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ADULT TRAUMA CL IN ICAL PRACT ICE GU IDEL INES

Initial Management of:: Closed Head Injury in Adults

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Suggested citation:

Dr Duncan Reed 2007, Adult Trauma Clinical Practice Guidelines, Initial Management

of Closed Head Injury in Adults, NSW Institute of Trauma and Injury Management.

Author

Dr Duncan Reed (FACEM), Director of Trauma, Central Coast Health

Editorial team

NSW ITIM Clinical Practice Guidelines Committee

Mr Glenn Sisson (RN), Trauma Clinical Education Manager, NSW ITIM

Ms Joan Lynch (RN), Project Manager, Trauma Service, Liverpool Hospital

Assoc. Prof. Michael Sugrue, Trauma Director, Trauma Service, Liverpool Hospital

Ms Nichole Woodward, Trauma Clinical Nurse Consultant, Central Coast Health

Dr Declan Stewart, Emergency Physician, Central Coast Health

Acknowledgments

Ms Gail Long, Secretary, Emergency Department, Gosford Hospital

Assoc. Prof. Michael Fearnside, Neurosurgeon, Director Surgical Services,

Westmead Hospital

Art and Design Unit, Gosford Hospital

This work is copyright. It may be reproduced in whole or in part for study

training purposes subject to the inclusion of an acknowledgement of the source.

It may not be reproduced for commercial usage or sale. Reproduction for purposes

other than those indicated above requires written permission from the NSW Insititute

of Trauma and Injury Management.

© NSW Institute of Trauma and Injury Management

SHPN (TI) 070020

ISBN 978-1-74187-078-7

For further copies contact:

NSW Institute of Trauma and Injury Management

PO Box 6314, North Ryde, NSW 2113

Ph: (02) 9887 5726

or can be downloaded from the NSW ITIM website

http://www.itim.nsw.gov.au

or the

NSW Health website http://www.health.nsw.gov.au

January 2007

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Important notice!'The Initial Management of Closed Head Injury in Adults' clinical practice guidelines areaimed at assisting clinicians in informed medical decision-making. They are not intended toreplace decision-making. The authors appreciate the heterogeneity of the patient populationand the signs and symptoms they may present with and the need to often modifymanagement in light of a patient's co-morbidities.

The guidelines are intended to provide a general guide to the management of specifiedinjuries. The guidelines are not a definitive statement on the correct procedures, rather theyconstitute a general guide to be followed subject to the clinicians judgement in each case.

The information provided is based on the best available information at the time of writing, which is December 2004. These guidelines will therefore be updated every five years and consider new evidence as it becomes available.

These guidelines are intended for use in adults only.

All guidelines regarding pre-hospital care should be read and considered in conjunction with NSW Ambulance Service protocols.

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ContentsAlgorithm 1 :: Initial Management of ‘Adult Closed Head Injuries’ ............................1

Algorithm 2 :: Initial Management of ‘Adult Mild Head Injury’....................................2

Summary of Guidelines....................................3

1 Introduction..............................................15

2 Methods...................................................17

3 What is the definition of Mild Head Injury? ................................19

4 What are the clinically important complications of Mild Head Injury?.........20

5 How should patients with Mild Head Injury be assessed? ...............22

6 Which patients with Mild HeadInjury require a CT scan?.........................28

7 What to do with high risk Mild HeadInjury patients when CT scan isunavailable? .............................................36

8 When can patients with Mild Head Injury be safely discharged home? ...................37

9 What are the proven treatments forpatients with ‘Moderate’ to ‘Severe’ Head Injuries?..........................................39

10 When should patients with closed head injury be transferred to hospitals with neurosurgical facilities? ...........................41

Evidence tables

Evidence Table 1. Definitions of Mild Head Injury .........44

Evidence Table 2. Initial GCS versus

Abnormal CT/Neurosurgery ..............45

Evidence Table 3. Risk factors for intracranial

injury in Mild Head Injury .................46

Evidence Table 4. Safe discharge of Mild Head Injury ...51

Evidence Table 5. Post concussive symptoms

and Mild Head Injury........................54

Evidence Table 6. Management of Severe Head Injury..56

Appendices

APPENDIX A ::

Westmead PTA Scale ...................................................60

APPENDIX B ::

Glasgow Coma Scale ...................................................62

APPENDIX C ::

Mild Head Injury Discharge Advice...............................63

APPENDIX D ::

NSW Brain Injury Rehabilitation Program (BIRP)............65

APPENDIX E ::

List of Search Terms to identify studies.........................66

References .....................................................67

List of tables

Table 1.1 Summary of closed head

injury classification and outcome ................16

Table 2.1 Levels of evidence.......................................18

Table 2.2 Codes for the overall assessment

quality of study checklists ...........................18

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Algorithm 1 :: Initial management of ‘Adult Closed Head Injuries’

GCS 3-8 GCS 9-13 GCS 14-15

Severe Head Injury (10%)1 Early intubation.1 Supportive care ABCDE's.1 Prevent secondary injury.1 Early CT scan.1 Early neurosurgical consult.1 Early retrieval consult if required.1 Consider ICP monitoring.1 Anticonvulsants optional.1 ICU admission.1 Routine brain injury rehabilitation consult.

NB. Minimum supportive care aims to prevent secondary brain injury:

1 PaO2 >60 1 SaO2 >90 1 PaCO2 35-401 Systolic BP >90 1 Head up 30º

Moderate Head Injury (10%)1 Supportive care ABCDE's.1 Prevent secondary injury.1 Early CT Scan.1 Period of clinical observation.1 Intubation if required to ensure adequate

oxygenation and ventilation or to safely perform CT scan.

1 Early neurosurgical consult if not clinically improving or abnormal CT scan.

1 Early retrieval consult if required.1 Admit to hospital unless early rapid clinical

improvement, normal CT scan and absence of other risk factors as listed below.

1 Consider routine post traumatic amnesia testing and referral to a brain injury rehabilitation service (or neurologist) due to high risk of cognitive behavioural social sequelae.

Mild Head Injury (80%)1 Initial period of clinical observation.1 Assess for risk factors of significant

intracranial injury as listed below.1 CT scan if GCS <15 at 2 hours post

injury or if other risk factors present.1 Admit to hospital if clinically not improving

at 4 hours post injury or abnormal CT scan.1 Consider hospital admission if elderly

(>65 years), known coagulopathy (warfarin, alcoholic), intoxicated or socially isolated.

1 Discharge home with head injury advice at 4 hours post injury if clinically improving with either no risk factors or normal CT scan.

1 Refer to local doctor for routine follow up and monitoring of any post concussion symptoms.

1 Consider referral to a brain injury rehabilitation service (or neurologist) if still has post traumatic amnesia after 24 hours or if still has post concussion symptoms after 4 weeks.

NB. See also separate Mild Head Injury Algorithm.

Initial Management of Adult Closed Head Injuries

Risk factors indicating potentially significant Mild Head Injury1 Persistent GCS <15 at 2 hours post injury.1 Deterioration in GCS.1 Focal neurological deficit.1 Clinical suspicion of skull fracture.1 Prolonged loss of consciousness (>5 min).1 Prolonged anterograde / retrograde amnesia.

What to do if a Closed Head Injury patient acutely deteriorates?

When should patients with Closed Head Injury be transferred to hospitals with neurosurgical facilities?

1 Post traumatic seizure.1 Persistent abnormal alertness / behaviour / cognition.1 Persistent vomiting (2 or more occasions).1 Persistent severe headache.1 Known coagulopathy (eg warfarin / alcoholic).1 Age >65 years.

1 Multi-system trauma.1 Dangerous mechanism.1 Clinically obvious drug or alcohol intoxication.1 Known neurosurgery / neurological impairment.1 Delayed presentation or representation.

Clinical approach1 Re-assess ABCDE's to exclude

non head injury cause.1 Supportive care of ABCDE's

(NB. oxygenation and perfusion).1 Consider early intubation and

short term hyperventilation to PaCO2 25-30.

1 Immediate CT scan if available.1 Consult neurosurgical service.1 Consult retrieval service early.1 Consider use of mannitol

boluses (1g/kg), in consultation with neurosurgical service, to reduce ICP for transfer.

1 Consider local burr holes in consultation with neurosurgical service if transfer likely to take more than 2 hours.

Indications of deterioration1 GCS falls by two or more points.1 Develops dilated pupil(s).1 Develops focal neurological

deficit.1 Delayed or focal seizure.1 Cushings response – bradycardia and hypertension.

Clinical approach1 When in doubt consult you

regional neurosurgical service.1 Patients with closed head

injuries should be observed in facilities that can manage any complications that are likely to arise. Clinical judgment regarding risk of deterioration is required and neurosurgical consultation may be appropriate.

1 Patients with closed head injuries should be transferred to the nearest appropriate hospital with neurosurgical facilities if there is significant risk of intracranial injury. Transfer of patients to hospitals with CT scan facilities but without neurosurgical services should be avoided.

Potential indications for transfer1 Patient with severe head injury

(GCS 3-8).1 Patient with moderate head injury

(GCS 9-13) if: – clinical deterioration – abnormal CT scan – normal CT scan but

not clinically improving – CT scan unavailable.1 Patient with mild head injury

(GCS 14-15) if:– clinical deterioration– abnormal CT scan– normal CT scan but not clinically improving– high risk mild head injury with CT scan unavailable, particularly if:

- persistent abnormal GCS- focal neurological deficit- clinical suspicion of skull fracture- persistent abnormal mental status, vomiting or severe headache at 4 hours post injury.

AMRS (adult) 1800 650 004

NETS (children) 1300 362 500Regional Neurosurgical tel.

'formerly the MRU'

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Initial Assessment and Stabilisation of ABCDE'sTrauma Team activation if initial GCS 3-13 or otherwise indicated

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Algorithm 2 :: Initial management of ‘Adult Mild Head Injury’

Clinical observation until at least four hours post time of injury.

Initial GCS 14-15 on arrival following blunt trauma. Stabilise ABCDE’s then assess risk factors.

Low risk Mild Head Injury

Normal during observation period.

Normal CT scan. Clinical symptoms improving at 4 hours post time of injury.

Normal CT scan. Clinical symptoms NOT improving at 4 hours post time of injury.

Socially safe for discharge for home observation if:1 Responsible person available to take home and observe.1 Able to return if deteriorates.1 Discharge advice is understood.

Clinically safe for discharge for home observation if:1 Normal alertness / behaviour / cognition.1 Clinically improving after observation.1 Normal CT scan or no indication for CT scan.1 Clinical judgment required if elderly and /

or known coagulopathy due to increased risk of delayed subdural haematoma.

Consider urgent transfer for CT scanning if:1 Persistent GCS <15 at 2 hours post injury.1 Deterioration in GCS.1 Focal neurological deficit.1 Clinical suspicion of skull fracture.1 Persistent abnormal mental status, vomiting or

severe headache at 4 hours post time of injury.

Admit for prolonged hospital observation and consult regional neurosurgical service regardingfurther management and disposition.

CT scan unavailable.

Initial Management of Adult Mild Head Injury

High risk Mild Head InjuryAny of ...1 Persistent GCS <15 at 2 hours post injury.1 Deterioration in GCS.1 Focal neurological deficit.1 Clinical suspicion of skull fracture. ::11 Prolonged loss of consciousness (>5 mins).1 Prolonged anterograde / retrograde amnesia (>30 mins).1 Post traumatic seizure. ::21 Persistent abnormal alertness / behaviour / cognition.1 Persistent vomiting (2 or more occasions).1 Persistent severe headache.1 Known coagulopathy (eg warfarin / alcoholic).1 Age >65 years. ::31 Multi-system trauma. ::41 Dangerous mechanism. ::51 Clinically obvious drug or alcohol intoxication. ::61 Known neurosurgery / neurological impairment. ::71 Delayed presentation or representation. ::8

Discharge for home observation and provide written discharge advice.

Abnormal alertness / behaviour / cognition.Clinically deteriorates or not improving.

Abnormal CT scan.

Note – Clinical judgement required::1 Clinical suspicion of skull fracture includes – history of focal blunt assault or injury; large scalp lacerations or haematomas; signs of base of skull fracture

– haemotympanum / CSF leak / raccoon eyes / Battles sign.

::2 Post traumatic seizures – prolonged, focal or delayed seizures are significant risk factors for intracranial injury but brief generalised seizures immediately following head injury are less concerning.

::3 Age >65yrs – elderly patients have increased risk of significant intracranial injury; routine CT scanning unless totally asymptomatic patient with no other risk factors.

::4 Multi-system trauma – beware patients with unstable vital signs or distracting injuries, as significant head injuries are easily missed.

::5 Dangerous mechanisms include MVA ejection / rollover; pedestrians / cyclists hit by vehicle; falls >own height or five stairs; falls from horses / cycles etc; focal blunt trauma, eg bat / ball / club.

::6 Clinically obvious drug or alcohol intoxication with altered mental status is an indication for CT scanning but drug or alcohol ingestion with normal mental status is not.

::7 Known neurosurgery/neurological impairment – conditions such as hydrocephalus with shunt or AVM or tumour or cognitive impairment from any cause make clinical assessment less reliable and may increase risk of intracranial injury.

::8 Delayed presentation or representation – consider both intracranial injury and post concussion symptoms and have a low threshold for CT scanning.

Indication for early CT scan and prolonged clinical observation.

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All of ...1 GCS 15 at 2 hours post injury.1 No focal neurological deficit.1 No clinical suspicion of skull fracture. ::11 Brief loss of consciousness (<5 mins).1 Brief anterograde / retrograde amnesia (<30 mins).1 No post traumatic seizure.1 Mild nausea or single episode of vomiting.1 Mild headache.1 No known coagulopathy.1 Age <65 years.1 Isolated head injury without dangerous mechanism.1 No drug or alcohol ingestion.1 No known neurosurgery / neurological impairment.


What is the definition ofMild Head Injury?

A patient with an initial GCS score of 14-15 on arrival at hospital III-2following acute blunt head trauma (with or without a definite history of loss of consciousness or amnesia).

Typical characteristics

:: Direct blow to the head or acceleration / deceleration injury.

:: Transient loss of consciousness or amnesia.

:: Transient abnormal alertness, behaviour or cognition.

:: Neurosurgical intervention rare.

:: Post concussion symptoms common.

:: Long term functional outcome good.

Risk stratification III-2

Mild Head Injury may be further sub-classified into 'High' and 'Low' risk groups, based on the risk of having an intracranialinjury requiring neurosurgical intervention. Stratification of

'high' and 'low' risk of intracranial injury is based on:1,6-9,14,16-19,23-46,62

:: initial GCS on admission and at two hours post injury

:: the duration of loss of consciousness or amnesia

:: the presence or absence of other specified risk factors.


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EDEFINITION LEVEL OF EVIDENCE

:: SUMMARY OF GU IDEL INES


Initial Management of Closed Head Injury in Adults :: NSW ITIM

Clinicians and patients should be aware of both the risk of neurosurgical III-2intervention and the risk of cognitive-behavioural-social sequelae following Mild Head Injury.

Clinicians and patients should also be aware that the absence of a structurallesion on CT scan following Mild Head Injury does not exclude the possibility of significant cognitive-behavioural-social sequelae.

Acute life-threatening complications requiring neurosurgical IVintervention are rare in Mild Head Injury patients:16,17,19,24-32,47,62

:: 'Low risk' Mild Head Injury range 0-3%.

:: 'High risk' Mild Head Injury range 0.5-6.5%.

Post concussion symptoms are common in Mild Head Injury patients and may IVhave significant cognitive-behavioural-social impacts on both patients and their families:3,8,9,36,48-52

:: Typical post concussion symptoms include:– headaches– dizziness – fatigue– memory impairment– poor concentration– mood swings– behavioural changes – social dysfunction.

:: Up to 50% of patients with Mild Head Injury may have significant post concussion symptoms which can last several weeks.

