Minor Traumatic Brain Injury How does the Guideline Impact Practice

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Minor Traumatic Brain Injury How does the
Guideline Impact Practice?

• Robert Butler MD FACEM
• Emergency Medicine
• Hawkes Bay Hospital

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He Just Fell

• 31 yo healthy male
• ?tripped while exiting parked vehicle and struck
  head on road
• LOC x 5 minutes
• Nausea, no vomiting
• Headache
• Oriented

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Rural ED Presentation -- t60

• Pale, not speaking
• Able to transfer
• No Etoh smell, no meds
• Vomited x 1
• GCS 13, HR 71, BP 128/85, RR 28, afebrile, BS 6.9
• Superficial lac right parietal scalp

What are you thinking?
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What You Might be Thinking

• GCS 13, minor mechanism, no focal neurology
• Options
• Observe?
• Transfer for CT now?
• Discharge in care of family with head injury
  instructions?
• Xrays?

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Observed x 4 hours

• VSS
• GCS 13/14 and not declining
• Vomits hourly
• Quiet, does not seem to recognize family or
  remember things
• Text from mother to pts aunt
• He was in a fight and somebody smacked him

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Now What Are You Thinking?

• GCS stable
• Still with short term memory problems
• Vomiting multiple times
• Not improving
• Mechanism perhaps not so minor after all

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Transfer to Hawkes Bay ED

• GCS 13
• Black Power tattoo on chest
• PERRL
• No haemotympanum, Battles sign or Racoons eyes
• No focal neurology
• CT requested

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Transfer to Wellington Neurosurgery

• No intervention, remained stable with slow
  improvement
• 10 days persistent memory and concentration
  impairment, slow processing
• 6 weeks occasional headache but otherwise
  improving

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Published GuidelinesQuestions in General

• What clinical problem does it address?
• Who wrote it?
• Why has it been written?
• What is the guideline intended to do?
• What is the practical utility for me?
• What changes to my practice might/should I make
  in order to conform to the guideline?

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What Clinical Problem does it Address?
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What is Traumatic Brain Injury?

• TBI is an acute brain injury resulting from
  mechanical energy applied to the head by external
  physical forces
• Criteria for clinical identification of TBI
  include one or more of the following
• confusion or disorientation
• loss of consciousness
• post-traumatic amnesia
• other neurological abnormalities, such as focal
  neurological signs, seizure and/or intracranial
  lesion.

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Who wrote it?
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Guideline Development

• The Australasian Faculty of Rehabilitation
  Medicine, The Royal Australasian College of
  Physicians (RACP)
• The Australasian College for Emergency Medicine
  (ACEM)
• The Paediatric Society of New Zealand
• The Pasifika Medical Association
• The Royal Australia and New Zealand College of
  Psychiatrists (RANZCP)
• The New Zealand College of Clinical Psychologists
  (NZCCP)
• The Royal New Zealand College of General
  Practitioners (RNZCGP)
• The College of Nurses Aotearoa (NZ) Inc
• The New Zealand Society of Physiotherapists Inc
  (NZSP)
• The New Zealand Speech-Language Therapy
  Association (NZSTA)

• The New Zealand Association of Occupational
  Therapists (NZAOT)
• Group Special Education in the Ministry of
  Education
• The Head Injury Society of New Zealand (HISNZ)
• The Brain Injury Association of New Zealand
  (BIANZ)
• Carers NZ
• Ranworth Healthcare
• Health Partners Limited
• The Disability Resource Centre (DRC), Auckland
• The Accident Compensation Corporation (ACC)
• The Royal Australasian College of Surgeons

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Why Has it Been Written?
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Extent of TBI Problem in NZ?NZGG Estimates

• Hospital attendances for TBI for all ages
• 10000 to 17000 cases annually
• 8-10 in moderate to severe categories
• 25 will be suspected but not definite TBI
• Best estimate for all medically attended TBI
• 16000 to 22500 cases annually
• gt25 will be suspected but not definite TBI
• Total TBI for NZ, including those not seeking
  medical attention
• 20000-30000 cases annually

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Societal Impact

• Financial costs
• In 2004, ACC paid gt100 million for post-acute tx
  and rehab of claimants with concussion and TBI
• Excludes ACC costs incurred during acute phase of
  care
• 2003
• 17514 new cases of concussion
• 12, 532, 834
• 1477 ongoing cases of TBI (gt1 year old)
• 93,728,240

