The Head Injury Patients With Gcs Biology Essay

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A STUDY ON THE HEAD INJURY PATIENTS WITH GCS 15.
Dissertation submitted in partial fulfillment by the requirements for the degree of
M.Ch. Branch –II
NEUROSURGERY
Examination in AUGUST 2013
INSTITUTE OF NEUROLOGY
MADRAS MEDICAL COLLEGE
CHENNAI – 3.
CERTIFICATE
This is to certify that this dissertation entitled "A STUDY ON THE HEAD INJURY PATIENTS WITH GCS 15" is the bonafide original work of Dr.H.Chelladurai Pandian in partial fulfillment of the requirements for Branch II, M.Ch Neurosurgery, examination of THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY to be held in August 2013.The period of post graduate study and training was from August 2010 – August 2013.
DEAN PROF. V.SUNDAR, M.Ch
Madras Medical College, Professor and Head of the Department,
Rajiv Gandhi Government Institute of Neurology,
General Hospital-RGGGH Madras Medical College,
Chennai -600003. Rajiv Gandhi Government
General Hospital-RGGGH
Chennai – 600003.
DECLARTION
I solemnly declare that this dissertation "A STUDY ON HEAD INJURY PATIENTS WITH GCS 15" was prepared by me in the Institute of Neurology, Madras Medical College and Rajiv Gandhi Government General Hospital-RGGGH Chennai under the able guidance and supervision of Professor of Neurosurgery, Madras Medical College and Rajiv Gandhi Government General Hospital-RGGGH Chennai between 2012 to 2013.
This dissertation is submitted to The Tamilnadu Dr.M.G.R. Medical University, Chennai in partial and fulfillment of the university requirements for the award of degree of M.Ch. Neurosurgery.
Place: ChennaiDr.H.Chelladurai Pandian,
Postgraduate Student,
Date :M.Ch Neurosurgery,
Institute of Neurology,
Madras Medical College,
Chennai – 600003.
ACKNOWLEDGEMENTS
I thank the Dean, Madras Medical College and Rajiv Gandhi Government General Hospital - RGGGH for permitting to carry out this study and also for providing necessary facilities.
I thank my teachers Prof.V.Sundar, Prof.K.Deiveegan, ,Prof.V.G.Ramesh, Prof.Sundaram, Prof.Maheshwar, Prof.S.D.Subbiah, Prof.Syamala under whom I had great privilege of working as a postgraduate student receiving their constant advice and valuable guidance. I thank my professors towards their immense support and encouragement in preparing this dissertation.
I have profoundly thankful to Prof.V.Sundar, professor in Neurosurgery, who initiated this study and who’s supervision this study went on smoothly.
My sincere thanks and gratitude to all my Assistant Professors of
Neurosurgery for their guidance and co-operation throughout this study. I thank all
my Patients and their relatives for participating in the study.
CONTENTS
Page no
Introduction 1
Aim of the study 3
Review of literature 7
Materials and methods
Results
Discussion
Conclusion
Proforma
Master chart
INTRODUCTION
HEAD INJURY, now better known as traumatic brain injury (TBI), is a silent epidemic of current era. It affects young and productive age group of people, leading to significant loss of life and economy. Head injury is classified as mild, moderate and severe head injury, depending upon the patient’s level of consciousness and it will be expressed in the Glasgow Coma Scale (GCS) score.Mild head injury constitutes the majority ( 70% to 85% ) of total patients
with head injuries3, 8, 11, and 24. The majority of patients (>90%) who were admitted are with normal or near normal level of consciousness (GCS score of 13–15) and are classified as mild head injury or mild traumatic brain injury (mTBI).Adding LOC to the assessment, Mild traumatic brain injuryis defined as any injury to the head resulting in LOC for less than 30 minutes, any alteration in mental status at the time of the accident, or amnesia.
The groups at highest risk of MTBI are the younger age group, eventhough older adults also prone for head injury. Mild traumatic brain injury is commoner in men. The most common causes are RTAs and fall.
Usually mild TBI patients managed conservatively butan estimated 6% to 9% may have intracranial injuries and 0.4% to 1% may need neurosurgical intervention.Consequences of mild head injury can be early, life threatening complications, and long-term disability. Skull radiography is sparingly used for skull fractures and CT scan brain has taken a lead position.. Computed Tomography (CT) of the head is now the investigation of choice. It is available in all small cities and provides reliable diagnosis.Computed tomography (CT) scanning of the head is an excellent investigation to identify intracranial injury and to identify those patients who may require neurosurgical intervention4,7.The question of whether the liberal use of Computed tomography of brainin cases of head injury is justified. The liberal use of CT brain can be justified as it is widely available, provides a quick analysis, and able to manage large number of cases with head injuries.
The consequences of a positive CT scan in head injury patients are varied
1. Management plan will be altered.
2. Hospital stay will be prolonged
3. Medico legal aspects and consequences
a. A positive CT scan may convert a simple injury into a grievous one.
b. Discharging a patient without subjecting to CT scanning and consequently
found to have a positive scan positive may result in risk of litigation especially in this consumer era.
