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Assistant professorAssistant professorDr. Hiwa Omer AhmedDr. Hiwa Omer Ahmed


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Medical StatisticsMedical Statistics

Good history takingGood history taking Good ExaminationGood Examination

Precise RecordingPrecise Recording Good selection ofGood selection ofInvestigations & imagingInvestigations & imaging

Good followupGood followup


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TypesTypesofof

researchesresearches


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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 STHPROF. ASSIST COLLEGE OF

MEDICINE UNIVERSITOF SLEMANI


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SUMMARY:SUMMARY:

Trauma remains theTrauma remains the leading killer ofleading killer ofchildren and young adultschildren and young adults, specially, specially

head trauma injuries of differenthead trauma injuries of differenttypes from fall from height (FFH) intypes from fall from height (FFH) inchildren to road traffic accident (RTA)children to road traffic accident (RTA)

and quarrelling in adolescence andand quarrelling in adolescence andyoung adults.young adults.


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Every day many victims with head traumaEvery day many victims with head traumawill arrive the Surgical Casualtywill arrive the Surgical Casualty

Department of STH, managed first byDepartment of STH, managed first byhouse officer and senior house officers inhouse officer and senior house officers ingeneral Surgery.general Surgery.

As long as there is no uniform methodAs long as there is no uniform methodfor management of these cases the authorfor management of these cases the authoris trying in this paperis trying in this paper to audit the lines ofto audit the lines ofmanagement for these victims in twomanagement for these victims in twodifferent surgical unitesdifferent surgical unites, each using away, each using awayof management different in many aspects.of management different in many aspects.Aiming that the conclusions may help inAiming that the conclusions may help inpromoting the practice in this fieldpromoting the practice in this field


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INTRODUCTLONINTRODUCTLON

Trauma in general is the mostTrauma in general is the mostcommon cause of death in children,common cause of death in children,

adolescence and young adults. Minoradolescence and young adults. Minorhead injury is common in modernhead injury is common in modernsociety (1).society (1). Care of the head injuredCare of the head injuredpatients begins with assessment ofpatients begins with assessment of

severity and protection of the brainseverity and protection of the brainfrom further insultfrom further insult. Outcome. Outcomedepends ondepends on recognitionrecognition,, severityseverity andandtreatment of two fundamentallytreatment of two fundamentallydistinct types of head injury: diffusedistinct types of head injury: diffuse


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To achieve correct management of thisTo achieve correct management of thiscommon problem, we needcommon problem, we need accurateaccurate

medical datamedical data recording andrecording and detailed anddetailed andrepeated neurosurgical examinationsrepeated neurosurgical examinations;;including records of repeated evaluation ofincluding records of repeated evaluation ofthe level of consciousness bythe level of consciousness by GlasgowGlasgow

Coma Scale (GCS),Coma Scale (GCS), to assess the severityto assess the severityof the injury, diagnosing the lifeof the injury, diagnosing the lifethreatening conditions, to protect thethreatening conditions, to protect thebrain from second trauma. Thisbrain from second trauma. This

recognition needs precise clinicalrecognition needs precise clinicalevaluation and imaging to differentiate theevaluation and imaging to differentiate thetype of the injury: is it focal or diffuse,type of the injury: is it focal or diffuse,which need different methods of treatmentwhich need different methods of treatment


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On the other hand (GCS) will help inOn the other hand (GCS) will help inclassifying the head injury intoclassifying the head injury into minorminor(13,14,15 scores(13,14,15 scores),), moderate (9,10,11,12moderate (9,10,11,12ScoresScores) and) and severe (8 or less scores)(2severe (8 or less scores)(2),),which have different outcome & may needwhich have different outcome & may needdifferent levels of care and treatment. Thedifferent levels of care and treatment. Theobjective of scoring is to provide a uniformobjective of scoring is to provide a uniform

way of describing injuries, which can onlyway of describing injuries, which can onlybe achieved by obeying the rules, this stillbe achieved by obeying the rules, this stillrequires practice, as there are manyrequires practice, as there are manypitfalls for the unwary, clinical outcome inpitfalls for the unwary, clinical outcome in

patients with minor head injury, mightpatients with minor head injury, mighthave been predicted from history & clinicalhave been predicted from history & clinicalexamination alone, and less than (1%) ofexamination alone, and less than (1%) ofthese patients will develop an intracranialthese patients will develop an intracranial

complication.complication.