:: About 10% of patients with Mild Head Injury will have persistent disabling post concussion symptoms.

What are the clinically importantcomplications of Mild Head Injury?

GUIDELINE LEVEL OF EVIDENCE

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E:: SUMMARY OF GU IDEL INES


Mild Head Injury patients should have a minimum of hourly III-2observations for four hours post injury.

:: These observations include:– GCS– alertness / behaviour / cognition– pupillary reactions– vital signs.

Serial neurological observations should be continued on any Mild Head Injury III-2patients who fail to clinically improve at four hours post injury or who are found to have structural lesions requiring hospital admission.7,53

Assessment for post traumatic amnesia (PTA) should be performed III-2on any Mild Head Injury patients who fail to clinically improve at four hours post injury or who are found to have structural lesions requiring hospital admission.3,55

Structured clinical assessment using clinical decision rules can identify those III-2patients at increased risk of intracranial injury requiring further investigation.16,17,19,62

Skull x-rays are not sufficiently sensitive to be used as a routine Iscreening investigation to identify significant intracranial lesions.37

CT scanning is the most appropriate investigation for the exclusion III-2of neurosurgically significant lesions in mild head injured patients.

CT scanning is indicated for those Mild Head Injury patients III-2identified by structured clinical assessment as being at increasedrisk of intracranial injury.16,17,19,25,38,39,62

If structured clinical assessment indicates the risk of intracranial injury III-2is low, the routine use of CT scanning is neither clinically beneficial nor cost effective.16,17,19,25,38,39


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How should patients withMild Head Injury be assessed?





Patients with ‘High Risk’ Mild Head Injury requiring CT scan

The following risk factors identify patients with Mild Head Injury III-2(initial GCS 14-15) at increased risk of clinically significant lesions requiring acute neurosurgical intervention or prolonged observationin hospital. These patients should have early CT scanningif available, if they have any of the following features:

Any of...

Initial assessment

:: Persistent GCS <15 at two hours post injury.**

:: Focal neurological deficit.

:: Clinical suspicion of skull fracture.

:: Prolonged loss of consciousness (>5min).

:: Prolonged anterograde or retrograde amnesia (>30min).

:: Post traumatic seizure.

:: Repeated vomiting (>2 occasions).

:: Persistent severe headache.

:: Known coagulopathy.

:: Age >65 years (clinical judgment appropriate if no other risk factors present).

After a period of observation (four hours post injury)

:: Any deterioration in GCS.

:: Persistent abnormal mental status (abnormal alertness, behaviour or cognition).**

:: Any patient who fails to clinically improve.

Clinical judgment required if:

:: age >65 years

:: drug or alcohol ingestion

:: dangerous mechanism

:: multi-system trauma

:: known neurosurgery / neurological impairment

:: delayed presentation or representation.

** NOTE: Includes patients with abnormal GCS due to drug or alcohol ingestion.

Which patients withMild Head Injury require a CT scan?


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Patients with ‘Low Risk’ Mild Head Injury not requiring CT scan

The following features indicate patients with Mild Head Injury III-2(initial GCS 14-15) at low risk of clinically significant lesions requiring acute neurosurgical intervention or prolonged observation in hospital.These patients should not routinely have CT scanning if they have all of the following features:

All of...

Initial assessment

:: GCS 15 at two hours post injury.

:: No focal neurological deficit.

:: No clinical suspicion of skull fracture.

:: Brief loss of consciousness (<5min).

:: Brief anterograde or retrograde amnesia (<30min).

:: No post traumatic seizure.

:: Mild nausea or single episode of vomiting.

:: No persistent severe headache.

:: No known coagulopathy.

:: Age <65 years.


:: Normal mental status including alertness and behaviour and cognition.

:: No deterioration during observation.

:: Clinically improving.


:: age >65 years







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EGUIDELINE LEVEL OF EVIDENCE




‘High Risk’ Mild Head Injury patients should be admitted for prolonged III-2hospital observation and considered for transfer for CT scanning. Patients at highest risk of intracranial injury who should be transferred for CT scanning include those with:16-19,27-34,37-39,47,70,71,76

:: persistent GCS <15 at two hours post injury.

:: deterioration in GCS.

:: focal neurological deficit.

:: clinical suspicion of skull fracture.

:: persistent abnormal mental status, vomiting or headache at four hours post injury.

Patients at ‘Highest Risk’ of intracranial injury should be discussed with Consensusthe regional neurosurgical service and a management plan established.

If patients are transferred for CT scanning they should ideally be transferred Consensusto a hospital with neurosurgical facilities to avoid secondary transfer.

A skull x-ray may be useful to confirm the presence of a skull fracture Ithat mandates an early CT scan due to the increased risk of deterioration.

All ‘High Risk’ patients who cannot have CT scanning should at a minimum Consensushave prolonged observation in hospital for at least 24 hours and until clinically improving.

What to do with ‘High Risk’Mild Head Injury patients when CT scan is unavailable?


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Mild Head Injury patients can be discharged for home observation after III-2initial period of in-hospital observation if they meet the following clinical, social and discharge advice criteria.16,17,19,24,26,27,29,32,66,68,69,77-79

Clinical criteria III-2

:: Normal mental status and behaviour with clinically improving minor post concussion symptoms after observation until at least four hours post injury.

:: No clinical risk factors indicating the need for CT scanning or normal CT scan if performed due to risk factors being present.

:: No clinical indicators for prolonged hospital observation (irrespective of CT scan result) such as:– clinical deterioration– persistent abnormal GCS or focal neurological deficit– persistent abnormal mental status or behaviour– persistent severe post concussion symptoms– persistent drug or alcohol intoxication– presence of known coagulopathy (relative)– presence of multi-system injuries (relative)– presence of intercurrent medical problems (relative)– age >65 (relative).

Social criteria Consensus

:: Responsible person available to take patient home.

:: Responsible person available for home observation.

:: Patient able to return easily in case of deterioration.

:: Written and verbal discharge advice able to be understood.

Discharge advice criteria Consensus

:: Discharge summary for local doctor.

:: Written and verbal head injury advice given to patient and nominated responsible person covering:– symptoms and signs of acute deterioration– reasons for seeking urgent medical attention– typical post concussion symptoms– reasons for seeking routine follow up.


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When can patients with Mild HeadInjury be safely discharged home?





Initial management of ‘Severe Head Injuries’ (GCS 3-8) III-2

Standard care15,22,80-87

:: Initial systematic resuscitation of ABCDE's.

:: Early CT scanning to identify neurosurgically correctable focal intracranial haematomas.

:: Prevention of secondary brain injury by avoiding hypoxaemia (oxygen saturation <90%) and hypotension (systolic BP <90).

:: Supportive care of ABCDE's with appropriate attention, posturing (30o head up), basic nursing care and avoidance of hyperventilation.

:: Early neurosurgical consult.

:: Use of ICP monitoring to guide management of cerebral perfusion pressure in patients with severe brain injury.

:: Optional use of anticonvulsants to prevent early post traumatic seizures.

:: Routine brain injury rehabilitation consult.

:: ICU admission.

Acute neurological deterioration

:: Resuscitation and stabilisation of ABCDE's.

:: Short term hyperventilation to PaCO2 25-30.

:: Mannitol 1g/kg IV Bolus.

:: Early CT scan with neurosurgical intervention as required.

Poor prognostic indicators

:: Low GCS (especially motor component).

:: Age >60 years (prognosis deteriorates with increasing age).

:: Absent pupillary reflexes (after systemic resuscitation).

:: Hypotension (systolic BP <90).

:: Hypoxaemia (oxygen saturation <90%).

What are the proven treatments for patients with ‘Moderate’ to ‘Severe’ Head Injuries?


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Initial management of ‘Moderate Head Injuries’ (GCS 9-13) III-2


:: Initial assessment and resuscitation of ABCDE's.


:: Period of ED observation.

:: Prevention of secondary brain injury by avoiding hypoxaemia (O2 saturation <90%) and hypotension (systolic BP <90).

:: Supportive care of ABCDE's.

:: Admit for prolonged hospital observation (24-48 hours) unless rapid clinical improvement, normal CT scan and absence of other risk factors.

:: Early neurosurgical consult if not clinically improving and/or abnormal CT scan.

:: Routine post traumatic amnesia (PTA) testing.

Outcome

:: Approximately 80% of moderate head injuries improve while 20% deteriorate and require management as per severe head injuries.

:: The majority of patients who suffer moderate head injuries will have some degree of cognitive behavioural social sequelae and should be considered for routine follow up with a brain injury rehabilitation service or a neurologist (see Appendix D of the Adult Trauma Clinical Practice Guideline, Initial Management of Closed Head Injury in Adults).


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EGUIDELINE LEVEL OF EVIDENCE




Patients with severe head injuries (GCS 3-8). Consensus

Patients with moderate head injuries (GCS 9-13) if: Consensus

i clinical deterioration

ii abnormal CT scan

iii normal CT scan but not clinically improving

iv CT scan unavailable.

Patients with mild head injuries (GCS 14-15) if: Consensus


ii abnormal CT scan


iv high risk Mild Head Injury with CT scan unavailable.

NOTE: Consult neurosurgical / retrieval service early.

When should patients with Closed Head Injury be transferred to hospitals with neurosurgical facilities?


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1 IntroductionTrauma is the leading cause of death and disability

in children and young adults in New South Wales and

closed head injuries cause a significant proportion of this

burden.1,2 Closed head injuries often result in lifelong

physical, cognitive, behavioural and social dysfunction for

patients who in turn may place major social and financial

burdens on their families and society.3 Recent Australian

figures indicate there are approximately 150 patients per

100,000 population admitted to hospital each year with

closed head injuries.3-5 Worldwide figures suggest an

incidence range of 200-350 per 100,000 population for

patients with closed head injury with mild head injury

accounting for 80%.6 Despite the fact that closed head

injuries are common, the classification and management

of head injures remains surprisingly controversial and

subject to variation in clinical practice [6-10]. Due to the

large numbers of patients involved it has been estimated

that even small improvements in closed head injury

management could have significant impact.11

Furthermore, it has been suggested that the greatest

improvements can be made in the better management

of those patients with mild to moderate head injury

rather than those with severe head injury.12

Much of the controversy that exists about closed head

injury management stems from the combination of a

lack of uniformity in definitions with a paucity of large

well designed studies in the area.11,13,14 ‘Head injury’ is

typically used to describe the initial clinical presentation

whilst ‘traumatic brain injury’ is used to describe the

subsequent functional outcome. It is difficult to find two

studies that define mild head injury in exactly the same

way so comparison of data becomes difficult.6-9,14

Similarly, comparison of data in moderate to severe head

injury studies is made difficult because controversy exists

about how and when best to apply Glasgow Coma

Score (GCS) to sedated or intubated patients.15 Perhaps

most significantly there have been very few large

prospective randomised controlled trials of sufficient

power and quality to guide management.11,13,14

However, in the past few years there has been some

progress in working toward uniform definitions and

some better quality trials and meta-analyses have been

published.6-9,16-19,62

The variety of clinical practice observed worldwide

cannot be explained solely by the lack of uniformity

of definitions and good quality studies. Much of the

variation in management strategies between the USA,

Canada, Europe and Australasia is driven by local issues

such as the availability of resources and the medico-legal

environment.6, 20 Thus the USA has higher rates of CT

scanning for mild head injuries compared to Canada,

Europe and the UK. Even within countries and within

institutions, considerable variation in practice has been

shown to exist.10,12,20,21 Whilst some variation in clinical

practice is to be expected, the introduction of clinical

practice guidelines can potentially improve care and

ensure adequate access to resources for more isolated

areas.6,19 Furthermore, clinical guidelines can potentially

reduce unnecessary tests and hospital admissions for

mild head injury patients, by identifying those patients

at low risk of neurosurgically significant

lesions.6,14,18,19,62

These guidelines are intended to assist clinicians

throughout NSW in delivering optimal care to patients

with closed head injuries. They are intended to provide a

clinically practical approach to the initial management of

closed head injuries based on the current best available

evidence. However, as with all guidelines, it should be

remembered that they are a clinical tool and should not

replace clinical judgement.

1.1 Defining closed head injuryThis guideline uses the terms ‘closed head injury’ and

‘mild, moderate or severe head injury’ to identify and

classify patients on arrival to hospital. The outcome

following ‘closed head injury’ will vary from rapid

complete recovery to a mixture of structural lesions and

functional deficits ranging from trivial to life threatening.

Important functional deficits following ‘closed head

injury’ range from persistent post concussion symptoms

and post traumatic amnesia to a variety of disabling

physical-cognitive-behavioural-social sequelae.

As this guideline concentrates on the initial management

of the target population it was felt that the term

‘head injury’ was more relevant to the initial clinical

presentation than the term ‘traumatic brain injury’ that

essentially refers to the subsequent functional outcome.

It was also felt that the clinicians at whom this guideline

is aimed would be far more familiar and comfortable

with using the term ‘head injury.’


1.2 Classification of closed head injuryThis guideline has used the ATLS/EMST classification of head injuries based on initial GCS on admission to hospital after

initial resuscitation and stabilisation.22 This classification is widely used clinically and the ATLS/EMST course provides the

common language of trauma care throughout the world. This system classifies patients with initial GCS score of 13 in the

moderate head injury group due to the patients having similarly patterns of intracranial injury and cognitive behavioural

sequelae. The following table is a summary based on the Brain Trauma Foundation and ATLS/EMST data gives a rough

guide to classification and outcome.15,22

PAGE 16 Initial Management of Closed Head Injury in Adults :: NSW ITIM

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EADULT TRAUMA CL IN ICAL PRACT ICE GU IDEL INES

The definition of ‘closed head injury’ in this document is as follows:

‘A patient presenting to hospital following acute blunt head trauma with or without a definite history loss of consciousness or amnesia.’

Typical characteristics:


:: Variable duration of initial loss of consciousness or amnesia.

:: Variable duration and severity of diffuse and / or focal neurological deficits.

Specific exclusions:

:: Clinically obvious penetrating head injury.

:: Non-traumatic brain injury.

CLOSED HEAD INJURY DEFINITION

Initial GCS 14-15 9-13 3-8

% of total 80 10 10

Abnormal CT scan (%) 10-15 40-50 90

Neurosurgical intervention (%) (excluding ICP) 1-3 10-15 40-50

Mortality (%) 1 <1 10-15 20-803

Good functional outcome (%) 1 >902 50 10-503

Mild Moderate Severe

1 Generally the lower the GCS the worse the prognosis.

2 Approximately 10% will have persistent post concussive symptoms at three to six months.

3 Outcome deteriorates with increasing age – ‘children do better and elderly do worse’.

Table 1.1. Summary of closed head injury classification and outcome



2 Methods2.1 Scope of the guidelinesThe guidelines are intended for use by clinicians

managing patients with closed head injuries in major

trauma services, regional, urban and rural hospitals.

The Initial Management of Closed Head Injury Guidelines

are concerned with the initial care of the mild, moderate

and severely head injured patient. The guideline

will make evidence based recommendations on

the diagnosis, resuscitation, and disposal of

patients with closed head injuries.

These guidelines however, are not prescriptive nor

are they rigid procedural paths. It is recognised that

the guidelines may not suit all patients in all clinical

situations. The guidelines rely on individual clinicians

to decipher the needs of individuals. They aim to

provide information on what decisions can be made,

rather than dictate what decisions should be made.

2.2 Aims and objectivesThe broad objectives of the guidelines are to reduce

morbidity and mortality in adult patients with closed

head injuries by providing clinicians with practical

evidenced based guidelines to assist them in managing

such patients. It is also hoped that the guidelines may

prevent unnecessary diagnostic tests and hospital

admissions especially in the mild head injury group.

At the start of the process of creating the guidelines

the clinicians on the Clinical Guidelines Committee

posed a series of questions about the initial management

of closed head injuries. The nature of the questions

reflected the feeling among the clinicians that the

greatest needs for guidelines related to the management

of mild head injuries and the timing of transfer of

patients with closed head injuries from centres with

limited resources. The initial management of patients

with moderate to severe head injuries was felt to

be less controversial.

