding with the steering wheel of a car during a road tra
in more severe injuries, such as a skull fracture, intracranial bleeding, and cerebral oedema. An increase in intracranial
pressure (ICP) from bleeding or oedema of the brain can result in compression of the brain and associated structures. This can
lead to herniation of the brain, compression of the brainstem (coning) and death.

Causes of head injuries

Head injuries can be acquired through trauma related to falls, road tra
occupational hazards. It is important to determine the mechanism of the injury as this can identify the severity and potential
complications of the injury.
The severity of head injuries widely ranges and is typically proportional to the severity of the trauma that resulted in the injury;
however, underlying risk factors can result in an exacerbated injury. Anticoagulated patients can sustain severe intracranial
haemorrhage from relatively minor trauma (e.g. a fall).

Types of head injury

A single traumatic head injury can result in multiple types of subsequent injury, from mild concussion to di
and death.
Concussion
weeks.
4
Concussion can result from a minor head injury and result in a mild headache, nausea and slight daze. This can last for several
Skull fracture
The skull comprises 22 bones, which fuse together to form sutures. If enough pressure is applied, the skull can fracture at any
location, but weaker areas are more prone to fractures than others.
Pterion
The pterion is a weak point of the skull where the frontal, parietal, temporal and sphenoidal bones fuse together to form
a relatively thin layer. Fractures to the pterion can rupture the middle meningeal artery, which lies directly beneath this
location, resulting in an extradural haematoma.
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Signs of basal skull fracture (fracture at the base of the skull) include the leakage of cerebrospinal
the nose or ears. Periorbital ecchymosis (panda eyes) and mastoid ecchymosis (Battle’s sign) can occur, although these signs
typically develop late after the injury.
Haemorrhage
Intracranial haemorrhage can be classi
Extradural (epidural) haematoma
Subdural haematoma
Subarachnoid haemorrhage
Intracerebral haemorrhage
Any bleeding within the skull can contribute to an increase in intracranial pressure, which, if it continues to build, can lead to
compression of intracranial structures.
The type of brain haemorrhage can be determined through key features in a patient’s history, the mechanism of injury and
appearance on imaging.
Oedema
Cerebral oedema is commonly associated with TBIs and disease mechanisms such as infection and in
meningitis). 5
As with intracranial bleeding, cerebral oedema can result in raised ICP, which, if left untreated, leads to
compression and damage of nearby structures.
Di
Neurons form the basis of connections throughout the nervous system. When force is exerted onto the brain, which results in it
moving within the skull, it can cause shearing of the axonal connections within deep parts of the brain, known as a di
axonal injury. This type of injury can result in a comatose state and death.
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Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

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Use open questioning to explore the patient’s presenting complaint\:
" W h a t i s t h e p r o b l e m t h a t I c a n h e l p y o u w i t h t o d a y ?”
" W h a t h a s b r o u g h t y o u i n t o s e e m e t o d a y ?”
" C a n y o u t e l l m e a b o u t t h e s y m p t o m s y o u a r e e x p e r i e n c i n g ?"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t h o w y o u h i t y o u r h e a d ?”
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di
It is particularly important to identify if the patient is coherent in their speech and their story when considering a head
injury. Patients with a concussion may report pain, but may also report dizziness, nausea, fatigue or malaise.

History of presenting complaint

A head injury can be caused by a multitude of processes, and the severity of the injury can be estimated by the mechanism
and features during and after it. Therefore, it is important to gain a detailed understanding of the history before, during and
after the injury, as well as clarify the consequences of the injury and how the patient feels now.