Eventhough life threatening complications are rare in mild TBI patients, fear of the consumer allegations has led many todo CT scan in patients with mild TBI. This leads to increasedCT usage in diagnosis.
A small percentage of patients who had near normal level of consciousness may suddenly expire. A very unusual phenomenon called as "Talk and Die" was also reported.The incidence varies between 1 to 3% who had mild TBI.
Emergency physicians frequently encounters with these cases. They have to decide regarding the need of CT Brain, who needs observation, and which patients who can be discharged. Ninety percent of head CT scans in head injury patients may have negative results for clinically important brain injury. The incidence of abnormal CT findings in mild head injuries varies in various reports ranging from 5% to 28%14, 16, 17, 19,21,23.of which 0.76% to 8.57% required surgical interventions2,5,19,37.Most physicians look for GCS score, LOC, mode of injury, any altered mentation to predict the intracranial lesion1,3,4,7,11,18,19,21,23,24.. But a normal clinical examination cannot rule out a clinically significant brain injury.
Various predictors of positive CT scans in mild head injury patients includes the
demographic data, historical data, physical examination data and radiological data
which were extensively analyzed and various guidelines were proposed by
several authors to help the clinician to decide which patients need CT scan in
mild head injuries1,3,4,7,9,11,13,18,19,21,23,24.
Hence this study conducted at Dept of Neurosurgery , Madras Institute of Neurology , to study the effectiveness of CT brain in mild head injury patients.
AIM OF THE STUDY
1. To discuss the usefulness of CT brain in head injury patients with GCS score 15.
2. To identify the factors which may decide a positive CT brain in head injury patients.
3. To compare the effectiveness of Canadian CT head rule (CCTHR) and New Orleans criteria(NOC) in Indiansetup.
4. To evaluate necessary neurosurgical intervention.
4. To analyze the outcome of head injury patients with GCS score 15.
REVIEW OF THE LITERATURE
Shack ford et al(1992)35 in their retrospective study derived the following implications,
1. A CT scan has to be recommended for all patients with a MHI because one in five may have anacute lesion detectable by the scan.
2. A CT scan is mandatory for any patient with a MHI and a GCS <15, sinceone in three may have an acute lesion and one in ten may require craniotomy.
Stein et al(1992)38in their retrospective review of 1538 patients reported 17.2%of abnormalities in initial CT scan and 3.77% of patients required surgery. In patientswith a GCS <14, 40% had abnormalities and 10% required neurosurgical intervention.None of these 1334 patients with normal CT scans on showed subsequent deteriorationand none needed surgery.
Nagy et al24 (1999), in their prospective study of 1170 patients including patient’s GCS score of 15with LOC, detected 3.3% abnormal CT findings. In their study 1.8% hadchanges in therapy.Patients Without obvious findings were not deteriorated. Theyconcluded that even though the change of management is altered in small number of patients , they consider a significant finding.
Haydel et al (2000) in theirfirst phase of a prospective study of 520 consecutive patients withmTBI (patients with GCS 15 and with loss ofconsciousness) noted that 6.9% had positive scans. Using recursive partitioning they identified all patients who had positive CT brain had one or more of these factors namely headache, vomiting,elderly people, intoxication and amnesia,external injury and seizures.In another study of 909 patients 6.3% had positive scans;the sensitivity of the factors combined was 100% (95% confidence interval).The conclusion is in mTBI CT scan needs to be taken for those who have any of the abovefindings.
Vilke et al44 (2000) in their prospective study which enrolled non penetrating head traumapatients of age more than 14years with GCS 15 and with history of LOC. Out of the 58 patients included in the study 5% had significant CT findings, and onepatient underwent surgery. They concluded that brain injury cannot be excluded in patients with mTBI despite a GCSof 15 .
Ibanez et al (2004)12in a prospective study which enrolled 1101 patients analyzed the risk factorsfor mild head injury (GCS 15 with or without LOC. Age >14). The intracranial lesions found in 7.5% and 1% underwent neurosurgical intervention. The head injuryrelated mortality rate in this series was 0.4%. A GCS <14, LOC, vomiting, headache, evidence of skull fracture, any deficit, coagulopathy,and hydrocephalus, any associated extra cranial lesions, andgeriatric patients were identified as risk factors They concluded that clinical variables are not very useful in prediction of significant brain injury.
Khaji A et al (2006) studied 1209 cases with Glasgow Coma Scale (GCS) score >13 who underwent brain CT scan.For 1209 patients, there were the following characteristics: mean age was 29.4 years; and the main cause of injurywas traffic accidents (60.1%), followed by falls (28.5%), fights (7.2%), and other reasons (4.2%). Seventy-seven cases had a GCS of 13, 212 patients had GCS 14, and 920 GCS 15. A total of 481 abnormalities on CT scan were reported for 405 patients (33.5%) with positive report of brain CT scan, while 804 cases (66.5%) didn’t report abnormalities. The most common intracranial lesion was extradural hemorrhage with 146 cases (30.3%). The rate of negative reporting of brain CT scan in patients with GCS 15 is 72.2%.