The questions are listed below.

1 What is the definition of a Mild Head Injury?

2 What are the clinically important complications

of Mild Head Injury?

3 How should patients with Mild Head Injury

be assessed?

4 Which patients with Mild Head Injury require

a CT scan?

5 What to do with high risk Mild Head Injury

patients when CT scan is unavailable?

6 When can patients with mild head injury be

safely discharged?

7 What are the proven treatments for patients

with moderate to severe head injuries?

8 When should patients with closed head injuries be

transferred to hospitals with neurosurgical facilities?

2.3 Literature ReviewThe Guideline Review Group used the methods outlined

in A Guide to the Development, Implementation and

Evaluation of Clinical Practice Guidelines (NHMRC 1999)

and the companying handbooks (NHMRC 2000abc,

2001, 2002) to review the literature and assess the

evidence used to support these guidelines.

Evidence from published studies was obtained from

a thorough search of MEDLINE, EMBASE and the

Cochrane Database of Systematic Reviews and the

Cochrane Library. Relevant articles were hand-searched.

A list of search terms used in these databases are listed

in Appendix E, p.66.

These databases were searched from 1980 to 30th

October 2004 for English language articles that met

the following general inclusion and exclusion criteria.

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2.5 Assessment of the evidence for strength, size and relevance

2.5.1 Level of evidenceThe articles were classified according to their general purpose and study type. From this each article was

allocated a level of evidence.


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2.4 Inclusion and exclusion criteria

Table 2.1 Levels of evidence

2.5.2 QualityThe included and excluded articles were appraised according to the NHMRC. The MERGE assessment tool

(Liddle, Williamson, and Irwig, 1996) was used. Full text of this document and the checklists (and their criteria)

used are available from http://www.health.nsw.gov.au/pubs/a-z/m.html.

The articles were rated for quality on a 4-point scale as follows:

Table 2.2 Codes for the overall assessment quality of study checklists

Inclusion criteria

Meta-analysis, controlled clinical trials

Closed head injury

Aged >16 years

� ✕

Low risk of bias A All or most evaluation criteria from the checklist are fulfilled,

the conclusions of the study or review are unlikely to alter.

Low-moderate risk of bias B1 Some evaluation criteria from the checklist are fulfilled. Where evaluation

criteria are not fulfilled or are not adequately described, the conclusions

of the study or review are thought unlikely to alter.

Moderate - High risk of bias B2 Some evaluation criteria from the checklist are fulfilled. Where evaluation criteria

are not fulfilled or are not adequately described, the conclusions of the study or

review are thought to alter.

High risk of bias C Few or no evaluation criteria fulfilled. Where evaluation criteria are not fulfilled

or adequately described, the conclusion of the study or review are thought

very likely to alter.

Level I Evidence obtained from a systematic review of all relevant randomised control trials.

Level II Evidence obtained from at least one properly-designed randomised control trial.

Level III-1 Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation

or some other method).

Level III-2 Evidence obtained from comparative studies (including systematic reviews of such studies) with concurrent controls

and allocation not randomised, cohort studies, case-control studies, or interrupted time series with a control group.

Level III-3 Evidence obtained from comparative studies with historical control, two or more single arm studies or interrupted

time series without a parallel control group.

Level IV Evidence obtained from a case-series, either post-test or pre-test/post-test.

Exclusion criteria

Case, Series, Case reports

Penetrating head injury

Aged <16 years


A patient with an initial GCS score of 14-15 on arrival at hospital III-2following acute blunt head trauma (with or without a definite history of loss of consciousness or amnesia).

Typical characteristics


:: Transient loss of consciousness or amnesia.

:: Transient abnormal alertness, behaviour or cognition.

:: Neurosurgical intervention rare.

:: Post concussion symptoms common.

:: Long term functional outcome good.

Risk stratification III-2

Mild Head Injury may be further sub-classified into 'High' and 'Low' risk groups, based on the risk of having an intracranialinjury requiring neurosurgical intervention. Stratification of

'high' and 'low' risk of intracranial injury is based on:1,6-9,14,16-19,23-46,62

:: initial GCS on admission and at two hours post injury

:: the duration of loss of consciousness or amnesia

:: the presence or absence of other specified risk factors.

DEFINITION LEVEL OF EVIDENCE


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3 What is the definition of Mild Head Injury?

3.1 Discussion

Recently published studies and guidelines use a variety ofcriteria to define mild head injury, which itself, is variablyreferred to as either mild head injury or mild traumaticbrain injury.6-9,14,16-19,62 The most common variationsconcern the initial classification according to GCS anddifferent requirements for loss of consciousness andamnesia (as summarised in Evidence Table 1. Definitions of Mild Head Injury, p.44). This variation in the literaturemakes comparison between studies difficult.

The main reason for this variability is a uniform desire toidentify those patients at higher risk of intracranial injuryin what is a heterogenous but essentially low risk group.There is ample evidence to suggest that patients with aninitial GCS of 13 should be considered as part of themoderate head injury group due to the frequency ofintracranial lesions (25-38%) and cognitive functionalsequelae (see Evidence Table 2. Initial GCS versus

abnormal CT/neurosurgery, p.45).24-26,29,31,35

Further sub-classification of mild head injury is thendependent on the presence of associated risk factors and different authors have different approaches. The approaches of some of the best quality studies and guidelines are summarised in Evidence Table 1.Definitions of Mild Head Inury, p.44). It is interesting to note that when all the initial GCS criteria, inclusion/exclusion criteria and sub-classification systems are all taken into account, that the findings are very similar. These findings are that mild head injury is a heterogenous group with patients at higher risk ofincreased intracranial injury identified by abnormal initialGCS, persistently abnormal GCS, presence of prolongedLOC or amnesia and certain other risk factors.1, 6-9, 14,

16-19, 23-46, 62 It is important to recognise that these risk factors for intracranial injury do not necessarilypredict the risk of post concussive symptoms which are the more common complication of mild head injury.


Clinicians and patients should be aware of both the risk of neurosurgical III-2intervention and the risk of cognitive-behavioural-social sequelae following Mild Head Injury.

Clinicians and patients should also be aware that the absence of a structurallesion on CT scan following Mild Head Injury does not exclude the possibility of significant cognitive-behavioural-social sequelae.

Acute life-threatening complications requiring neurosurgical IVintervention are rare in Mild Head Injury patients:16,17,19,24-32,47,62

:: 'Low risk' Mild Head Injury range 0-3%.

:: 'High risk' Mild Head Injury range 0.5-6.5%.

Post concussion symptoms are common in Mild Head Injury patients and may IVhave significant cognitive-behavioural-social impacts on both patients and their families:3,8,9,36,48-52

:: Typical post concussion symptoms include:– headaches– dizziness – fatigue– memory impairment– poor concentration– mood swings– behavioural changes – social dysfunction.

:: Up to 50% of patients with Mild Head Injury may have significant post concussion symptoms which can last several weeks.

:: About 10% of patients with Mild Head Injury will have persistent disabling post concussion symptoms.



4 What are the clinically importantcomplications of Mild Head Injury?

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I The identification of patients requiring early acute neurosurgical intervention.

II The identification of patients requiring admission to hospital due to the increased risk of deterioration from complications.

III The identification of patients who can be safely discharged for home observation.

IV The provision of discharge advice to allow the identification and early return of patients with unexpected deterioration.

V The provision of discharge advice to allow the identification, treatment and follow-up of patients who develop disabling post

concussion symptoms.


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4.1 DiscussionClinically important complications of mild head injury

include both structural lesions and functional deficits.

The most important structural lesions to identify are

those requiring acute neurosurgical intervention.

However, functional deficits resulting in cognitive-

behavioural-social sequelae are far more common

and may have significant impact on patients and their

families. It is important that doctors, patients and their

families understand that the absence of a structural

lesion on CT scan following a mild head injury does

not exclude the possibility of significant cognitive-

behavioural-social sequelae.

Acute intracranial haematomas requiring acute

neurosurgical intervention are the most dramatic

and life threatening complications of mild head injury.

The identification of structural lesions requiring acute

neurosurgical intervention is the most important function

of CT scanning because the presence or absence of

other structural lesions does not usually significantly

alter outcome. However, multiple studies have shown

that these neurosurgically significant lesions are relatively

uncommon with incidences of 0.1-3.2% for GCS 15

and 0.5-6.5% for GCS 14 (see Evidence Table 2.

Initial GCS versus abnormal CT/neurosurgery, p.45).

Other intracranial injuries and skull fractures are more

frequently noted on CT scans but are usually only

clinically important as indicators of the potential for

clinical complications such as delayed intracranial

haematomas, post traumatic seizures and post

concussion symptoms.26,36 Delayed acute intracranial

haematomas requiring neurosurgical intervention are

uncommon following normal CT scans (range <1%).

Post concussion symptoms are common following

mild head injury and may have significant cognitive-

behavioural-social impact on patients and their

families.3,8,9,36,48-52 Post concussion symptoms have

been shown to occur in up to 50% of patients with

mild head injury.3,8,9,36,48-50 Post concussion symptoms

include headaches, dizziness, fatigue and cognitive,

behavioural and social dysfunction. These symptoms

usually resolve within three months, but in about 10%

of cases they may persist with significant psychological

overlay as post concussion syndrome.3,8,9,36,48-50

The best clinical predictors of post concussion symptoms

and functional outcome are initial GCS on admission,

duration of loss of consciousness and duration of post

traumatic amnesia (PTA).3 If post traumatic amnesia

does not persist beyond 24 hours then significant post

concussion symptoms are less common.3 The most

widely used screening tool for PTA in New South Wales

is the Westmead PTA Scale (see Appendix A, p.61).

Evidence Table 5. Post concussive symptoms and Mild

Head Injury, p.54 details the most relevant studies

relating to recovery from mild head injury and post

concussion symptoms. The cognitive-behavioural-social

dysfunction caused by mild head injury can be quite

disabling, and some researchers have suggested that the

severity of impact on lifestyle makes the term ‘mild’

inappropriate for some patients.3,48,49 Patients with

significant post concussive symptoms should be referred

to a brain injury rehabilitation service or neurologist (see

Appendix D, p.65).

:: 4 WHAT ARE THE COMPLICATIONS OF MILD HEAD INJURY?

The clinically important complications of Mild Head Injury suggest that the management priorities should be:


Mild Head Injury patients should have a minimum of hourly III-2observations for four hours post injury.

:: These observations include:– GCS– alertness / behaviour / cognition– pupillary reactions– vital signs.

Serial neurological observations should be continued on any Mild Head Injury III-2patients who fail to clinically improve at four hours post injury or who are found to have structural lesions requiring hospital admission.7,53

Assessment for post traumatic amnesia (PTA) should be performed III-2on any Mild Head Injury patients who fail to clinically improve at four hours post injury or who are found to have structural lesions requiring hospital admission.3,55

Structured clinical assessment using clinical decision rules can identify those III-2patients at increased risk of intracranial injury requiring further investigation.16,17,19,62

Skull x-rays are not sufficiently sensitive to be used as a routine Iscreening investigation to identify significant intracranial lesions.37

CT scanning is the most appropriate investigation for the exclusion III-2of neurosurgically significant lesions in mild head injured patients.

CT scanning is indicated for those Mild Head Injury patients III-2identified by structured clinical assessment as being at increasedrisk of intracranial injury.16,17,19,25,38,39,62

If structured clinical assessment indicates the risk of intracranial injury III-2is low, the routine use of CT scanning is neither clinically beneficial nor cost effective.16,17,19,25,38,39



5 How should patients with Mild Head Injury be assessed?

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5.1 DiscussionClinical history and examination remain the basis for

the initial assessment of patients with closed head injury.

However, additional clinical tools are available to assist in

assessment and management. These clinical tools include

GCS, serial neurological observation, skull x-rays, CT

scanning and clinical decision rules.

5.1.1 Glasgow Coma ScaleThe Glasgow Coma Scale (see Appendix C, p.64) was

originally developed by Teasdale and Jennett53 for the

neurological observation of patients with prolonged

coma. It was intended to ensure inter-observer reliability

and to identify deterioration of patients over time. Since

its original introduction its use has been extended such

that it is now the standard tool for assessment of level

of consciousness in many clinical settings.

GCS is used both for the initial assessment and

classification of closed head injuries and for serial

assessment of closed head injuries. Initial GCS on

admission to hospital is used to classify head injuries

into the broad prognostic groups of mild (GCS 14-15),

moderate (GCS 9-13) and severe (GCS 3-8). The Brain

Trauma Foundation concluded that there is good quality

evidence to relate initial GCS score to outcome.15

However, it must be noted that these are broad outcome

measures and initial GCS is only about 75% accurate.15

GCS is unreliable if measured before initial resuscitation

and stabilisation of the ABCDE’s has been completed.15

Fearnside et al54 identified that both intubation and

sedation interfered with accurate assessment of initial

GCS in more severely injured patients and there

is lack of uniformity of approach to classifying

GCS in these situations.

The other significant area of controversy relates

to timing of initial GCS. In unstable patients requiring

resuscitation, the optimal time to record initial GCS

remains controversial.15,54 Similarly, in mild head injury

patients the time of presentation related to time

of injury will influence the initial GCS and therefore

potentially influence clinical decision making in relation

to CT scanning.6,9,16,19 Perhaps the most crucial point to

note about initial GCS is that it cannot predict outcome

for patients with similar GCS scores.

This is particularly important for mild head injury

patients because GCS primarily assesses the risk of

structural lesions. Subtle cognitive changes are not

well discriminated within the mild head injury group.

This led to the development of the extended Glasgow

Coma Scale that assesses the duration of post traumatic

amnesia as a means of identifying patients at increased

risk of cognitive problems.55 Thus, a patient with

an initial GCS of 14-15 may have no significant injury,

long-term cognitive-behavioural dysfunction or a life

threatening extradural haematoma. Despite these

limitations initial GCS on admission remains the

standard method for initial classification of

head injuries.

When assessing initial GCS in patients with head injury

it is worthwhile considering time of injury. Clearly initial

GCS for a given patient may vary depending on time of

presentation to hospital. Few studies have related GCS

to the time of injury with the exception of Stiell et al19

who found GCS <15 at two hour post injury was a

significant predictor of intracranial injury for mild head

injury patients.19 Fabbri et al16 showed that most mild

head injuries present around one hour post injury. Initial

GCS is therefore most likely to overestimate the risk of

intracranial injury in mild head injuries who present early.

Prehospital GCS, motor score and return of orientation

are other factors to consider when assessing initial GCS.

Prehospital GCS was felt to be unreliable56 but with

more organised prehospital systems is gaining further

attention.15,57 Motor score is the best predictor

of outcome of the GCS components.15 Orientation

returns most commonly in the sequence of person,

place then time.58

The Glasgow Coma Scale is also used as one of the

parameters in serial observation of head injury patients.

Both the original studies and subsequent studies have

validated its use in this fashion and prior to the advent

of CT scanning alteration in GCS was the most useful

tool in predicting intracranial injury.7,53 Currently, serial

GCS remains a standard tool in the monitoring of head

injuries when CT scanning is unavailable or when clinical

symptoms persist despite normal CT scanning.

:: 5 HOW SHOULD PATIENTS WITH MILD HEAD INJURY BE ASSESSED?


Summary

:: Initial GCS score is useful to classify closed head

injuries into broad prognostic groups requiring

further assessment.

:: The extended GCS which assesses duration of

PTA may help identify mild head injury patients

at increased risk of post concussion symptoms.

:: Serial GCS scores are useful for identifying patients

with significant risk of intracranial injury in:

– patients with an initial abnormal GCS score

who fail to improve

– patients whose initial GCS score deteriorates.

:: Initial and serial GCS scores are not as valuable

in excluding significant injury in:

– patients with an initial normal GCS score who

remain normal

– patients with an initial abnormal GCS score

who improve.

