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MILD HEAD INJURY (MHI)

MILD HEAD INJURY (MHI). Bernard Foley Auckland Hospital Emergency Department 6th October 2001. SCENARIO 1. A 15-year-old boy is brought to your clinic by his mother He had been out rollerblading and was observed to fall and hit his head He was not knocked out

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MILD HEAD INJURY (MHI)

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  1. MILD HEAD INJURY (MHI) Bernard Foley Auckland Hospital Emergency Department 6th October 2001

  2. SCENARIO 1 • A 15-year-old boy is brought to your clinic by his mother • He had been out rollerblading and was observed to fall and hit his head • He was not knocked out • He complains of mild headache

  3. SCENARIO 2 • A 23-year-old man presents by ambulance • He had been drinking at a pub and subsequently assaulted 1 hour ago • GCS 14, PERLA, No focal neurology or signs of skull fracture

  4. SCENARIO 3 • A 45-year-old woman presents following an RTC • Briefly K.O.’D at the scene • GCS 12 (E3,M5,V4) • PERLA • No focal neurology • Large haematoma over right temple region

  5. MHI EPIDEMIOLOGY • @ 130 MILD HEAD INJURIES/100,000/yr. • @ 100/MONTH AT AUCKLAND ED • MALE 2 : 1 FEMALE • PEAK AGE 15-24 YEARS • LOWEST RATES AGE 35-65 • ALCOHOL > 17mmol/L PRESENT IN 2/3rds OF THOSE TESTED FOR IT

  6. MHI CAUSES • ROAD CRASH 40% • FALLS 20% • ASSAULT 15% • SPORTS 12% • CHILDREN CONSIDER NAI

  7. MHI DIAGNOSES • CONCUSSION 80% • FACIAL/SKULL FRACTURE 10% • CONTUSION 5% • HAEMORRHAGE 1%

  8. CONCUSSION • Transient alteration in cerebral function • Usually associated with L.O.C. • Thought to be due to disturbance in reticular activating system function • No structural brain injury • May lead to post-concussive syndromes

  9. POST CONCUSSION SYMDROMES • Typically mild headache and cognitive disturbances • Confusion,nausea,dizziness,fatigue • Typically last 1-2 days • May last months • If symptoms last >6 weeks should be seen by head injury specialist

  10. CONTUSION • Bruising of brain substance • Morbidity relates to size and site of contusion • Commonly occur in frontal and temporal lobes

  11. INTRACRANIAL BLEEDING • Extradural • Subdural • Intracerebral • Subarachnoid • Intraventricular

  12. DIFFUSE AXONAL INJURY • Shearing and rotational forces resulting in major structural and functional damage at a microscopic level. • CT scan often appears normal • Pathogenesis unclear

  13. MINIMAL HEAD INJURY • GCS 15 and… • No or only mild headache and nausea • No L.O.C. • No antegrade amnesia • No seizure • No vomiting • 2< AGE< 65 • Likelihood of CT abnormality essentially 0%

  14. MILD HEAD INJURY • GCS 14 or 15 and…. • Any L.O.C., seizure or vomiting • Intoxication, Coagulopathy • Clinical skull fracture or large scalp haematoma • Focal neurological abnormality • Abnormal pupillary reactions

  15. MILD HEAD INJURY 2 • Likelihood of abnormal CT @ 10% • Neurosurgical intervention <1%

  16. MODERATE HEAD INJURY • GCS 9-13 • Likelihood of abnormal CT 40% • Neurosurgical intervention @ 8% • Mortality 20% • Long term disability 50%

  17. SEVERE HEAD INJURY • GCS <9 • Mortality 40% • Long term disability >90%

  18. HISTORY • Accident events • Duration of L.O.C. • Seizure? • Amnesia • Nausea/vomiting • Drug use • Coexistent medical problems/allergies etc.

