Guidelines on the early Guidelines on the early management of head injurymanagement of head injury

J KerrJ Kerr

A&EA&E

Royal Infirmary, EdinburghRoyal Infirmary, Edinburgh

Head InjuryHead Injury 10% of A/E workload10% of A/E workload

A/E Dept seeing 85,000 annual attendancesA/E Dept seeing 85,000 annual attendances 8,500 head injuries8,500 head injuries 1,700 admissions1,700 admissions 35 head injuries requiring resuscitation35 head injuries requiring resuscitation 20 require neurosurgery20 require neurosurgery 220 patients require CT scan220 patients require CT scan 5100 patients can be discharged safely from A/E5100 patients can be discharged safely from A/E

Significant costSignificant cost Expeditious management reduces secondary brain injuryExpeditious management reduces secondary brain injury Associated injuries and secondary effectsAssociated injuries and secondary effects High proportion of patients have a subsequent disabilityHigh proportion of patients have a subsequent disability

GuidelinesGuidelines Guidelines for initial management after head injury in adults -Guidelines for initial management after head injury in adults -

Suggestions from a group of neurosurgeons MarchSuggestions from a group of neurosurgeons March 1984 1984 Commission on the Provision of Surgical Services. Report of the Commission on the Provision of Surgical Services. Report of the

Working Party on Head Injuries. London: RCS; Working Party on Head Injuries. London: RCS; 19861986 European Brain Injury Consortium. Guidelines for the management European Brain Injury Consortium. Guidelines for the management

of severe head injury in adults of severe head injury in adults 19971997 British Neurological Surgeons British Neurological Surgeons 19981998 Report of the Working Party on the Management of Patients with Report of the Working Party on the Management of Patients with

Head Injuries - Prof Galasko; Royal College of Surgeons of Head Injuries - Prof Galasko; Royal College of Surgeons of England JuneEngland June 1999 1999

SIGN August SIGN August 20002000 Canadian CT Head Rules Canadian CT Head Rules 20012001 NICE June NICE June 20032003

SIGNSIGN

Scottish Intercollegiate Guidelines NetworkScottish Intercollegiate Guidelines Network Formed in 1993Formed in 1993 Development of SIGN Guidelines - series of Development of SIGN Guidelines - series of

70+ publications 70+ publications No 46: ‘Early Management of Patients with a No 46: ‘Early Management of Patients with a

Head Injury’ - published August 2000Head Injury’ - published August 2000

NICENICE

National Institute for Clinical ExcellenceNational Institute for Clinical Excellence Established as a Special Health Authority in Established as a Special Health Authority in

England and Wales, April 1st 1999England and Wales, April 1st 1999 Technology appraisals and clinical guidelinesTechnology appraisals and clinical guidelines ‘‘Head Injury; Triage, assessment, investigation Head Injury; Triage, assessment, investigation

and early management of head injury in and early management of head injury in infants, children and adults’ published June infants, children and adults’ published June 20032003

Guidance represents the view of the Institute, which was Guidance represents the view of the Institute, which was

arrived at after a careful consideration of the available arrived at after a careful consideration of the available

evidence. Health professionals are expected to take it evidence. Health professionals are expected to take it

fully into account when exercising their clinical fully into account when exercising their clinical

judgement, it does not however override their individual judgement, it does not however override their individual

responsibility to make appropriate decisions in the responsibility to make appropriate decisions in the

circumstances of the individual patient, in consultation circumstances of the individual patient, in consultation

with the patient and/or guardian or carer.with the patient and/or guardian or carer.

NICE SIGN

AGREE

HISTORYHISTORY

Mechanism of Injury (MOI)Mechanism of Injury (MOI) FallFall RTARTA AssaultAssault Blunt or penetrating traumaBlunt or penetrating trauma Associated injuriesAssociated injuries ALCOHOLALCOHOL

SymptomsSymptoms

LOCLOC AmnesiaAmnesia Nausea and/or vomitingNausea and/or vomiting EpistaxisEpistaxis Visual disturbanceVisual disturbance HeadacheHeadache Dizziness/drowsinessDizziness/drowsiness

GLASGOW COMA GLASGOW COMA SCALESCALE

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

Motor response 6 obeys commands5 localizes to pain4 flexion3 abnormal flexion2 extension1 no movement

Verbal response 5 orientated4 confused3 inappropriate words2 incomprehensible sounds1 no speech

Indications for referral to Indications for referral to hospitalhospital

GCS < 15 at any time since the injuryGCS < 15 at any time since the injury AmnesiaAmnesia Neurological symptomsNeurological symptoms Clinical evidence of a skull fractureClinical evidence of a skull fracture Significant extracranial injuriesSignificant extracranial injuries MOI not trivialMOI not trivial Continuing uncertainty about diagnosisContinuing uncertainty about diagnosis Medical co-morbidityMedical co-morbidity Adverse social factorsAdverse social factors

Periorbital bruisingPeriorbital bruising Subconjunctival Subconjunctival

haemorrhagehaemorrhage CSF CSF

rhino/otorrhoearhino/otorrhoea EpistaxisEpistaxis HaemotympanumHaemotympanum Battle’s signBattle’s sign

Base of skull fracture

BASE OF SKULLFRACTURE

Skull x-ray indications - SIGNSkull x-ray indications - SIGN

GCS < 15 orGCS < 15 or GCS 15, but: GCS 15, but:

MOI not trivialMOI not trivial LOCLOC Amnesia or has vomitedAmnesia or has vomited Full thickness scalp laceration/boggy haematomaFull thickness scalp laceration/boggy haematoma Inadequate historyInadequate history