:: Initial GCS should only be used for prognostic

purposes after initial resuscitation and stabilisation

of ABCDE’s.

5.1.2 Serial clinical neurologicalobservations

In mild head injury patients the primary aims of serial

neurological observation are the early identification of

acute neurological deterioration and the identification

and monitoring of persistent mild neurological deficits.

Serial neurological observations remain the basic

standard of care for the initial management of mild head

injury patients and should be used in conjunction with

clinical decision rules to determine the need for CT

scanning and / or prolonged observation.

Serial neurological observations remain a standard tool

for assessing mild head injury patients despite the advent

of CT scanning. CT scanning is primarily used to identify

structural abnormalities at a given point in time while

serial neurological observations are used to monitor

clinical conditions over a longer period of time. Serial

neurological observations typically consist of hourly

pupillary reactions and GCS assessment in conjunction

with vital signs. The symmetry of motor responses should

be routinely noted as part of the GCS assessment.

Neurological assessment should also include qualitative

assessment of alertness, behaviour and cognition as this

may identify more subtle neurological impairment.

Controversy exists over the appropriate duration of

serial neurological observation for both mild head

injury patients who are improving and those who have

persistent clinical symptoms or abnormalities on CT scan.

Although four hours of initial neurological observations

post injury are fairly standard following mild head injury,

there is little evidence to support this. There is also some

debate as to whether the initial period of observation

should be until four fours post injury or for four hours

following arrival at hospital. Stiell et al19 demonstrated

that GCS<15 at two hours post injury was one of the

most significant risk factors for intracranial injury. Since

this guideline has used this important criteria it was felt

that the initial clinical observation period should also

be based on time post injury. The initial period of

neurological observation should therefore be until

four hours post time of head injury.

If serial neurological observations are not improving at

four hours post injury then clinical decisions need to be

made about the need for CT scanning and/or prolonged

observation. The period of prolonged observation is also

controversial as there is little evidence to support the

general recommendation of twenty four hours. This

period of observation is derived from limited studies

and case reports that show that clinical deterioration

is unusual in mild head injury patients after twelve to

twenty four hours. The best location for prolonged

neurological observation for lower risk patients is also

debated because some studies have shown that

admission to hospital does not guarantee that

regular neurological observation will occur.29

Summary

:: Serial neurological observations are a useful tool

for the early identification of acute neurological

deterioration and the identification and monitoring

of persistent mild neurological deficits.

:: Serial neurological observations should include

a minimum of hourly GCS assessment, pupillary

reactions and vital signs. Neurological observations

should also include qualitative assessment of

alertness, behaviour and cognition to detect

subtle changes in mental status not assessed

by the Glasgow Coma Scale.

:: Mild head injury patients should have initial serial

neurological observations until four hours post injury

at which point decisions about further management

should be made.


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5.1.3 Post traumatic amnesia (PTA) testingThe assessment of the duration of PTA following

mild head injury is the best tool for predicting whether

a patient will have significant post concussion

symptoms.3,55 PTA is most simply defined as that period

of time following head injury during which a patient is

unable to lay down new memories. While it has been

identified that prolonged PTA is a risk factor for

significant post concussion symptoms, the standard tool

for identifying PTA in NSW, the Westmead PTA Scale

(see Appendix A, p.61), is designed to be used over

several days. There has been considerable interest in

developing bedside PTA screening tools to allow early

prediction of which patients are at greatest risk of

developing post concussion symptoms. The Extended

Glasgow Coma Score and the Modified Westmead PTA

Score are examples of tools developed to try to identify

persistent PTA in mild head injury patients as a marker

for increased risk of post concussion symptoms.55,90

Summary

:: The identification of persistent PTA in mild head

injury patients is a potentially useful marker for the

risk of developing post concussive symptoms.

:: PTA testing should be performed on any patient

admitted to hospital following mild head injury.

5.1.4 Clinical decision rulesClinical decision rules are increasingly being used to

assist clinicians in determining the need for particular

investigations or management. By identifying individual

risk factors and combining them to establish clinical

decision rules, which are then prospectively validated,

useful evidence based diagnostic tools can be

established. Well established clinical decision rules

also include the NEXUS criteria for cervical spine

assessment and the Ottawa Ankle Rules.59,60

Although clinical decision rules are potentially very

useful clinicians need to be aware of the specific

inclusion/exclusion criteria used to develop them and

the overall quality of the original studies before applying

them to their patients. Sound clinical decision rules have

been developed through review of large cohorts of

patients and prospectively applied to patients to

determine their sensitivity and specificity.16,17,19

In recent years a number of attempts have been made

to develop clinical decision rules for mild head injuries

for both adults and children. The studies aim to identify

those patients at increase risk of intracranial injury and

develop clinical decision rules about those who require

CT scanning or prolonged observation. The main design

features of these trials and those of NEXUS II, which is

currently in progress, are summarised in Evidence Table

4. Safe discharge of Mild Head Injury, p.51.14,16,17,19

The main findings of other studies examining

the accuracy of certain risk factors are summarised

in Evidence Table 3. Risk factors for intracranial injury

in Mild Head Injury, p.46.

The most consistent findings of these studies are that

abnormal initial GCS or mental status, clinical suspicion

of skull fracture and focal neurological deficit are the

best predictors of risk of intracranial injury. Loss of

consciousness, amnesia, vomiting, headache and

seizure are also relevant predictors of risk. Depending

on their inclusion / exclusion criteria the authors used

combinations of those risk factors to derive clinical

decision rules of varying sensitivity and specificity

(see Evidence Table 3. Risk factors for intracranial

injury in Mild Head Injury, p.46).

At present, the findings of Haydel et al17 have been

adopted as an ACEP policy whilst the findings of Stiell

et al19 have been adopted by the NICE guidelines (UK).

A recent Australian study looked at applying the clinical

decision rules developed by Haydel et al17 and Stiell

et al19 to Australian practice and concluded that both

had limitations.61 The NEXUS II study which intends

to enrol the largest patient groups yet, is likely to

provide the most definitive clinical decision rule

once completed.14.

In a recent study Ibanez et al62 attempted to

prospectively identify clinical risk factors predicting

intracranial injury and to assess the reliability of

previously published clinical guidelines. They found that

while clinical risk factors could not detect all intracranial

injuries they could be used to detect clinically relevant

lesions with a negative predictive power approaching

99%. They concluded clinicians should be aware

of the limitations of clinical decision rules when

using clinical guidelines.

Summary

:: Clinical decision rules provide useful adjuncts

to the assessment and management of mild

head injury patients.

:: Studies by Haydel et al17 and Stiell et al19

have provided evidence based clinical decision

rules for mild head injury in adults.



5.1.5 Skull x-raysThe literature clearly identifies that both the clinical

suspicion of skull fractures and the radiological

evidence of skull fracture are significant risk factors

for the presence of an intracranial lesion requiring

neurosurgical intervention.6,16,17,19,27,37

If CT scanning is available, the current indications

for skull x-rays are few. However, if CT scanning is

unavailable, the role of skull x-rays as a screening test

is less clear. A detailed meta analysis by Hofman et at37

concluded that whilst the presence of skull fracture

greatly increased the risk of intracranial injury, the

absence of a skull fracture did not rule it out

(calculated sensitivity 38% calculated specificity 95%).

In subsequent clinical guidelines, authors have differed

as to whether skull x-rays should be used to detect

patients at higher risk of intracranial injury. Jagoda

et al7 argued that the sensitivity of skull x-ray is not

sufficient to be used as a screening test. Vos et al9 and

Servadei et al6 felt that in the absence of CT scanning,

a positive skull x-ray can be useful to help allocate

patients into higher risk groups for management

purposes. On existing evidence, both approaches seem

reasonable depending on local management guidelines.

Summary

:: Clinical evidence or suspicion of skull fracture is

associated with increased risk of intracranial injury.

:: Skull x-rays are not sufficiently sensitive to be used

as a routine screening test to identify patients at

increased risk of intracranial injury.

:: Where CT scanning is unavailable, skull x-ray may

be used as an adjunct to identify patients at greater

risk of intracranial injury (but not to exclude

intracranial injury).

5.1.6 CT scanningThe widespread availability of CT scanning has greatly

assisted the management of patients with head injuries.

CT scanning has been particularly useful in identifying

focal injuries in patients with altered level of

consciousness. CT scanning is regarded as mandatory

for all head injury patients with an initial or persistent

altered level of consciousness. However, the role of

the CT scanning in a patient with mild head injury with

a normal level of consciousness remains controversial.

Particular concerns about the routine use of CT scanning

for mild head injury include the financial-resource

burden, the potential hazards of radiation and the

potential pitfalls of reliance on technology at the

expense of clinical assessment.20,38,47,63-65

Furthermore CT scans do not identify patients who have cognitive dysfunction which is the most significantcomplication for most patients. The various pros andcons of CT scanning are summarised below:

Pros

:: Early identification of patients with intracranialinjuries requiring acute neurosurgical intervention(see Evidence Table 3. Risk factors for intracranialinjury for Mild Head Injury, p.46 and Evidence Table 4. Safe discharge of Mild Head Injury, p.51).

:: Early identification of patients with other intracranialinjuries requiring admission to hospital due to risk ofdeterioration (see Evidence Table 1. Risk factors forintracranial injury for Mild Head Injury, p.46 andEvidence Table 4. Safe discharge of Mild Head Injury, p.51).

:: Identification of patients at low risk of deteriorationand suitable for discharge (see Evidence Table 4. Safe discharge of Mild Head Injury, p.51).

:: Identification of patients with structural lesionsindicating increased risk of post concussive symptoms.36

:: Potential cost benefit due to early CT scanningallowing discharge home rather than hospitaladmission in some patients.63

Cons

:: Routine use of CT scanning for mild head injury has a huge financial and resource impact given thatmore than 90% of scans are negative and less than1% of scans indicate the need for neurosurgicalintervention.14,19

:: Patients may develop focal neurosurgical lesions(especially subdurals) despite initial normal CTscanning.32,66,67

:: Early CT scans may not demonstrate intra-cerebralcontusions which take time to become apparent onCT scanning.

:: CT scanning will not demonstrate diffuse axonalinjury in most patients.3

:: Patients may suffer significant post concussivesymptoms despite an initial normal CT scan.3,36,48-50

:: Routine use of CT scanning does not guarantee better identification of significant intracranial injuriesif different institutions are compared.12,20

:: The risk of cumulative radiation exposure especiallyamong children is of concern.64,65

:: May delay definitive management of more significantinjuries in multi system trauma patients.


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Timing of CT scanning

There is no direct evidence to confirm what the best

time to perform CT scanning in relation to time of injury

is. The primary role of early CT scanning in mild head

injury is early recognition of extradural haematomas

prior to clinical deterioration.32 Early neurosurgical

intervention prior to clinical deterioration is associated

with improved outcome. However, early CT scan may

potentially miss other intracranial injuries such as

subdurals or contusions which are slower to become

evident.32 Fortunately, most studies have shown that an

initial normal CT scan allows safe discharge and that the

few patients who deteriorate usually have good

outcome.7,29,68,69 Therefore, it is reasonable

to suggest that CT scans should be performed shortly

after a decision is made that one is necessary.

Summary

:: CT scanning is the best investigation for the early

identification of neurosurgically significant focal

intracranial lesions following mild head injury.

:: Early CT scanning may not demonstrate some

subdural haematomas and cerebral contusions.

:: CT scanning should be used as an adjunct to clinical

assessment.

:: CT scanning does not accurately predict the risk

of post concussion symptoms in mild head injury

patients.

:: Where clinical assessment indicates the risk of

significant intracranial lesion is low, the routine

use of CT scanning is unlikely to be of benefit.



Patients with ‘High Risk’ Mild Head Injury requiring CT scan

The following risk factors identify patients with Mild Head Injury III-2(initial GCS 14-15) at increased risk of clinically significant lesions requiring acute neurosurgical intervention or prolonged observationin hospital. These patients should have early CT scanningif available, if they have any of the following features:

Any of...

Initial assessment

:: Persistent GCS <15 at two hours post injury.**

:: Focal neurological deficit.

:: Clinical suspicion of skull fracture.

:: Prolonged loss of consciousness (>5min).

:: Prolonged anterograde or retrograde amnesia (>30min).

:: Post traumatic seizure.

:: Repeated vomiting (>2 occasions).

:: Persistent severe headache.

:: Known coagulopathy.

:: Age >65 years (clinical judgment appropriate if no other risk factors present).


:: Any deterioration in GCS.

:: Persistent abnormal mental status (abnormal alertness, behaviour or cognition).**

:: Any patient who fails to clinically improve.


:: age >65 years






** NOTE: Includes patients with abnormal GCS due to drug or alcohol ingestion.



6 Which patients with Mild Head Injury require a CT scan?

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:: 6 WHICH PATIENTS WITH MILD HEAD INJURY REQUIRE A CT SCAN?

Patients with ‘Low Risk’ Mild Head Injury not requiring CT scan

The following features indicate patients with Mild Head Injury III-2(initial GCS 14-15) at low risk of clinically significant lesions requiring acute neurosurgical intervention or prolonged observation in hospital.These patients should not routinely have CT scanning if they have all of the following features:

All of...

Initial assessment

:: GCS 15 at two hours post injury.

:: No focal neurological deficit.

:: No clinical suspicion of skull fracture.

:: Brief loss of consciousness (<5min).

:: Brief anterograde or retrograde amnesia (<30min).

:: No post traumatic seizure.

:: Mild nausea or single episode of vomiting.

:: No persistent severe headache.

:: No known coagulopathy.

:: Age <65 years.


:: Normal mental status including alertness and behaviour and cognition.

:: No deterioration during observation.

:: Clinically improving.


:: age >65 years








6.1 DiscussionMild head injury patients (initial GCS 14-15) require a CT

scan if they are clinically assessed as being at significant

risk of acute deterioration from an underlying intracranial

injury. The clinical risk factors that indicate patients are

at increased risk of intracranial injury are discussed in

the following text, and most of the relevant studies

summarised in the evidentiary tables. The absence

of clinical risk factors on initial assessment combined

with a period of observation during which the patients

clinically improves makes the probability of a significant

intracranial injury extremely unlikely. These low risk

mild head injury patients can be discharged for home

observation without CT scanning. In the high risk group,

which includes initially low risk patients who fail to

clinically improve, both CT scanning and prolonged

clinical observation are indicated.

Early CT scanning allows identification of acuteintracranial haematomas requiring urgent neurosurgicalintervention and other structural lesions that put thepatient at increased risk of deterioration fromcomplications such as delayed intracranial haematomas,raised intracranial pressure, post traumatic seizures,Syndrome of Inappropriate Antidiuretic Hormone (SIADH)and disabling post concussive symptoms. However it isimportant to recognise that the absence of a structurallesion on CT scan does not exclude the possibility ofsignificant post concussion symptoms.

Patients with an abnormal CT scan should be admittedfor prolonged observation in hospital. Conversely, anormal CT scan makes acute clinical deterioration highlyunlikely and allows safe discharge for home observationas long as the patient is clinically improving. It isimportant to stress that CT scanning should be used as aclinical tool in conjunction with clinical assessment andobservation as part of an overall management strategyfor mild head injury patterns.


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GUIDELINE

A persistent GCS <15 at two hours post injury is an absolute indication for CT scanning. An initial GCS <15 is a relative indication for CT scanning.16,19,24-29,34,35,62,70

Several studies have noted the heterogeneity of the

original GCS 13-15 mild head injury classification and

these findings are summarised in Evidence Table 2. Initial

GCS versus abnormal CT/neurosurgery, p.45. Patients

with an initial GCS 13 have been shown to have similar

rates of intracranial injury to those with initial GCS 9-

12.29,54 Although patients with initial GCS 14-15 have

lower rates of intracranial injury as a group, the more

recent studies16,17,19 have confirmed a higher risk of

intracranial injury for initial GCS 14. This higher risk

of intracranial injury for initial GCS 14 does not take

into account either associated risk factors nor the

time of injury.

