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AUDIT OF MANAGEMENT OF HEAD TRAUMA

IN SLEMANI TEACHING HOSPITAL 2001 – 2002

DR. HIWA OMER AHMED


MB.CHB. C.A.B.S
CONSULTANT SURGEON STH
ASSISTANT PROFESSOR – COLLEGE OF MEDICINE – UNIVERSITY
OF SLEMANI

SUMMARY:
Background; Trauma remains the leading killer of children and young
adults, specially head trauma injuries of different types from fall from height (FFH) in
children to road traffic accident (RTA) and quarrelling in adolescence and young adults.
Every day many victims with head trauma will arrive the Surgical Casualty
Department of STH, managed first by house officer and senior house officers in general
Surgery.
Aim: to compare a study group with controle group to evaluate the role of
different lines and grugs in the management of head injured patients.
Patients, Methods and Materials: A retrospective review was undertaken of
160 patients admitted with headinjuries over a period of years from 1st April 2003 to 1st April
2004 ,in Sulemani Teaching Hospital. Demographic data obtained from the patients files ,study
has been designed that may predict the
outcome of these two types of managements. Eiety patients (Group- A) managed in the
authors surgical unit and the rest (Group B) managed by a colleague surgeons in another
surgical unit.
Comparative analysis between the two groups through multiple variables was
done to identify any different between them in the aspect of management and outcome.
Results: Most of the patients in both groups were males , most of the
injuries were mild. The most common type of trauma was fall from height, there was no
any correlation between # skull and physical findings as most of the patients with
physical findings.Differnt unneccessory drugs and lines of managements were used in the
controlled group , which add no any benefit to the patients, but increase the
complications.
Conclusion: we need a uniform standard revised updated schedule
for management of head injured patients in our casualty, aiming in saving lives and time
of the physician, nursing and radiological Staffs

Key words: Head injury, Glasgow coma scale, Audit


INTRODUCTLON

Trauma in general is the most common cause of death in children, adolescence


and young adults. Minor head injury is common in modern society (1). Care of the head
injured patients begins with assessment of severity and protection of the brain from
further insult. Outcome depends on recognition, severity and treatment of two
fundamentally distinct types of head injury: diffuse and focal.
To achieve correct management of this common problem, we need accurate
medical data recording and detailed and repeated neurosurgical examinations; including
records of repeated evaluation of the level of consciousness by Glasgow Coma Scale
(GCS), to assess the severity of the injury, diagnosing the life threatening conditions, to
protect the brain from second trauma. This recognition needs precise clinical evaluation
and imaging to differentiate the type of the injury: is it focal or diffuse, which need
different methods of treatment.
On the other hand (GCS) will help in classifying the head injury into minor
(13,14,15 scores), moderate (9,10,11,12 Scores) and severe (8 or less scores)(2), which
have different outcome & may need different levels of care and treatment. The objective
of scoring is to provide a uniform way of describing injuries, which can only be achieved
by obeying the rules, this still requires practice, as there are many pitfalls for the unwary,
clinical outcome in patients with minor head injury, might have been predicted from
history & clinical examination alone, and less than (1%) of these patients will develop an
intracranial complication.
The aim of this study is to audit two different methods of management of head
trauma patients in two surgical unites, to assess methods, which may improve the
outcome.
PATIENTS AND METHODS:
A retrospective review was undertaken of 160 patients admitted with headinjuries over a
period of years from 1st April 2003 to 1st April 2004 ,in Sulemani Teaching Hospital.
Demographic data obtained from the patients files ,study has been designed that may predict
the outcome of these two types of managements. Eiety patients (Group- A) managed in the
authors surgical unit and the rest (Group B) managed by a colleague surgeons in another
surgical unit.
Demographic details were extracted from action taken on basis of the finding was
noted Comparative analysis between the two groups through multiple variables was done
to identify any different between them in the aspect of management and outcome
.
RESULTS
Most of the patients in both groups (A & B) were males as in (Group A); male/
female ratio was 5/3 and in (Group B); was 5.1/2.9. Majority of the patients was in the
age group of (0-19 years) as shown in table I

No. of patients No. of patents


Age groups in years
Group A Group B
0 - 9 25 38
10 + 19 14 15
20 - 29 9 14
30 - 39 13 6
40 - 49 7 3
50 - 59 6 2
60 - 69 2 -
70 - 79 4 2

Table I: Showing age groups in both groups (A &B) of patients.