Skull x-ray indications - NICESkull x-ray indications - NICE

Skull x-rays have a role in the detection of non-Skull x-rays have a role in the detection of non-accidental injury in childrenaccidental injury in children

Skull x-rays in conjunction with high-quality in-Skull x-rays in conjunction with high-quality in-patient observation also have a role where CT patient observation also have a role where CT scanning resources are unavailablescanning resources are unavailable

Skull X-raySkull X-ray

AdvantagesQuickNo need for radiologistLow dose of radiation (0.14mSv)Inexpensive

DisadvantagesIncreased workloadInconclusive

CT Indications - SIGNCT Indications - SIGN

GCS 12/15 or lessGCS 12/15 or less Deteriorating GCS or progressive focal neurological Deteriorating GCS or progressive focal neurological

signssigns Confusion or drowsiness (GCS 13-14) followed by Confusion or drowsiness (GCS 13-14) followed by

failure to improve within at most 4 hours of clinical failure to improve within at most 4 hours of clinical observationobservation

Radiological/clinical evidence of fractureRadiological/clinical evidence of fracture GCS 15, no fracture but:GCS 15, no fracture but:

Severe/persistent headache, N+V, irritability or altered Severe/persistent headache, N+V, irritability or altered behaviour, seizurebehaviour, seizure

CT Indications - NICECT Indications - NICE GCS less than 13 at any point since the injuryGCS less than 13 at any point since the injury GCS 13 or 14 at 2 hours after the injuryGCS 13 or 14 at 2 hours after the injury Suspected open or depressed skull fractureSuspected open or depressed skull fracture Any sign of BOS fractureAny sign of BOS fracture Post-traumatic seizurePost-traumatic seizure Focal neurological deficitFocal neurological deficit >1 episode of vomiting>1 episode of vomiting Amnesia > 30 minutes before impactAmnesia > 30 minutes before impactIn patients with some LOC or amnesia since the injury:In patients with some LOC or amnesia since the injury: Age > 65Age > 65 CoagulopathyCoagulopathy Dangerous MOIDangerous MOI

CT ScanCT Scan

AdvantagesHigh sensitivity/specificityDetection of intracranial haematomaDefinitive (except ultra early)

DisadvantagesHigh dose of radiation (2.0mSv)Radiologist required

NICE vs SIGNNICE vs SIGN

NICE based on Canadian CT head rulesNICE based on Canadian CT head rules NICE lowers threshold for CT scanningNICE lowers threshold for CT scanning Difficulty in obtaining out-of-hours CT scansDifficulty in obtaining out-of-hours CT scans Massive increase in workload of radiology Massive increase in workload of radiology

departmentsdepartments Increased patient exposure to radiationIncreased patient exposure to radiation Increase in costIncrease in cost

ManagementManagement ABC (including C spine control)ABC (including C spine control) GCSGCS O2, analgesia, tetanus, ?antibiotics, IVIO2, analgesia, tetanus, ?antibiotics, IVI ?bloods?bloods ImagingImaging Neuro obs:Neuro obs:

pupil size and reactivitypupil size and reactivity Repeated GCS scoreRepeated GCS score General obs including p, BP, temp, BM, O2 sats, RRGeneral obs including p, BP, temp, BM, O2 sats, RR AlcometerAlcometer

Admission or Discharge?Admission or Discharge?

GCS < 15GCS < 15 GCS 15, butGCS 15, but

Continuing amnesiaContinuing amnesia Continuing nausea/vomitingContinuing nausea/vomiting Severe headacheSevere headache Any seizureAny seizure Focal neurological signsFocal neurological signs Skull fractureSkull fracture Abnormal CTAbnormal CT

Significant medical problemsSignificant medical problems Social problems/no supervision at homeSocial problems/no supervision at home

Discharge from A/EDischarge from A/E

None of the above exclusion criteriaNone of the above exclusion criteria Patient must be given head injury advicePatient must be given head injury advice Responsible adult to supervise the patientResponsible adult to supervise the patient Easy access to a telephoneEasy access to a telephone Reasonable access to a hospitalReasonable access to a hospital Easy access to transportEasy access to transport

Transfer to NeurosurgeryTransfer to Neurosurgery

Abnormal CT scanAbnormal CT scan CT is indicated but cannot be done within an appropriate CT is indicated but cannot be done within an appropriate

periodperiod Clinical features which warrant neurosurgical assessment, Clinical features which warrant neurosurgical assessment,

monitoring or management:monitoring or management: Persisting coma (GCS 8/15)Persisting coma (GCS 8/15) Persisting confusionPersisting confusion Deteriorating GCSDeteriorating GCS Progressive focal neurologyProgressive focal neurology Seizure without full recoverySeizure without full recovery Depressed skull fractureDepressed skull fracture Penetrating injuryPenetrating injury CSF leak/BOS fractureCSF leak/BOS fracture

Neurosurgical assessment and Neurosurgical assessment and monitoringmonitoring

Experienced staffExperienced staff

Intensive, specific monitoringIntensive, specific monitoring intracranial pressure monitoringintracranial pressure monitoring dedicated neuro-intensive carededicated neuro-intensive care specialised theatre suitesspecialised theatre suites

Rapid access to theatreRapid access to theatre

Head Injury AuditHead Injury Audit

Scottish Trauma Audit Group (STAG) Scottish Trauma Audit Group (STAG) 98% coverage throughout Scotland98% coverage throughout Scotland All head injuries attending A/E Departments in All head injuries attending A/E Departments in

4 teaching hospitals4 teaching hospitals All head injuries admitted to Scottish hospitalsAll head injuries admitted to Scottish hospitals

Pre-implementationPre-implementation November 1999November 1999Post-implementationPost-implementation May 2001May 2001

QUESTIONS?