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The aim of this study is to audit twoThe aim of this study is to audit twodifferent methods of management ofdifferent methods of management of

head trauma patients in two surgicalhead trauma patients in two surgicalunites, to assess methods, whichunites, to assess methods, whichmay improve the outcome.may improve the outcome.


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PATIENTS ANDPATIENTS AND

METHODS:METHODS:

The retrospective study was carried out atThe retrospective study was carried out atSlemani Teaching Hospital (STH), in two surgicalSlemani Teaching Hospital (STH), in two surgicalunites on (160) consecutive patients who wereunites on (160) consecutive patients who were

admitted between 1st of April 2001 to 1st Apriladmitted between 1st of April 2001 to 1st April2002, with acute trauma to the head, of these2002, with acute trauma to the head, of these(80) patients (Group- A) managed in the authors(80) patients (Group- A) managed in the authorssurgical unit and the rest (Group B) managed bysurgical unit and the rest (Group B) managed bya colleague surgeon in another surgical unit.a colleague surgeon in another surgical unit.

Demographic details were extracted fromDemographic details were extracted fromaction taken on basis of the finding was noted.action taken on basis of the finding was noted. Comparative analysis between the two groupsComparative analysis between the two groups

through multiple variables was done to identifythrough multiple variables was done to identifyany different between them in the aspect ofany different between them in the aspect ofmanagement and outcome.management and outcome.


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RESULTSRESULTS

Most of the patients in both groupsMost of the patients in both groups(A & B) were males as in (Group A);(A & B) were males as in (Group A);

male/ female ratio was 5/3 and inmale/ female ratio was 5/3 and in(Group B); was 5.1/2.9. Majority of(Group B); was 5.1/2.9. Majority ofthe patients was in the age group ofthe patients was in the age group of

(0-19 years) as shown in table I(0-19 years) as shown in table I


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2470 - 79

-260 - 69

2650 - 59

3740 - 49

61330 - 39

14920 - 29

151410 + 19

38250 - 9

No. of patents

Group B

No. of patients

Group AAge groups in years

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


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The most common type of trauma was fall from height as shown in

table II

811Quarrelling

2921Road traffic accident

4348Fall From height

No. of patients

Group B

No. of patients

Group A

Types of the

trauma

Table II: showing types of the trauma in both groups (A&B) of patients


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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.

-35

626

1-7

1-8

Severe

129

-210

12111

7612

Moderate

5-134414

436015

Minor

No. of patients

Group -B

No. of

patients

Group

-A

Glasgow Coma

Scale

Scores

Severity

Table III. Showing GCS scoring in both groups (A&B) of patients


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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. .

0145 days

0142 days

1039 days

0121 days

1-13 days

23143 - 9 days

314424 - 47 hours

23190 - 23 hours

No. of patients

Group -B

No. of patients

Group -A

Period of

admission

Table IV: showing period of admission in both groups (A-B) of patients.


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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.

145th day of admission





53rd day of admission

52nd day of admission

NORECORD

64Same day of admission

No. of patients in

Group -B

No. of patients

Group A

Day in which GCS scores

became full (15)

Table V: showing time when the GCS became full scored


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Minority of the patients had positive physical finding as shown in

table VI:

11

Battle Sign

31

Otorrhagia

44

Rhinorrhea, Rhinorrhagia

1014

Black eye due to Ant. cranial fossa #

No. Record5

Cranial nerve palsy

No. of patents Group BNo. of patents Group APhysical Findings

Table VI: Showing physical findings in both groups (A & B) of patients.


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Skull radiographs were taken routinely for every patient in both groups, but revealing

skull # just in 9 and 5 patients in Group A and Group B respectively, and there was no

any correlation between # skull and physical findings as most of the patients with

physical findings like (black eyes, rhinorrhea etc), has no # in the skull radiographs,

as shown in table VII.

-1+

1--

Battle sign

21-

Otorrhia

1-+

34-

Rhinorrhia

No. of patients

Group B

No. of patients

Group A# on skull X rayFindings

Table VII: Showing correlation Between # skull and physical findings


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Minority was sent for CT scan, it was normal in 3, 2 of the scans in group A, grope B respectively.