The most common type of trauma was fall from height as shown in table II
No. of patients No. of patients
Types of the trauma
Group A Group B
Fall From height 48 43
Road traffic accident 21 29
Quarrelling 11 8
Table II: showing types of the trauma in both groups (A&B) of
patients

Most of the injuries were mild (64patients in group-A), (52patients in group-B),


as showed in table III, which is clarifying the GCS of the patients on arrival.

Glasgow Coma No. of patients No. of patients


Severity
Scale Scores Group -A Group -B
15 60 43
Minor 14 4 4
13 - 5
12 6 7
11 1 12
Moderate
10 2 -
9 2 1
8 - 1
7 - 1
Severe
6 2 6
5 3 -
Table III. Showing GCS scoring in both groups (A&B) of
patients

Most of the patients (63 patients in group-A, 56 patients in group –B) remained in
hospital for up to 47 hours as shown in table IV. .

Period of admission No. of patients Group No. of patients


-A Group -B
0 - 23 hours 19 23
24 - 47 hours 44 31
3 - 9 days 14 23
13 days - 1
21 days 1 0
39 days 0 1
42 days 1 0
45 days 1 0
Table IV: showing period of admission in both groups (A-B) of patients.

GCS scoring was full (15 scores) in most (64patients in group-A) of the patients
Within 24 hours of admission, while there was no any records of this in the files of the
(group-B) as shown in Table V.

Day in which GCS scores No. of patients No. of patients in


became full (15) Group –A Group -B
Same day of admission 64
2nd day of admission 5
3rd day of admission 5
4th day of admission 2
NO RECORD
8th day of admission 1
16th day of admission 1
44th day of admission 1
45th day of admission 1

Table V: showing time when the GCS became full scored


Minority of the patients had positive physical finding as shown in table VI:

No. of patents No. of patents


Physical Findings
Group A Group B
Cranial nerve palsy 5 No. Record
Black eye due to Ant. cranial
14 10
fossa #
Rhinorrhea, Rhinorrhagia 4 4
Otorrhagia 1 3
Battle Sign 1 1
Table IIX: Showing results of the CT scans in patients form both groups (A, B).

These patients were managed in the casualty department and later in the surgical
unite on follow up as showing in table IX.

No. of patients No. of patients


Management
Group- A Group-B
Elevation of the head of the
80 60
patient
IVF 21 39
Craniotomy 2 No Record
Phenobarbiturate 10 7
Steroids - 61
Diuretic 1 4
Antibiotics 2 72
Analgesia - 63
Diazepam 1 4
Antiemetic - 3
Blood 2 6
Tracheostomy 2 -
Table IX: lines of the treatment in the both groups (A & B)
DISCUSSION:
We may notice from the results, that majority of the victims were children,
adolescence, sustaining minor head trauma (64.4% =116 patients) as shown in table I,
with GCS Scoring of (13,14,15). Majority were kept under observation for necessary
time (48) hours (table II), but routinely expressed to two views of skull radiographs with
only (14 patients) positive skull radiographs findings (table IV), while the majority of the
patients (64.4%) with minor head trauma may be evaluated clinically alone & skull
radiographs adds no further information to the decision weather to admit or send home
patients with a minor head injury and there in a report from Annals of Royal college of
Surgeons of England claiming that “ not to take skull radiographs routinely, “specially for
patients who are able to walk and talk when they reached medical
contact”(3).