Bamvita JM et al (2006) in their retrospective study including patients with GCS 13 to 15; no LOC ; without any fracture; a CT brain was done. There were 405 patients and CT found lesions in 12% .Three percent needed neurosurgical intervention. T
Manessiez O et al (2007) Validated the clinical criteria, which, when absent, would make it safe to bypass CT scan examination in mild cranial injuries. In their Prospective study including 285 patients with mild cranial injury with a Glasgow score of 15, a normal clinical examination but transitory LOC or suspected transitory LOC. Of the patients studied, 7% presented aintracranial lesion and 7% a facial bone lesion. Intervention needed in 0.4% of the patients and maxillofacial surgery in 2.5%. 
Schmalet al (2008) in his study 1841 patients with TBI were included, 1042 patients with a mTBI and age >14  were included.New Orleans Criteria – (NOC) was applied. The conclusion was 98.8 % of the patients needs CT scan. The patients under alcohol influence reached 44 %.
Morochovic R, et a (2008) in their retrospective study of all patients older than 15 years there were 151 alcohol intoxicated patients. 22.5% had any one evidence for TBI. 68.2% had no evidence of TBI, 9.3% patients had fractures only. Five (3.3%) patients were operated, 3 (2%) for fractures and 2 (1.3%) for SDH. In alcohol intoxicated patients the incidence of mTBI is 22.5% and 3.3% needed intervention.
Yavasi et al (2011) in their retrospective study included 923 patients. Ct scan was positive in 1.8 and 0.6% needed intervention. Statistically significant correlations were found among headache, presence of clinical findings of skull fracture, focal neurological deficit and positive cranial CT findings. Eventhough the incidence of TBI is less liberal use of computed tomography is justified.
Marghli S et al (2012) study which enrolled 1,582 patients neurosurgical intervention was performed in 34 patients (2.1%) and positive in 13.8%.Sensitivity and specificity were 100% and 60% respectively for and 82% and 26% for NOC. Negative predictive values for the abovementioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively for patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value.
Brkic et al in the study which encompassed 1830 with mTBI .Basic clinical variables were recorded and a subset of patients meeting either Canadian or New Orleans criteria were subjected to CT. Outcome in terms of "positive" CT scans and number of patients requiring surgery was recorded.The mean age was 30.4 years.The conclusion was computed tomography to be done as suggested by CCTHR or NOC criteria.
MATERIALS AND METHODS
Selection of patients for CT imaging in recent years, some guidelines were published, namely the New Orleans Criteria (NOC) and the Canadian CT Head Rule (CCHR) which are useful in identifying the usefulness of CT brain in mild head injury patients. Both are highly sensitive in detecting intracranial injuries, but specificity varies.
The comparison of Canadian CT Head Rule and the New Orleans Criteria was been compared in Canadian, Dutch, Italian, and Australian patients, but
in India there is no such analysis. The purpose of this study is to compare the performance of the Canadian CT Head Rule and the New Orleans Criteria in detecting the intracranial injuries with Glasgow coma scale 15 in Indian population. Also the need for neurosurgical intervention is studied.
CANADIAN CT HEAD RULE: (CCTHR)
CT scan is only required for patients with minor head injuries who have any 1 of the following findings:
High risk (for neurologic intervention)
1. GCS score <15 at 2 hours after injury
2. Suspected open or depressed skull fracture
3. Any sign of basal skull fracture (ex, haemotympanum, raccoon eyes, cerebrospinal fluid leak [otorrhoea or rhinorrhea], and Battle sign)
4. Vomiting ≥ 2 episodes
5. Age ≥ 65 y
Medium risk (for brain injury on CT)
1. Amnesia before impact ≥ 30 min
2.Dangerous mechanism (ie, pedestrian struck by motor vehicle; occupant ejected from motor vehicle; fall from height ≥ 3 ft or 5 stairs)
Haydel et al proposed New Orleans Criteria (NOC) which shows 100% sensitivity for neurosurgical lesions. Differences between the both are age cutoff of 60 years in the NOC versus 65 in the CCTHR; headache, intoxication, and seizure are criteria in the NOC; and trauma above the clavicle is a criteria of the NOC but not of the CCTHR (which includes evidence of skull fracture). Furthermore, the CCTHR includes mechanism of injury while the NOC does not. Two
studies comparing the rules also found that both rules were sensitive in predicting intracranial lesions not requiring neurosurgical intervention,
although one study found the CCTHR less sensitive for these (83.4% vs 98.3%). Both studies showed the CCTHR to have greater specificity and
hence more ability to decrease the number of CT scans done.
