Guidelines on the early management of head injury

J Kerr A&E Royal Infirmary, Edinburgh

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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

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

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

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

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.

AGREE NICE SIGN

HISTORY

Mechanism of Injury (MOI)  Fall  RTA  Assault  Blunt or penetrating trauma  Associated injuries  ALCOHOL

Symptoms

 LOC  Amnesia  Nausea and/or vomiting  Epistaxis  Visual disturbance  Headache  Dizziness/drowsiness

GLASGOW COMA SCALE

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

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

Base of skull fracture

 Periorbital bruising  Subconjunctival haemorrhage  CSF rhino/otorrhoea  Epistaxis   Haemotympanum Battle’s sign

BASE OF SKULL FRACTURE

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

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

Skull X-ray

Advantages Quick No need for radiologist Low dose of radiation (0.14mSv) Inexpensive Disadvantages Increased workload Inconclusive

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

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

CT Scan

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

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

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

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

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

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

Neurosurgical assessment and monitoring

 Experienced staff  Intensive, specific monitoring    intracranial pressure monitoring dedicated neuro-intensive care specialised theatre suites  Rapid access to theatre

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 Post-implementation November 1999 May 2001

QUESTIONS?