4

No. recording orpaper1

Extradural

haematoma

13Normal

Done

7576Not done

No. of patients

Group- B

No. of patients

Group -ACT scan

Table IIX: Showing results of the CT scans in patients form both groups (A, B).


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

table IX.

-2Tracheostomy

62Blood

3-Antiemetic

41Diazepam

63-Analgesia

722Antibiotics

41Diuretic

61-Steroids

710Phenobarbiturate

No Record2Craniotomy

3921IVF

6080Elevation of the head

of the patient

No. of patients

Group-B

No. of

patients

Group-A

Management

Table IX: lines of the treatment in the both groups (A & B)


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DISCUSSION:DISCUSSION: We may notice from the results, that majority oWe may notice from the results, that majority of

the victims were children, adolescence, sustainingthe victims were children, adolescence, sustainingminor head trauma (64.4% =116 patients) asminor head trauma (64.4% =116 patients) asshown in table I, with GCS Scoring of (13,14,15).shown in table I, with GCS Scoring of (13,14,15).Majority were kept under observation for necessaryMajority were kept under observation for necessarytime (48) hours (table II), buttime (48) hours (table II), but routinely expressedroutinely expressedto two views of skull radiographsto two views of skull radiographs with only (14with only (14patients) positive skull radiographs findings (tablepatients) positive skull radiographs findings (tableIV), while the majority of the patients (64.4%) withIV), while the majority of the patients (64.4%) withminor head trauma may be evaluated clinicallyminor head trauma may be evaluated clinicallyalone &alone & skull radiographs adds no furtherskull radiographs adds no furtherinformation to the decision weather to admit orinformation to the decision weather to admit orsend homesend home patients with a minor head injury andpatients with a minor head injury andthere in a report from Annals of Royal college othere in a report from Annals of Royal college ofSurgeons of England claiming that Surgeons of England claiming that not to takenot to takeskull radiographs routinely, specially for patientsskull radiographs routinely, specially for patientswho are able to walk and talk when they reachedwho are able to walk and talk when they reached

medical contact(3).medical contact(3).


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On the other hand there wasOn the other hand there was no hard correlationno hard correlationbetween findings in the skull radiographs and thebetween findings in the skull radiographs and thephysical findingsphysical findings for example (table VI), there wasfor example (table VI), there was

seven cases of rhinorrhea and rhinorrhagia whichseven cases of rhinorrhea and rhinorrhagia whichmeans anterior cranial fossa #, with onlymeans anterior cranial fossa #, with onlyradiological finding in one of them. Also there wasradiological finding in one of them. Also there wasfour cases of otorrhagia with only one radiologicalfour cases of otorrhagia with only one radiologicalreport of # in one of them.report of # in one of them.

These may be either due to the fact that most ofThese may be either due to the fact that most ofthe # usually are in the base of skull, which arethe # usually are in the base of skull, which arenot evident on AP & lateral skull views, but neednot evident on AP & lateral skull views, but needSpecialSpecial (Town view)(Town view) which in not in practice atwhich in not in practice atleast in Surgical Casualty Department or there isleast in Surgical Casualty Department or there isa gush of routing skull X-rays (100%) which willa gush of routing skull X-rays (100%) which willput a have burden on radiological staff who isput a have burden on radiological staff who isalone on duty personal, the result will be badalone on duty personal, the result will be badquality skull radiographs which add nothing to thequality skull radiographs which add nothing to theclinical evaluation and decisionclinical evaluation and decision


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Few patients (9 patients) send selectively for CT-Few patients (9 patients) send selectively for CT-scanning of the skull & brain (Table IIX), with (4)scanning of the skull & brain (Table IIX), with (4)normal results, one extradural haematoma, andnormal results, one extradural haematoma, and

unfortunately there isunfortunately there is no paper or report or datano paper or report or datarecordingrecording in the files of the patents with the restin the files of the patents with the rest(5 patients in group B). Majority of our patients(5 patients in group B). Majority of our patientswere with minor hand injury which need justwere with minor hand injury which need justobservation and elevation of the head,observation and elevation of the head,

unfortunately we found the elevation of the headunfortunately we found the elevation of the headnot practiced for all the patients in group-Bnot practiced for all the patients in group-B (Table(TableIX).IX). Different drugs used in most of the patientsDifferent drugs used in most of the patientswhich is not necessary for patients with full GCSwhich is not necessary for patients with full GCSscoring for example patient with file numberscoring for example patient with file number

(21211) had full Scoring (15),(21211) had full Scoring (15), had no any injury,had no any injury,but received all the types of the drugs & lines ofbut received all the types of the drugs & lines oftreatment which you will see in (Table IX).treatment which you will see in (Table IX).