NEW ORLEANS CRITERIA (NOC)
CT scan is indicated if a patient has 1 or more of the following criteria:
1. Headache
2. Vomiting
3. Age > 60 y
4. Drug or alcohol intoxication
5. Persistent anterograde amnesia (ex: deficits in short-term memory )
6. Visible trauma above the clavicle
7. Seizure
Several prediction rules have been published since 2001, but many still require validation, including the CT in Head Injury Patients
(CHIP) rule, which divides criteria into major or minor risk of intracranial lesion. The authors of the CHIP rule recognized coagulopathy as an
important risk factor. (Coagulopathy was an exclusion criterion in the CCTHR, and there were not enough patients in the NOC to determine its significance.). The most sensitive predictors of intracranial hemorrhage found by the CHIP investigators were below
CHIP RULE
Skull fracture,
High-risk mechanism of injury,
Posttraumatic amnesia for more than 4 hours,
Seizure,
Neurological deficit,
Vomiting,
Decrease in GCS score, and
Coagulopathy.
Similar guidelines have been published by the World Health Organization Taskforce on MTBI and the Neurotraumatology Committee of the World Federation of Neurosurgical Societies.
Our hospital Government Rajiv Gandhi Government General Hospital is a tertiary referral hospital for southTamilnadu. Admission includes both referral cases and direct admissions from our casualty. Inour head injury ward all isolated head injury cases as well as polytrauma cases withpredominant head injury are admitted through the casualty by the casualty medical officerdirectly. All cases are entered in the accident register and were treated as medico legal cases.Admission is entirely at the discretion of Casualty MedicalOfficer.All cases were examined by the duty neurosurgery residents and by the dutyneurosurgeon who are on stay duty round the clock. Poly trauma will be dealt by respectivespecialists on call.
Management protocol
The following is the management protocol we follow for mild head injury patients:
Head Injury
Standard Neurological examination
CT scan
CT Normal CT Abnormal
Close observation
Serial neurological exam
Conservative Treatment Surgery, if needed
Follow up CT
Normal Abnormal
Discharge Repeat CT
After normalization
Discharge
Study pattern
Ours is a prospective study which enrolled consecutively admitted patients in our headinjury ward. All patients were subjected to CT scanning without any historical or clinicalselection criteria. Our study included patients in all age group.
Exclusion criteria
1. Patients who were admitted in head injury ward 24 hours after the occurrence of injury.
2. Patients referred with CT brain from outside our institution.
3. Patients with Glasgow coma scale less than 15
Reasons for these exclusion criteria were
Patients who were admitted after 24hrs of the occurrence of injury are referred for thepersistent symptoms or neurological illness they had and most of them had positive CT brain.
Patients who were referred with CT brain done at outside institution frequently had positiveCT, as both these factors will artificially inflate the total positive CT scans andvitiate our study.
Inclusion criteria
All patients with GCS score of 15 irrespective of age and mode of injury who were admitted in our head injury unit.
Criteria for CT scan
All patients were subjected to CT brain without any selection criteria.
Operational definitions
Positive CT scanOne that demonstrated any of the following35
a. Extradural hematoma
b. Subdural hematoma
c. Subarachnoid hemorrhage.
d. Intracerebral hematoma
e. Intraventricular hemorrhage
f. Pneumocephalus
g. Contusion
h. Linear or depressed fractures
i. Basilar fracture
Negative CT scan If there is no acute injury to the cranium and for
brain
History of loss of consciousness (LOC)
Patient who were amnestic of the trauma event, gave ahistory of loss of consciousness or had a witnessed loss of consciousness were considered to have a positive LOC.
Scalp injury Defined as trauma above the clavicle and includes the
lesions such as abrasions and even small lacerations andsigns of facial or skull fracture.
Focal neurologicaldeficit (FND)
Defined as unequal or asymmetrically reactive pupils,nystagmus, other abnormal eye movements, focal extremityweakness or Babinski’s reflex, any cranial nerve
involvement.
Seizure Suspected or witnessed seizure after the traumatic event.
Associated polytrauma Thoracic, abdominal, spinal cord injury or facial / limb fracture.
VomitingAny emesis after the traumatic event.
The Interpretation of a CT scan as Positive or Negative scan was defined as follows
Abnormal scan
One that showed any acute or chronic pathologic state or abnormality (an old infarct,extra cranial soft tissue swelling, a facial fracture).
Positive scan
Scan with an acute pathologic state in the skull or brain (a basilar or linearskull fracture, cerebral contusion etc.).
A CT scan was interpreted as negative scan if there was no acute injury to the craniumand /or brain.
The following factors were studied and analyzed descriptively and statistically, whether they could prove as positive predictive factors / risk factors:
I. Demographic data
a. Age
b. Sex
c. Mode of injury
II. Historical data
a. LOC
b. Post traumatic seizure
c. ENT bleed
d. Vomiting
e.Watery discharge from ear / nose.
III. Physical examination data
a. Scalp injury
b. Associated polytrauma
c. Focal neurological deficit
IV. Radiological data
a. CT Brain.
Following were the intervention and outcome profiles studied and analyzed
a. Surgical interventions.
b. Length of hospital stay.
c. Late complications.
d. Deterioration.
e. Discharge GCS score.
f. Residual neurological deficit.
g. Systemic vegetative symptoms.
h. Death.
