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Mallika Khwanmuang Phatcharapol Udomluck Jitsupa Litleangdej

Mallika Khwanmuang Phatcharapol Udomluck Jitsupa Litleangdej ------------------------------------------------------------------- 5 th year medical students of Naresuan university, Phitsanulok , Thailand.

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Mallika Khwanmuang Phatcharapol Udomluck Jitsupa Litleangdej

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  1. Mallika Khwanmuang Phatcharapol Udomluck Jitsupa Litleangdej ------------------------------------------------------------------- 5th year medical students of Naresuan university, Phitsanulok , Thailand The Correlation between Mild Head Injury and Positive CT Scan of the Brain in the Patients with Moderate Risks at Naresuan University Hospital

  2. Magnitude of problem • Casualty due to accident is the third cause of death following to cancer and cardiovascular disease • Head injury is the most common site (30%) of all injuries. Mortality rate of severe head injury is 29% and is increasing steadily • CT brain is gold standard for diagnosis of intracerebral hemorrhage which requires specialized instruments and only available in tertiary center

  3. Magnitude of problem • There is increasing trends of screening patient before performing CT brain based on clinical characteristics of patient because of its availability , cost and specialist requirements . • The study objective is to define clinical characteristic criteria for screening patient who is at risk of intracerebral hemorrhage , which is insight for diagnosis , treatment , referral to reduce morbidity , mortality rate and cost for health on source section

  4. Operational definitions

  5. Gap of Knowledge

  6. Research Question Clinical characteristic findings for abnormal CT brain results

  7. Literature Review • The relevant literature contains many studies on the use of CT scan in patients with minor head injury, yet no consensus has been reached.

  8. Literature Review • A study by Haydel et al. suggested that CT scan is indicated only in patients with minor head injury with any one of seven risk factors, the New Orleans Criteria. A similar study by Stiell et al. identified a different set of factors, the Canadian CT Head Rule. Both decision rules had 100% sensitivity for identifying patients with traumatic brain injury, but both rules had low specificities.

  9. Literature Review • Servadei et al. classified patients with minor head injury as low-, medium-, or high-risk They evaluated patients with a GCS score of 15 requiring surgical intervention in these patients as 0.2%. • Patients with one or more of these four symptoms (temporary loss of consciousness, amnesia, vomiting, or widespread headache) were classified as medium-risk head injury, and the risk of intracranial hemorrhage in these patients was determined to be 1–3%. They recommended CT scan for medium-risk patients.

  10. Objective • Define definitive clinical characteristics associated with abnormal computed tomographic scan finding in mild head injuries • Guideline for appropriate requirement to perform CT brain • Guideline for management and referral

  11. Advantages • Can predict clinical characteristics of patients at risk for intracerebral hemorrhage in mild head injuries • Can reduce cost for health on source section for performing CT brain • Can discharge patients with mild head injuries who do not require CT brain and with no consequences after discharge

  12. Methods • Retrospective cohort studies

  13. Reference population Inclusion criteria • Patients treated at the emergency department between January 1, 2008 and May 31, 2011 • Mild head injury (GCS score of 13 to 15) • CT performed within 3 hours of the admit

  14. Reference population Inclusion criteria • Moderate risk criteria • Significant subgaleal swelling • Post traumatic seizure • Retrograde amnesia • Alcohol consumption • Basal skull fractures • Serious facial injury • Loss of consciousness • Vomiting • Progressive headache • Multiple traumas

  15. Reference population Exclusion criteria • Bleeding disorder or used anticoagulants • Coumadin • Spontaneous intracerebral hemorrhage • Idiopathic thrombocytopenic purpura • Leukemia • Stroke

  16. Methods • Data were collected on patient characteristics (age, sex time of injury), mechanisms of trauma and CT scan findings. • Data were analyzed with chi-squared tests. • The research ethics committees of the study hospitals approved.

  17. Results • Medical charts of 64 males and 45 females. • An average age of 17-60 years. • Mechanisms of trauma were motorcycle accident, 74; fall 21; and other, 12. • Initial CT scan was performed on all 109 patients. • Abnormal findings were identified in 28 (25.7%).

  18. Traumatic findings at CT

  19. Correlation between moderate-risk criteria and initial abnormal CT scan in all patients

  20. Correlation between moderate-risk criteria and initial abnormal CT scan in all patients

  21. Discussion • Univariable analysis from this study was found that age and sex were not significant risk factor associated with intracranial hemorrhage • Clinical characteristics that had significant associated with abnormal CT brain scan (p<0.05) was significant subgaleal swelling

  22. Discussion • All patients who had significant subgaleal swelling were found that accompanied with other symptoms. • Therefore, we used the Crude analysis to find the potential confounder by choose co-symptoms which had p-value<0.2. • There were loss of consciousness, basal skull fracture, and multiple traumas. But, from analysis, these symptoms did not affect the relation.