Before the head injury

Clarify exactly when the head injury happened\:
" C a n y o u t e l l m e a t w h a t t i m e y o u w e r e i n j u r e d ?”
Many patients require a period of observation post-injury to ensure that symptoms (e.g. headache) improve and that no adverse
e
place.
Ask about activities before the head injury\:
" C a n y o u t e l l m e w h a t y o u w e r e d o i n g j u s t b e f o r e y o u w e r e i n j u r e d ?”
" W h e r e w e r e y o u ?"
" W a s t h e r e a n y o n e e l s e a r o u n d ?"
Understanding how the injury was obtained is important when considering the severity of damage incurred and potential
associated injuries (e.g. C-spine injury).
Ask about any precipitating causes of the head injury\:
" H o w w e r e y o u f e e l i n g b e f o r e t h e i n j u r y ?"
" D i d y o u h a v e a n y s y m p t o m s b e f o r e , l i k e d i z z i n e s s o r c h a n g e s i n y o u r v i s i o n ?"
Understanding how a patient felt before the head injury is important when considering the mechanism of injury and any
contributing causes (e.g. a patient who felt dizzy before acquiring a head injury from falling). Identifying symptoms such as
dizziness, light-headedness, fatigue, visual or hearing disturbances, headache, and muscular pain or weakness is important.
Check for previous head injuries\:
" H a v e y o u e v e r h a d a h e a d i n j u r y b e f o r e ?"
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This can identify patterns of head injuries that may raise safeguarding concerns (e.g. assault or abuse), or that additional
support is required (e.g. repeated falls). Multiple head injuries can increase the risk of chronic traumatic encephalopathy,
which may include early symptoms such as changes in mood, behaviour or personality, and develop into short-term memory
loss, confusion and dementia.
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During the head injury

Try to gather as much information about the event as possible.
Determine the mechanism of injury\:
" H o w d i d y o u i n j u r e y o u r h e a d ?"
" D i d y o u f a l l ? H o w d i d y o u l a n d ?"
The mechanism by which an injury occurred provides vital information about its potential severity. It is also important to identify
any criminal involvement, safeguarding concerns, and determine whether the police may need to be informed. Clarify where
the head injury was obtained (e.g. an object, surface, person, or animal). This can guide further investigation and additional
treatments required (e.g. a tetanus booster for a dirty/rusty object).
Determine if there was loss of consciousness\:
" D i d y o u p a s s o u t o r l o s e c o n s c i o u s n e s s a t a n y t i m e ?"
" C a n y o u r e m e m b e r h i t t i n g y o u r h e a d ?"
If there has been loss of consciousness, it is particularly important to determine if there were any witnesses who can provide
more information (e.g. seizure activity). Determine whether the patient can recollect the entire event and whether their
perception of the event matches that reported by witnesses.
Falls
If the head injury was the result of a fall, it is essential to explore this in more detail. Always consider underlying causes of
falls such as hypotension, hypoglycemia, poor mobility etc.
The Geeky Medics fall history taking OSCE guide covers this.

After the head injury

Try to gain an understanding of the events immediately following the head injury.
Ask about red
" H o w d i d y o u f e e l a f t e r y o u w e r e i n j u r e d ?"
" H a v e y o u v o m i t e d s i n c e t h e h e a d i n j u r y ? I f s o , h o w m a n y t i m e s ?"
" C a n y o u r e c a l l e v e r y t h i n g b e f o r e , d u r i n g a n d a f t e r t h e h e a d i n j u r y ?"
Vomiting, headache, and amnesia can signify potential intracranial injury. Understanding if the patient can recall the injury can
indicate if confusion or amnesia is present. Various red
head injuries below.
Determine how long they were at the scene of the injury\:
" D i d y o u n e e d h e l p f r o m s o m e o n e a f t e r t h e h e a d i n j u r y ?"
" H o w l o n g d i d y o u r e m a i n a t t h e s c e n e o f t h e i n j u r y f o r ?"
This can help to form a timeline from the point of injury to presentation and put into context their current mobility.

Now

Try to clarify the injuries and symptoms the patient has now.
Ask what symptoms are still present now\:
" H o w a r e y o u f e e l i n g n o w ?"
" W h e r e d o e s y o u r h e a d h u r t n o w ?"
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The location of a head injury can be easy to determine if it is externally visible, such as a laceration of the scalp, but this can be
more di
Accurate description and documentation are important, particularly for injuries that have occurred as a result of an alleged
assault, as this information may be relied upon as a professional witness statement.
Determine if other injuries were sustained during the incident\:
" D o y o u h a v e a n y o t h e r i n j u r i e s o r s y m p t o m s ?"
" D o y o u h a v e a n y p a i n i n y o u r n e c k ?"
" H a v e y o u n o t i c e d a n y c h a n g e s s i n c e t h e i n j u r y o c c u r r e d ?"
It is important to determine whether the patient has any neck pain or restricted movement, as a cervical spine injury may have
occurred. Identify whether there have been any changes in their injuries or symptoms since the injury occurred (e.g.
progressively worsening headache or increasing dizziness and vomiting).
Red
Head injuries can have severe or life-threatening consequences. It is essential to screen for red
investigation (i.e. CT head). These include\:
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Loss of consciousness following the injury or GCS \<15 on initial assessment
Post-injury seizure or vomiting
Persistent and constant headache since the injury
Focal neurological de
Signs of a penetrating injury or visible trauma to the scalp or skull, including fractures (e.g. leakage of blood or
from the nose or ears)
Amnesia (speci
Dangerous mechanism of head injury (e.g. high-speed road tra
It is also important to consider possible non-accidental causes of the injury and report any safeguarding concerns.
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Ideas, concerns and expectations (ICE)