RESULTS
The following were the constituents of the study population.
Total patients:
Total patients : 5308
Total number of patients admitted in the trauma ward in the past six months for head injuries were 5308,out of which 3536 patients presented with GCS 15 which corresponds to 66% of the total population.
Total patients with GCS 15:
Total patients with GCS 15 : 3536
All the patients with GCS 15 were taken CT brain, Out of the total patients 455 patients had one or more findings in CT Brain.
Patients with findings in CT correspondto 12.86 % of the total population.
Sex as a predictive factor for positive CT scan:
The total number of males is 383 – 84 %
The total number of females is 73 – 16 %
SEX DISTRIBUTION:
SEX
FREQUENCY
PERCENTAGE
P VALUE
MALE
382
84.0
<0.001**
FEMALE
73
16.0
TOTAL
455
100
Sex was analyzed using chi square test and N-Par tests. Taking sex as a predictive factor for positive CT scan inhead injured patients with GCS 15 was found to be statistically significant (p<.001**).
Male patients were more prone to have positive CT brain than female patients(because males constituted largest number in the study group).
AGE DISTRIBUTION:
The age distribution is described below
Age Gp
Patients
Percentage
16 – 20
46
10.1%
21 – 30
138
30.3%
31 – 40
102
22.4%
41 – 50
81
17.9%
51 – 60
48
10.5%
61 – 70
30
6.6%
>70
10
2.2%
When different ages were analyzed using chi square test as a predictor of positive CT scan inhead injured patients with GCS 15 it was found to be statistically not significant (p = 0.78)
Mode of Injury:
The most common mode of injury is RTA – 281 patients – 61.8%
Next common mode of injury is Fall – 134 patients – 29.5%
Followed by Assault – 35 patients – 7.5 %
Followed by Fall from train – 6 patients – 1.3%
Total number of patients - 455
MODE OF INJURY
MODE OF INJURY
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
RTA
281
61.8
61.8
61.8
<0.001**
ASSAULT
134
29.5
29.5
91.2
FALL
34
7.5
7.5
98.7
FALL -
TRAIN
6
1.3
1.3
100.0
TOTAL
455
100
100
RTA was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests RTA was found to be statistically significant (p<.001**).
CT Findings:
CT Findings
Patients
Percentage
Contusion
115
25.2%
EDH
42
9.2%
SDH
50
11%
IVH
1
0.2%
Fracture
176
38.7%
SAH
47
10.3%
Multiple
24
5.3%
Total patients - 455Management:
The total patients admitted with GCS 15 and were operated corresponds to 0.9% compared to total population of patients with GCS 15.
Alcoholic influence as a predictor of positive CT scan
ALCOHOL
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
380
83.5
83.5
83.5
<0.001**
PRESENT
75
16.5
16.5
100.0
TOTAL
455
100
100
Alcoholic influence was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests this was found to be statistically significant (p<.001**).
Headache as a predictor of positive CT scan
HEADACHE
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
70
15.4
15.4
15.4
<0.001**
PRESENT
385
84.6
84.6
100.0
TOTAL
455
100
100
Presence of headache was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests headache was found to be statistically significant (p<.001**).
LOC as a predictor of positive CT scan
LOC
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
269
59.1
59.1
59.1
<0.001**
PRESENT
186
40.9
40.9
100.0
TOTAL
455
100
100
Presence of LOC was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests LOC was found to be statistically significant (p<.001**).
Seizures as a predictor of positive CT scan
SEIZURES
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
434
95.4
95.4
95.4
<0.001**
PRESENT
21
4.6
4.6
100.0
TOTAL
455
100
100
Presence of seizures was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests seizures was found to be statistically significant (p<.001**).
Vomiting as a predictor of positive CT scan
VOMITING
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
304
66.8
66.8
66.8
<0.001**
PRESENT
151
33.2
33.2
100.0
TOTAL
455
100
100
Presence of vomiting was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests vomiting was found to be statistically significant (p<.001**).
ENT Bleed as a predictor of positive CT scan
Presence of ENT Bleed was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests ENT bleed was found to be statistically significant (p<.001**).
ENT BLEED
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
404
88.8
88.8
88.8
<0.001**
PRESENT
51
11.2
11.2
100.0
TOTAL
455
100
100
CSF Leak as a predictor of positive CT scan
CSF LEAK
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
427
93.8
93.8
93.8
<0.001**
PRESENT
28
6.2
6.2
100.0
TOTAL
455
100
100
Presence of CSF Leak was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests CSF Leak was found to be statistically significant (p<.001**).
Presence of External injury as a predictor of positive CT scan
EXT INJ
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
388
85.3
85.3
85.3
<0.001**
PRESENT
67
14.7
14.7
100.0
TOTAL
455
100
100
Presence of External injuries was analyzed as a predictive factor in predicting positive CT brain in head injured patients with GCS 15. Using chi square test and N-Par tests External injuries was statistically significant (p<.001**).
Absence of symptoms in positive CT scan
Out of the 455 patients who had positive CT scan 37 patients had no symptoms .It corresponds to 8.1%.
