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Guidelines on the early management of head injury

Guidelines on the early management of head injury. J Kerr A&E Royal Infirmary, Edinburgh. Head Injury. 10% of A/E workload A/E Dept seeing 85,000 annual attendances 8,500 head injuries 1,700 admissions 35 head injuries requiring resuscitation 20 require neurosurgery

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Guidelines on the early management of head injury

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  1. Guidelines on the early management of head injury J Kerr A&E Royal Infirmary, Edinburgh

  2. Head Injury • 10% of A/E workload • A/E Dept seeing 85,000 annual attendances • 8,500 head injuries • 1,700 admissions • 35 head injuries requiring resuscitation • 20 require neurosurgery • 220 patients require CT scan • 5100 patients can be discharged safely from A/E • Significant cost • Expeditious management reduces secondary brain injury • Associated injuries and secondary effects • High proportion of patients have a subsequent disability

  3. Guidelines • Guidelines for initial management after head injury in adults -Suggestions from a group of neurosurgeons March 1984 • Commission on the Provision of Surgical Services. Report of the Working Party on Head Injuries. London: RCS; 1986 • European Brain Injury Consortium. Guidelines for the management of severe head injury in adults 1997 • British Neurological Surgeons 1998 • Report of the Working Party on the Management of Patients with Head Injuries - Prof Galasko; Royal College of Surgeons of England June 1999 • SIGN August 2000 • Canadian CT Head Rules 2001 • NICE June 2003

  4. SIGN • Scottish Intercollegiate Guidelines Network • Formed in 1993 • Development of SIGN Guidelines - series of 70+ publications • No 46: ‘Early Management of Patients with a Head Injury’ - published August 2000

  5. NICE • National Institute for Clinical Excellence • Established as a Special Health Authority in England and Wales, April 1st 1999 • Technology appraisals and clinical guidelines • ‘Head Injury; Triage, assessment, investigation and early management of head injury in infants, children and adults’ published June 2003

  6. Guidance represents the view of the Institute, which was arrived at after a careful consideration of the available evidence. Health professionals are expected to take it fully into account when exercising their clinical judgement, it does not however override their individual responsibility to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

  7. HISTORY Mechanism of Injury (MOI) • Fall • RTA • Assault • Blunt or penetrating trauma • Associated injuries • ALCOHOL

  8. Symptoms • LOC • Amnesia • Nausea and/or vomiting • Epistaxis • Visual disturbance • Headache • Dizziness/drowsiness

  9. GLASGOW COMA SCALE Eye opening 4 eyes open spontaneously 3 open to speech 2 open to pain 1 no opening Motor response 6 obeys commands 5 localizes to pain 4 flexion 3 abnormal flexion 2 extension 1 no movement Verbal response 5 orientated 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no speech

  10. Indications for referral to hospital • GCS < 15 at any time since the injury • Amnesia • Neurological symptoms • Clinical evidence of a skull fracture • Significant extracranial injuries • MOI not trivial • Continuing uncertainty about diagnosis • Medical co-morbidity • Adverse social factors

  11. Base of skull fracture • Periorbital bruising • Subconjunctival haemorrhage • CSF rhino/otorrhoea • Epistaxis • Haemotympanum • Battle’s sign

  12. BASE OF SKULL FRACTURE

  13. Skull x-ray indications - SIGN • GCS < 15 or • GCS 15, but: • MOI not trivial • LOC • Amnesia or has vomited • Full thickness scalp laceration/boggy haematoma • Inadequate history

  14. Skull x-ray indications - NICE • Skull x-rays have a role in the detection of non-accidental injury in children • Skull x-rays in conjunction with high-quality in-patient observation also have a role where CT scanning resources are unavailable

  15. Skull X-ray Advantages Quick No need for radiologist Low dose of radiation (0.14mSv) Inexpensive Disadvantages Increased workload Inconclusive

  16. CT Indications - SIGN • GCS 12/15 or less • Deteriorating GCS or progressive focal neurological signs • Confusion or drowsiness (GCS 13-14) followed by failure to improve within at most 4 hours of clinical observation • Radiological/clinical evidence of fracture • GCS 15, no fracture but: • Severe/persistent headache, N+V, irritability or altered behaviour, seizure

  17. CT Indications - NICE • GCS less than 13 at any point since the injury • GCS 13 or 14 at 2 hours after the injury • Suspected open or depressed skull fracture • Any sign of BOS fracture • Post-traumatic seizure • Focal neurological deficit • >1 episode of vomiting • Amnesia > 30 minutes before impact In patients with some LOC or amnesia since the injury: • Age > 65 • Coagulopathy • Dangerous MOI

  18. CT Scan Advantages High sensitivity/specificity Detection of intracranial haematoma Definitive (except ultra early) Disadvantages High dose of radiation (2.0mSv) Radiologist required

  19. NICE vs SIGN • NICE based on Canadian CT head rules • NICE lowers threshold for CT scanning • Difficulty in obtaining out-of-hours CT scans • Massive increase in workload of radiology departments • Increased patient exposure to radiation • Increase in cost

  20. Management • ABC (including C spine control) • GCS • O2, analgesia, tetanus, ?antibiotics, IVI • ?bloods • Imaging • Neuro obs: • pupil size and reactivity • Repeated GCS score • General obs including p, BP, temp, BM, O2 sats, RR • Alcometer

  21. Admission or Discharge? • GCS < 15 • GCS 15, but • Continuing amnesia • Continuing nausea/vomiting • Severe headache • Any seizure • Focal neurological signs • Skull fracture • Abnormal CT • Significant medical problems • Social problems/no supervision at home

  22. Discharge from A/E • None of the above exclusion criteria • Patient must be given head injury advice • Responsible adult to supervise the patient • Easy access to a telephone • Reasonable access to a hospital • Easy access to transport

  23. Transfer to Neurosurgery • Abnormal CT scan • CT is indicated but cannot be done within an appropriate period • Clinical features which warrant neurosurgical assessment, monitoring or management: • Persisting coma (GCS 8/15) • Persisting confusion • Deteriorating GCS • Progressive focal neurology • Seizure without full recovery • Depressed skull fracture • Penetrating injury • CSF leak/BOS fracture

  24. Neurosurgical assessment and monitoring • Experienced staff • Intensive, specific monitoring • intracranial pressure monitoring • dedicated neuro-intensive care • specialised theatre suites • Rapid access to theatre

  25. Head Injury Audit • Scottish Trauma Audit Group (STAG) • 98% coverage throughout Scotland • All head injuries attending A/E Departments in 4 teaching hospitals • All head injuries admitted to Scottish hospitals Pre-implementation November 1999 Post-implementation May 2001

  26. QUESTIONS?

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