Guidelines on the early management of head injury J Kerr A&E Royal Infirmary, Edinburgh

Head Injury 10% of A/E workload 10% of A/E workload A/E Dept seeing 85,000 annual attendances A/E Dept seeing 85,000 annual attendances 8,500 head injuries 8,500 head injuries 1,700 admissions 1,700 admissions 35 head injuries requiring resuscitation 35 head injuries requiring resuscitation 20 require neurosurgery 20 require neurosurgery 220 patients require CT scan 220 patients require CT scan 5100 patients can be discharged safely from A/E 5100 patients can be discharged safely from A/E Significant cost Significant cost Expeditious management reduces secondary brain injury Expeditious management reduces secondary brain injury Associated injuries and secondary effects Associated injuries and secondary effects High proportion of patients have a subsequent disability High proportion of patients have a subsequent disability

Guidelines Guidelines for initial management after head injury in adults - Suggestions from a group of neurosurgeons March 1984 Guidelines for initial management after head injury in adults - Suggestions from a group of neurosurgeons March 1984 Commission on the Provision of Surgical Services. Report of the Working Party on Head Injuries. London: RCS; 1986 Commission on the Provision of Surgical Services. Report of the Working Party on Head Injuries. London: RCS; 1986 European Brain Injury Consortium. Guidelines for the management of severe head injury in adults 1997 European Brain Injury Consortium. Guidelines for the management of severe head injury in adults 1997 British Neurological Surgeons 1998 British Neurological Surgeons 1998 Report of the Working Party on the Management of Patients with Head Injuries - Prof Galasko; Royal College of Surgeons of England June 1999 Report of the Working Party on the Management of Patients with Head Injuries - Prof Galasko; Royal College of Surgeons of England June 1999 SIGN August 2000 SIGN August 2000 Canadian CT Head Rules 2001 Canadian CT Head Rules 2001 NICE June 2003 NICE June 2003

SIGN Scottish Intercollegiate Guidelines Network Scottish Intercollegiate Guidelines Network Formed in 1993 Formed in 1993 Development of SIGN Guidelines - series of 70+ publications Development of SIGN Guidelines - series of 70+ publications No 46: ‘Early Management of Patients with a Head Injury’ - published August 2000 No 46: ‘Early Management of Patients with a Head Injury’ - published August 2000

NICE National Institute for Clinical Excellence National Institute for Clinical Excellence Established as a Special Health Authority in England and Wales, April 1st 1999 Established as a Special Health Authority in England and Wales, April 1st 1999 Technology appraisals and clinical guidelines Technology appraisals and clinical guidelines ‘Head Injury; Triage, assessment, investigation and early management of head injury in infants, children and adults’ published June 2003 ‘Head Injury; Triage, assessment, investigation and early management of head injury in infants, children and adults’ published June 2003

Guidance represents the view of the Institute, which was arrived at after a careful consideration of the available evidence. Health professionals are expected to take it fully into account when exercising their clinical judgement, it does not however override their individual responsibility to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

HISTORY Mechanism of Injury (MOI) Fall Fall RTA RTA Assault Assault Blunt or penetrating trauma Blunt or penetrating trauma Associated injuries Associated injuries ALCOHOL ALCOHOL

Symptoms LOC LOC Amnesia Amnesia Nausea and/or vomiting Nausea and/or vomiting Epistaxis Epistaxis Visual disturbance Visual disturbance Headache Headache Dizziness/drowsiness Dizziness/drowsiness

GLASGOW COMA SCALE Eye opening4eyes open spontaneously 3open to speech 2open to pain 1no opening Motor response6obeys commands 5localizes to pain 4flexion 3abnormal flexion 2extension 1no movement Verbal response5orientated 4confused 3inappropriate words 2incomprehensible sounds 1no speech

Indications for referral to hospital GCS < 15 at any time since the injury GCS < 15 at any time since the injury Amnesia Amnesia Neurological symptoms Neurological symptoms Clinical evidence of a skull fracture Clinical evidence of a skull fracture Significant extracranial injuries Significant extracranial injuries MOI not trivial MOI not trivial Continuing uncertainty about diagnosis Continuing uncertainty about diagnosis Medical co-morbidity Medical co-morbidity Adverse social factors Adverse social factors

Periorbital bruising Periorbital bruising Subconjunctival haemorrhage Subconjunctival haemorrhage CSF rhino/otorrhoea CSF rhino/otorrhoea Epistaxis Epistaxis Haemotympanum Haemotympanum Battle’s sign Battle’s sign Base of skull fracture

BASE OF SKULL FRACTURE

Skull x-ray indications - SIGN GCS < 15 or GCS < 15 or GCS 15, but: GCS 15, but: MOI not trivial MOI not trivial LOC LOC Amnesia or has vomited Amnesia or has vomited Full thickness scalp laceration/boggy haematoma Full thickness scalp laceration/boggy haematoma Inadequate history Inadequate history