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ELEVATION OF THE HEADELEVATION OF THE HEAD

Now it is clear that cerebral edema &Now it is clear that cerebral edema &hemorrhage within the cranial vault willhemorrhage within the cranial vault willrapidly increase intracranial pressurerapidly increase intracranial pressure

(ICP), because the brain, unlike other(ICP), because the brain, unlike otherorgans is rigidly confined with the skull (4)organs is rigidly confined with the skull (4)and in trauma the Brain Blood Barrierand in trauma the Brain Blood Barrier(BBB) will disrupt. So elevation of the head(BBB) will disrupt. So elevation of the headwill help in facilitation of venous drainage,will help in facilitation of venous drainage,

which is the only way, as there are nowhich is the only way, as there are nolymphatic vessels in the brain, and thelymphatic vessels in the brain, and theveins are thin walled, containing noveins are thin walled, containing nomuscle fibers in their wall which makemuscle fibers in their wall which makethem capable to distend considerably.them capable to distend considerably.


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IVFIVF

It is better not to give intravenous fluidIt is better not to give intravenous fluid(IVF) routinely for head injured patients,(IVF) routinely for head injured patients,specially when there is no vomiting & thespecially when there is no vomiting & the

patient is conscious, and able to takepatient is conscious, and able to takeorally. When IVF is indicated, it is better toorally. When IVF is indicated, it is better torestrict the IVF therapy at least to 2/3 ofrestrict the IVF therapy at least to 2/3 ofthat of normal maintenance. Also it isthat of normal maintenance. Also it isbetter to avoid 5% glucose in water as itbetter to avoid 5% glucose in water as it

enhances the edema process. So IVFenhances the edema process. So IVFShould be administered Judiousely toShould be administered Judiousely toprevent overhydration which augmentsprevent overhydration which augmentscerebral edema as mild dehydration wilecerebral edema as mild dehydration wileprotect the brain from insult secondary toprotect the brain from insult secondary tofluid over load (5).fluid over load (5).


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PHENOBARBITONE:PHENOBARBITONE:

It will help in decreasing agitation,It will help in decreasing agitation,controls Seizures and decreasescontrols Seizures and decreases

brain edema.brain edema.


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STEROIDES:STEROIDES:

Are notAre notrecommended forrecommended for

the treatment ofthe treatment ofacute head injury.acute head injury.


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DIURETICS:DIURETICS:

In the emergency department should beIn the emergency department should beadministered only with the consent of aadministered only with the consent of aneurosurgeon or to gain time when neurosurgicalneurosurgeon or to gain time when neurosurgical

capabilities will be delayed and the patientscapabilities will be delayed and the patientscondition is deteriorating, because its beneficialcondition is deteriorating, because its beneficialeffect is transient, the drug can severely altereffect is transient, the drug can severely alterserum electrolyte and osmolarityserum electrolyte and osmolarity

Patients who are given Steroid, osmoticPatients who are given Steroid, osmotic

diuretics, anticonvulsant & hyperosmolar feedingdiuretics, anticonvulsant & hyperosmolar feedingare prone to develop hyperosmolar state, someare prone to develop hyperosmolar state, sometimes leading to hyperglycemic nonketotic comatimes leading to hyperglycemic nonketotic coma(6).(6).

when may be analyzed as deterioration of thewhen may be analyzed as deterioration of theneurosurgical condition of the patient.neurosurgical condition of the patient.


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ANTIBIOTICSANTIBIOTICS

Prophylactic antibiotics are not usedProphylactic antibiotics are not usedroutinely because recent prospectiveroutinely because recent prospective

studies have failed to demonstratestudies have failed to demonstrateany benefit from their use (7), soany benefit from their use (7), sorarely indicatedrarely indicated


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ANALGESIAANALGESIA

Aspirin & other nonsteroidalAspirin & other nonsteroidalAnalgesia all increase the risk ofAnalgesia all increase the risk of

upper GIT bleeding and peptic stressupper GIT bleeding and peptic stressulcers, so it is better not to be usedulcers, so it is better not to be usedroutinely.routinely.


