mallika khwanmuang phatcharapol udomluck jitsupa litleangdej...
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Mallika Khwanmuang
Phatcharapol Udomluck
Jitsupa Litleangdej
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5th year medical students of
Naresuan university, Phitsanulok , Thailand
The Corre lat ion between Mi ld Head In jury and Pos i t ive CT Scan o f the Bra in in the Pat ients wi th Moderate R isks at Naresuan Un ivers i ty Hosp i ta l
Magn i tude o f p rob lem
Casualty due to accident is the third cause of
death following to cancer and cardiovascular
disease
Head injury is the most common site (30%) of
all injuries. Mortality rate of severe head
injury is 29% and is increasing steadily
CT brain is gold standard for diagnosis of
intracerebral hemorrhage which requires
specialized instruments and only available in
tertiary center
Magn i tude o f p rob lem
There is increasing trends of screening
patient before performing CT brain based on
clinical characteristics of patient because of
its availability , cost and specialist
requirements .
The study objective is to define clinical
characteristic criteria for screening patient
who is at risk of intracerebral hemorrhage ,
which is insight for diagnosis , treatment ,
referral to reduce morbidity , mortality rate
and cost for health on source section
Mild head
injury
patients with GCS score of 13-15
Positive CT scan one that demonstrated an acute pathological state
in the skull or brain attributable to head injury
(Epidural hematoma, Subdural hematoma,
Subarachnoid hemorrhage, Intracerebral
hemorrhage, Hemorrhagic contusion,
Hydrocephalus).
Basal skull
fractures
Evidence of basilar skull fracture including
Raccoon’s eyes: periorbital ecchymoses,
Battle’s sign: postauricular ecchymoses
(around mastoid air sinuses), CSF
rhinorrhea/otorrhea, Hemotympanum or
laceration of external auditory canal
Opera t i ona l defi n i t i ons
Head injuryMild head injury
(GCS 13-15)Low risk criteria
Moderate risk criteria
High risk criteria
Moderate head injury(GCS 9-12)
Severe head injury(GCS ≤ 8 )
Gap of Knowledge
Research Quest ion
Clinical characteristic findings
for abnormal CT brain results
Li terature ReviewThe relevant literature contains many studies
on the use of CT scan in patients with minor
head injury, yet no consensus has been
reached.
Li terature ReviewA study by Haydel et al. suggested that CT
scan is indicated only in patients with minor
head injury with any one of seven risk
factors, the New Orleans Criteria. A similar
study by Stiell et al. identified a different set
of factors, the Canadian CT Head Rule. Both
decision rules had 100% sensitivity for
identifying patients with traumatic brain
injury, but both rules had low specificities.
Li terature ReviewServadei et al. classified patients with minor
head injury as low-, medium-, or high-risk
They evaluated patients with a GCS score of
15 requiring surgical intervention in these
patients as 0.2%.
Patients with one or more of these four
symptoms (temporary loss of consciousness,
amnesia, vomiting, or widespread headache)
were classified as medium-risk head injury,
and the risk of intracranial hemorrhage in
these patients was determined to be 1–3%.
They recommended CT scan for medium-risk
patients.
Object ive
1. Define definitive clinical characteristics
associated with abnormal computed
tomographic scan finding in mild head
injuries
2. Guideline for appropriate requirement to
perform CT brain
3. Guideline for management and referral
Advantages
1. Can predict clinical characteristics of
patients at risk for intracerebral
hemorrhage in mild head injuries
2. Can reduce cost for health on source
section for performing CT brain
3. Can discharge patients with mild head
injuries who do not require CT brain and
with no consequences after discharge
MethodsRetrospective cohort studies
Mild head injury + Moderate risks
+ CT scanModerate risksYes
Abnormal CT
Normal CT
No
Abnormal CT
Normal CT
Reference population
Inclusion criteria
Patients treated at the emergency
department between January 1, 2008 and
May 31, 2011
Mild head injury (GCS score of 13 to 15)
CT performed within 3 hours of the admit
Inclusion criteria Moderate risk criteria
Significant subgaleal swelling Post traumatic seizure Retrograde amnesia Alcohol consumption Basal skull fractures Serious facial injury Loss of consciousness Vomiting Progressive headache Multiple traumas
Reference population
Exclusion criteria
Bleeding disorder or used anticoagulants
Coumadin
Spontaneous intracerebral hemorrhage
Idiopathic thrombocytopenic purpura
Leukemia
Stroke
Reference population
Data were collected on patient
characteristics (age, sex time of injury),
mechanisms of trauma and CT scan
findings.