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Societal Impact

• Mortality -- not known
• Lost productivity -- not known, but significant
  based on ACC claims
• Sequelae for brain-injured patients
• Physical
• motor and sensory impairment
• Cognitive
• impairment of memory attention, and judgment
• Behavioural
• emotional and mood problems, inappropriate
  behaviour
• Communicative
• language expression and comprehension

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What is the Guideline Intended to Do?
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Guideline Scope

• Provides a diagnostic, acute management and
  rehabilitation framework for the care and
  management of TBI
• Intended to inform and guide
• All TBI acute and rehabilitation treatment
  providers
• Specialists throughout New Zealand
• Funding agencies such as ACC and DHBs
• People with TBI and the people who care for them,
  including family/whanau and unpaid carers

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Guideline Scope

• Guideline addresses the acute care and post-acute
  rehabilitation for
• All levels of severity of TBI
• All ages
• All locations of care
• Pre-hospital
• Hospital
• Community-based assessment and management

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What is its Practical Utility for Me?What
Changes to My Practice Might/Should I Make in
Order to Conform to the Guideline?
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Diagnostic Evaluation of the Head-injured Patient

• Essential Components of the Initial History and
  Examination

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Focus of the Assessment

• Are there historical features, injury mechanism
  elements, physical or neurologic signs
  indicating
• Increased intracranial pressure?
• Intracranial bleeding
• Brain swelling
• Increased risk of acute complications?

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Historical elements

• Age
• gt65 years
• lt12 months
• Drugs
• Anticoagulants
• Warfarin
• Aspirin
• Gingko biloba
• Alcohol
• Illicit drugs
• Neurosurgery
• ?shunt

• Symptoms
• Seizure
• Vomiting
• Amnesia
• Mechanism
• Falls gt 1 meter
• High risk injury
• Pedestrian v vehicle
• Ejection from vehicle
• Non-accidental injury

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Symptoms

• Amnesia
• Seizure
• Headache
• Vomiting
• Irritability

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Physical Examination

• Signs of skull fracture
• CSF otorrhea, rhinorrhea
• Battles sign, raccoon/panda eyes
• Subgaleal haematoma
• Penetrating, or small square area of impact
• Directed neurologic exam
• GCS
• Cranial nerves
• Motor

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Procyon lotor
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Davy Crockett
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Glasgow Coma Scale -- E4 V5 M6

• Best Eye Response
• 4 Eyes open spontaneously
• 3 Eyes open to verbal
• command
• 2 Eyes open to painful stimulus
• 1 No eye opening
• Best Verbal Response
• 5 Oriented
• 4 Confused
• 3 Inappropriate words
• 2 Incomprehensible sounds (grunts and groans)
• 1 No verbal response

• Best Motor Response
• 6 Obeys commands
• 5 Localises painful stimulus
• 4 Withdrawal from painful stimulus
• 3 Abnormal flexion (decorticate posturing))
• 2 Abnormal extension (decerebrate posturing
• 1 No motor response

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Cranial Nerve and Motor Exams

• Cranial nerve abnormalities and
  lateralizing/focal motor findings suggest a
  structural or space-occupying pathology as a
  cause of altered mental status

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The Rest of the Presentation

• Review a couple of typical cases
• Based on the ACC case studies distributed to ED
  doctors in 2006
• Review the Acute Management of Head Injuries
  chart distributed by ACC
• Mostly about decision to CT scan
• Brief look at
• Referral guidelines
• Discharge guidelines

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Decision Making In TBI

• Who do I worry about?
• Who do I send to hospital?
• Who goes by ambulance?
• Who needs a CT scan?
• Who needs hospital admission?

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The New TBI Guidelines

• Define clinical factors which should influence
  decision to (among other things)
• Refer to hospital
• Transport by ambulance
• CT scan
• Admit for observation

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Jacks Saturday Night Bash

• Bottle v side of head 1 hour ago
• LOC for approx 1 minute
• Now
• Mild dysarthria
• Disorientated in time
• Amnesia for events
• Giving quizzical looks

What are you thinking?
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What You Might Be Thinking

• Common presentation with high risk features
• Concurrent alcohol intoxication
• After hours presentation
• From out of town
• Intoxicated mate to look after him
• Left parieto-temporal injury-important site
• Middle meningeal artery
• GCS of 14 at best
• Not storing short term memory

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What You Might Do Next

• Jack needs
• Further review of history
• Consideration of cervical spine injury
• Secondary survey and focused exam
• Blood glucose measurement
• Possibly blood ethanol level interpret with
  caution
• Wound care
• Observation

