ࡱ> L( %$/ 00DTimes New RomanȷȷԳ0 0DArialNew RomanȷȷԳ0 0" DWingdingsRomanȷȷԳ0 00DSymbolgsRomanȷȷԳ0 0   @n?" dd@  @@`` P)#        j(I  0@8Hg42d2d 0 ppp@ <4!d!dȷ <4BdBdȷȷg4SdSd 0p@ pp~___PPT9`X@0___PPT10 pp? %D&Minor Head Injury Dr J Martin SHO in A&E LGI Minor Head Injury GWhat it is How to investigate it How to stratify risk What to do then 2FFEvidence (EBM grading)Ia meta-analysis of RCTs Ib 1 RCT IIa systematic review of Cohort studies IIb 1 Cohort study IIIa systematic review of Case control Studies IIIb 1 Case control study IV 1 Case Series V Evidence obtained from experts#"# " '#"#"z # $$      $    +  G Evidence based GuidelinesN Standards  Class I evidence (RCTs)  Guidelines  Class II evidence or lots of Class III and IV  Options  Class V (expert opinion) much less useful' C< !! ! !7! !!2!!Traumatic Brain Injury10% of all A&E attendance and hospital admission Occurs for 300/100,000 population Subset of acquired brain injury Most head injuries are minor (80%) 4/100,000 has handicap or disability 6/12 after 0.37/100,000 require long-stay care<Z0! ! $0  Mechanisms of InjuryPrimary injury and Secondary injury: Primary injury  Mechanical nervous  shear causing axonal injury, direct pressure vascular  hemorrhage, hematoma,thrombosis Secondary injury (biochemical) Genetic (Apoptosis) programmed cell death Metabolic upset eg. acidosis Ischemia ( ICP, Vasospasm) Free radicals Excitotoxins @%c $#"# "  #"6#"+ # $"$(#(,",*0#04"4(8#8888#8<<P h7  Pathophysiology Scalp injuries Lacerations contusions abrasions Fractures of the skull vault or base simple or compound depressed or planar Brain injury Focal Intra-cranial haematomas Extradural Subdural Intracerebral Contusions Coup, Contre-coup - contralateral Diffuse (diffuse axonal injury)ZZ"Z%Z'ZZZZ"Z Z"Z Z"#!#"$ # "&#"# # $#$$#$("(,#, ,#,"0#04#48"8b   ! /Natural History of Minor Traumatic Brain Injury00 >No set definition of Minor Injury Diffuse Axonal injury does occur Secondary injury also occurs Can take up to 2/52 to develop fully But 80% recover within 2/52 Up to 20% ongoing symptoms - miserable minority American neuropsychologists now spend most of their professional time evaluating traumatic brain injury! ?Z##E#"%# # ##"R Predictors of Outcome  FDSM IV  Post Concussional Disorder$    A: History of head injury including 2+ of: LOC >5 mins PTA >12 hours Onset of seizures <6/12 afterwards B: Current symptoms 1+ cognitive difficulties: Learning or memory (recall) Concentration 3+ affective or vegetative symptoms: Easy fatiguability aggression Insomnia Anxiety, depression Headache Personality change Vertigo/dizziness Aspontaneity/apathy C: Can t maintain premorbid occupational, social or academic performance,Z@lZZlZ.Z&lZZIZ+# #  ### # $#$((,#,,#,004#488$<#<<#<##f #  # I#P3 a  .Guideline HuntingLots American vs European Difficult to get good evidence No standardisation of terminology SIGN Guidelines:  Early Management of Patients with a Head Injury 08/2000 WHO Guidelines:  Defining Acute Mild Head Injury in Adults 07/2001 lZ<ZZ7ZZl<7 Transfer to HospitalWPotential for brain damage exists Presence of a wound that might need surgical repair .XV!!  