Out of the 37 patients
Fractures - 27
Contusion – 5
EDH - 1
SDH – 3 SAH – 1
Total patients - 455
Out of the 27 patients of depressed fractures 1 was a compound depressed fracture which was operated.
One case of EDH which had no symptoms was taken over and patient developed symptoms on third day and patient was operated.
SYMP
FREQUENCY
PERCENTAGE
VALID %
CUMULATIVE%
P VALUE
ABSENT
37
8.1
8.1
8.1
<0.001**
PRESENT
418
91.9
91.9
100.0
TOTAL
455
100
100
Even without symptoms CT picked up 37 patients in a CT population of 455 and
GCS 15 population of 3536 patients.
DISCUSSION
Of all head injured hospitalized patients, those with mild head injury
predominate, it constitutes 80 to 85 percent of the group. In our study this was 67%.The etiology is lower than expected because our center which deals with
large number of referral cases. Our institute is one of the high volume trauma centers all over the world. The incidence is higherin males, our study also confirm the same with an incidence of 84%. The male: female ratio in our study is 5.2:1. In most of the studies Road Traffic Accidentwas the most common mode of injury. In our study also road traffic accidentconstituted 61.8% followed by assault (29.5%) accidental fall (7.5%) and fall from train (1.3%).
Prior to the advent of modern diagnostic neuroimaging, mild head injury
was believed to be reversible or transient. Because the mild nature of the injury the confirmatory diagnosis was made only in some cases in which mortality was attributable to co-morbid disease.
Despite more than two decades of debate and study, the evaluation of mild head injury patients remains controversial. CT scan is now the mainstay in the diagnostic workup..Previous recommendations have taken one of four approaches. Most authors recommendCT of the head for every patient with blunt head trauma and a history of loss ofconsciousness or amnesia despite a normal mental status on
admission8 ,16, 17.
Some authors prefer to observe these patients because theyield of abnormal CT results is low. A third group recommends CT in only
selected patients in an attempt to reduce the number of negative studies. A final
group recommends a combination of CT and observation8,16,17.Our approach
was to subject, all the patients with GCS score of 15, admitted in our trauma ward to scan brain irrespective of age, sex and mode of injury orneurological status.
Most physicians rely on clinical criteria such as GCS, LOC, mode of injury, or changes in mentation to predict the probability of intracranial lesion1,3,4,7,11,13,18,19.
This has led some authors to recommend liberal use of CT scanning in
patients with a Glasgow coma scale < 15 or a history of a significant mechanism
of injury2-4,8,11,16,21.We under took this study to detect and to analyse the indication for CT scanning in head injured patients with GCS 15.
Haydel et al (2000)11 in the 1st phase of a prospective study of 520
patients who had minor head injury (patients with Glasgow coma scale 15, normal
neurological examination but with history of loss of consciousness) noted that
6.9% had positive scans. But in our study we included all patients with Glasgow coma scale 15 with or without loss of consciousness. 12.86 percent of our study
group had positive CT brain. Using N-par tests and Chi-square tests gave a set of factors which identified patients who had positive CT brain they were LOC, headache, vomiting, seizures, alcohol intoxication, deficits
in short term memory, external injury and CSF leak., which were
statistically significant in predicting positive CT brain.
Lee et al (1995) in their prospective study that included a series of 1812
mild head injury patients (patients of age more than 16years with GCS
15 with one or more of the following – a blow to the head, LOC, or post-traumatic amnesia < 30 minutes duration). In their study, 1.5% deteriorated after head injury, 1.3% required
surgical intervention. In our study head injury patients with Glasgow coma scale
of 15 of all age groups with or without loss of consciousness were included
and 1% of our study population required surgical intervention and none of our patients deteriorated.
Vilke et al (2000) in their prospective study which includednon-penetrating
head trauma patients of age more than 14years with history of loss of
consciousness. Of the 58 patients included in the study 5% had positive scan, only one patient underwent neurosurgical intervention. In our study
head injury patients with Glasgow coma scale of 15 and age >14 with or without
LOC were included. 12.86 percent of our study group had
positive CT brain and 1% required surgical intervention. They concluded
that significant brain injury and need for CT scanning cannot be excluded in
patients with minor head injury despite a GCS score of 15 and a normal complete
neurological examination on presentation.
Nagy et al (1999), in their prospective study of 1170 patients who had
Glasgow coma scale of 15 with loss of consciousness, detected 3.3% abnormal CT
findings. 1.8% had changes in therapy as a direct result of their CT results,
including 4 operative procedures. No patient with a negative CT results
deteriorated which was also noted in our study. They concluded that CT isuseful test in patients with mild head
injury, since it may lead to a change in therapy in a small but significant
population .