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More about Jack

• His laceration is sutured
• No obvious fracture under wound
• Fingerstick blood glucose 7mmol/l
• Blood ethanol 34 mmol/l
• At 2 hours post injury
• Vomiting
• Less cooperative swearing, trying to leave,
  staggering about

What are you thinking now?
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What You Might Be Thinking Now

• GCS now 13 or less but how much less?
• Eye opening 3/4
• Verbal 3/5 or 4/5
• Motor 5/6 or 6/6
• Vomiting could be from raised ICP
• These changes are not consistent with alcohol
  intoxication

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What You Are Thinking Now

• Jack needs
• More thorough assessment, especially of GCS and
  pupils
• If his fall in GCS is genuine, and continues,
  then he needs prompt management
• ABC management
• Concurrent call to Neurosurgeon
• CT scan
• Consider Mannitol on Neurosurgery advice

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Next Case
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Vexed Veterans Day

• John, tripped and fell one hour ago
• Fall not well witnessed - ?Loss of consciousness
• Dismissive - ?confused

What are you thinking?
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What You Might Be Thinking

• Is he altered or obstreperous?
• Other than age, are there red flags?
• What about the neck, and especially the hips?
• John needs
• More history, including social
• A benchmark of cognition/behaviour
• Secondary survey with focus

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More About John

• Abrasion on forehead
• No other injuries
• Atrial fibrillation
• Muddled
• Past history of CVA
• On warfarin

What are you thinking now?
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What You Are Thinking Now

• John is not right
• He is high risk
• He needs
• Close observation
• CT head
• Neurosurgical consultation
• Possibly reversal of anticoagulation

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ACC/NZGG guidelines

• Mostly based on the NICE guidelines
• Which were mostly based on the Canadian CT head
  rules
• Influenced by WHO Collaborating Centre Task Force
  on Mild TBI, and other published evidence.

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Canadian CT Head Rules

• Retrospective derivation of 7 indicators for CT,
  and prospective validation
• 5 high risk indicators for neurosurgery
• GCSlt15 at 2 hours
• Suspected open or depressed skull
• Any sign of basal skull
• Vomiting gt 1 episode
• Age gt65 years
• 2 medium risk indicators for brain injury on CT
• Retrograde amnesia gt 30 minutes
• Dangerous mechanism (pedestrian, ejected, fall
  fromgt 3 feet or 5 stairs)
• (GCS lt 13, age lt 16, focal signs, seizure, and
  on warfarin were exclusions)
• 50 specificity for clinically significant brain
  injury
• 100 sensitivity for predicting need for
  neurosurgical intervention

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GCS lt 8?

• Head injury severity based on GCS
• 13 15 minor ? observe, /- CT
• 9 - 12 moderate ? CT, /- ventilate
• lt 9 severe ? ventilate and CT

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Any One Of

• GCS lt 13 at any time
• when assessed, irrespective of the time elapsed
  since the injury
• GCS 13 14 at 2 hours, from time of injury
• Deteriorating GCS
• Suspected open, depressed or basal
• Post-traumatic seizure
• Focal neurological deficit
• Repeated vomiting (gt1)
• Retrograde amnesia gt30 minutes
• although this is a low risk criterion in the
  Canadian CT rules

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Amnesia and

• Age gt 65
• (odds ratio for clinically significant
  complication of TBI of 4.1, when age assoc with
  LOC or amnesia. Canadian CT head rules had this
  as a high risk criterion)
• Coagulopathy
• Amnesia gt 30 minutes
• (Guidelines say amnesia for events before the
  injury)
• Dangerous mechanism
• (pedestrian hit by motor vehicle, occupant
  ejected from motor vehicle, fall from a height
  greater than one metre or five stairs)

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Hierarchy Of Criteria For Minor Cases(GCS gt 12
only)

• CT scan urgently if high risk features
• Deteriorating GCS
• GCS 13 14 after 2 hours
• Suspected open, depressed or basal
• Post-traumatic seizure
• Focal neurological deficit
• Retrograde amnesia gt30 minutes
• Repeated vomiting (gt1)
• Or less urgently if lower risk features
• Age gt 65
• Coagulopathy
• Dangerous mechanism
• Retrograde amnesia gt30 minutes

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But, Of The High Risk Criteria

• These
• Deteriorating GCS
• GCS 13 14 at 2 hours
• Suspected open, depressed or basal
• Focal neurological deficit
• Are more pressing than these
• Post-traumatic seizure
• Repeated vomiting (gt1)
• Retrograde amnesia gt30 minutes
• When access to CT is difficult

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Possible Hierarchy(varied according to clinical
concerns and local circumstances)

• CT now
• Deteriorating GCS
• CT soon
• GCS not deteriorating but
• Focal neurological deficit
• GCS 13 14 at 2 hours
• CT needed
• None of the above but
• Suspected open, depressed or basal
• Post-traumatic seizure
• Repeated vomiting (gt1)
• Retrograde amnesia gt30 minutes
• Age gt 65
• Coagulopathy
• Dangerous mechanism

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What About Children?