Impaired consciousness Post traumatic amnesia Neurological symptoms severe and persistent headache nausea and vomiting irritability or altered behaviour seizure Clinical evidence of a skull fracture CSF leak periorbital haematoma Significant extracranial injuries A mechanism of injury suggesting a high energy injury possible penetrating brain injury ?NAI ? diagnosis after first assessment Medical co-morbidity anticoagulant use alcohol abuse Adverse social factorsHDZ]Z&ZZCZ=Z8Z ZZ#"# " #"#" # $"$!(#(,",0#04"4&8#88#8<"<!#" # " 7#"#"" # $"$(#((#(,",0#044R         /              7  " 4  Assessment of PatientjATLS A  with C-spine control B  with ventilatory support C  with haemorrhage control To maintain adequate cerebral perfusion and oxygenation to prevent secondary brain injury GCSnSZ :Z  '   (GCS in 7,656 Scottish patients with HI .( (!(  ImagingReverse of pneumonia Intracranial lesions can be detected radiologically earlier than clincially Therefore radiology potentially more useful in this setting But which test? !,: M4X-rays  how bad are they?Risks associated with radiation measured in Sieverts CT brain 2.0mSv SXR 0.14mSv 0.04 lethal cancers per Sievert. Cigarettes. One lethal cancer per 80,000 packs. 1mSv = 3.2 packs of cigarettes x4!"!" !  0!! ,,>T <CT head = 6.4 packs of cigarettes SXR (3 films) = 9 fags F<!! ! Risk factors for an intracranial lesion  surgically significant intracranial haematoma After Teasdale et al 19902rW"""  SXR or CTVEven the people who made the guidelines couldn t really agree on whether CT or SXR was the way forward Graded evidence level V There are NO trials in this area as yet. ZZ*Zf! ! ! (!  Workable SXR guidelinesSXR if CT is not being performed and : GCS 15/15 but: the mechanism of injury has not been trivial consciousness has been lost the patient has loss of memory or has vomited the scalp has a full thickness laceration or a boggy haematoma the history is inadequate. GCS 14/15 T'  &#" # " #",#" # $"$-(#(,",>0#04"48#8<"< #"&    ,  - 5       Providing, of course we see the skull fracture on the x-ray In 1987 in a Glasgow Casualty dept over 9/12 saw 3500 pts with HI SHOs diagnosed 66 skull # - 27 weren t # Radiologist reported 45 #  6 missed by cas officers vZ_!!) ! !4!!,~N CTIf any of the following: The patient is eye opening only to pain or does not converse (GCS 12/15 or less) A deteriorating level of consciousness or progressive focal neurological signs GCS 13-14/15 not improving over max 4hrs Radiological/clinical evidence of a fracture, whatever the level of consciousness New focal neurological signs GCS 15/15 with no fracture but other features severe and persistent headache nausea and vomiting irritability or altered behaviour a seizure. LZgZaZ#<#" # "N#"(# " Q$#$("(L,#,0#04"48#8<"<!