Head Injury

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1. (Management of Trauma Patients) 2. (Management of Head Injury) 3. (Management of Mild Head Injury) 1. Glasgow Coma Scale score (GCS) 2. (Risk factors to detect intracranial abnormalities) 3. 4.

(head injured patient) (modified Jenett and Teasdale 1981)2 3 3 2550 100,733 11,830 14,733 61,742 4-5 30%4,5 (severe head injury) 29 6 (Strength of recommendation) 3 (level) I, II, III ( 1) 3 1. ( 1) 2. ( 2) 3. ( 3)

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1 (Strength of Recommendation) Grade I II III Recommendation supported by data from good quality RCT supported by data from moderate quality RCT, good quality cohort studies, good quality case-control supported by data from poor quality RCT, moderate or poor quality cohort, moderate or poor quality case control, case series, database or registries, expert opinion

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1 (Management of Trauma Patients)Trauma Patients

Primary Survey Initial Assessment & Resuscitation7 Adjunct* : EKG, Pulse Oximetry, ABG urinary / gastric catheter, FAST, DPL, CXR, X-ray : C-spine (lateral cross table), Pelvis (AP)

No

Vital signs stable yes Secondary Survey AMPLE, head to toe evaluation

No Head Injury But other organ injuries

Head Injury and other organ injuries

Head Injury

Definitive Management

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* Adjunct

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1 (trauma patients) (primary survey) 7 ATLS (Adjunct) - EKG - Pulse oximetry - Arterial blood gas (ABG) - (urinary/gastric catheter) - Ultrasound abdomen (FAST : Focused Assessment with Sonography for Trauma) - Diagnostic Peritoneal Lavage (DPL) - X-rays : Chest : C-spine ( lateral cross table) : Pelvis ( AP) (vital signs) (secondary survey) (AMPLE : A = Allergy, M= Medication, P= Past history, L = Last meal, E = Events) (primary survey) 2

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2 (Management of Head Injury)Head Injury (HI)

Moderate to Severe HI (GCS = 3-12)

Mild HI (GCS = 13-15)

Consult neurosurgeon

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2 Glasgow Coma Scale (GCS) score ( 1) - GCS < 13 - GCS = 13-15 3

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3 (Management of Mild Head Injury)Mild Head Injury (GCS 13-15)

Risk factors

High

Moderate

Low

CT scan and/or Consult neurosurgeon

Admit for observation at least 6 hrs. or CT brain

Observe at home with instruction sheet

3 (GCS = 13-15) (risk factors) 3 ( 2) 1. Low risk 2. Moderate risk 3. High risk (low risk) ( 3) (recommendation III) (moderate risk) 1 ( 4) 6 CT brain (recommendation III) (high risk) 1 CT brain (recommendation III) /

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1. World report on road traffic injury prevention: summary, M.P.e. al., Editor. 2004, World Health Organization: Geneva. 2. Jennett B, Teasdale G. Management of head injury. Philadelphia: F.A.Davis, 1981;2. 3. (age-adjusted death rate) 100,000 2539-2548. 2548, . 4. , . 2008. 5. , ., ..2550. 2008, . 6. Ratanalert S, Kornsilp T, Chintragoolpradub N and Kongchoochouys. The impacts and outcomes of implementing head injury guidelines: clinical experience in Thailand. Emerg Med J. 2007;24;25-30. 7. American Collage of Surgeon. Advanced Trauma Life Support Program for Doctors. 7th ed. Chicago, IL : 2004. 8. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357: 1391-1396. 9. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343:100-5. 10. Marion S, Diederik WJ., Ewout W S, Gijs GH, Helena MD, Pieter EV, et al. Predicting Intracranial Traumatic Findings on Computed Tomography in Patients with Minor Head Injury: The CHIP Prediction Rule. Ann Intern Med. 2007;146:397-405. 11. Ibaez J, Arikan F, Pedraza S, Snchez E, Poca MA, Rodriguez D, Rubio E. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg. 2004 May;100(5):825-34.

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1 Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS) 3 ()

Glasgow Coma Scale (GCS)Best motor response (M) - Obey commands appropriately - Localizes to pain stimulation - Withdraws from pain stimulation - Abnormal flexion response - Abnormal extension response - No motor response = 3 E + M + V = 15 Eye opening (E) - Spontaneous 4 - To speech 3 - To pain only 2 - No eye opening 1 6 5 4 3 2 1 Best verbal response (V) - Oriented and appropriate - Confused conversation - Inappropriate words - Incomprehensible sounds - No verbal response 5 4 3 2 1

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2 (Risk factors to detect intracranial abnormalities)Low risk1. 2. 3. 4. 1. 2. 3. 4. 5. 6. 7. Asymptomatic Glasgow Coma Scale score of 15 No headache 10,* Scalp injury - bruise or laceration 10 Vomiting (< 2 episodes) 9 Hx Loss of consciousness 10,11 Headache 8,11 Post-traumatic amnesia 8,9,10 Transient loss of consciousness (seconds) 10 Drug/Alcohol intoxication, initial Glasgow Coma Scale score of 13-14 8,10 Age > 60 8,9,10

Moderate risk

High risk1. Clinical signs of skull fracture :- 8,9,10 palpable discontinuity of the skull, leakage of cerebrospinal fluid, periorbital or post-auricular ecchymosis, hemotympanum and bleeding from the nose or ear 2. Vomiting ( > 2 Episode) 8,9,10,** 3. Decrease of score at least 2 points, 9,10 not clearly caused by seizures, drugs, decreased cerebral perfusion or metabolic factors 4. Focal neurological signs 10,11 5. Penetrating skull injury 6. Palpable depressed skull fracture 7. Compound skull fracture 8. Post-traumatic seizure 8,10 9. No drug/alcohol intoxication with Glasgow Coma Scale score of 13-14 10 * headache ** episode

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4 1-4 1. Vital signs 2. Glasgow Coma Score 3. Neurological deficit 4. Clinical progression

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