Stiell et al in their prospective cohort study which was conducted in ten
Hospitals in Canada included 3121patients of age more than 16years with GCS
score of 13-15.Only 67% of the study group underwent CT scanning, remaining
33% underwent the validation by a nurse. In their study group 8% hadclinically important injury on CT, 4% had clinically unimportant injury on CT. In our study 6% had unimportant injury punctate contusions and linear fractures while remaining 6% had clinically significant injury. One percent of the study group required neurosurgical intervention which is similar to our study. They
derived a CT rule which consists of following high-risk factors (failure to reachGCS of 15 within 2hours, suspected open skull fracture, any CSF leak, vomiting more than 2 episodes, or age ≥65years) and two additional
medium-risk factors (amnesia before impact >30min and dangerous mechanism
of injury).
Our study is different from the other studies in the following aspects
1. Both retrospective and prospective study.
2. All adult patients with GCS 15 were included.
3. Patients with GCS 15 with and without loss of consciousness were included.
4. No historical or clinical criteria were used to select the patients for CTscan.
Exclusion criteria of our study are those patients who were admitted 24
hours after the incident of injury and those patients who were referred with CT
brain done at outside. We found when patients were referred
more than 24hours after injury or referred with a CT brain done at outside
institution, they had a higher chance of positive CT which may
artificially inflate the total number of positive CT brain and vitiate our study.
All patients with GCS 15 were subjected to CT brain without any
historical or clinical criteria for subjecting them to CT scan. The results were
evaluated and assessed on the following perspective.
1. To discuss the usefulness of CT brain in head injury patients with GCS score 15.
2. To identify the factors which may decide a positive CT brain in head injury patients.
3. To compare the effectiveness of Canadian CT head rule (CCTHR) and New Orleans criteria(NOC) in Indiansetup.
4. To evaluate necessary neurosurgical intervention.
5. To analyze the outcome of head injury patients with GCS 15.
6. Whether any of the demographic data (age, sex, mode of injury), historical
data (history of loss of consciousness, post traumatic seizure, ENT bleed,
vomiting), physical examination data (scalp injury, associated polytrauma,
focal neurological deficit), headinjury patients with GCS 15 could predict a positive CT scan.
7. The neurosurgical intervention required in patients with positive CT scan.
8. Medicolegal implications of positive CT scans in head injured patients with
GCS 15.
10.Economic advantage of preventing unnecessary CT scan in head injured
patients with GCS 15.
1. Incidence of positive CT scan in various settings
In the total study population (n=5308) = 12.8%
In male patients = 84%
In female patients = 16%
Patients with history of RTA = 61.8%
Patients with history of assault = 29.5%
Patientswith history of accidental fall = 7.5%
Patients with history of fall from train = 1.3%
Patients with LOC = 40.9%
Patients with seizure = 4.6%
Patients with ENT bleed = 11.2%
Patientswith vomiting = 33.2%
Patients with scalp injury = 14.7%
Patientswith CSF leak = 6.2%
Patientswith out any symptoms = 8.1%
2. Predictors of positive CT scan
The various factors of demographic data (age, sex, mode of injury),
historical data (history of LOC, post traumatic seizure, ENT bleed, vomiting),
Physical examination data (scalp injury, CSF leak , ENT bleed were analyzed by chi square test, pvalue of each factor seen. The factors which were statistically significant toidentify positive CT brain were as follows
1. Headache
2. Loss of consciousness
3. ENT bleed
4. CSF leak
5. Vomiting
6. Mode of injury
7. Alcohol influence
8. External injuries
These statistically significant risk factors for positive CT brain were
analyzed by Chi – square tests and N-par tests..
If any one of the above risk factors was present in a patient with
admission GCS 15, CT scan should be advised to rule out any intracranial
injury.
5. Neurosurgical intervention
Of the 3536 patients, 455 had positive CT brain, 36 of them underwent
neurosurgical intervention. 24 patients were operated for compound depressed
fractures, 6 cases were done craniotomy for evacuation of extradural hematoma, five cases of SDH , burr hole for evacuation of Pneumocephalus.
Our study reports the incidence of neurosurgical intervention in head injured
patients with GCS 15 as 1 % of non-selective consecutive population.
6. Duration of hospital stay
In our study the average duration of hospital stay of patients in the study
group was 3.3 days. The duration of hospital stay for patients with positive CT scans isprolonged.
The factors that prolonged the hospital stay were:
i. Requirement of close observation and serial neurological examination.
ii. Surgical intervention
iii. For the purpose of follow up CT scan
iv. Anticipation and management of complications
v. Institution of aggressive medical therapy
vi. Management of injuries, other than head injury.
7. Safe discharge of patients
All patients in our study underwent CT scanning. 12.8 % had positive CT
scans and 87.2% had negative CT scan.
Value of positive CT scan
A patient with a initial positive scan was closely observed,
neurologically examined serially, aggressive medical therapy instituted
appropriately, surgically intervened when necessary, follow up CT scan was
done as and when required and discharged after ascertaining improvement or
ascertaining negligible chance of further deterioration and with specific
instructions regarding future follow up regarding medications, rehabilitation
and awareness of warning signs and symptoms of deterioration.