A number of recent, well designed studies have

attempted to identify risk factors which can predict

which patients with initial GCS 14-15 are at highest risk.16,17,19 The evidence would suggest that other risk

factors can be used to stratify risk within the initial GCS

14-15 group.

Perhaps the most relevant finding to clinical practice is

that of Stiell et al [19] who showed that for patients

with an initial GCS 13-15 that GCS <15 at two hours

post injury was a useful predictor of risk of intracranial

injury. By applying this criteria, both time of injury and

GCS are usefully combined in a clinically practical

assessment tool.

Individual factors predicting risk of intracranial injury and therefore the need for CT scanning in patients with mild head injury:

6.1.1 Initial GCS

GUIDELINE

Focal neurological deficit mandates CT scanning [16-19, 28-30, 32-34, 62, 70, 71].

6.1.2 Focal neurological deficits

Focal neurological deficits have been shown to

significantly increase the risk of intracranial

injury.16,18,29,31 Both Haydel et al17 and Stiell et al19

excluded focal neurological deficits in their studies due

to the previously proven nature of risk. Conversely

Vilke et al45 showed that a normal neurological

examination does not rule out underlying brain injury

in mild head injuries.



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EClinical suspicion or evidence of skull fracture has been

shown to be a significant risk factor for intracranial

injury. The meta analyses by Hofman et al [37] showed

that the x-ray presence of skull fracture had a specificity

of 95% for intracranial injury. Clinical suspicion or

evidence of skull fracture has been shown by several

authors including Stiell et al [19], Haydel et al [17] and

Palchek et al [18] to be a major risk factor for the

presence of intracranial injury. Clinical suspicion of open,

depressed or base of skull fractures is based on the

presence of large scalp lacerations or haematomas

(especially in children <2 years), obvious skull

depression, and base of skull signs such as raccoon

eyes, haemotympanum, Battles sign, or CSF leak.

The presence of significant facial fracture may also

indicate the possibility of skull fracture.


GUIDELINE

Clinical suspicion or evidence of skull fracture is an absolute indication for CT scanning. 17-19,27,28,30,31,34,37,38,47,62,71

6.1.3 Skull fractures

GUIDELINE

Brief loss of consciousness (<5 minutes) should not be considered an independent indication for CT scan. Prolonged loss of consciousness (>5 minutes) should be considered a strongindication for CT scanning.1,6,16-18,27,33,39-44

6.1.4 Loss of consciousness

Loss of consciousness increases the risk of intracranial

injury and is used by many authorities to define mild

head injury (See Evidence Table 1. Definitions of Mild

Head Injury, p.44).

However, the absolute risk associated with loss

of consciousness is small.6,27 The absence of loss

of consciousness or amnesia has been used to classify

patients as ‘minimal risk’.6-9 The absence of loss

of consciousness has been shown not to rule out

intracranial lesions in children.18,41 Similarly,

adult studies have shown that transient LOC does

not accurately predict the risk of intracranial

injury.33,39,40,42,62

Duration of loss of consciousness is also controversial.

‘Brief’ loss of consciousness in mild head injury patients

is usually associated with good functional outcome while

‘prolonged’ loss of consciousness is not clearly

associated with poorer outcome.9,27,43,44 However, the

exact definitions of what should be considered a low-risk

duration vary greatly from momentary to five minutes, to

20 minutes to 30 minutes.6-9

From a practical viewpoint obtaining a definite history

and duration of loss of consciousness is often difficult.

Head injuries are frequently unwitnessed, observers

unreliable and patients often affected by alcohol.

It is perhaps simplest to consider loss of consciousness

in terms of no loss of consciousness, brief loss of

consciousness less than five minutes, prolonged loss

of consciousness greater than five minutes or unreliable

history. The clinical recommendation of the neurosurgical

committee of the Royal Australasian College of Surgeons

(RACS) is that loss of consciousness should be

considered brief if less than five minutes.1

GUIDELINE

Persistent anterograde or retrograde amnesia of greater than 30 minutes duration mandates CTscanning. Amnesia for the event does not warrant CT scanning.16,17,19,27

6.1.5 Amnesia

The presence of amnesia is associated with higher risk

of intracranial injury and recent studies have established

certain durations as significant. Amnesia for the event

implies transient neurological dysfunction and indicates

mildly increased risk of intracranial injury although the

absolute risk remains small.27 Retrograde amnesia

(defined as the period of loss of memory prior to the

event) has been shown by Stiell et al19 to be

of significance if greater than 30 minutes duration.

Duration of anterograde amnesia or post traumatic

amnesia (the period of inability to lay down new

memories post event) has been shown to be associated

with both risk of intracranial injury and cognitive –

behavioural sequelae.3,17,19


Haydel et al identified short term memory deficit

(a surrogate for PTA) as a significant risk factor for

intracranial injury.17 Post traumatic amnesia that persists

for more than 24 hours has been shown to

be a significant risk factor for persistent cognitive-

behavioural-social dysfunction.3 Stiell et al19

also identified anterograde amnesia of more than

30 minutes as a risk factor but did not include

it in their clinical decision rule.

From a practical point of view, any patient with

persistent anterograde or retrograde amnesia for more

than 30 minutes duration should be considered at higher

risk. It is useful to assess the patients recall of events

following their injury by asking specific questions such as

what is their first clear memory, who helped them at the

scene and how they got to hospital. This can be used to

estimate the period of anterograde amnesia. A simple

memory assessment technique such as three object

recall can be used as a bedside screening test for

anterograde amnesia, to supplement the ‘history’

of amnesia for events.


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GUIDELINE

Post traumatic seizures are an indication for CT scanning.17,18

6.1.4 Post traumatic seizure

Brief generalised post traumatic seizures are common

immediately following mild head injury and are not

usually associated with poor outcome. They are

frequently seen on sporting fields and in young children.

Prolonged, delayed or focal post traumatic seizures are

more likely to be associated with significant intracranial

injury. However, most mild head injury studies do not

differentiate between types of seizures when assessing

risk factors for intracranial injury.17,18 Most published

guidelines have identified any post traumatic seizures as

risk factors warranting routine CT scanning.

GUIDELINE

Persistent or recurrent vomiting is an indication for CT scanning.16-19,32,38,47

6.1.5 Vomiting

Vomiting has been identified as a significant risk factor

for intracranial injury in many studies.17-19,32,38 There has

been some debate whether persistent vomiting is more

relevant than isolated vomiting. Stiell et al19 identified

repeated vomiting (more than one occasion) as being a

significant risk factor.

GUIDELINE

Persistent severe headache is an indication for CT scanning.16-18,32,38,47

6.1.6 Headache

Many studies have identified headache as a significant

risk factor for intracranial injury.17,18,32,38

The general trend of the literature would suggest

that persistent moderate to severe headache

should be considered a significant risk factor.



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GUIDELINE

Known coagulopathy is both an indication for CT scan and also an indication to consider prolongedhospital observation.6-9,16,17,19,72

6.1.7 Coagulopathy

Most guidelines and studies on mild head injury mention

coagulopathy either as a significant risk factor or an

exclusion criteria in the assessment of risk of intracranial

injury.6-9,16,17,19 However, there is no compelling

evidence to either support or refute this reasonable

assertion in the mild head injury patient group.

Mina et al72 demonstrated that pre-existing

anticoagulation significantly increased the risk of death

from intracranial injury in trauma patients with head

injury. However, this was a heterogenous patient group

with significantly abnormal ISS (mean 17.0 +/- 7.8) and

GCS (mean 11.8 +/- 4.0).

GUIDELINE

Patient age >65 years is a relative indication for CT scanning. Clinical judgment may be used in anasymptomatic patient age >65 years if no other risk factors are present.6,16,17,19,24,30,31

6.1.8 Age

Extremes of age have been shown to be associated

with increased risk of intracranial injury. The paediatric

literature identifies young children (age <5 years

and particularly <2 years) as being at increased

risk of intracranial injury due to a combination of

communication difficulties, non-accidental injury,

anatomical considerations and the lack of localising

clinical signs and symptoms.18,73

Several published studies have shown that there is an

increased risk of intracranial injury for patients aged

over 60-65 years with mild head injury.17,19,24,30,31

In particular, both Haydel et al17 and Stiell et al19

included age >60-65 years as indicators of the need

for CT scan. Mack et al74 recommended routine head

CT for elderly patients suffering mild head injury as they

could not identify any useful predictors of intracranial

injury in the elderly. The Brain Trauma Foundation

concluded that ‘increasing age is a strong independent

factor in prognosis, with significant increase in poor

outcome above 60 years of age’ for patients with severe

head injuries.15 Similarly Williams et al36 demonstrated

that elderly patients were more likely to sustain

complications of mild head injury. Although there

is no doubt advanced age is a risk factor for mild head

injury, there are practical difficulties in applying this

to the general population. As Servadei et al6 have

pointed out it is unlikely there is a specific age at which

risk of intracranial injury dramatically increases. Fabbri et

al16 found that using age >60 years alone to predict the

need for CT scanning in patients with mild head injury

was impractical from a cost-resource consideration

during a study to validate a set of guidelines.

Interestingly, of the 705 patients meeting guidelines

criteria for CT scanning based on age >60 years alone

(who did no have CT scans) Fabbri et al found that

only one patient deteriorated within 48 hours. From

a practical viewpoint extremes of age need to be

recognised as risk factors for intracranial injury. Whether

all patients age >60 years with mild head injury should

have CT scans based on age alone remains controversial.

It is worth noting that the NSW Institute of Trauma and

Injury Management Trauma Death Review Committee

has identified that in 2003 / 2004 elderly NSW patients

with head injuries represented a significant number

of potentially preventable deaths.75



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GUIDELINE

Persistent abnormal mental status manifested by drowsiness, abnormal behaviour or cognitiveimpairment is an indication for CT scanning.17-19,28,32,39,70

6.1.9 Abnormal mental status

Although initial GCS partially assesses mental status

it primarily addresses level of consciousness. Clinical

observation of alertness, behaviour and cognition will

detect more subtle changes in mental status than GCS

and should be part of routine neurological observation.

Abnormal alertness, abnormal behaviour and cognitive

impairment have also been shown to be associated with

intracranial injury [17-19]. Abnormal alertness or

behaviour and cognitive impairment requires careful

observation by staff and relatives and is particularly

important in children or adults with pre-existing

neurological impairment. In patients with pre-existing

neurological conditions a lower threshold for CT

scanning is appropriate [6, 62].

GUIDELINE

Drug or alcohol ingestion with a normal mental state is not an indication for CT scanning. Drug or alcohol intoxication resulting in an abnormal mental state is an indication for CT scanning.16,17,19,23

6.1.10 Drug or alcohol intoxication

Drug or alcohol intoxication is frequently present in

patients with head injuries and makes patients difficult

to assess and manage. Cook et al23 in a study

of alcohol intoxicated patients found that clinical

examination could not predict which alcohol intoxicated

patients had abnormal CT scans. However, they

observed that the rate of abnormal CT scan and

neurosurgical intervention was similar to that of the

non-intoxicated mild head injury population. Several

studies have shown that drug or alcohol intoxication

is a risk factor for intracranial injury but the exact

definition of intoxication remains vague.16,17

Stiell et al19 took a different approach and used GCS

<15 at two hours post injury as their variable to predict

abnormal mental status for whatever reason. They

argued that drug or alcohol intoxication was not an

independent predictor of intracranial injury if the patient

had a normal mental status at two hours post injury.

From a practical viewpoint, clinically obvious drug or

alcohol intoxication should be treated as a risk factor

for intracranial injury because it manifests as abnormal

mental status which impairs clinical assessment and

must be assumed to be due to intracranial injury.

GUIDELINE

In the absence of other risk factors, dangerous mechanism is only a relative indication for CT scan.Clinical judgment is required.19,30,31,46

6.1.11 Dangerous mechanisms of injury

Epidemiological studies have generally identified motor

vehicle accidents, falls and assaults as the commonest

causes of head injuries. In studies on patients with mild

head injuries, specific high risk factors for intracranial

injury that have been identified include assault,30,46

pedestrians or cyclists struck by motor vehicles19,30,31

and falls >1m.19



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GUIDELINE

In mild injury patients with multi-system trauma clinical judgement is required regarding the needfor CT scanning.

6.1.11 Multi-system trauma

Most guidelines and studies on mild head injury have

specifically excluded patients with multi-system trauma

or unstable vital signs. It is therefore difficult to make

evidence based recommendations and clinical judgment

is required. A relatively low threshold for performing

head CT scan in multi-system trauma patients should

be used as subtle signs of neurological deficit are easily

missed in the presence of distracting injuries.

GUIDELINE

Pre-existing neurosurgery or neurological impairment is a relative indication for CT scanning [6, 62].

6.1.12 Pre-existing neurosurgery / neurological impairment

Pre-existing neurosurgery has been suggested as an

indication for CT scanning particularly in the presence

of hydrocephalus and shunt placement.6 The World

Federation of Neurosurgical Societies guideline6

recommended routine CT scanning for patients with

either previous neurosurgery or epilepsy. From a practical

viewpoint any pre-existing medical condition resulting

in neurological impairment (eg stroke, dementia,

and developmental delay) may make clinical

assessment difficult.

6.1.13 Presentation

Although mild head injuries are very common it is

thought that the majority do not present to hospital.13,14

Therefore, those that do present to hospital are already a

group at slightly increased risk. Of particular concern are

those who have a delayed presentation due to

persistence of symptoms or those who represent

because of ongoing or new symptoms.

However, as Fabbri et al16 showed the overall risk

of intracranial injury in patients who represent after

mild head injuries is low if their initial risk was low.

6.1.14 Unwitnessed event / unreliable history

A good history of injury may help predict risk of

intracranial injury by identifying dangerous mechanism

of injury or significant features such as prolong loss

of consciousness or seizures. This is of particular

importance in children. However, in the absence

of other significant risk factors there are few studies

identifying unwitnessed event or unreliable history

as a significant independent risk factor.71



7 What to do with ‘High Risk’Mild Head Injury patients when CT scan is unavailable?

‘High Risk’ Mild Head Injury patients should be admitted for prolonged III-2hospital observation and considered for transfer for CT scanning. Patients at highest risk of intracranial injury who should be transferred for CT scanning include those with:16-19,27-34,37-39,47,70,71,76

:: persistent GCS <15 at two hours post injury.

:: deterioration in GCS.

:: focal neurological deficit.

:: clinical suspicion of skull fracture.

:: persistent abnormal mental status, vomiting or headache at four hours post injury.

Patients at ‘Highest Risk’ of intracranial injury should be discussed with Consensusthe regional neurosurgical service and a management plan established.

If patients are transferred for CT scanning they should ideally be transferred Consensusto a hospital with neurosurgical facilities to avoid secondary transfer.

A skull x-ray may be useful to confirm the presence of a skull fracture Ithat mandates an early CT scan due to the increased risk of deterioration.

All ‘High Risk’ patients who cannot have CT scanning should at a minimum Consensushave prolonged observation in hospital for at least 24 hours and until clinically improving.


7.1 DiscussionIn patients with high risk mild head injury, a normal CT

scan combined with clinical assessment will allow the

patient to be safely discharged for home observation.

If CT scan is unavailable then the patient will require

either admission for prolonged observation or early

transfer for CT scanning depending on clinical

assessment of risk. Prolonged clinical observation

for at least 24 hours, associated with clinical

improvement, has been shown to make a significant

injury unlikely in the majority of mild head injury

patients. However, those patients at highest risk for

an intracranial injury identified by persistently abnormal

GCS or mental status, deterioration in GCS, focal

neurological deficit, or clinical suspicion of skull fracture

should be transferred for CT scan to allow the early

identification of potentially neurosurgically significant

injury.

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8 When can patients with Mild HeadInjury be safely discharged home?

