1 / 36

MILD HEAD INJURY (MHI)

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

sawyer-spencer
Télécharger la présentation

MILD HEAD INJURY (MHI)

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. MILD HEAD INJURY (MHI) Bernard Foley Auckland Hospital Emergency Department 6th October 2001

  2. 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

  3. 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

  4. 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

  5. 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

  6. MHI CAUSES • ROAD CRASH 40% • FALLS 20% • ASSAULT 15% • SPORTS 12% • CHILDREN CONSIDER NAI

  7. MHI DIAGNOSES • CONCUSSION 80% • FACIAL/SKULL FRACTURE 10% • CONTUSION 5% • HAEMORRHAGE 1%

  8. 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

  9. 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

  10. CONTUSION • Bruising of brain substance • Morbidity relates to size and site of contusion • Commonly occur in frontal and temporal lobes

  11. INTRACRANIAL BLEEDING • Extradural • Subdural • Intracerebral • Subarachnoid • Intraventricular

  12. 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

  13. 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%

  14. 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

  15. MILD HEAD INJURY 2 • Likelihood of abnormal CT @ 10% • Neurosurgical intervention <1%

  16. MODERATE HEAD INJURY • GCS 9-13 • Likelihood of abnormal CT 40% • Neurosurgical intervention @ 8% • Mortality 20% • Long term disability 50%

  17. SEVERE HEAD INJURY • GCS <9 • Mortality 40% • Long term disability >90%

  18. HISTORY • Accident events • Duration of L.O.C. • Seizure? • Amnesia • Nausea/vomiting • Drug use • Coexistent medical problems/allergies etc.

  19. PHYSICAL EXAMINATION • Primary survey • GCS • Check/protect C-spine • Pupils • Signs of skull/ basal skull fracture • Focal neurology • Other injuries

  20. NEUROLOGICAL OBSERVATIONS • No good evidence of usefulness • No evidence regarding duration • 4-hours v 24-hours • Possibly useful if no imaging available

  21. 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

  22. 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

  23. CT HEAD CONS • EXPENSE • AVAILABILITY • MAY REQUIRE TRANSPORT TO ANOTHER FACILITY • RADIATION EXPOSURE • PATIENT ISOLATION • ?SEDATION REQUIRED esp. KIDS

  24. 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

  25. 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

  26. 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

  27. 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

  28. WHO TO SCAN • AGE > 65 • INTOXICATED • SEVERE HEADACHE • VOMITING • SEIZURE • SIGNS OF SKULL FRACTURE • FOCAL NEUROLOGY • ? ALL LATE PRESENTERS

  29. MANAGEMENT • Analgesia • Attend to other injuries • ? Tetanus prophylaxis • ? Observation • Referral if requires inpatient care • Documentation (incl.. ACC)

  30. 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

  31. 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

  32. 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

  33. 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

More Related