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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 l.jpg

MILD HEAD INJURY (MHI)

Bernard Foley

Auckland Hospital Emergency Department

6th October 2001


Scenario 1 l.jpg
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


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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


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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


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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


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MHI CAUSES

  • ROAD CRASH 40%

  • FALLS 20%

  • ASSAULT 15%

  • SPORTS 12%

  • CHILDREN CONSIDER NAI


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MHI DIAGNOSES

  • CONCUSSION 80%

  • FACIAL/SKULL FRACTURE 10%

  • CONTUSION 5%

  • HAEMORRHAGE 1%


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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


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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


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CONTUSION

  • Bruising of brain substance

  • Morbidity relates to size and site of contusion

  • Commonly occur in frontal and temporal lobes


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INTRACRANIAL BLEEDING

  • Extradural

  • Subdural

  • Intracerebral

  • Subarachnoid

  • Intraventricular


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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


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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%


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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


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MILD HEAD INJURY 2

  • Likelihood of abnormal CT @ 10%

  • Neurosurgical intervention <1%


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MODERATE HEAD INJURY

  • GCS 9-13

    • Likelihood of abnormal CT 40%

    • Neurosurgical intervention @ 8%

    • Mortality 20%

    • Long term disability 50%


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SEVERE HEAD INJURY

  • GCS <9

    • Mortality 40%

    • Long term disability >90%


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HISTORY

  • Accident events

  • Duration of L.O.C.

  • Seizure?

  • Amnesia

  • Nausea/vomiting

  • Drug use

  • Coexistent medical problems/allergies etc.


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PHYSICAL EXAMINATION

  • Primary survey

  • GCS

  • Check/protect C-spine

  • Pupils

  • Signs of skull/ basal skull fracture

  • Focal neurology

  • Other injuries


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NEUROLOGICAL OBSERVATIONS

  • No good evidence of usefulness

  • No evidence regarding duration

    • 4-hours v 24-hours

  • Possibly useful if no imaging available


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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


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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


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CT HEAD CONS

  • EXPENSE

  • AVAILABILITY

    • MAY REQUIRE TRANSPORT TO ANOTHER FACILITY

  • RADIATION EXPOSURE

  • PATIENT ISOLATION

  • ?SEDATION REQUIRED esp. KIDS


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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


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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


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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


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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


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WHO TO SCAN

  • AGE > 65

  • INTOXICATED

  • SEVERE HEADACHE

  • VOMITING

  • SEIZURE

  • SIGNS OF SKULL FRACTURE

  • FOCAL NEUROLOGY

  • ? ALL LATE PRESENTERS


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MANAGEMENT

  • Analgesia

  • Attend to other injuries

  • ? Tetanus prophylaxis

  • ? Observation

  • Referral if requires inpatient care

  • Documentation (incl.. ACC)


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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


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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


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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


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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