• Mostly the same, but
• CT has more of a down-side the younger the
  patient
• Infants have a higher rate of TBI complications
  than adults, (although older children have a
  lower rate)
• Paediatric version of GCS should be used
• NAI should be considered, and may be another
  indication for CT
• For infants, additional risk factors include
• Scalp swelling or haematoma
• Occipital or temporal/parietal location of injury
• Age under 1 year

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Paediatric GCS

• Best eye response same as for adult
• 4 Eyes open spontaneously
• 3 Eyes open to verbal command
• 2 Eyes open to painful stimulus
• 1 No eye opening
• Best verbal response specific for children
• Best motor response same as for adult
• 6 Obeys commands
• 5 Localises painful stimulus
• 4 Withdrawal from painful stimulus
• 3 Abnormal flexion (decorticate posturing)
• 2 Abnormal extension (decerebrate postruring)
• 1 No motor response

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Paediatric Verbal Response Score

• Best grimace response
• (for pre-verbal or intubated children)
• 5 Spontaneous normal facial or oro-motor activity
• 4 Less than usual spontaneous ability or only
  responds to touch stimuli
• 3 Vigorous grimace to pain
• 2 Mild response to pain
• 1 No response to pain

• Best vocal response
• 5 Alert, babbles, coos, words or sentences to
  usual ability
• 4 Less than usual ability and/or spontaneous
  irritable cry
• 3 Cries inappropriately
• 2 Occasional whimpers and/or moans
• 1 No vocal response

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Last Case
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The Gun Went Off

• 8 yo sitting with family
• Family member handling pellet gun, which
  accidentally discharged
• Child shot in right temple, cried out
• Taken by mother to GP after hours clinic
• Alert, head hurts, but consolable

What are you thinking?
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Observed for 45 Minutes

• Vomits x 1
• GCS ?13/14, estimate from notes
• Drowsy
• No seizure
• No focal neurology

What do you do?
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Transfer to HB ED.

• GCS 13 on arrival
• Entrance wound left temple, oozing blood and
  ?clear fluid
• Irritable when stimulated
• CT arrangedwhile awaiting scan, she become
  irritable and GCS drops to 12
• No focal neurology
• Intubated for scan and secondary to dropping
  mental status

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Who Gets Admitted?

• Clinically significant CT abnormalities
• (including skull fractures)
• CT indicated but not possible
• GCS lt 15, or deteriorating GCS
• Focal or abnormal neuro signs
• Persisting symptoms
• Post traumatic seizure
• Inadequate discharge arrangements

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What If You Were At The Club With John?

• Reassure and dont refer?
• Transfer to hospital (or after hours clinic if
  appropriate) by car?
• Transfer to hospital by ambulance?

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Transfer To Hospital By Ambulance If

• Any deterioration
• GCS lt 15
• Any focal neurological deficit
• Suspicion of skull fracture, or penetrating head
  injury
• Any seizure since the injury
• A high-energy head injury
• Suspected neck injury
• No other form of transport

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Transfer To Hospital (Or After Hours Clinic If
Appropriate) By Car If

• Any loss of consciousness
• Amnesia
• Persistent headache
• Irritability or altered behaviour
• Any vomiting
• History of bleeding or clotting disorders
• Anticoagulant use, including Ginkgo Biloba
• Current drug or alcohol intoxication
• Any previous cranial neurosurgical interventions
• Suspicion of NAI
• Age over 65 or less than 1
• Concern about symptoms

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Summary Of New Guidelines

• Minor HI patients (GCS 13, 14 or 15) get a CT
  scan urgently if high risk features
• Deteriorating GCS
• GCS 13 14 after 2 hours
• Suspected open, depressed or basal
• Focal neurological deficit
• Post-traumatic seizure
• Repeated vomiting (gt1)
• Retrograde amnesia gt30 minutes
• Or less urgently if lower risk features
• Age gt 65
• Coagulopathy
• Dangerous mechanism
• Referral guidelines follow similar criteria, with
  referral for all who are knocked out and an
  ambulance call for the higher risk

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Thank you