Mild Head Injury patients can be discharged for home observation after III-2initial period of in-hospital observation if they meet the following clinical, social and discharge advice criteria.16,17,19,24,26,27,29,32,66,68,69,77-79

Clinical criteria III-2

:: Normal mental status and behaviour with clinically improving minor post concussion symptoms after observation until at least four hours post injury.

:: No clinical risk factors indicating the need for CT scanning or normal CT scan if performed due to risk factors being present.

:: No clinical indicators for prolonged hospital observation (irrespective of CT scan result) such as:– clinical deterioration– persistent abnormal GCS or focal neurological deficit– persistent abnormal mental status or behaviour– persistent severe post concussion symptoms– persistent drug or alcohol intoxication– presence of known coagulopathy (relative)– presence of multi-system injuries (relative)– presence of intercurrent medical problems (relative)– age >65 (relative).

Social criteria Consensus

:: Responsible person available to take patient home.

:: Responsible person available for home observation.

:: Patient able to return easily in case of deterioration.

:: Written and verbal discharge advice able to be understood.

Discharge advice criteria Consensus

:: Discharge summary for local doctor.

:: Written and verbal head injury advice given to patient and nominated responsible person covering:– symptoms and signs of acute deterioration– reasons for seeking urgent medical attention– typical post concussion symptoms– reasons for seeking routine follow up.


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8.1 DiscussionMild head injury patients can be safely discharged from

hospital for home observation when the risk of acute

deterioration from an underlying intracranial injury is

assessed as being low. Safe discharge also requires that

the patient has adequate social supports and appropriate

advice on when to return to hospital.

The duration of in-hospital observation required will

be determined by clinical assessment combined with

selective use of imaging. Deterioration following

mild head injury may occur due to missed or delayed

intracranial haematomas or other complications such as

SIADH, post traumatic seizures or severe post concussive

symptoms. Although clinical assessment and observation

combined with appropriate imaging will identify most

at risk patients, the risk of deterioration is never zero.

Although uncommon, deterioration may occur even

after prolonged periods of observation and / or following

normal CT scanning. The challenge of managing mild

head injuries is to identify what is reasonable risk and

to ensure that the patient is aware of the potential

for delayed deterioration.

The mild head injury management algorithm summaries

the key points in management relating to safe discharge

and Evidence Table 4. Safe discharge of Mild Head Injury,

p.51 present some of the significant studies relating to

safe discharge. Mild head injury patients should

essentially be divided into low and high risk groups

based on clinical assessment. Low risk mild head injury

patients can be discharged for home observation after

a short period of observation in hospital if clinically

improving. High risk patients require CT scanning and/or

prolonged observation. High risk patients with clinically

important abnormalities on CT scan require admission

for prolonged observation. High risk patients with

normal CT scanning should also be admitted for

prolonged observation unless rapid clinical improvement

occurs. In both high and low risk mild head injury

patients’, potential clinical indications for admission such

as intercurrent medical problems and injuries need to be

considered. Whatever the period of observation selected,

the provision of safe discharge advice and assessment

of the patients social situation is mandatory because

occasional cases of deterioration following discharge

are unavoidable. An example of a suitable head injury

discharge advice sheet is attached in Appendix C,p.63.


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9 What are the proven treatmentsfor patients with ‘Moderate’

to ‘Severe’ Head Injuries?

Initial management of ‘Severe Head Injuries’ (GCS 3-8) III-2


:: Initial systematic resuscitation of ABCDE's.


:: Prevention of secondary brain injury by avoiding hypoxaemia (oxygen saturation <90%) and hypotension (systolic BP <90).

:: Supportive care of ABCDE's with appropriate attention, posturing (30o head up), basic nursing care and avoidance of hyperventilation.

:: Early neurosurgical consult.

:: Use of ICP monitoring to guide management of cerebral perfusion pressure in patients with severe brain injury.

:: Optional use of anticonvulsants to prevent early post traumatic seizures.

:: Routine brain injury rehabilitation consult.

:: ICU admission.

Acute neurological deterioration

:: Resuscitation and stabilisation of ABCDE's.

:: Short term hyperventilation to PaCO2 25-30.

:: Mannitol 1g/kg IV Bolus.

:: Early CT scan with neurosurgical intervention as required.

Poor prognostic indicators

:: Low GCS (especially motor component).

:: Age >60 years (prognosis deteriorates with increasing age).

:: Absent pupillary reflexes (after systemic resuscitation).

:: Hypotension (systolic BP <90).

:: Hypoxaemia (oxygen saturation <90%).




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9.1 Discussion

Recent exhaustive reviews by the Brain Trauma

Foundation and The Cochrane Review Group have

looked at the management of severe head injuries.15,

22,80-87,91 The findings of those reviews are summarised

in Evidence Table 6. Management of severe head injury,

p.56. For the purposes of this guidelines it is assumed

that moderate head injury patients (GCS 9-13) either

improve (80%) and should be managed in a similar

fashion to complicated mild head injuries or deteriorate

(20%) and should be managed as severe head injuries.22

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Initial management of ‘Moderate Head Injuries’ (GCS 9-13) III-2


:: Initial assessment and resuscitation of ABCDE's.


:: Period of ED observation.

:: Prevention of secondary brain injury by avoiding hypoxaemia (O2 saturation <90%) and hypotension (systolic BP <90).

:: Supportive care of ABCDE's.

:: Admit for prolonged hospital observation (24-48 hours) unless rapid clinical improvement, normal CT scan and absence of other risk factors.

:: Early neurosurgical consult if not clinically improving and/or abnormal CT scan.

:: Routine post traumatic amnesia (PTA) testing.

Outcome

:: Approximately 80% of moderate head injuries improve while 20% deteriorate and require management as per severe head injuries.

:: The majority of patients who suffer moderate head injuries will have some degree of cognitive behavioural social sequelae and should be considered for routine follow up with a brain injury rehabilitation service or a neurologist (see Appendix D of the Adult Trauma Clinical Practice Guideline, Initial Management of Closed Head Injury in Adults).

GUIDELINES LEVEL OF EVIDENCE



10 When should patients with Closed Head Injury be transferred to

hospitals with neurosurgical facilities?

10.1 Discussion:: Patients with closed head injuries should be observed

in facilities that can manage any complications that

are likely to arise. Clinical judgment regarding risk

of deterioration is required and early neurosurgical

consultation is advisable.

:: Patients with closed head injuries should be

transferred to the nearest appropriate hospital if

there is significant risk of intracranial injury. Transfer

of patients to a hospital with CT scanning facilities

but without neurosurgical services should be avoided.

:: The evidence for which patients are at significant risk

is outlined in the preceding text and evidence tables.

Patients with severe head injuries (GCS 3-8). Consensus

Patients with moderate head injuries (GCS 9-13) if: Consensus


ii abnormal CT scan


iv CT scan unavailable.

Patients with mild head injuries (GCS 14-15) if: Consensus


ii abnormal CT scan


iv high risk Mild Head Injury with CT scan unavailable.

NOTE: Consult neurosurgical / retrieval service early.

DEFINITION LEVEL OF EVIDENCE

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Haydel et al Prospective Minor HI 15 LOC / Minimal head injury. Excluded minimal head injury.

200017 study amnesia. Penetrating. Excluded GCS 13-14.

Neurodeficit. Excluded neurodeficit.

Identified risk factors.

Stiell et al Prospective Minor HI 13-15 LOC / Minimal head injury. Excluded minimal head injury.

20019 study amnesia. Penetrating. Excluded neurodeficit.

Neurodeficit. Excluded some risk factors.

Seizure. Identified risk factors.

Coagulopathy.

Representation.

Unstable vitals.

Fabbri et al Prospective Minor HI 14-15 All. Penetrating. Sub-classification into mild,

20046 study medium and high risk based on:

i initial GCS

ii LOC / amnesia

iii risk factors.

Servadei et al Guideline Mild HI 14-15 All. Penetrating. Sub-classification into mild,

20016 (WFNS) medium and high risk based on:

i initial GCS

ii LOC/amnesia

iii risk factors.

Vos et al Guideline Mild TBI 13-15 LOC <30min. Penetrating. Sub-classified categories

20029 (EFNS) PTA <60min. 0-3 based on:

i initial GCS

ii LOC/amnesia

iii risk factors.

Jagoda et al Guideline Mild TBI 15 LOC/ Minimal head injury. Excluded GCS 13-14.

20027 (ACEP) amnesia. Penetrating. Excluded minimal head injury.

Neurodeficit. Identified risk factors.

Coagulopathy.

Multisystem trauma.

Cushman et al Guideline Mild TBI 13-15 LOC/ Penetrating. Excluded minimal head injury.

20018 (EAST) amnesia. Neurodeficit. Used CT scanning to define

LOC <20min. Seizure. mild head injury.

Normal CT scan.

Mower et al Nexus II Study Minor HI 15 All. Penetrating. Excluded GCS 13-14.

200214 methodology Aim to identify risk factors.

Termin- Initial Sub-classification of risk

Author Source ology GCS Inclusion Exclusion of intracranial injury

Evidence Table 1. Definitions of Mild Head Injury


Dacey III-2 B2 18 N/A 33 59 N/A 6.5 533 N/A 1.5

198635

Teasdale III-2 B1 – – – – – – 7,838 0.03

199027

Shackford III-2 B2 221 33 10.8 646 17.5 3.8 1,899 14.8 3.20

199229

Stein IV B2 120 37.5 – 301 24.2 – 1,117 13.2 –

199278

Jeret III-2 B2 – – – – – – 712 9.4 0.30

199330

Borczuk III-2 C 40 27.5 7.5 197 18.2 3.6 1,211 5.9 0.10

199531

Dunham III-2 B1 1,160 25 3.5 435 12.4 0.5 1,481 3.0 0.13

199624 13 30 – 57 28 – 150 10 –

Culotta III-2 B1 173 28 4.5 755 16 1.6 2,179 4 0.40

199625

Hsiang III-2 B2 45 57.8 20 138 35.5 5.1 1,177 18.5 2.20

199726

Miller III-2 B1 – – – – – – 2,143 6.4 0.20

199747

Nagy III-2 B1 – – – – – – 1,170 3.3 0.34

199968

Haydel III-2 B1 – – – – – – 1,429 6.5 0.40

200017

Stiell III-2 A 110 41 – 522 17 – 2,489 4.8 –

200119

GCS 13 GCS 14 GCS 15

Author Neuro Neuro Neuro

and Level of CT scan SX CT scan SX CT scan SX

Year evidence Quality Patients abnormal required Patients abnormal required Patients abnormal required

No. % % No. % % No. % %


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Age >14-60 Age>14-60 Age 14-60

Age >60 Age >60 Age >60

:: EVIDENCE TABLES

Evidence Table 2. Initial GCS versus abnormal CT / neurosurgeryStudies showing the relationship between Initial GCS and frequency of abnormal CT scans or neurosurgical intervention



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Evidence Table 3. Risk factors for intracranial injury in Mild Head InjuryEvidence table for risk factors predicting intracranial injury based on abnormal CT scan and / or neurosurgical intervention

Author& Year

Level ofevidence

Study population

Studyobjectives

Relevant findings Comment Quality

Dacey

198635

III-2 – Prospective 610

patients.

– LOC / amnesia.

– GCS 13-15.

Neurosurgical

intervention.

– Initial GCS <15.

– Skull fractures.

Primarily looking at skull x-rays. B2

Masters

198771

III-2 Major risk factors

include:

– persistent abnormal

– mental state focal

– neurological deficit

skull fracture.

Skull x-ray may be useful in

identifying higher risk patients if

CT scan unavailable although

does not exclude intracranial

injury.

B1

Rockswold

198776

IV 215 patients with

severe head injury.

Talk and

deteriorate.

Patients who talk and

deteriorate are high risk.

Confirms seriousness

of ‘deterioration’.

C

Feuerman

198870

IV – Retrospective

373 patients.

– GCS 13-15.

Assess skull x-ray,

CT scan and

observation.


Abnormal mental states.

– Neurological deficit.

Loss of consciousness

not useful.

B2

Teasdale

199027

III-2 Prospective 8406

head injuries adults

and children.

Neurosurgical

intervention.


– Skull fracture.

– LOC / amnesia

with GCS 15.

History of LOC / amnesia with

initial GCS 15 was only a minor

absolute risk (1 in 6,663 vs 1 in

31,370 if no LOC / amnesia).

B1

Shackford

199229

III-2 – Retrospective

2,166 patients.

– GCS 13-15

isolated head

injuries.

Positive CT or

deterioration.

– GCS 13.


Also found that ‘admission

to hospital does not guarantee

skilled neurological observation’.

B2

Jeret

199330

III-2 – Prospective

712 patients.

– LOC / amnesia

– GCS 15.

Clinical predictors

of abnormality on

CT scan.

– Age.

– Skull fracture.

– Dangerous

mechanism.

Concluded that no clinical

prediction rule could be

developed to exclude

intracranial injury.

B2

Borczuk

199531


1,228 patients.

– GCS 13-15.

Clinical predictors

of abnormal CT

scan.

– Age >60.

– Skull fracture.


– Cranial soft tissue

injury.

Combined variables

91.6% sensitive for CT

abnormality (46.2% specific).

Absence of LOC / amnesia did

not exclude significant injury.

C

Madden

199528

III-2 – Phase 1,540.

– Phase 2,273.

– Inclusion criteria

not defined.

Clinical predictors

for CT selection.


– Abnormal mental status.

– Deterioration.

– LOC.

– Skull fracture (any).

– Focal neurological

signs (pupils).

– Facial injury.

Criteria detected all patients

requiring neurosurgical

intervention in Phase II but

missed two patients with

abnormal scans.

B1

Lee

199532

III-2 Prospective 1,812

patients GCS 15

with one of blow

to head / LOC /

amnesia.

Clinical predictors

of deterioration.

Risk factors fordeterioration:– age >60 years– abnormal mental

status (drowsiness)– focal neurological

deficit– headache– vomiting.

Majority of patients who

deteriorated (28 or 1.5%) did so

in first 24 hours (57%). Of those

who deteriorated 23 patients

required neurosurgery.

B2



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Author& Year

Level ofevidence

Study population

Studyobjectives


Lucchi

199533

IV Retrospective 300

patients ‘Mild Head

Injuries’.

Role of CT in Mild

Head Injuries.

Focal neurological

deficit.

Found there was no

relationship between LOC

and positive CT scans.

B2

Gomez

199634


2,484 patients.

– GCS 13-15.

Abnormal CT

findings.

Initial GCS <15.

Skull fracture.

Focal neurological deficit.

Relatively few CT scans

were performed.

B2

Dunham

199624


2,587 patients.

– GCS 15 with

LOC / amnesia.

– GCS 14 or GCS 13.

To identify risk

factors for

abnormal CT.

Risk factors were:

– GCS <15

– age >60

– cranial soft

tissue injury.

Time since injury average

one hour. Noted that initial

GCS may suffer interobserver

and inter-centre variability.

B1

Culotta

199625

III-2 – Consecutive

3,370 patients.

– GCS 13-15.

LOC present.

Relationship of

GCS to abnormal

scans

neurosurgery.

Initial GCS <15 a

significant risk for

both abnormal CT

scan and neurosurgical

intervention.

Significant difference in injury

patterns between GCS 13-14

and GCS 15.

B1

Miller

199638

III-2 Prospective 1,382

patients with GCS

15 and LOC or

amnesia.

Clinical value of

routine CT scans.

Neurosurgery required

in only 0.2%. Higher

risk if nausea / vomiting

/ headache or skull

fracture.

Routine CT scan not

recommended for patients

with GCS 15 and LOC / amnesia

without other clinical signs and

symptoms of head injury or

skull fracture.

B2

Miller

199747


2,143 patients.

– GCS 15 LOC.

Predictive value of

severe headache,

nausea, vomiting

and skull fracture

for abnormal

CT scans.

– Severe headache.

– Nausea.

– Vomiting.

