A one - year cross-sectional observation study of the acute management of adult mild head injury in the Emergency Department Hospital Universiti Sains Malaysia
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Date
2001-11
Authors
Chan, Hiang Chuan
Journal Title
Journal ISSN
Volume Title
Publisher
Universiti Sains Malaysia
Abstract
Mild Head Injury (MHI) is one of the common presentation to
Emergency Department. Most MHI patients recover fully but there is a
significant proportion of them harbor intracranial hematoma that might
deteriorate if the diagnosis is missed. The Neurological outcome of MHI
patients are less favorable once deteriorated. The objectives of this study are;
I) to assess whether clinical parameters are useful to predict
the likelihood of intracranial injury,
II) to determine the justification of selective use of cranial
CT scans versus cranial CT for all MHI patients,
Ill) to evaluate the differences between patients with GCS 13,
14 and 15,
IV) ability to identify patients at risk before deterioration as
neurological outcome are less favourable and
V) to find out the incidence of missed intracranial injury in our
current practice. 330 adult patients with initial Glasgow Coma Scale of 13-15 presented
within 24 hours after blunt head trauma were collected from 1st January to 31st
December 2000 at Hospital University Science Malaysia Emergency
Department.
For every patient, a standard questionnaires is used to document
clinical parameters under study i.e. Loss of consciousness, moderate to severe
headache, vomiting twice or more, Ear Nose and Throat bleed, skull fracture on
plain radiograph, focal neurological deficit, post-traumatic seizure, mechanism
of injury, alcohol or drug influences, significant past medical history and age >
60 years. Patient vital signs, systemic injury/injuries and other relevant factors
are also noted. For those with cranial Computed Tomography scan done, the
indication and finding (normal/abnormal) are documented. Each patient's
modality of initial management is also determined. Patients who are admitted,
especially those with no initial cranial CT done, will be followed up till
discharge to detect any late deterioration including morbidity and mortality.
Neurological charting, hemodynamic status and other relevant information in
the ward are also noted.
The data are analyzed using various descriptive studies. Chi-square
analysis and Binary logistic regression are used to determine the significant of
each clinical predictor in relation to cranial CT abnormality and mode of
management. Level of significance is taken asp-value< 0.05. The result of this study is to highlight the awareness of the staff of
Emergency Department and the in-patient team regarding which patients at
higher risk of developing life-threatening intracranial injury in Mild Head Injury,
which have different pathophysiology, severity and clinical outcome within this
broad group.
From this study, it was found that
1. Incidence of skull fracture on plain radiograph, 13.3o/o was relatively
high.
2. There was 24.8o/o of abnormal cranial CT scan though only 31.8°/o of
the sample underwent the investigation. Thus, 78.1 °/o of those with
cranial CT scans done, had acute intracranial injury which need
medical or neurosurgery intervention.
3. Skull fracture and persistent ENT bleed are the two risk factors that
are strongly associated with abnormal cranial CT scan statistically.
(with p<0.001 and 0.04 respectively).
4. LOC, headache, vomiting, maxillo~facial injury, unequal pupils, age>
60 years old, substance influence, amnesia and seizure are not
statistically significant.
5. Percentage of obtaining abnormal cranial CT scan vary with GCS
score; 62.5°/o, 74.2°/o and 89.7°/o of abnormal CT for GCS 15, 14
and 13 respectively.
6. Statistically, there is significant difference between GCS 13 and 15 of obtaining abnormal cranial CT with p < 0.02.
7. Patients with GCS 13 and 14 have higher chance of undergoing
medical or neurosurgery intervention when compare to GCS 15 with
both have p < 0.001.
8. 7 patients (2.1 o/o) deteriorated in the ward. 2 patients had no initial
CT scan done. 6 out of 7 patients that deteriorated had GCS < 15.
All the patients had one or more risk factors that are involved in the
study. Based on the results of this study, the following guidelines have been
proposed:
1. Current practice in regard to the use of plain skull radiograph in MHI
should be continued. There is no practical way to diagnose skull
fracture except radiologically.
2. Selective use of cranial CT scan for MHI is justified based on
current standard of practice and to reduce escalating medical cost
3. Clinical parameters are useful to predict acute and delayed
intracranial injury. Patients deemed at higher risk should have more
closed neurological observation and even early cranial CT scan
when indicated to prevent deterioration.
4. There is heterogeneity between patients with different GCS in MHI in
term of pathophysiology, severity of injury and clinical outcome.
Serious consideration must be given to the segregation of patients
with GCS 13 and even 14 from those with GCS 15. 5. Patients with GCS 15 and GCS 14 without or with minimal
symptoms can be observed at ED observation ward instead of
admission.
Description
Keywords
Mild Head Injury (MHI)