Data were analyzed with chi-squared
tests.
The research ethics committees of the
study hospitals approved.
Methods
Results
Medical charts of 64 males and 45 females.
An average age of 17-60 years.
Mechanisms of trauma were motorcycle
accident, 74; fall 21; and other, 12.
Initial CT scan was performed on all 109
patients.
Abnormal findings were identified in 28
(25.7%).
7%
18%
61%
14%
Traumatic findings at CT
Hemorrhagic con-tusion
Traumatic sub-arachnoid hemor-rhageSubdural hematoma
Epidural hematoma
Traumatic findings at CT
Sign
ifica
nt sub
gale
al swel
ling
Post t
raum
atic sei
zure
Retro
grad
e am
nesia
Alcoh
ol o
r dr
ug in
toxica
tion
20
3
65
35
91
14 9
Correlation between moderate-risk criteria and initial abnormal CT scan
in all patientsNumber of patients Abnormal CT scan number
Corre lat ion between moderate-r isk cr i ter ia and in i t ia l abnormal CT scan in a l l pat ients
Basal
sku
ll frac
ture
s
Seriou
s fa
cial
inju
ry
Loss
of c
onsc
ious
ness
Vomiti
ng
16 15
68
27
7 3
219
Correlation between moderate-risk criteria and initial abnormal CT scan
in all patientsNumber of patients Abnormal CT scan number
Corre lat ion between moderate-r isk cr i ter ia and in i t ia l abnormal CT scan in a l l pat ients
Univariable analysis from this study was
found that age and sex were not
significant risk factor associated with
intracranial hemorrhage
Clinical characteristics that had significant
associated with abnormal CT brain scan
(p<0.05) was significant subgaleal swelling
Discussion
All patients who had significant subgaleal
swelling were found that accompanied with
other symptoms.
Therefore, we used the Crude analysis to find
the potential confounder by choose co-
symptoms which had p-value<0.2.
There were loss of consciousness, basal skull
fracture, and multiple traumas. But, from
analysis, these symptoms did not affect the
relation.
Discussion
We cannot certainly conclude that the
patients who had subgaleal swelling
symptom were also associated with
abnormal CT brain scan everyone.
Because of
Small size of sample
Incomplete medical record
some patients did not perform the CT brain scan
Discussion
This research was studied only at
Naresuan university hospital that can not
refer to another population of patients
with mild head injury.
Design of this study would be better in
prospective cohort study design
Suggestion
Patients with mild head injury who had
significant subgaleal swelling and other
symptoms which were risk to intracranial
hemorrhage should perform computed
tomography brain scan.
Current study findings demand future
researches in larger population by
prospective cohort study design in the future.
Conclusion
Bahner J, Don R, Stein S, Ross S. The value of computed tomographic scans in patients with low-risk head injuries [Online]1990 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/073646799190431E.
Cattamanchi S, Siva A, Raja A, Thiagarajan NR, Trichur RV. 86: Comparison of the Canadian CT Head Rule and the New Orleans Criteria In Minor Head Injury Patients With Glasgow Coma Scale 15/15.[Online]2010 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0196064410007134.
de Andrade AF, de Almeida AN, Bor-Seng-Shu E, Lourenço L, Mandel M, Marino JR. The value of cranial computed tomography in high-risk, mildly head-injured patients.[Online]2006 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0090301905007937.
Falimirski ME, Gonzalez R, Rodriguez A, Wilberger J. The need for head computed tomography in patients sustaining loss of consciousness after mild head injury. [Online] 2003 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12855873 2003
Havdel M, Preston C, Mills T, al. e. Indications for computed tomography in patients with minor head injury [Online]2001 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S073567570180111X.
References
References Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce
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References
References
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References