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DIAZEPAMDIAZEPAM

Sedation reduces posturing &Sedation reduces posturing &combat activity, both of whichcombat activity, both of which

elevate ICPelevate ICP


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ANTIEMETICANTIEMETIC

When used, it has symptomaticWhen used, it has symptomaticbenefit but also may inducesbenefit but also may induces

occulogyric crises, which will beocculogyric crises, which will bemisinterpreted for unwary personal.misinterpreted for unwary personal.There is a large difference betweenThere is a large difference between

the line of treatment in these twothe line of treatment in these twogroups, but the mortality was samegroups, but the mortality was samein both groups (A&B), one patient inin both groups (A&B), one patient ineach groupeach group


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CONCLUSIONCONCLUSION

We may conclude from this audit, thatWe may conclude from this audit, thatskull radiographs and many drugs withskull radiographs and many drugs withsteroid, antibiotics, IVF, diuretics weresteroid, antibiotics, IVF, diuretics wereused routinely without any additionalused routinely without any additionalbenefit to the standard management ofbenefit to the standard management ofthe head injured patients, we need athe head injured patients, we need a

uniform standard revised updateduniform standard revised updatedschedule for management of head injuredschedule for management of head injuredpatients in our casualty, aiming in savingpatients in our casualty, aiming in savinglives and time of the physician, nursinglives and time of the physician, nursing

and radiological Staffsand radiological Staffs


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AKWOWLEAAEMENTAKWOWLEAAEMENT I would like to thank all the houseI would like to thank all the house

officers & nursing staffs in myofficers & nursing staffs in mysurgical unite & statistical staffs insurgical unite & statistical staffs inSTH, Forensic medicine for theirSTH, Forensic medicine for their

valuable technical helpvaluable technical help


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REFERENCESREFERENCES B. R. Duns, T. Boesen, prognostic Signs in theB. R. Duns, T. Boesen, prognostic Signs in theevaluation of patients with minor head injuries,evaluation of patients with minor head injuries,British journal of surgery. 1997, Vol. 80, No. 8 ,pageBritish journal of surgery. 1997, Vol. 80, No. 8 ,page(989)(989)

American College of Surgeons Committee on Trauma:American College of Surgeons Committee on Trauma:Head trauma in Advanced Trauma life Support, Ed.6,Head trauma in Advanced Trauma life Support, Ed.6,American College of Surgeons. 1997. Chap 6, pp.184.American College of Surgeons. 1997. Chap 6, pp.184.

F. W. cross: Care of RTA victims in district generalF. W. cross: Care of RTA victims in district generalhospital: Annals of the Royal college of England, Novhospital: Annals of the Royal college of England, Nov

1992, Vol. 74, No 6, Page 438.1992, Vol. 74, No 6, Page 438. Nigel. We6ster. Monitoring the critically ill patients:Nigel. We6ster. Monitoring the critically ill patients:

Journal of College of Surgeons of Edinburgh. 1999,Journal of College of Surgeons of Edinburgh. 1999,Vol. 44, No.6, page 395.Vol. 44, No.6, page 395.

Robert H. Wilkins, Settee S. Rengachary. Text bookRobert H. Wilkins, Settee S. Rengachary. Text bookof Neurosurgery 1st edition Vol. I, McGraw Hillof Neurosurgery 1st edition Vol. I, McGraw Hill

company New York, 1985, page 404.company New York, 1985, page 404. 6. Spencer, Shires, Neurosurgery cited in Schwartz,6. Spencer, Shires, Neurosurgery cited in Schwartz,

Spencer, Shires & Daleys Principles of Schwartz,Spencer, Shires & Daleys Principles of Schwartz,1999, Vol. 3, (1879), McGraw Hill1999, Vol. 3, (1879), McGraw Hill

7. Raymond H. Alexander, Herbert J, Advanced7. Raymond H. Alexander, Herbert J, AdvancedTrauma life Support, 1st edition American College ofTrauma life Support, 1st edition American College of

Surgeons, 1993, Page 179.Surgeons, 1993, Page 179.


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