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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

MILD HEAD INJURY (MHI)

Bernard Foley

Auckland Hospital Emergency Department

6th October 2001

scenario 1
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
scenario 2
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
scenario 3
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
mhi epidemiology
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
mhi causes
MHI CAUSES
  • ROAD CRASH 40%
  • FALLS 20%
  • ASSAULT 15%
  • SPORTS 12%
  • CHILDREN CONSIDER NAI
mhi diagnoses
MHI DIAGNOSES
  • CONCUSSION 80%
  • FACIAL/SKULL FRACTURE 10%
  • CONTUSION 5%
  • HAEMORRHAGE 1%
concussion
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
post concussion symdromes
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
contusion
CONTUSION
  • Bruising of brain substance
  • Morbidity relates to size and site of contusion
  • Commonly occur in frontal and temporal lobes
intracranial bleeding
INTRACRANIAL BLEEDING
  • Extradural
  • Subdural
  • Intracerebral
  • Subarachnoid
  • Intraventricular
diffuse axonal injury
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
minimal head injury
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%
mild head injury
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
mild head injury 2
MILD HEAD INJURY 2
  • Likelihood of abnormal CT @ 10%
  • Neurosurgical intervention <1%
moderate head injury
MODERATE HEAD INJURY
  • GCS 9-13
    • Likelihood of abnormal CT 40%
    • Neurosurgical intervention @ 8%
    • Mortality 20%
    • Long term disability 50%
severe head injury
SEVERE HEAD INJURY
  • GCS <9
    • Mortality 40%
    • Long term disability >90%
history
HISTORY
  • Accident events
  • Duration of L.O.C.
  • Seizure?
  • Amnesia
  • Nausea/vomiting
  • Drug use
  • Coexistent medical problems/allergies etc.
physical examination
PHYSICAL EXAMINATION
  • Primary survey
  • GCS
  • Check/protect C-spine
  • Pupils
  • Signs of skull/ basal skull fracture
  • Focal neurology
  • Other injuries
neurological observations
NEUROLOGICAL OBSERVATIONS
  • No good evidence of usefulness
  • No evidence regarding duration
    • 4-hours v 24-hours
  • Possibly useful if no imaging available
investigations
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
ct head pro s
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
ct head cons
CT HEAD CONS
  • EXPENSE
  • AVAILABILITY
    • MAY REQUIRE TRANSPORT TO ANOTHER FACILITY
  • RADIATION EXPOSURE
  • PATIENT ISOLATION
  • ?SEDATION REQUIRED esp. KIDS
canadian ct head rules lancet 2001 357 1391 96
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
canadian head ct rules
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
canadian head ct rules28
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
canadian head ct rules29
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
who to scan
WHO TO SCAN
  • AGE > 65
  • INTOXICATED
  • SEVERE HEADACHE
  • VOMITING
  • SEIZURE
  • SIGNS OF SKULL FRACTURE
  • FOCAL NEUROLOGY
  • ? ALL LATE PRESENTERS
management
MANAGEMENT
  • Analgesia
  • Attend to other injuries
  • ? Tetanus prophylaxis
  • ? Observation
  • Referral if requires inpatient care
  • Documentation (incl.. ACC)
management severe injury
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
discharge
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
discharge advice
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
discharge advice35
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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