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
" W h a t d o y o u t h i n k c a u s e d t h e h e a d i n j u r y ?”
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t , a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
" W h a t’ s y o u r n u m b e r o n e c o n c e r n a t t h e m o m e n t ?”
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
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" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
" N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers, unexpected weight loss, fatigue
Cardiovascular\: chest pain, palpitations, syncope
Respiratory\: wheeze, cough, dyspnoea
Gastrointestinal\: nausea or vomiting, constipation or diarrhoea, abdominal pain
Musculoskeletal\: muscle pains or aches, injuries acquired with the head injury
Dermatological\: bruises, abrasions, lacerations

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?”
If the patient has a medical condition, you should gather more details to assess how well-controlled the disease is and what
treatment(s) the patient receives. It is also important to ask about any complications associated with the condition,
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. removal of a pituitary adenoma)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?”
Examples of relevant medical conditions
Medical conditions relevant to head injuries include\:
Previous head injuries\: there are generally poorer outcomes for patients with repeated head injuries; ensure you
identify any underlying causes or safeguarding concerns for a history of head injuries
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Bleeding or coagulation disorders\: patients are more at risk of intracranial bleeds from trauma
Previous brain surgery (e.g. removal of a brain tumour)\: fragile sites can be more easily damaged by trauma
Seizures or epilepsy\: consider how their head injury may impact this, or vice versa
Bone disorders (e.g. osteoporosis)\: conditions such as these can increase the likelihood of other injuries

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
" A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over-the-counter medications, document the medication name, dose, frequency, form,
and route.
Ask the patient if they’re currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Examples of relevant medications
Medications relevant to a head injury include\:
Anticoagulants (e.g. warfarin, low-molecular-weight heparin, rivaroxaban)
Antiplatelets (e.g. aspirin, clopidogrel)
Antiepileptics (e.g. levetiracetam, phenytoin, carbamazepine)
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs

Family history

Though it is not always relevant, you can ask the patient if any relevant medical conditions run in their family (e.g. bleeding or
coagulation disorders).

Social history

General social context
Explore the patient’s general social context including\:
The type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
Who else the patient lives with and their personal support network. This is important when considering if there is someone at
home to observe them for signs of deterioration rather than admission for observation in hospital
What tasks they can carry out independently and what they require assistance with (e.g. self-hygiene, housework, food
shopping)
If they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for to determine their risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Smoking is a signi
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Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
It is important to ask about intoxication at the time of injury as this may have been a contributing factor (e.g. fall, assault, or road
tra
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs, and if so, determine the type of drugs and frequency of their use.
Occupation
Ask about the patient’s current occupation to clarify their job role. The impact on patients who occupy jobs that involve manual
labour, driving or operating heavy machinery should be considered carefully, as they may face restrictions. The rules of
driving after medical incidents are determined by the Driver and Vehicle Licensing Agency (DVLA), and patients should be
adequately informed.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. National Institute for Health and Care Excellence (NICE). H e a d i n j u r y . 2021. Available from\: [LINK].
2. Reed-Guy L. H e a d I n j u r y . Heathline. 2023. Available from\: [LINK].
3. National Institute of Neurological Disorders and Stroke. T r a u m a t i c B r a i n I n j u r y ( T B I ) . 2024. Available from\: [LINK].
4. National Health Service (NHS). H e a d i n j u r y a n d c o n c u s s i o n . 2021. Available from\: [LINK].
5. Roybal B. B r a i n S w e l l i n g . WebMD. 2022. Available from\: [LINK].
6. Young B. D i LINK].
7. National Health Service (NHS). C h r o n i c t r a u m a t i c e n c e p h a l o p a t h y . 2022. Available from\: [LINK].
8. National Institute for Health and Care Excellence (NICE) CKS. S c e n a r i o \: H e a d i n j u r y . 2021. Available from\: [LINK].

Reviewer

Dr Surinder Panpher
Emergency Medicine Consultant
Source\: geekymedics.com
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