  23. Discussion • We cannot certainly conclude that the patients who had subgaleal swelling symptom were also associated with abnormal CT brain scan everyone. Because of • Small size of sample • Incomplete medical record • some patients did not perform the CT brain scan

  24. Suggestion • This research was studied only at Naresuan university hospital that can not refer to another population of patients with mild head injury. • Design of this study would be better in prospective cohort study design

  25. Conclusion • Patients with mild head injury who had significant subgaleal swelling and other symptoms which were risk to intracranial hemorrhage should perform computed tomography brain scan. • Current study findings demand future researches in larger population by prospective cohort study design in the future.

  26. References • Bahner J, Don R, Stein S, Ross S. The value of computed tomographic scans in patients with low-risk head injuries [Online]1990 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/073646799190431E. • Cattamanchi S, Siva A, Raja A, Thiagarajan NR, Trichur RV. 86: Comparison of the Canadian CT Head Rule and the New Orleans Criteria In Minor Head Injury Patients With Glasgow Coma Scale 15/15.[Online]2010 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0196064410007134. • de Andrade AF, de Almeida AN, Bor-Seng-Shu E, Lourenço L, Mandel M, Marino JR. The value of cranial computed tomography in high-risk, mildly head-injured patients.[Online]2006 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0090301905007937. • Falimirski ME, Gonzalez R, Rodriguez A, Wilberger J. The need for head computed tomography in patients sustaining loss of consciousness after mild head injury. [Online] 2003 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12855873 2003 • Havdel M, Preston C, Mills T, al. e. Indications for computed tomography in patients with minor head injury [Online]2001 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S073567570180111X.

  27. References References • Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients.[Online]1997 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0736467997000711. • Murshid WR. Management of minor head injuries: admission criteria, radiological evaluation and treatment of complications.[Online]1998 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9522909. • Ratanalert S, Kornsilp T, Chintragoolpradub N and Kongchoochouys. The impacts and outcomes of implementing head injury guidelines: clinical experience in Thailand. [Online] 2007 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17183038 • Royal college of surgeons of Thailand. Head injury. [Online] 2008 [cited 29 July 2554]. Available from: http://www.surgeons.or.th/view.php?group=8&id=208

  28. References References • Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury.[Online]2005 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16189365. • Stein SC, Ross SE. Mild head injury: a plea for routine early CT scanning.[Online]1992 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1635094. • Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. . [Online] 2001 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11356436 • SüleymanTüredi MD , AltugHasanbasoglu MD, AbdulkadirGunduz MD ,Mustafa Yandi MD. Clinical Decision Instruments for CT scan in Minor Head Trauma. [Online] 2008 [cited 29 July 2554]. Available from: http://www.sciencedirect.com/science/article/pii/S0736467907006117

  29. References References • Voss M, Knottenbelt J, PEEDEN M. Patients who reattend after head injury: A high-risk group [Online]1995 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S073646799785175X. • Yavuz MS, Asirdizer M, Cetin G, GunayBalci Y, Altinkok M. The correlation between skull fractures and intracranial lesions due to traffic accidents.[Online]2003 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14634472. • กองพัฒนาการจราจรและบริการประชาชนสำนักงานตำรวจแห่งชาติ, เอกสารประกอบโครงการสัมมนาการกวดขันวินัยจราจรและลดอุบัติเหตุทั่วประเทศ. 2008. • ดำนาคแก้ว, ก., การบาดเจ็บรุนแรงจากอุบัติเหตุขนส่ง พ.ศ.2550. 2008, สำนักระบาดวิทยากรมควบคุมโรค กระทรวงสาธารณสุข. • อัตราตายปรับฐานอายุ (age-adjusted death rate) ต่อประชากร 100,000 คน ด้วยกลุ่มโรคหัวใจ หลอดเลือด กลุ่มโรคมะเร็ง และการบาดเจ็บ และโรคในกลุ่มโรคหัวใจหลอดเลือดและ โรคเบาหวาน ปี 2539-2548. 2548, ศูนย์ข้อมูลโรคไม่ติดต่อ สำนักโรคไม่ติดต่อ กรมควบคุมโรค กระทรวงสาธารณสุข.

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