– Skull fracture.

Clinical criteria selected shown

to be predictive of need for

neurosurgery (PPV 100%)

but not sensitive for abnormal

CT scans (65% sensitivity).

B1

Hsiang

199726


1,360 patients.

– GCS 13-15.

Define Mild

Head Injury.

Initial GCS <15

associated with higher

risk abnormal CT,

neurosurgery or

poor outcome.

Vomiting not found

to be a significant risk.

B2

Stiell

199720


1,699 patients.

– GCS 13-15.

LOC/amnesia.

– Seven Canadian

major teaching

hospitals.

Assess need for

and use of CT

scanning for

Mild Head Injury.

6.2% with abnormal

CT scan and 0.5% with

extradural. Significant

variability in use of

CT scanning. Missed

haematomas occurred

in those institutions

with higher rates of

CT scanning.

CT scanning not necessarily

useful if use not standardised.

Need for clinical decision.

B2

Nagy

1999 [68]


1,170 patients

GCS 15.

– LOC/amnesia.

– All CT.

– All 24 hour

observation.

– Using CT to

allow safe

discharge.

– Positive CT or

deterioration.

Neurosurgical

incidence of 4 (0.34%).

No patients deteriorated

following normal

CT scan.

Recommended discharge if

initial CT normal. Study had

969 patients with unknown

LOC emphasising clinical

difficulties in assessment.

B1



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Level ofevidence

Study population

Studyobjectives


Vilke

200045

IV – Prospective

58 patients.

– GCS 15.

– LOC / amnesia.

To determine if

intracranial injury

could be excluded

in initial GCS 15

and normal

complete Neuro

examination.

Need for CT scanning

could not be ruled out

by GCS 15 and normal

neurological examination

on presentation.

B2

Hofman

200037

I Meta analysis of

risk of intracranial

injury after MHI

related to skull

fractures.

Assess use of

skull fracture

in predicting

intracranial injury.

– Prevalence of ICH

0.083 (8 in 100).

– Skull x-ray sensitivity

0.39 specificity 0.95.

– Skull fracture is a

significant risk for ICH.

Skull fracture is associated with

increased risk of intracranial

injury. Skull x-rays are not

useful screening tools.

B1

Haydel

200017

III-2 – Prospective.

– Phase I 520.

– Phase II 909.

– GCS 15.

– LOC / amnesia.

– Age >10.

– Exclusion criteria:

– neurodeficit

– coagulopathy

(only one

patient).

To identify clinical

predictors of

patients who

do not require

CT scan.

All patients with

positive CT scan had

one of seven criteria

(likelihood ratio):

– deficit in STM (15.0)

(anterograde amnesia)

– trauma above clavicle

(11.0) (mostly skull

fracture)

– drug or alcohol

intoxication (11.0)

– seizure (3.0)

– age >60 (3.0)

– headache (2.0)

– vomiting (0.2).

Clinical decision rule of seven

criteria was 100% sensitive

(95% CT 95-100) and 25%

specific with a negative

predictive value of 100%.

Application of the criteria

would have reduced the

number of CT scans by 22%.

B1

Horowitz

200142

IV Chart review

665 patients.

Evaluation of

pre-hospital triage

using brief LOC

or head injuries.

Transient LOC did

not predict need

for neurosurgical

intervention.

Transient LOC not predictive

of neurosurgical intervention.

B2

Sharma

200140

III-2 100 patients Assess importance

of history of

unconsciousness.

– GCS useful.

– Presence of LOC

not useful.

– Duration of LOC

more useful.

A history of brief LOC

did not accurately predict

risk of intracranial injury

in Mild Head Injury.

B1

Stiell

200119

III-2 Prospective multi-

centre 3,121

patients GCS

13-15 one of

LOC / amnesia/

disorientation

Exclusion:

– neurodeficit

– seizure

– coagulopathy

– reassess

– unstable

multi-system.

To develop clinical

decision rule for

use of CT scan

in mild head injury

to identify clinically

important brain

injury.

Developed seven risk

factors.

High risk (OR):

– GCS <15 at 2 hr

post injury (7.3)

– skull fracture (base)

(5.2)

– skull fracture (non-

base) (3.6)

– age > 65 (4.1)

– vomiting (3.8)

Medium risk:

– dangerous mechanism

(2.8)

– retrograde amnesia

>30 min(1.4).

High risk factors alone

were 100% sensitive and

69% specific for predicting

neurosurgical intervention

and require only 32% of

patients to undergo CT scan.

High risk and medium risk

factors together were 98.4%

sensitive and 49.6% specific for

clinically important brain injury

and would require 54% of

patients to have CT scan.

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Level ofevidence

Study population

Studyobjectives


Mina

200272


inception cohort.

380 patients.

– Any injury with

pre-injury

anticoagulation.

Effect of

anticoagulation

on incidence of

intracranial lesion.

Preinjury anticoagulation

and intracranial injury

has a four- to-five-fold

higher risk of death than

the non-anticoagulated

patient.

Not typical mild head injury

patients, average ISS 17

and GCS 11.

B1

Falmirski

200339


331 patients.

– GCS 14-15.

– LOC.

To identify

significance of

constitutional signs

and symptoms

in predicting need

for CT scan.

Constitutional signs

and symptoms

predicted presence

of abnormalities on CT

scan requiring a change

in management.

LOC alone is not predictive of

significant head injury and the

need for CT scan. Other clinical

features need to present.

B1

Mack

200374

III-2 – 133 patients.

– GCS 13-15.

Identify risk factors. – Acute Intracranial

injuries 14.3%.

– No risk factors

useful for identifying

intracranial injury

in elderly.

Suggest routine CT scan

if age>65 years.

C

Palchak

200318


2,043 children.

– Blunt head

trauma.

– All GCS.

– Exclude trivial

injury.

Clinical decision

rule for low risk

traumatic brain

injury.

Significant risk factors

identified for abnormal

CT or neurosurgical

intervention (relative

risk of neurosurgical

intervention brackets).

– Abnormal mental

status (21.7).

– Skull fracture (11.3).

– Focal neurological

deficit (10.6).

– Loss of

consciousness (7.6).

– Seizure (5.3).

– Amnesia (4.7).

– Headache (4.5).

– Vomiting (3.5).

Clinical decision rule identified

using four factors:

1 Abnormal mental status.

2 Evidence of skull fracture

(including scalp haematoma

<2 yr old).

3 Headache.

4 Vomiting.

Abnormal CT prediction:

– 99% sensitive (95-100).

– 26% specific (23-28).

– 99% NPV (98-100).

Neurosurgical intervention

prediction:

– 100% sensitive (97-100).

– 43% specific (40-45).

– 100% NPV (99-100).

B2

:: EVIDENCE TABLES



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Level ofevidence

Study population

Studyobjectives


Fabbri

200416


5,578.

– GCS 14-15.

– Blunt trauma.

– Excluded

penetrating multi-

system injury.

– Validation of

mild head injury

guideline.

– Outcomes of

post traumatic

lesion on CT,

neurosurgical

intervention,

outcome at 6/12.

High risk

GCS 14 or

GCS 15 with

any of:

– neurodeficit

– skull fracture

– risk factors

- coagulopathy

- age >60

- previous

neuro-

symptoms

- epilepsy

- alcohol / drug

intoxication.

Medium risk

GCS 15 with

clinical findings:

– LOC

– amnesia

– vomiting

– diffuse headache.

Low risk

GCS 15 with

none of above.

– Best predictors of post

traumatic injury and

neurosurgical injury

were abnormal GCS,

skull fracture and to a

lesser extent clinical

findings.

– Unfavourable outcome

was most related to

abnormal GCS skull

fracture and not

surprisingly risk factors

or neurological deficits.

– Sensitivity and

specificity of high vs.

medium / low risk

were:

- post traumatic 92%

- sensitive 54%

- specificity

- neurosurgical 93%

- sensitive 53%

specificity

- unfavourable outcome

100% sensitive

- 52% specificity.

– Risks of post concussive

symptoms were similar in

all groups, while rates of

intracranial injury were much

higher in the high risk group.

– Neurosurgical intervention

occurred in 71 patients. None

from low risk, five (0.4%) from

medium risk and 66 (2.4%)

from the high risk group.

– Only 67% of the high risk

group had CT scans due to

cost and local resource issues.

– Age alone was not used as a

risk factor due to cost and

resource issues. Only one

patient (1 of 705) with age

>60 as the sole high risk

factor had an undiagnosed

ICH. Suggests age alone need

not be used as a risk factor.

B1

Ibanez

200462


1,101 patients.

– GCS 14-15.

– Identify risk

factors.

– Evaluate

guidelines

Acute intracranial

lesions 7.5%.

Risk factors identified

– GCS 14

– LOC

– Neurological deficit

– Skull fracture

– Vomiting

– Severe headaches

– coagulopathies

– Aged>65years

– significant extracranial

lesions

– hydrocephalus

with shunt.

Guidelines

– miss some abnormal

CT scans

– identify clinically

important lesions.

– Findings consistent with

previous studies identifying

risk factors. Support use of

clinical decision rules for

identifying clinically important

lesions. Excellent discussion

on the pros and cons of

clinical guidelines.

– Identify absence of LOC

as not being useful in ruling

out intracranial injury.

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Level ofevidence

Study population

Studyobjectives


Stein

199079


658 patients.

– GCS 13-15.

Detect abnormal

CT scan and

deterioration in

mild head injury

patients.

None of 542 patients

with initial normal CT

scan deteriorated.

Safe to discharge Mild Head

Injury if normal CT and

neurological examination.

B2

Stein

199278


1,538.

– GCS 13-15.

– LOC / amnesia

‘Normal’

neurology.

– All CT scanned

and admitted.

Detect abnormal

CT scan or

deterioration in

mild head injury

patients.

None of 1,339 patients

with initial normal CT

scan deteriorated.

Safe to discharge mild

head injury if normal CT

scan and normal neurological

examination.

B2

Shackford

199229


multi-centre 2.

– 66 patients.

– GCS 13-15.

– Isolated head

injuries.

– To prove that

a patient with

normal

neurological

examination and

normal CT scan

would have

negligible risk of

neurosurgical

lesion.

– Distinguished

abnormal, positive

and relevant

positive scans.

– Normal

neurological

examination

included

abnormal mental

states or focal

neurological

deficit.

– None of 1,170

patients with normal

CT scan deteriorated.

– None of 933

patients with

normal CT scan and

normal neurological

deteriorated.

– Identified significant

risk factors as

GCS 13 or focal

neurological deficit.

– ‘Reliable patients with a

mild head injury with normal

neurological examination and

negative CT scan can be

safely discharged.’

– The utility of abnormal CT

scan or abnormal neurological

examination in detecting

neurosurgical lesions was:

– sensitivity 100%

– specifically 51%

– NPV 100%.

B2

Taheri

199377


310 patients.

– GCS 15.

– Assess safe

discharge for

Mild Head Injury.

Patients who required

neurosurgical

intervention with initial

GCS 15 had either:

i skull fracture

ii neurological deficit.

Safe discharge required:

i initial GCS 15

ii no skull fracture clinically

or radiologically

iii no neurological deficit.

B2

Teasdale

199027


8,406 patients.

– All head injuries.

Assess risk of

intracranial

haematoma.

Best predictors of injury:

– abnormal LOC

– focal neurology

– skull fractures.

Safe discharge if:

– initial GCS 15

– no focal neurological deficit

– no skull fracture.

B1

Evidence Table 4. Safe discharge of Mild Head Injury

Lee

199532


1,812 patients.

– GCS 15.

Clinical predictors

of deterioration.

Risk of deterioration

associated with:

– age >60

– abnormal

mental states

– focal deficit

– headache

– vomiting.

Deterioration most common in

first 24 hours due to extradural.

Delayed deterioration due to

subdurals occurred up to a

week later. Initial CT scan may

not rule out risk of deterioration

due to subdurals SIADH

or seizure.

B2

:: EVIDENCE TABLES



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Level ofevidence

Study population

Studyobjectives


Dunham

199624


2,587 patients.

– GCS 13-15.

To identify

risk factors for

abnormal CT scan.

– No patients required

neurosurgical

intervention if initial CT

scan was normal.

– All patients requiring

craniotomy

deteriorated within

four hours of arrival.

Safe discharge implied after

observation if:

i initial GCS 15:

– age <60

– no evidence skull fracture

– no neurodeficit

– no headache

– no vomiting

ii initial GCS 13-14:

– age <60

– normal CT scan

– no persistent neurodeficit

– no persistent headache

– no persistent vomiting.

B1

Hsiang

199726


1,360 patients.

– GCS 13-15.

– Good follow

up at 6/12.

Define high risk

Mild Head Injury.

GCS 15 with normal

CT scan or skull x-ray

associated with good

outcome.

Safe discharge if initial

GCS 15 with normal

CT scan or skull x-ray.

B2

Nagy

199968

IV – Prospective

1,170 patients.

– GCS 15.

– LOC / amnesia.

– All CT.

– All 24 hour

admissions.

Assess role of

CT scanning in

identifying lesions

and risk of

deterioration.

No patients with

a normal initial

CT scan deteriorated.

Safe discharge if initial GCS 15

and normal CT scan.

B1

Livingston

200069

III-2 – Prospective.

– GCS 14-15.

– LOC / amnesia.

Discharge after

normal CT scan.

– One of 1,788 patients

with initial negative

CT scan deteriorated

requiring neurosurgery.

– Thirty-three others

required variable

intervention.

Safe to discharge if normal CT

scan and clinical improvement.

B2

Jagoda

20027

III-2 Systematic review – Can a patient

with MTBI be

safely discharged

from ED if a non

contrast head CT

scan shows no

acute injuries?

– Exclusion criteria.

– GCS <15.

– Coagulopathy.

– Focal neurological.

– Multi-system trauma.

Safe discharge if:

– GCS 15

– normal examination

– normal CT scan

– six hours observation

– responsible observer.

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Study population

Studyobjectives


Fabbri

200416

III-2 – Prospective,

multi-centre.

– 5,578 patients.

– GCS 14-15.

– Blunt trauma.

– Excluded

penetrating

multi-system

injury.

– Validation of a

set of criteria to

classify mild

head injury

patients into

different risk

categories for

management.

– Outcome

measures:

- post traumatic

lesions

- neurosurgical

intervention

- outcome

at 6/12.

1.676 low risk patients:

– 1 missed intracranial

injury

– 52 post concussive

symptoms

1,200 medium

risk patients:

– 22 intracranial injuries


injuries


symptoms.

2,702 high risk patients:

– 301 intracranial injuries


injuries


symptoms.

Sensitivity and specificity

of high risk vs. medium

/ low risk for identifying

outcomes were:

– post traumatic

lesions:

92% sensitivity

54% specificity

– neurosurgical

intervenion:

93% sensitivity

53% specificity

– unfavourable

outcomes:

100% sensitivity

52% specificity.

Basically validated safe to

discharge patients if:

1 Initial GCS 15:

– no LOC/amnesia

– no headache/ vomiting

– no neurodeficit

– no skull fracture

– no risk factors

– no imaging

– brief ED observation.

2 Initial GCS 15:

– LOC or amnesia or

vomiting or headache

– no neurodeficit

– no skull fracture

– no risk factors

– normal CT scan and

brief ED observation

or

normal skull x-ray and

24 hr hospital observation

or

24 hr hospital observation.

Note that there was no direct

association between risk

categorisation and frequency

of post concussive symptoms.

Note that even on those patients

who had CT scans there were

eight cases of delayed

intracranial haemorrhage not

detected on initial CT (eight of

1774). Thus while CT may

identify most acute extradurals it

may miss delayed subdurals.

B2

Fabbri

200466

III-2 Prospective

1,480 patients.

Safety discharging

‘high risk’ Mild

Head Injury after

normal CT scan.

No significant difference

in outcome between in

hospital and home

monitoring.

