Head Injuries

Any suspected head injury should receive a detailed assessment (15). The time, place, and nature of the injury should be ascertained from the detainee or from any witnesses who were present. The duration of any loss of conscious-

Table 5

Head Injuries Indications for Hospital Assessment

A patient with a head injury should be referred to the hospital if any of the following are present (a head injury is defined as any trauma to the head, other than superficial injuries to the face):

• Impaired consciousness (GCS <15/15) at any time since injury

• Any focal neurological symptoms or signs (e.g., problems understanding, speaking, reading or writing; decreased sensation; loss of balance; general weakness; visual changes; abnormal reflexes; and problems walking)

• Any suspicion of a skull fracture or penetrating injury (e.g., cerebrospinal fluid leak; black eye with no associated damage around the eyes; bleeding from or new deafness in one or both ears; mastoid hematoma; signs of penetrating injury; visible trauma to the scalp or skull of concern to the FP)

• Amnesia for events before or after the injury

• Persistent headache since the injury

• Any vomiting since the injury

• Any seizures since the injury

• Medical comorbidity (e.g., previous cranial surgery; anticoagulant therapy; bleeding or clotting disorder)

• A high-energy head injury (e.g., RTA, fall from a height of >1 m or more than five stairs)

• Current drug or alcohol intoxication

• Significant extracranial injuries

• Continuing uncertainty about the diagnosis after first assessment

• Age greater than or equal to 65 yr

ness and the behavior since the injury should be noted. Examination should include measurement of pulse and blood pressure, Glasgow Coma Scale (16), and neurological assessment. The indications for hospital assessment include situations in which there are problems with the assessment of the patient or an increased risk of skull fracture or an intracranial bleed (Table 5) (17).

Ingestion of alcohol or drugs and relevant past medical history should be ascertained. Although deaths in police custody are rare, head injuries accounted for 10% and substance abuse, including alcohol and drugs, accounted for 25% in a survey of such deaths between 1990 and 1997 in England and Wales (18). There should be a low threshold for referral to hospitals, especially if a detainee with a head injury is also under the influence of alcohol or drugs.

If the detainee is to remain in custody, then instructions regarding the management of patients with head injuries should be left verbally and in writing with the custody staff and given to the patient on release (19). Police

Brief Mental State Examination

Appearance Speech Thought Perception

Obsessive/compulsive Mood

Self-care, behavior Rate, volume

Association, content (delusions) Hallucinations, illusions Behaviors

Biological symptoms

Cognitive function Risk behaviors

(sleep, appetite, energy, concentration, memory) Short-term memory, concentration, long-term memory Self harm, harm to others should be advised that when checking a detainee's conscious level they are required to rouse and speak with the detainee, obtaining a sensible response. Appendix 3 outlines the Glasgow Coma Scale, a head injury warning card for adults, and an observation checklist for custody staff responsible for the health care of detainees.

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