A severe head injury must always be treated in hospital to minimise the risk of complications.

Initial treatment

When you arrive at the emergency department of a hospital, or before getting to hospital if you called an ambulance, the doctors or paramedics treating you will prioritise any injury that may be life threatening. This could mean:

• checking your airway is clear
• checking you are breathing, and starting cardiopulmonary resuscitation (CPR or mouth-to-mouth) if you are not
• stabilising your neck and spine, for example using a neck brace
• stopping any severe bleeding
• providing pain relief if you are in a lot of pain
• splinting any fractured or broken bones (strapping them into the correct position)

Once you are stable, further treatment will be arranged, as necessary, including any tests you need to help determine the severity of your injury. Read about diagnosing a severe head injury for more information about tests you may have.

Observation

If you need to stay in hospital for observation, doctors and nurses treating you will check:

• your level of consciousness and how alert you are
• the size of your pupils, and how well they react to light
• how well you can move your arms and legs
• your breathing
• your heart rate
• your blood pressure
• your temperature
• the level of oxygen in your blood

These checks will be made every half an hour until it is clear you know where and who you are, you can speak and move as instructed, and your eyes are open. After this, checks will be made less frequently.

Any changes in your condition or behaviour will also be closely monitored. If your condition worsens, you may need to have further tests, such as a computerised tomography (CT) scan. 

If there has been any bleeding or swelling inside the skull, a small device called an intracranial pressure (ICP) monitor may be fitted. This involves inserting a thin wire into the space between the skull and the brain, through a small hole drilled into the skull. This wire is attached to an electronic device that alerts hospital staff about any changes in the pressure inside your skull.

Cuts and grazes

If you have any external cuts or grazes to your head, these will be cleaned and treated to prevent further bleeding or infection. If there are any foreign bodies in the wound, such as broken glass, these will need to be removed.

Deep or large cuts may require stitches (sutures) to keep them closed until they heal. Local anaesthetic may be used to numb the area around the cut so you do not feel any pain.

Neurosurgery

Neurosurgery is any kind of surgery used to treat a problem with the nervous system (the brain, spinal cord and nerves). In cases of severe head injury, neurosurgery is usually carried out on the brain.

Possible reasons for neurosurgery include:

• a haemorrhage – severe bleeding inside your head, such as a subarachnoid haemorrhage, which puts pressure on the brain and may result in brain injury and, in severe cases, death
• a haematoma – a blood clot inside your head, such as a subdural haematoma, which can also put pressure on the brain
• cerebral contusions – bruises on the brain, which can develop into blood clots
• skull fracture (see below)

These conditions will be identified during tests, such as a CT scan, and a neurosurgeon (an expert in surgery of the brain and nervous system) may come and speak to you or your family about whether surgery is necessary.

As the above conditions can be serious and may require urgent treatment, in some cases there may not be time to discuss the surgery before it is carried out. After the operation, your surgeon will take the time to discuss the details of the surgery with both you and your family.

Craniotomy

One of the main types of surgical operation carried out to treat severe head injuries is called a craniotomy.

A craniotomy involves making a hole in your skull so that the surgeon can access your brain. This will be carried out under general anaesthetic, which means you will be unconscious and will not feel anything while it is performed.

Once your surgeon has access to your brain, they will remove any blood clots that may have formed and repair any damaged blood vessels. When any bleeding inside your brain has stopped, the piece of skull bone will be replaced. In many cases, the piece of skull is reattached using small metal screws.

Skull fractures

Your skull can fracture during an injury to your head. If this happens, you will usually have a CT scan to determine the extent of the injury.

There are different types of skull fractures, including:

• simple (or closed) fracture – where the skin has not broken and the surrounding tissue is not damaged
• compound (or open) fracture – where the skin has broken and the surrounding tissue may be damaged
• linear fracture – where the break in the bone looks like a straight line
• depressed fracture – where part of the skull is crushed inwards
• basal fracture – a fracture to the base of the skull

Open fractures may be more serious because there is a higher risk of infection by bacteria if the skin is broken. Depressed fractures can also be very serious because small pieces of bone can press inwards against the brain.

Treating skull fractures

Most skull fractures will heal by themselves, particularly if they are simple, linear fractures. The healing process can take many months, although any pain will usually disappear in around five to 10 days.

If the fracture is open, you may be prescribed antibiotics to prevent an infection.

If the fracture is severe or depressed, you may need surgery to help prevent any damage to the brain. This will usually be carried out under general anaesthetic.

During your operation, any pieces of bone that have been pressed inwards can be removed and returned to their correct position. If necessary, metal wire or mesh may be used to reconnect the pieces of your skull.

Once the bone is back in place, it should heal naturally. Your surgeon can explain the procedure you are having in more detail.

After surgery

Depending on how serious your operation was, you may need to recover in an intensive care unit (ICU). This is a small, specialised ward where your condition will be constantly monitored. 

In an intensive care unit, you may be placed on a ventilator. This is an artificial breathing machine that moves oxygen-enriched air in and out of your lungs.

Once you are well enough, you will be moved to a high-dependency unit (HDU) or another ward and your condition will continue to be observed (see above) until you are well enough to leave hospital.

Read more about recovering from a severe head injury.