Early home discharge ‘safe’. B2

:: EVIDENCE TABLES



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Author& Year

Level ofevidence

Study population

Studyobjectives


Rimel

198148

IV – 538 patients.

– GCS 13-15.

Evaluate disability

at three months.

– Persistent headaches

(79%).

– Persistent memory

problems (59%).

– Persistent

unemployment (34%).

Included potentially complicated

patients with initial GCS 13-14.

B2

Alves

198651

III-2 847 patients. Post traumatic

symptoms

characteristics for

mild head injury.

– Persistent headache

commonest symptom.

– Post concussive

symptoms usually

resolved by three

months.

Headache common,

most improve by 3/12.

B1

Hugenholtz

198850

III-2 22 patients. Time to recovery. Mild cognitive

impairment with

deficits in attention and

information processing

gradual recovery over

three months.

Headache and mild cognitive

impairment common.

B2

Williams

199036

III-2 Compared

neurobehavioural

outcome over

six months for:

– uncomplicated

mild head injury

(GCS 13-15)

– complicated mild

head injury (GCS

13-15) with brain

injury or skull

fracture

– moderate head

injury (GCS 9-12).

Assess relationship

of neurobehaviour

complications to

initial injury.

– Outcome for

uncomplicated mild

head injury was better

than complicated

mild head injury or

moderate head injured

(which were similar).

– Age was associated

with poor outcome.

– An abnormal

intracranial lesion

was more predictive of

poor outcome than an

isolated skull fracture.

– Uncomplicated mild head injury

had a good outcome

in 97% of patients. However

complicated mild head injury

or moderate head injury had a

good outcome in only 70-80%.

– Patients with complications

need follow up.

A

Lee

19932

III-2 – 1,812 patients.

– GCS 15.

Outpatient follow

up for three

months.

– At three months post

injury nearly all had

good outcome.

Delayed deterioration

may occur with mild

head injury.

Outcome is generally good. B2

Evidence Table 5. Post concussive symptoms and Mild Head InjurySelected studies and guidelines looking at post concussive symptoms follow up and outcome for Mild Head Injury



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Author& Year

Level ofevidence

Study population

Studyobjectives


Chambers

199688

III-2 Follow up of

mild head

injury patients.

Assessment of

complications.

– Post concussive

symptoms are

common and gradually

reduce with time.

– Headache or memory

problems most

common.

Post concussive symptoms

common.

B2

Nell

200055

III-2 561 patients. – Evaluate

extended

Glasgow

Coma Scale.

A potentially useful tool

to flag mild head injury

patients at increased risk

of cognitive impairment

using an amnesia scale.

B2

Thornhill

200049

III-2 2,962 patients with

head injury (362

with mild head

injury analysed).

To determine

outcome at

one year.

Among patients with no

pre-existing problems

about 1/3 failed to

achieve good outcome

significant problems

included cognitive

behavioural and

employment dysfunction.

Significant disability may

occur in the undifferentiated

GCS 13-15 ‘mild’ head injury

group.

B2

Cushman

20018

III-2 EAST guidelines. Recommendations

(paraphrased).

– Mild cognitive

impairment is common

and usually resolved

by one month post

injury (Level II).

– Patients with post

concussive symptoms

that persist for more

than 6/52 should

have formal

neuropsychological

testing (level II).

Persistent post concussive

symptoms may identify a

subgroup at risk of prolonged

cognitive deficits.

N/A

Vos

20029

III-2 European (EFNS)

guidelines.

Recommendations

(paraphrased).

– Patients with high risk

head injury admitted to

hospital should have

outpatient follow up.

– Post concussive

symptoms are

common but usually

resolve by 3-6 months.

Post concussive symptoms

persisting after six months may

benefit from neuropsychological

testing.

N/A

Savola

200389

III-2 172 patients with

mild head injury

GCS 13-15.

Early predictors of

post concussive

symptoms.

Best beside predictors

of post concussive

symptoms were:

– skull fracture

– dizziness on admission

– headache on

admission.

Serum protein S-100 B

was also found to be a

good predictor of post

concussive symptoms.

Initial GCS and duration

of PTA were not found

to be good predictors.

B1

:: EVIDENCE TABLES



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Evidence Table 6. Management of Severe Head Injury

Author& Year

Level ofevidence

Quality Study objectives Relevant findings

Brain Trauma

Foundation15

I B1 Systematic review of the

management and prognosis

of severe traumatic brain

injury.

Recommendations

Overall management strategies:

– Organised trauma systems.

– Initial systemic ABCDE resuscitation fundamental to successful

neurological outcome.

– Prevention of secondary brain injury from hypoxaemia

or hypotension crucial to outcome.

– Specific therapy directed at raised intracranial pressure should

not interfere with systemic resuscitation.

Hypoxaemia and hypotension:

– Systemic hypoxaemia (SaO2<90) and hypotension

(systolic BP <90) following head injury are both associated

with poor outcome.

– Adequate oxygenation and fluid resuscitation should be the

priority in multiply injured patients.

ICP Monitoring

– ICP monitoring should be used as a guide to optimise cerebral

perfusion pressure.

– Specific indications for ICP monitoring include:

i GCS 3-8 abnormal CT scan.

ii GCS 3-8 normal CT scan if two of:

- age >40

- motor posturing

- systolic BP <90.

Supportive care ABCDE’s

– Supportive care with attention to stabilising ABCDE’s, adequate

nutrition, appropriate posturing (30O head up), basic nursing

care and prevention of complications is more effective than

most other interventions.

Anticonvulsants

– Anticonvulsants such as phenytoin are effective at preventing

early post traumatic seizures but do not prevent late post

traumatic seizures.

Hyperventilation

– Routine hyperventilation (PaCO2<35mmHg) should be avoided

in head injury patients as it is associated with poor outcome.

– Acute hyperventilation (PaCO225-30mmHg) is proven effective

for short term reduction of raised ICP associated with acute

neurological deterioration.

Mannitol

– Mannitol (0.5g-1g/kg) is effective at reducing raised ICP.

– Care should be used to avoid hypovolemia and serum

osmolarity >320.

– It should be largely reserved for patients with acute neurological

deterioration.

Therapies not shown to be effective

– Barbiturates.

– Steroids.

Factors clearly associated with poor prognosis

– GCS (lower GCS = worse outcome with motor component

most predictive).

– Age >60 (gradual trend with age most significant at age >60).

– Absent pupillary reflexes (when systemic ABCDE causes

eliminated).

– Hypotension (systolic BP <90mmHg).

– Hypoxaemia (O2 sat <90%).



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Author& Year

Level ofevidence

Quality Study objectives Relevant findings

Forsyth

200380

I A To determine if routine

ICP monitoring in acute

coma is beneficial.

Insufficient evidence to clarify role.

Roberts et al

200381

I A To determine role

of hyperventilation in

head injury.

Insufficient evidence to clarify role.

Roberts et al

200382

I A To determine role of

mannitol for acute

traumatic brain injury.

Mannitol beneficial for pre-operative management of raised ICP.

Schierhout et al

200191


anti-epileptics for acute

traumatic brain injury.

– Anti-epileptics reduce early post traumatic seizures.

– Anti-epileptics do not alter outcome.

– Anti-epileptics do not prevent late post traumatic seizures.

Alderson et al

200383


corticosteroids for acute TBI.

Insufficient evidence.

Roberts

200384


barbiturates for acute TBI.

No evidence that barbiturates improve outcome.

Langham

200385


calcium channel blockers

for acute TBI.

Insufficient evidence.

Gadkary

200386


therapeutic hypothermia

for acute TBI.

No evidence that hypothermia is beneficial.

Fleminger

200387

I A To determine role

of pharmacological

management for agitation

and aggression following

acquired brain injury.

B blockers (especially propranolol) may be effective in reducing

aggression and agitation in the long term.

:: EVIDENCE TABLES


::


The Westmead Post Traumatic Amnesia (PTA) Scale, developed by NEV Marosszeky, L Ryan, EA Shores, J Batchelor and

JE Marosszeky, was published in 1986. The Westmead PTA Scale consists of seven orientation questions and five memory

items designed to objectively measure the period of PTA. The Westmead PTA Scale is a standardised and prospective

measure of PTA. A person is said to be out of PTA if they can achieve a perfect score on the Westmead PTA Scale for

three consecutive days.

The Westmead PTA Scale form (as seen by the example on the following page) and nine picture cards are required

to perform the test. As the test was designed to measure PTA in a standard fashion to enable comparison of patients

from different hospitals, the supplied picture cards must be used. They are available for purchase with instruction on

their use from the Department of Rehabilitation Medicine, Westmead Hospital, Westmead NSW 2145 for a minimal fee.

More information is available on the Westmead PTA Scale at:

web. http://www.psy.mq.edu.au/pta/index.html or

email. [email protected]


Westmead PTA scale

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EAPPEND IX 1



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APPEND IX A :: WESTMEAD PTA SCALE



Glasgow Coma Scale

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EAPPEND IX B

Eye Opening (E) Verbal Response (V) Motor Response (M)

4 = Spontaneous 5 = Normal conversation 6 = Normal

3 = To voice 4 = Disoriented conversation 5 = Localizes to pain

2 = To pain 3 = Words, but not coherent 4 = Withdraws to pain

1 = None 2 = No words... only sounds 3 = Decorticate posture

1 = None 2 = Decerebrate

1 = None

Total (Glasgow Coma Score) = E+V+M



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Mild Head Injury discharge advice

APPEND IX C

Important points about Mild Head Injury:: You have been assessed as having a Mild Head Injury. This means that the doctor has not found any evidence

to suggest a serious underlying brain injury and feels you are suitable for observation at home.

:: Due to the small risk of you developing a serious complication after discharge from hospital, it is important that

a responsible adult observes you for the next 24 hours and returns you to hospital if necessary.

:: Although you do not have evidence of a serious underlying brain injury, it is common to have some mild post concussion symptoms for up to several weeks.

:: If you still have significant post concussion symptoms that are not improving after a few days you

should see your local doctor. Your local doctor may refer you for specialist review if your symptoms persist.

Please read the following fact sheet that details what you should expect while you recover from your head injury.

WARNING SIGNS!

Return to HOSPITAL IMMEDIATELY if you deteriorate and develop any of the following:

:: excessive drowsiness or lethargy

:: confusion or disorientation

:: abnormal behaviour or irritability

:: fitting or seizures

:: blurred vision or slurred speech

:: severe headache

:: persistent vomiting

:: abnormal clumsiness

FIRST 24–48 HOURS

! Warning signs You should be observed and returned to hospital if you develop any of the above warning signs.

Rest / Sleeping Rest and avoid strenuous activity for at least 24 hours. It is alright for you to sleep

tonight but you should be woken every four hours by someone to make sure you

are alright.

Driving Do not drive for at least 24 hours, as you may be unable to concentrate properly.

This is a legal requirement.

Drinking / Drugs Do not drink alcohol, take sedatives or use recreational drugs in the next 48 hours,

as they may make you feel worse and / or mask symptoms of deterioration.

Pain relief Use paracetamol or paracetamol/codeine for headaches. Do not use aspirinor an anti-inflammatory pain reliever such as ibuprofen or naproxen (NSAIDs)

which may increase the risk of bleeding.

zz



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EAPPEND IX C :: MILD HEAD INJURY D ISCHARGE ADV ICE

THE FIRST FOUR WEEKS

Post concussion symptomsThe following symptoms are common after a Mild Head Injury and usually resolve within a few weeks:

:: fatigue :: poor concentration :: mood swings :: dizziness :: mild headache

:: forgefulness :: mild nausea :: mild behavioural change

Rest / Sleeping It is important to get adequate amounts of sleep as you may feel more tired

than normal.

Relationships Sometimes your post concussion symptoms will affect your relationship with family and

friends, as you may suffer irritability and mood swings. See your local doctor if you or

your family are worried.

Driving Do not drive until you feel much better and can concentrate properly.

Drinking / Drugs Do not drink alcohol or use recreational drugs until you are fully recovered

– they will make you feel much worse.

Work / Study Most people return to work or study within a few days following a Mild Head Injury.

Some people find it difficult to concentrate properly when returning to work or study

following a Mild Head Injury. See your doctor and notify your employer or teachers

if you are having problems at work or with study. You may need to take on reduced

work or study duties for a short period.

Sport / Lifestyle It is important to avoid another head injury. You should avoid contact sports and

other activities where you may suffer another head injury for at least four weeks

– 'if in doubt – sit it out'.

Recovery You should start to feel better within a few days and be ‘back to normal’ within

about four weeks. See your local doctor if you are not starting to feel better

within a few days of your head injury.

zz

PERSISTENT POST CONCUSSION SYMPTOMSThe majority of people recover rapidly following a Mild Head Injury. However, a minority of people may

suffer from persistent post concussion symptoms. If you still have post concussion symptoms a few days after

a Mild Head Injury, you should see your local doctor. Your local doctor will monitor these symptoms, which

would normally improve within four weeks. Your local doctor may refer you to a Traumatic Brain Injury Clinic

or a Neurologist for specialist review if your symptoms persist.

SUMMARY:: Return to hospital immediately if you develop any of the warning signs

:: Most people recover rapidly from mild head injuries and have no significant problems

:: Mild post concussion symptoms are common but usually resolve within a few weeks

:: See your local doctor if you still have post concussion symptoms a few days after your head injury

Dr. Duncan Reed, Director of Trauma, Gosford Hospital



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NSW Brain Injury Rehabilitation Program (BIRP)

APPEND IX D

SYDNEY

WEST

GREATER SOUTHERN

HUNTER /

NEW ENGLAND NO

RTH

CO

AST

MET

RO

North Coast Head Injury

•

• New EnglandBrain InjuryRehabilitation

•Dubbo Brain InjuryRehabilitation

• Mid Western BrainInjury Rehabilitation

South West BrainInjury Rehabilitation•

• Southern AreaBrain Injury Service

• Hunter BrainInjury Service

Westmead BrainInjury Rehabilitation • • Royal

RehabilitationCentreSydney

•Liverpool Hospital

Brain Injury Rehabilitation Unit

• Illawarra AreaBrain Injury Service

SYD STH

WEST

SOUTH EASTERN

SYDNEY / ILLAWARRA

NORTHERN

SYDNEY /

CENTRAL COAST

GREATER WESTERN


The following search phrases were used in Medline:

1 exp Head Injuries, Closed/

2 exp *tomography, x-ray/

3 Patient Discharge/

4 Patient Transfer/

5 intubation/ or exp intubation, intratracheal/

6 *Intracranial Pressure/

7 Drainage/

8 (7 and (ventricular or intra?ventricular or extra?ventricular).mp.) or ((ventricular or intra?ventricular or extra?ventricular) adj drain)).mp.

9 (icp monitor$ or intracranial pressure monitor$).mp.

10 exp Aggression/

11 exp Mannitol/

12 exp Hyperventilation/

13 Adrenal Cortex Hormones/

14 Craniotomy/

15 Trephining/

16 exp emergency treatment/

17 exp *head injuries, closed/su, th or (exp head injuries, closed/ and management.mp.)

18 (or/2-6) or (or/8-16)

19 (1 and 18) or 17

The following search phrases were used in Embase:(head injury/ and closed$.mp.) or (closed head injury or closed head trauma$).mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name]

2 exp computer assisted tomography/

3 patient transport/ or discharg$.mp.

4 exp RESPIRATORY TRACT INTUBATION/ or INTUBATION/

5 Intracranial Hypertension/

6 cerebrospinal fluid drainage/

7 [(ventricular or intra?ventricular or extra?ventricular) adj drain]).mp.

8 (icp monitor$ or intracranial pressure monitor$).mp.

9 exp aggression/

10 Mannitol/

11 exp Hyperventilation/

12 exp Corticosteroid/

13 craniotomy/

14 (trephin$ or burr hole$).mp.

15 exp emergency treatment/

16 (su or th).fs. or management.mp.

17 1 and (or/2-16)

18 limit 17 to human


List of search terms to identify studies

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