#" #  U  N ( Q j       Admission to hospitalGCS <15/15 GCS 15/15 but any of: continuing amnesia continuing nausea and/or vomiting a seizure focal neurological signs irritability or abnormal behaviour clinical or radiological evidence of a skull fracture suspected penetrating injury abnormal CT scan severe headache or other neurological symptoms the patient has significant medical problems, e.g. anticoagulant use the patient has social problems "ZtZZ #"#5# "  #"#"" # $"$5(#(,",0#04"48#8<"<.#"D# " #"  L       5   . D  Pitfalls Recovered, GCS 15, but LOC or amnesia of the event Length of LOC Amnesia Post-traumatic Retrograde There is no evidence for a cut off Higher risk certainly of PCD Z4ZZZ#Z ZZ"3#" #  # #cc#WHO guidelines for MILD HILow risk GCS 15 No LOC, amnesia, vomiting, diffuse headache Haematoma risk <1in1000 Home Medium risk GCS 15 + one of LOC, amnesia, vomiting, diffuse headache If 1 CT scanner per 100,000 then CT else SXR Haematoma risk 3% if # becomes High risk ZPZ ZZ #2#"# "  c  #8#"U# "  High Risk GCS 14-15 + Skull # +/- neuro deficits CT Haematoma 6-10% Coagulopathy, drugs, EtOH, previous NeuroSx, epilepsy, >60 automatically High risk ~  !&! ! R!P#   *Questions unansweredWhat is the sensitivity and specificity of the clinical exam? Should everyone with LOC & GCS 15 have a CT? What to do if CT is Normal Less severe injury Normal CT head and D/C Or IP observation & D/C? Z1Z=! ,! ! !/! P  ` f3f3` ff̙` ___` ff` 3ff3f>?" dd@,?lPd@   Z l<@ d`"  n?" dd@   @@``PR    @ ` ` p>> 91 (   ^T y   y"Z   S B7 C DEHFPv @?q 6 6 n(dx  G b q %(@B y"2   ZG1?"  Tgֳgֳ ?P  T Click to edit Master title style! !"  Tgֳgֳ ?``  =*"  Tgֳgֳ ?`   ?*"  TDgֳgֳ ?`   ?*"$  0   RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S"`  Hd޽h? ?  f3f3 Soaring  ` (  T t  t"Z  S BsC5 DEHFPv @?3 r4 rv$[I_l3HxF 3 %(@ "2  3 CRENGCJRQ1? `TO`TR`TO`TRR`TRRt"  TXgֳgֳ ?/O X T Click to edit Master title style! !"  TğXgֳgֳ ?pp  X W#Click to edit Master subtitle style$ $"  T$Xgֳgֳ ?`` X =*"  TXgֳgֳ ?`  X ?*"   TXgֳgֳ ?`  X ?*"`  Hd޽h? ? f3f3 0 @.(    0ԃ P    Y*   04     [* d  c $ ?    0  @ X RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  6 `P  X Y*   6T `  X [* H  0޽h ? ̙33 04(    0T P    =*   0     ?*   6 `P   =*   6t `   ?* H  0޽h ? ̙33$ P$(  r  S DX X r  S Xpp  X H  0޽h ? f3f380___PPT10.4>k   |(    S 4 P<$D 0     S  <$ 0  H  0޽h ? ̙33'___PPT10.+vDg' = @B D"' = @BA?%,( < +O%,( < +DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D~' =%(D&' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<* D' =1:Bvisible*o3>+B#style.visibility<* %(D~' =%(D&' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<* !D' =1:Bvisible*o3>+B#style.visibility<* !