Jacques Ker

8/12/2019 Jacques Ker

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Guidelines on the early

management of head injury J Kerr

A&ERoyal Infirmary, Edinburgh


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Head Injury

10% of A/E workloadA/E Dept seeing 85,000 annual attendances8,500 head injuries1,700 admissions35 head injuries requiring resuscitation

20 require neurosurgery220 patients require CT scan5100 patients can be discharged safely from A/E

Significant cost

Expeditious management reduces secondary braininjuryAssociated injuries and secondary effectsHigh proportion of patients have a subsequentdisability


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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 ofthe Working Party on Head Injuries. London: RCS; 1986

European Brain Injury Consortium. Guidelines for themanagement 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 Surgeonsof England June 1999 SIGN August 2000Canadian CT Head Rules 2001

NICE June 2003


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SIGN

Scottish Intercollegiate Guidelines NetworkFormed in 1993

Development of SIGN Guidelines - series of70+ publications

No 46: Early Management of Patients with aHead Injury - published August 2000


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NICE

National Institute for Clinical ExcellenceEstablished as a Special Health Authority inEngland and Wales, April 1st 1999Technology appraisals and clinical guidelinesHead Injury; Triage, assessment, investigationand early management of head injury ininfants, children and adults published June2003


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Guidance represents the view of the Institute, whichwas arrived at after a careful consideration of the

available evidence. Health professionals are expected totake it fully into account when exercising their clinical

judgement, it does not however override their individualresponsibility to make appropriate decisions in the

circumstances of the individual patient, in consultationwith the patient and/or guardian or carer.


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NICE SIGN

AGREE


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HISTORY

Mechanism of Injury (MOI)Fall

RTA AssaultBlunt or penetrating trauma

Associated injuries ALCOHOL


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Symptoms

LOCAmnesia

Nausea and/or vomitingEpistaxisVisual disturbance

HeadacheDizziness/drowsiness


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GLASGOW COMA SCALE

Eye opening 4 eyes open spontaneously3 open to speech2 open to pain1 no opening

Motor response 6 obeys commands

5 localizes to pain4 flexion3 abnormal flexion2 extension1 no movement

Verbal response 5 orientated4 confused3 inappropriate words2 incomprehensible sounds1 no speech


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Indications for referral tohospital

GCS < 15 at any time since the injuryAmnesia

Neurological symptomsClinical evidence of a skull fractureSignificant extracranial injuriesMOI not trivialContinuing uncertainty about diagnosisMedical co-morbidityAdverse social factors


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Periorbital bruisingSubconjunctival

haemorrhageCSF rhino/otorrhoeaEpistaxisHaemotympanumBattles sign

Base of skull fracture


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BASE OF SKULLFRACTURE


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Skull x-ray indications - SIGN

GCS < 15 orGCS 15, but:

MOI not trivial

LOCAmnesia or has vomitedFull thickness scalp laceration/boggy haematomaInadequate history


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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 CTscanning resources are unavailable


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Skull X-ray

Advantages Quick

No need for radiologist

Low dose of radiation(0.14mSv)

Inexpensive

Disadvantages Increased workloadInconclusive


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CT Indications - SIGN

GCS 12/15 or lessDeteriorating GCS or progressive focal neurologicalsigns

Confusion or drowsiness (GCS 13-14) followed byfailure to improve within at most 4 hours of clinicalobservationRadiological/clinical evidence of fracture

GCS 15, no fracture but:Severe/persistent headache, N+V, irritability or altered

behaviour, seizure


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CT Indications - NICE

GCS less than 13 at any point since the injuryGCS 13 or 14 at 2 hours after the injurySuspected open or depressed skull fractureAny sign of BOS fracture

Post-traumatic seizureFocal neurological deficit>1 episode of vomitingAmnesia > 30 minutes before impact

In patients with some LOC or amnesia since the injury:

Age > 65CoagulopathyDangerous MOI


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CT Scan

AdvantagesHigh sensitivity/specificityDetection of intracranial

haematomaDefinitive (except ultra

early)

Disadvantages

High dose of radiation(2.0mSv)Radiologist required


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NICE vs SIGN

NICE based on Canadian CT head rules NICE lowers threshold for CT scanning

Difficulty in obtaining out-of-hours CT scansMassive increase in workload of radiologydepartmentsIncreased patient exposure to radiationIncrease in cost


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Management

ABC (including C spine control)GCSO2, analgesia, tetanus, ?antibiotics, IVI

?bloodsImaging

Neuro obs: pupil size and reactivityRepeated GCS scoreGeneral obs including p, BP, temp, BM, O2 sats, RRAlcometer


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Admission or Discharge?

GCS < 15GCS 15, but

Continuing amnesiaContinuing nausea/vomitingSevere headache

Any seizureFocal neurological signsSkull fracture

Abnormal CT

Significant medical problemsSocial problems/no supervision at home


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Discharge from A/E

None of the above exclusion criteriaPatient must be given head injury advice

Responsible adult to supervise the patientEasy access to a telephoneReasonable access to a hospitalEasy access to transport


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Transfer to Neurosurgery

Abnormal CT scanCT 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 confusionDeteriorating GCSProgressive focal neurologySeizure without full recoveryDepressed skull fracturePenetrating injuryCSF leak/BOS fracture


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Neurosurgical assessment andmonitoring

Experienced staff

Intensive, specific monitoringintracranial pressure monitoringdedicated neuro-intensive carespecialised theatre suites

Rapid access to theatre


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Head Injury Audit

Scottish Trauma Audit Group (STAG)98% coverage throughout ScotlandAll head injuries attending A/E Departments in4 teaching hospitalsAll head injuries admitted to Scottish hospitals

Pre-implementation November 1999Post-implementation May 2001


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QUESTIONS?

Documents

Jacques Ker