Clinical assessment of head injury: The history

A quick and concise history is essential in the care of the patient with head injury. Necessary details include:
• Age
• Type of accident that caused the head injury and the events surrounding it
• Time of occurrence
• Details of rescue/transportation to the hospital
• Occurrence and details of

o Vomiting: may indicate raised ICP
o Convulsions (early/late post traumatic seizures)
o Bleeding (craniofacial orifices and others)
o CSF leaks
o Fever
o Loss of consciousness

• Allergies (avoid drugs of allergy)
• Last meal (stomach may need to be emptied before general anaesthesia)
• Details of pre-hospital care
• Co-morbidities

The history is obtained from a conscious patient while relations and bystanders at the site of the accident or from the ambulance officers are important informants for both the conscious and the unconscious .