%(D~' =%(D&' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*!6D' =1:Bvisible*o3>+B#style.visibility<*!6%(D~' =%(D&' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*6FD' =1:Bvisible*o3>+B#style.visibility<*6F%(+p+0+ ++0+ +<  p|(    S ĢX P<$D 0     S X <$ 0  H  0޽h ? f3f3<  |(    S DX P<$D 0     S X <$ 0  H  0޽h ? f3f3<  |(    S DX P<$D 0     S X <$ 0  H  0޽h ? f3f3<   |(     S ĨX P<$D 0  X   S $X <$ 0  H  0޽h ? f3f3<  $|(  $ $ S DX <$D 0    $ S { <$ 0  H $ 0޽h ? f3f3<  (|(  ( ( S ԅ{ <$D 0    ( S 4{  <$ 0  H ( 0޽h ? f3f3+7  66hi,k6(  ,r , S     5F Xc i, P` 5@ U` g,U`@ ( &,( , 6+ \ , "   ` %, 0(@ (  (,(  , 6Sg  zProbable Good/Rapid Recovery @ #"` ', 0( @  U *, U , 6 * #Possible Poor/Slow Recovery Curve @# "#"` ), 0 U@ (  ,,(  , 6+  aInjury > # "  ` +, 0( @ (  .,(   , 6DSg  FNo collateral injuries; no structural lesions; no or short LOC + PTA :F E# "  ` -, 0( @  U  0, U   , 6 *  Ccollateral injuries; possible structural lesions; longer LOC + PTA :C B# "  ` /, 0 U @  ( 2, (  , 6+  _Pain > # "  ` 1, 0 (@ (   4,(    , 6dS g  YNo : # "  ` 3, 0(  @  U 6, U  , 6 * ZYes : # "  ` 5, 0 U@ (  8,(   , 6$+  ^Age > # "  ` 7, 0( @ (  :,(  , 6Sg  c Young adult :   # "  ` 9, 0( @  U  <, U  , 6  *  sOlder adult (or young child) : # "  ` ;, 0 U @  ( >, ( , 6d!+  iGeneral Health > # "  ` =, 0 (@ (   @,(   , 6!S g  \Good : # "  ` ?, 0(  @  U B, U , 6$" * \Poor : # "  ` A, 0 U@ (  D,(  , 6"+  }!Intellectual/cognitive abilities @!  # "  ` C, 0( @ (  F,(  , 6#Sg  gHigh to average : # "  ` E, 0( @  U  H, U  , 6d$ *  iLow (or very high) : # "  ` G, 0 U @  (  J, (  , 6$%+   Previous HI, Neuro problem > # "    ` I, 0 ( @ (  L,(  , 6%S g  ZNo : # "  ` K, 0( @  U  N, U  , 6% *  ZYes : # "  ` M, 0 U @  (  P, (  , 6ԕ+   uAlcohol/drug abuse at time > # "  ` O, 0 ( @ (  R,(  , 64S g  [No : # "  ` Q, 0( @  U  T, U  , 6 *  ZYes : # "  ` S, 0 U @  ( V, ( , 6+  3Previous psychiatric history or present depression @3 2# "  ` U, 0 (@ (  X,(  , 6TS g  ZNo : # "  ` W, 0( @  U Z, U , 6 * ZYes : # "  ` Y, 0 U@ ( \,( , 6+ 5Psychosocial, economic and vocational support system >5 4# "  ` [, 0(@ (  ^,(   , 6ԘSg  ^Strong : # "  ` ], 0( @  U `, U !, 64 * \Poor : # "  ` _, 0 U@ (` b,(` ", 6+` xHead injury information & F/U > # "  ` a, 0(`@ ( ` d,( ` #, 6TSg ` ZYes : # "  ` c, 0( `@  U` f, U` $, 6 *` YNo : # "  ` e, 0 U`Z h, s *XcH , 0޽h ? f3f3R  0(  0 0 S  <$D 0    0 S t ` <$ 0  "p`PpH 0 0޽h ? f3f3H  \(  \ \ c $ P<$D 0    \ c $T <$ 0  H \ 0޽h ? f3f3<  8|(  8 8 S  P<$D 0    8 S  <$ 0  H 8 0޽h ? f3f3  F><(  < < S t <$ 0  H < 0޽h ? f3f3H   d(  d d c $4 P<$D 0    d c $ <$ 0  H d 0޽h ? f3f3  7/0'@(  @ @ S T  <$ 0    P`J '@J,$D 0#""**,* %@ B? `  NChildren   @` #@ B?  LAdults @` !@ BD ?P  IGCS @`  @ B ? `J J0.5% @`  @ B!?  J H1% @`  @ Bd!?P J H<8 @`  @ B!? `  J3.5% @`  @ B$"?  H6% @` @ B"?P   J9-14 @` @ B"? `  I96% @` @ BD#?  I93% @` @ B#?P   H15 @`fB @ 6o ?P``B @ 01 ?P ` `B @ 01 ?P ` fB @ 6o ?PJ`JfB @ 6o ?PPJ`B @ 01 ?J`B @ 01 ?  JfB @ 6o ?``J`B "@ 01 ?P ` H @ 0޽h ? f3f3<  @D|(  D D S d$ P<$D 0    D S $ <$ 0  H D 0޽h ? f3f3<  PH|(  H H S % P<$D 0    H S % <$ 0  H H 0޽h ? f3f3j  `L(  Lr L S D& 0  H L 0޽h ? f3f3 &  %%p7HPI%(  P P S & <$D 0   k$ P HP ,$D 0#"6*  (P <'?px  P1 in 4 @` 'P <'?x p XSkull fracture @` &P <$(?x  T  @` %P <(?Px  T  @` $P <D)?pY x  R1 in 27    @` #P <*?Y px  U No fracture   @` "P <d*?Y x  P1 in 7 @` !P <*?PY x  M3-8 @`  P <$+?p: Y  P1 in 5 @` P <?: pY  XSkull fracture @` P <?: Y  T  @` P <d?P: Y  T  @` P <$?p :  R1 in 180   @` P <䯁? p:  U No fracture   @` P <D? :  Q1 in 51 @` P <?P :  N9-14 @` P <?p  Q1 in 29 @` P <ı?p  `Skull fracture and PTA @` P <$?  