Skull x-ray indications - NICE Skull x-rays have a role in the detection of non- accidental injury in children Skull x-rays have a role in the detection of non- accidental injury in children Skull x-rays in conjunction with high-quality in- patient observation also have a role where CT scanning resources are unavailable Skull x-rays in conjunction with high-quality in- patient observation also have a role where CT scanning resources are unavailable

Skull X-ray Advantages Quick No need for radiologist Low dose of radiation (0.14mSv) Inexpensive Disadvantages Increased workload Inconclusive

CT Indications - SIGN GCS 12/15 or less GCS 12/15 or less Deteriorating GCS or progressive focal neurological signs Deteriorating GCS or progressive focal neurological signs Confusion or drowsiness (GCS 13-14) followed by failure to improve within at most 4 hours of clinical observation Confusion or drowsiness (GCS 13-14) followed by failure to improve within at most 4 hours of clinical observation Radiological/clinical evidence of fracture Radiological/clinical evidence of fracture GCS 15, no fracture but: GCS 15, no fracture but: Severe/persistent headache, N+V, irritability or altered behaviour, seizure Severe/persistent headache, N+V, irritability or altered behaviour, seizure

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

CT Scan Advantages High sensitivity/specificity Detection of intracranial haematoma Definitive (except ultra early) Disadvantages High dose of radiation (2.0mSv) Radiologist required

NICE vs SIGN NICE based on Canadian CT head rules NICE based on Canadian CT head rules NICE lowers threshold for CT scanning NICE lowers threshold for CT scanning Difficulty in obtaining out-of-hours CT scans Difficulty in obtaining out-of-hours CT scans Massive increase in workload of radiology departments Massive increase in workload of radiology departments Increased patient exposure to radiation Increased patient exposure to radiation Increase in cost Increase in cost

Management ABC (including C spine control) ABC (including C spine control) GCS GCS O2, analgesia, tetanus, ?antibiotics, IVI O2, analgesia, tetanus, ?antibiotics, IVI ?bloods ?bloods Imaging Imaging Neuro obs: Neuro obs: pupil size and reactivity pupil size and reactivity Repeated GCS score Repeated GCS score General obs including p, BP, temp, BM, O2 sats, RR General obs including p, BP, temp, BM, O2 sats, RR Alcometer Alcometer

Admission or Discharge? GCS < 15 GCS < 15 GCS 15, but GCS 15, but Continuing amnesia Continuing amnesia Continuing nausea/vomiting Continuing nausea/vomiting Severe headache Severe headache Any seizure Any seizure Focal neurological signs Focal neurological signs Skull fracture Skull fracture Abnormal CT Abnormal CT Significant medical problems Significant medical problems Social problems/no supervision at home Social problems/no supervision at home

Discharge from A/E None of the above exclusion criteria None of the above exclusion criteria Patient must be given head injury advice Patient must be given head injury advice Responsible adult to supervise the patient Responsible adult to supervise the patient Easy access to a telephone Easy access to a telephone Reasonable access to a hospital Reasonable access to a hospital Easy access to transport Easy access to transport

Transfer to Neurosurgery Abnormal CT scan Abnormal CT scan CT is indicated but cannot be done within an appropriate period CT is indicated but cannot be done within an appropriate period Clinical features which warrant neurosurgical assessment, monitoring or management: Clinical features which warrant neurosurgical assessment, monitoring or management: Persisting coma (GCS 8/15) Persisting coma (GCS 8/15) Persisting confusion Persisting confusion Deteriorating GCS Deteriorating GCS Progressive focal neurology Progressive focal neurology Seizure without full recovery Seizure without full recovery Depressed skull fracture Depressed skull fracture Penetrating injury Penetrating injury CSF leak/BOS fracture CSF leak/BOS fracture

Neurosurgical assessment and monitoring Experienced staff Experienced staff Intensive, specific monitoring Intensive, specific monitoring intracranial pressure monitoring intracranial pressure monitoring dedicated neuro-intensive care dedicated neuro-intensive care specialised theatre suites specialised theatre suites Rapid access to theatre Rapid access to theatre

Head Injury Audit Scottish Trauma Audit Group (STAG) Scottish Trauma Audit Group (STAG) 98% coverage throughout Scotland 98% coverage throughout Scotland All head injuries attending A/E Departments in 4 teaching hospitals All head injuries attending A/E Departments in 4 teaching hospitals All head injuries admitted to Scottish hospitals All head injuries admitted to Scottish hospitals Pre-implementationNovember 1999 Post-implementationMay 2001

QUESTIONS?