On the other hand there was no hard correlation between findings in the skull
radiographs and the physical findings for example (table VI), there was seven cases of
rhinorrhea and rhinorrhagia which means anterior cranial fossa #, with only radiological
finding in one of them. Also there was four cases of otorrhagia with only one radiological
report of # in one of them.
These may be either due to the fact that most of the # usually are in the base of
skull, which are not evident on AP & lateral skull views, but need Special (Town view)
which in not in practice at least in Surgical Casualty Department or there is a gush of
routing skull X-rays (100%) which will put a have burden on radiological staff who is
alone on duty personal, the result will be bad quality skull radiographs which add nothing
to the clinical evaluation and decision
Few patients (9 patients) send selectively for CT-scanning of the skull & brain
(Table IIX), with (4) normal results, one extradural haematoma, and unfortunately there
is no paper or report or data recording in the files of the patents with the rest (5 patients in
group B). Majority of our patients were with minor hand injury which need just
observation and elevation of the head, unfortunately we found the elevation of the head
not practiced for all the patients in group-B (Table IX). Different drugs used in most of
the patients which is not necessary for patients with full GCS scoring for example patient
with file number (21211) had full Scoring (15), had no any injury, but received all the
types of the drugs & lines of treatment which you will see in (Table IX).
ELEVATION OF THE HEAD
Now it is clear that cerebral edema & hemorrhage within the cranial vault will
rapidly increase intracranial pressure (ICP), because the brain, unlike other organs is
rigidly confined with the skull (4) and in trauma the Brain Blood Barrier (BBB) will
disrupt. So elevation of the head will help in facilitation of venous drainage, which is the
only way, as there are no lymphatic vessels in the brain, and the veins are thin walled,
containing no muscle fibers in their wall which make them capable to distend
considerably.
IVF
It is better not to give intravenous fluid (IVF) routinely for head injured patients,
specially when there is no vomiting & the patient is conscious, and able to take orally.
When IVF is indicated, it is better to restrict the IVF therapy at least to 2/3 of that of
normal maintenance. Also it is better to avoid 5% glucose in water as it enhances the
edema process. So IVF “Should be administered Judiousely to prevent overhydration
which augments cerebral edema as mild dehydration wile protect the brain from insult
secondary to fluid over load
(5)
.

PHENOBARBITONE:
It will help in decreasing agitation, controls Seizures and decreases brain edema.
STEROIDES:
Are not recommended for the treatment of acute head injury.
DIURETICS:
In the emergency department should be administered only with the consent of a
neurosurgeon or to gain time when neurosurgical capabilities will be delayed and the
patient’s condition is deteriorating, because its beneficial effect is transient, the drug can
severely alter serum electrolyte and osmolarity
Patients who are given Steroid, osmotic diuretics, anticonvulsant & hyperosmolar
feeding are prone to develop hyperosmolar state, some times leading to hyperglycemic
nonketotic coma (6).
when may be analyzed as deterioration of the neurosurgical condition of the
patient.
ANTIBIOTICS
Prophylactic antibiotics are not used routinely because recent prospective studies
have failed to demonstrate any benefit from their use (7), so rarely indicated.

ANALGESIA
Aspirin & other nonsteroidal Analgesia all increase the risk of upper GIT bleeding
and peptic stress ulcers, so it is better not to be used routinely.

DIAZEPAM
Sedation reduces posturing & combat activity, both of which elevate ICP.

ANTIEMETIC
When used, it has symptomatic benefit but also may induces occulogyric crises,
which will be misinterpreted for unwary personal. There is a large difference between the
line of treatment in these two groups, but the mortality was same in both groups (A&B),
one patient in each group.
CONCLUSION
We may conclude from this audit, that skull radiographs and many drugs with
steroid, antibiotics, IVF, diuretics were used routinely without any additional benefit to
the standard management of the head injured patients, we need a uniform standard
revised updated schedule for management of head injured patients in our casualty, aiming
in saving lives and time of the physician, nursing and radiological Staffs
AKWOWLEAAEMENT
I would like to thank all the house officers & nursing staffs in my surgical unite &
statistical staffs in STH, Forensic medicine for their valuable technical help.
REFERENCES
1. B. R. Duns, T. Boesen, prognostic Signs in the evaluation of patients
with minor head injuries, British journal of surgery. 1997, Vol. 80, No. 8
,page (989)

2. American College of Surgeons Committee on Trauma: Head trauma


in Advanced Trauma life Support, Ed.6, American College of Surgeons. 1997.
Chap 6, pp.184.

3. F. W. cross: Care of RTA victims in district general hospital: Annals


of the Royal college of England, Nov 1992, Vol. 74, No 6, Page 438.
4. Nigel. We6ster. Monitoring the critically ill patients: Journal of
College of Surgeons of Edinburgh. 1999, Vol. 44, No.6, page 395.

5. Robert H. Wilkins, Settee S. Rengachary. Text book of Neurosurgery


1st edition Vol. I, McGraw Hill company New York, 1985, page 404.
6. Spencer, Shires, Neurosurgery cited in Schwartz, Spencer, Shires & Daleys
Principles of Schwartz, 1999, Vol. 3, (1879), McGraw Hill
7. Raymond H. Alexander, Herbert J, Advanced Trauma life Support, 1st edition
American College of Surgeons, 1993, Page 179.