  19. PHYSICAL EXAMINATION • Primary survey • GCS • Check/protect C-spine • Pupils • Signs of skull/ basal skull fracture • Focal neurology • Other injuries

  20. NEUROLOGICAL OBSERVATIONS • No good evidence of usefulness • No evidence regarding duration • 4-hours v 24-hours • Possibly useful if no imaging available

  21. INVESTIGATIONS • Blood tests • Consider Glucose, U&E’s, FBC, Group and Hold • Skull x-rays • No • Perhaps in suspected depressed skull fracture • CT head • Investigation of choice • Considerable debate about who should be scanned

  22. CT HEAD - PRO’S • ACCURATE DIAGNOSIS OF INTRACRANIAL INJURY • AIDS SURGICAL PLANNING/ TRIAGE • MAY IDENTIFY AREAS WHERE INJURY OTHERWISE OCCULT • MAY IDENTIFY INJURY WHERE NOT SUSPECTED • MOST STUDIES IN LEVEL 1 TRAUMA CENTRES

  23. CT HEAD CONS • EXPENSE • AVAILABILITY • MAY REQUIRE TRANSPORT TO ANOTHER FACILITY • RADIATION EXPOSURE • PATIENT ISOLATION • ?SEDATION REQUIRED esp. KIDS

  24. CANADIAN CT HEAD RULESLANCET 2001;357 1391-96 ELIGIBILITY • Blunt trauma within 24 hours • Witnessed L.O.C. or definite amnesia or disorientation • GCS 13 or greater • EXCLUSIONS • Obvious penetrating injury, depressed skull fracture or focal neurology on exam

  25. CANADIAN HEAD CT RULES 5 HIGH RISK PREDICTORS • 1) GCS < 15, 2 hours after injury • 2) Suspected open or depressed skull fracture • 3) Any sign of basal skull fracture • 4) Vomiting (2x or more) • 5) Age > 65

  26. CANADIAN HEAD CT RULES • 2 Additional medium risk factors • Amnesia >30 minutes before event • Dangerous mechanism of injury • Fall > 3 feet or 5 stairs • Pedestrian struck by motor vehicle • Ejected from car

  27. CANADIAN HEAD CT RULES • USING 5 HIGH-RISK CRITERIA • 100% sensitivity (identifying those dying or requiring neurosurgery • Specificity 69% • USING ABOVE + 2 MEDIUM RISK CRITERIA • 98.4% sensitivity and 54% specificity

  28. WHO TO SCAN • AGE > 65 • INTOXICATED • SEVERE HEADACHE • VOMITING • SEIZURE • SIGNS OF SKULL FRACTURE • FOCAL NEUROLOGY • ? ALL LATE PRESENTERS

  29. MANAGEMENT • Analgesia • Attend to other injuries • ? Tetanus prophylaxis • ? Observation • Referral if requires inpatient care • Documentation (incl.. ACC)

  30. MANAGEMENT (SEVERE INJURY) • Discuss with hospital/neurosurgeon • Oxygen/ ? Intubate and ventilate • IV access • Treat hypotension with fluids • Protect spine • Consider neuroprotection • Role of mannitol and hyperventilation controversial

  31. DISCHARGE • ALL MINIMAL HEAD INJURY • If sober and competent observer • ALL MHI WITH NORMAL CT SCAN • Unless other injuries • All require competent supervision • ADMIT ALL MODERATE/SEVERE • ADMIT ALL WITH ABNORMAL CT

  32. DISCHARGE ADVICE • Written advice • Explain and give to observer • 67% will carry out instructions correctly • If given to patient to arrange <20% • ANNALS OF EMRGENCY MEDICINE • 15:2 FEB 1986

  33. DISCHARGE ADVICE • EXPLAIN POST CONCUSSION SYMPTOMS • REST AND TIME OFF WORK • ANALGESIA • RETURN IF ANY CONCERNS • AVOID • Alcohol • Driving? Major decisions for 24 hours • Further injury for 3 weeks

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