T  @` P <?P  T  @` P <䲁?p Q1 in 81 @` P <?p XSkull fracture @` P <? T  @` P <d?P T  @` P <$?p S 1 in 6700   @` P <䵁?p `Post traumatic amnesia @` P <D? T  @`  P <?P T  @`  P <d?p T 1 in 31300   @`  P <ķ?p NNone @`  P <? S 1 in 3165   @`  P <丁?P L15 @` P <D?p NRisk @` P <$?p XOther Features @` P <? NRisk @` P <?P MGCS @``B )P 01 ?P`B *P 01 ?P`B +P 01 ?P`B ,P 01 ?P`B -P 01 ?P`B .P 01 ?P  `B /P 01 ?P: : `B 0P 01 ?PY Y `B 1P 01 ?Px x fB 2P 6o ?PfB 3P 6o ?PP`B 4P 01 ?`B 5P 01 ?`B 6P 01 ?ppfB 7P 6o ?fB 9P 6o ?H P 0޽h ? f3f3<  T|(  T T S D P<$D 0    T S  <$ 0  H T 0޽h ? f3f3<  X|(  X X S d P<$D 0    X S  <$ 0  H X 0޽h ? f3f3  F>(    S  0 <$ 0  H  0޽h ? f3f3<  h|(  h h S   <$D 0    h S d  `P<$ 0  H h 0޽h ? f3f3<  l|(  l l S ! <$D 0    l S ! pP<$ 0  H l 0޽h ? f3f3<  p|(  p p S D" P<$D 0    p S " <$ 0  H p 0޽h ? f3f3<  t|(  t t S d# P<$D 0    t S #  <$ 0  H t 0޽h ? f3f3  F>x(  x x S $  <$ 0  H x 0޽h ? f3f3<  ||(  | | S & P<$D 0    | S d& <$ 0  H | 0޽h ? f3f3rLXmKӈ[ |=7H ,^n:~$0gahkp` &Oh+'0@ hp   , 8 DPXMinor Head Injurye.noMC:\Program Files\Microsoft Office\Templates\Presentation Designs\Soaring.pot\pauligr9ulMicrosoft PowerPointoso@' @W+@&6GoM   :& &&#TNPPp0D & TNPP &&TNPP    &&--&&- $<<- $<xx<- $xx- $- $,,- $,hh,- $hh- $- $- $XX- $XXj- $T- $  ?- $ HH +- $HH- $&&&- & $&&-&& &&-&&&&- $<<- $<xx<- $xx- $- $,,- $,hh,- $hh- $- $- $XX- $XXj- $T- $  ?- $ HH +- $HH- $&- --&&&&W&--&&/w- $W~~W1|- $~~4- $7- $<- $ A- $??#F- $?ee?&L- $ee(R- $+W- $-[- $/^- $&&0a- $&MM&1c- $MttM2d- $tt2e- $&&&- &($UWr0AVm&5(AJIfPSU&&-&& &&-&&($UWr0AVm&5(AJIfPSU&&/w- $W~~W1|- $~~4- $7- $<- $ A- $??#F- $?ee?&L- $ee(R- $+W- $-[- $/^- $&&0a- $&MM&1c- $MttM2d- $tt2e- $&- --&&&X3f--:%4Sp/^!Bfy* 4$<<DSJlORTU--&&&G& |w|wgw - &Gy& --[X*-- "Arial( |w|wgw( - .!2 Minor Head Injury1 ! *!! ! . f.!2 Minor Head Injury1 ! *!! ! .--!hH-- fTimes New Roman|wgw - .2 5 Dr J Martin  & . .2 SHO in A&E LGI  ! .--"Systemw[f@  -&TNPP &՜.+,D՜.+,    [On-screen Show.-s!$j !Times New RomanArial WingdingsSymbolSoaringMinor Head Injury Minor Head Injury Evidence (EBM grading)Evidence based GuidelinesTraumatic Brain InjuryMechanisms of InjuryPathophysiology0Natural History of Minor Traumatic Brain InjuryPredictors of Outcome$DSM IV Post Concussional DisorderGuideline HuntingTransfer to HospitalNo Slide TitleAssessment of PatientNo Slide TitleImagingX-rays how bad are they?No Slide TitlerRisk factors for an intracranial lesion surgically significant intracranial haematoma After Teasdale et al 1990 SXR or CTWorkable SXR guidelinesNo Slide TitleCTAdmission to hospital PitfallsWHO guidelines for MILD HINo Slide TitleQuestions unanswered  Fonts UsedDesign Template Slide Titles 6> _PID_GUIDAN{F1A4AB17-A2E4-11D6-B088-00D0B7B51A9A}_ pauli  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntrydO)Current UserSummaryInformation(pPowerPoint Document(!DocumentSummaryInformation8 &