Guidelines on the early

management of head injury

J Kerr
A&E
Royal Infirmary, Edinburgh
Head Injury
10% of A/E workload
A/E Dept seeing 85,000 annual attendances
8,500 head injuries
1,700 admissions
35 head injuries requiring resuscitation
20 require neurosurgery
220 patients require CT scan
5100 patients can be discharged safely from A/E
Significant cost
Expeditious management reduces secondary brain
injury
Associated injuries and secondary effects
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
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
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
SIGN August 2000
Canadian CT Head Rules 2001
NICE June 2003

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


NICE
National Institute for Clinical Excellence
Established as a Special Health Authority in
England and Wales, April 1st 1999
Technology appraisals and clinical guidelines
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.
NICE SIGN
AGREE
HISTORY
Mechanism of Injury (MOI)
Fall
RTA
Assault
Blunt or penetrating trauma
Associated injuries
ALCOHOL
Symptoms
LOC
Amnesia
Nausea and/or vomiting
Epistaxis
Visual disturbance
Headache
Dizziness/drowsiness
GLASGOW COMA SCALE
Eye opening 4 eyes open spontaneously
3 open to speech
2 open to pain
1 no opening

Motor response 6 obeys commands
5 localizes to pain
4 flexion
3 abnormal flexion
2 extension
1 no movement

Verbal response 5 orientated
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no speech
Indications for referral to
hospital

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


Periorbital bruising
Subconjunctival
haemorrhage
CSF rhino/otorrhoea
Epistaxis
Haemotympanum
Battles sign
Base of skull fracture
BASE OF SKULL
FRACTURE
Skull x-ray indications - SIGN

GCS < 15 or
GCS 15, but:
MOI not trivial
LOC
Amnesia or has vomited
Full thickness scalp laceration/boggy haematoma
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 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
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
Radiological/clinical evidence of fracture
GCS 15, no fracture but:
Severe/persistent headache, N+V, irritability or altered
behaviour, seizure
CT Indications - NICE
GCS less than 13 at any point since the injury
GCS 13 or 14 at 2 hours after the injury
Suspected open or depressed skull fracture
Any sign of BOS fracture
Post-traumatic seizure
Focal neurological deficit
>1 episode of vomiting
Amnesia > 30 minutes before impact
In patients with some LOC or amnesia since the injury:
Age > 65
Coagulopathy
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 lowers threshold for CT scanning
Difficulty in obtaining out-of-hours CT scans
Massive increase in workload of radiology
departments
Increased patient exposure to radiation
Increase in cost





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




Admission or Discharge?
GCS < 15
GCS 15, but
Continuing amnesia
Continuing nausea/vomiting
Severe headache
Any seizure
Focal neurological signs
Skull fracture
Abnormal CT
Significant medical problems
Social problems/no supervision at home
Discharge from A/E
None of the above exclusion criteria
Patient must be given head injury advice
Responsible adult to supervise the patient
Easy access to a telephone
Reasonable access to a hospital
Easy access to transport
Transfer to Neurosurgery
Abnormal CT scan
CT is indicated but cannot be done within an appropriate
period
Clinical features which warrant neurosurgical assessment,
monitoring or management:
Persisting coma (GCS 8/15)
Persisting confusion
Deteriorating GCS
Progressive focal neurology
Seizure without full recovery
Depressed skull fracture
Penetrating injury
CSF leak/BOS fracture
Neurosurgical assessment and
monitoring
Experienced staff

Intensive, specific monitoring
intracranial pressure monitoring
dedicated neuro-intensive care
specialised theatre suites

Rapid access to theatre





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

Pre-implementation November 1999
Post-implementation May 2001
QUESTIONS?