Guidelines for the Management of Minor Head Injury in Adults

1. Guidelines for the Management ofMinor Head Injury in Adults Società Italiana di Medicina di Emergenza-Urgenza (SIMEU) Study Group for SIMEU Guidelines Torino, May 2000

2. Società Italiana di Medicina di Urgenza ed Emergenza (SIMEU) Study Group for SIMEU guidelines Ivo CasagrandaDaniele CoenPaolo DemattéVittorio DemicheliCarlo LocatelliFranco PerraroMassimo Pesenti-CampagnoniFernando PorroGiuseppe Re Torino, May 2000

3. Minor Head InjuryEpidemiology • 300 - 400 admissions / every year/ 100.000 inhabitants • 10% severe head injury • 10% moderate head injury • 80% minor head injury • 1-3% intracranial hematoma development

4. Minor Head InjuryDefinition • All people with head injury that arrive in Emmergency Department with a GCS Score of 15 or 14. • With the exception of: • Focal neurological deficits • Depressed skull fracture • Clinical signs of basal skull fracture

5. Minor Head InjuryClassification Group 0 pain limited to the impact zone, dizziness Group 1 brief loss of consciousness post-traumatic amnesia worsening headache vomiting Group 2 GCS 14

6. Minor Head InjuryRisk Factors • alcoholism • Coagulopathies • Previous neurosurgery • Drug use • epilepsy • Old age

7. Minor Head InjuryQuestions to be answered • What is the sensitivity and the specificity of clinical examination ? • Should all patients who arrive in ED with a GCS Score of 15 and brief loss of consciousness undergo a CT scan? • Does x-ray still play a role? • What is the procedure if the CT scan results negative?

8. Minor Head InjuryManagement Grouprecommendationslevel of evidence 0 - clinical assessment B - radiological examination is not B necessary - can be discharged with an information C sheet

9. Minor Head InjuryManagement grouprecommendationslevel of evidence 0 with added - observation for at least 24 hours C risk factors - CT scanning should be taken into C consideration

10. Minor Head InjuryManagement grouprecommeandationlevel of evidence 1 - observation for at least 6 hours C - perform a skull CT scan as soon as possible B - skull x-ray is not indicated B

11. Minor head InjuryManagement grouprecommendationlevel of evidence 1 - skull x-ray if CT scan not available B - if a fracture is found perform a CT scan B - CT should be carried out in an istitution with a neurosurgery ward C

12. Minor Head injuryManagement grouprecommendationlevel of evidence 1 with added - observation for at least 24 hours C risk factors - perform a CT scan B - cogulopathic patients should repeat CT C scan before discharge

13. Minor Head InjuryManagement grouprecommendationlevel of evidence 2 - perform a CT scan B - keep under continous observation C and discharge when proven to be neurologically intact

14. Minor Head InjurySensibilityandspecificityofneurologicalexamination • Negative neurological examination does not exclude intracranial lesions • CT scan detects intracranial lesions in 3 – 17% of patients with a GCS Score of 15 • Neurosurgical intervention in 0 - 3 % of patients

15. Minor Head InjuryRole of skull x-ray • If CT scan is not available • CT scan must be done with bone-windows

16. Minor Head InjuryRole of skull CT scan • All good quality literature recommends performjng a CT scan in patients with a GCS score of 15 and loss of consciousness • Even if the CT scan is negative the patient should be discharged with written advice for home observation