mallika khwanmuang phatcharapol udomluck jitsupa litleangdej
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Mallika Khwanmuang Phatcharapol Udomluck Jitsupa Litleangdej ------------------------------------------------------------------- 5 th year medical students of Naresuan university, Phitsanulok , Thailand. - PowerPoint PPT PresentationTRANSCRIPT
Mallika Khwanmuang Phatcharapol Udomluck
Jitsupa Litleangdej -------------------------------------------------------------------
5th year medical students of Naresuan university, Phitsanulok , Thailand
The Corre la t ion between Mi ld Head In ju ry and Pos i t i ve CT Scan o f the Bra in in the Pat ients w i th Moderate R isks a t 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 lemThere 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 defin 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 ive1. 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
NoAbnormal CT
Normal CT
Reference populationInclusion 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
Signifi
cant
subg
aleal
swell
ing
Post t
raum
atic s
eizur
e
Retrog
rade
amne
sia
Alcoho
l or d
rug i
ntox
icatio
n
203
65
35
9 114 9
Correlation between moderate-risk criteria and initial abnormal CT scan
in all patientsNumber of patients Abnormal CT scan number
Correlat 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
skull
frac
ture
s
Serio
us fa
cial in
jury
Loss
of co
nscio
usne
ss
Vomitin
g
16 15
68
277 3
219
Correlation between moderate-risk criteria and initial abnormal CT scan
in all patientsNumber of patients Abnormal CT scan number
Correlat 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
head CT scan ordering for minor head trauma patients.[Online]1997 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0736467997000711.
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Royal college of surgeons of Thailand. Head injury. [Online] 2008 [cited 29 July 2554]. Available from: http://www.surgeons.or.th/view.php?group=8&id=208
References
References Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, et al.
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References
References Voss M, Knottenbelt J, PEEDEN M. Patients who reattend after head
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กองพฒันาการจราจรและบรกิารประชาชนสำานักงานตำารวจแห่งชาติ, เอกสารประกอบโครงการสมัมนาการกวดขนัวนัิยจราจรและลดอุบติัเหตทัุ่วประเทศ. 2008.
ดำานาคแก้ว, ก., การบาดเจบ็รุนแรงจากอุบติัเหตขุนสง่ พ.ศ.2550. 2008, สำานักระบาดวทิยา กรมควบคมุโรค กระทรวงสาธารณสขุ.
อัตราตายปรบัฐานอายุ (age-adjusted death rate) ต่อประชากร 100,000 คน ด้วยกลุ่ม โรคหัวใจ หลอดเลือด กลุ่มโรคมะเรง็ และการบาดเจบ็ และโรคในกลุ่มโรคหัวใจหลอดเลือดและ โรค เบาหวาน ปี 2539-2548. 2548, ศูนยข์อ้มูลโรคไมติ่ดต่อ สำานักโรคไมติ่ดต่อ กรมควบคมุโรค
กระทรวงสาธารณสขุ.
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