The Head Injury Patients With Gcs

Published Date: 02 Nov 2017

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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.