Value of negative CT scan in safe discharge of patients
The high incidence of negative CT scans in the population of head injury
patients with GCS 15 as reported in our study and other similar studies
might appear to be an over enthusiastic and cost intensive way of investigation
with patients with MHI. However, as noted in our study and in other
studiesnegative CT scans in MHI have the following advantages.
As no patient in our study and in other studies with negative CT scan
deteriorated, these patients with negative CT scan can be safely discharged
home. This saves valuable hospital resources and better utilization of the
available for more severely head injured patients especially in resources scarce
country like India, where hospital service are stretched to their limits.
More important, a normal CT scan and neurologic examination can
accurately triage the patients who can be safely discharged from the emergency
department. This approach enabled them more than 80% of all patients
sustaining head injury to be discharged, thus allowing better utilization of
limited physician, nursing and hospital resources.
Our data and other similar studiesconclusively demonstrate that
patients with a CT scan, that shows no intracranial injury, and who do
not have systemic injuries or a persistence of any neurological finding
can be safely discharged from the emergency department without a period of
either prolonged IP or OP observation. Livingstone et al
recommends that, implementation of this practice could result in a potential
decrease of more than 500,000 hospital admission annually in USA. In developing
country like India, where hospital services are stretched to their limits,
this is much more important.
8. Medicolegal implications of a positive CT scan
As mentioned earlier, the medicolegal implications of a positive CT scan
are as follows:
i. Positive CT scan can convert a simple injury into a grievous one.
ii. Discharging patient without subjecting to CT scanning and if the
patients is found to have a positive CT scan subsequently, may result in
risk of litigation, especially in this consumer era.
CONCLUSION
In our study we have analyzed the risk factor which are statistically
significant in predicting positive CT brain in head injury patients with
admission GCS 15.. Hence head injury patients with negative CT scan can be advised to return home.
Incidence of positive CT in our consecutive, non-selective
population of 3536 patients with admission GCS of 15 was 12.8%.
1. Operative neurosurgical intervention was required in 1% of our study population.
2. The risk factors which were statistically significant in our study were:
1. Headache
2. Loss of consciousness
3. ENT bleed
4. CSF leak
5. Vomiting
6. Mode of injury
7. Alcohol influence
8. External injuries
3. Patients with
a. Admission GCS of 15
b. Normal neurological examination
c. Normal CT
can be safely discharged without need for admission orobservation.
4. Earlier discharge of patients with negative CT scan
will reduce the costand enable rational utilization of manpower.
5. The medico legal implications of a positive CT scan are as follows; a
positive CT scan can convert a simple injury in to a grievous one; discharging a
patient without subjecting to CT scanning and if that patient is found to
have positive CT scan subsequently may result in risk of litigation,
especially in this consumer era.
INSTITUTE OF NEUROLOGY
GOVERNMENT GENERAL HOSPITAL, CHENNAI
PROFORMA
"ANALYSIS OF HEAD INJURY PATIENTS WITH GCS 15"
Serial No:
Name: Age: MIN No: I.P. No:
Sex: M / F
Time interval between injury and admission:
Mode of Injury: RTA / Fall /Assault / Others
Alcohol intoxication : Present / Absent
History
History of loss of consciousness (LOC): Present / Absent
LOC in minutes:
History of vomiting: Present / Absent – No. of episodes:
– Contents : Food matter/Blood .– Projectile/Non projectile
History of seizure – Present / Absent
Type of seizure – Generalized / Focal – No. of episodes
History of Ear, Nose, Throat bleeding : Present / Absent
History of memory disturbances :Present / Absent
On examination
Admission Glasgow coma scale : 15
Scalp Injury :Present / Absent
Polytrauma :Present / Absent
Higher function examination: Normal / Abnormal
Cranial nerve examination: Present / Absent
Spinomotor system: Normal / Abnormal
Sensory system:Normal / Abnormal
Cerebellar functions: Normal / Abnormal
Cardiovascular and respiratory system: Normal / Abnormal
Other systems
Investigations
CT brain :
Cerebral contusion
Pneumocephalus
Depressed fracture
Epidural hematoma
Subdural hematoma
Intracerebralhematoma
Subarachnoid hemorrhage
Management
Surgery or conservative management
Surgery :
Done on :
Outcome
Any focal neurological deficit:
Any deterioration
Any death:
Total number of days as in patient:
Discharge Glasgow coma scale
ABBREVATIONS USED IN MASTER CHART
Alcohol
0 – Not under influence
1 –Under influence.
Headache
0 – No headache
– Headache.
LOC
0 – No LOC
– LOC present.
Seizures
0 – No Seizures
– Seizures present.
Vomiting
0 – No vomiting
– Vomiting present.
ENT Bleed
0 – No ENT bleed
– ENT bleed present.
CSF Leak
0 – No CSF Leak.
– CSF Leak present.
External injuries
0 – No External injuries.
– External injury present.
Symptoms
0 – No Symptoms
1 – Any one symptom present.
Multiple
0 – Single lesion
– Multiple lesions.
Management
C – Conservative
S – Surgery done.
Outcome
D -- Discharged in stable condition.

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