Tag Archives: TBI

General

(In)appropriate Neurosurgical Consultation

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Emergency physicians and trauma surgeons routinely assess patients with potential neurotrauma and decide whether to obtain CT scans and/or neurosurgical consultations. The criteria they use to make these decisions are not always clear.

The neurosurgery department at the University of California – Davis performed a prospective study that looked at the appropriateness of consults they received and of CTs of the head ordered by other physicians in trauma and non-trauma patients. A total of 99 patients entered the study (32 head trauma, 29 spine trauma, 34 other disease, 4 not documented).

After reviewing the consultations, they found that 69 were appropriate, 32 were not appropriate, and 7 could not be classified. Additionally, they felt that 10 of the head CTs in injured patients (31%) were not indicated.

“Appropriateness” was difficult to define well in this study, and there is certainly a great deal of subjectivity involved. The authors recommend using the Canadian CT Head Rule to fine-tune use of head CT in trauma patients.

The bottom line: 1 in 4 consults were not appropriate, and 1 in 3 head CTs were not indicated. Despite its flaws, this study shows that we need to be better at evaluating our patients to reduce unnecessary consults and radiation!

Reference: (In)appropriate neurosurgical consultation. van Essen et al. Clinical Neurology and Neurosurgery. In press, for publication 10/2010.

General

Repeated Head CT Scans: Are They Really Necessary?

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There is an increasing public interest regarding exposure to medical radiation. It represents the major exposure source for the population at large. There may be a presumption on the part of medical providers that “what you can’t see can’t hurt you” but this is just not the case.

A number of studies have shown that there is risk association with repeated exposure to xray. This risk is particularly important when dealing with pediatric patients. It’s time to start critically looking at our imaging practices and to start critically thinking about every one that we order.

One common source of repeat radiation is the repetitive CT scans of the head that patients who suffer TBI undergo. Frequently, there is little rhyme or reason to the patter of these scans. Should we repeat in 6 hours? 24 hours? When any lesions finish evolving?

It turns out that there is a reasonable amount of guidance in the brain literature. For the most part, they suggest that patients who are not in an ICU only need a repeat CT if their mental status changes. Any others obtained did not result in any management change. The first 6 papers listed below agree with this.

However, number 7 is interesting. It was published in the Journal of the American College of Surgeons and was a retrospective study of patients seen at a Level I Trauma Center. All patients had a lesion seen on initial scan, and underwent repeat scanning. The authors found that 6% of their patients underwent a surgical or medical “intervention” based on changes on the repeat head CT. What troubled them the most was that 21 of these 51 patients did not have any substantial neurologic change. They conclude that routine repeat head CT is very useful.

It’s not clear why their results are so disparate from the others. It is retrospective, and the authors do not state what the interventions exactly are. Nor do they speculate on why their results are so different from others. Nor do they show any difference in outcomes.

The bottom line: Repeat head CT is probably not needed in patients with mild TBI who are not on anti-coagulants or anti-platelet agents. However, regular mental status checks and GCS measurements must be taken.

References:

  1. Is repeated head computed tomography necessary for traumatic intracranial hemorrhage? American Surgeon 2005 Sep;71(9):701-4.
  2. Routine repeat head CT for minimal head injury is unnecessary. J Trauma 2006, Mar;60(3):494-9.
  3. A prospective evaluation of the value of repeat cranial computed tomography in patients with minimal head injury and an intracranial bleed. J Trauma 2006 Oct;61(4):862-7.
  4. Indications for routine repeat head computed tomography (CT) stratified by severity of traumatic brain injury. J Trauma 2007 Jun;62(6):1339-44.
  5. The role of early follow-up computed tomography imaging in the management of traumatic brain injury patients with intracranial hemorrhage. J Trauma 2007 Jul;63(1):75-82.
  6. Value of repeat cranial computed tomography in pediatric patients sustaining moderate to severe traumatic brain injury. J Trauma 2008 Dec;65(6):1293-7.
  7. Schedule repeat CT scanning for traumatic brain injury remains important in assessing head injury progression. J Amer Coll Surgeons 2010 May;210:824-32.
General

Evaluation After Head Injury in Adolescents

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Traumatic brain injury (TBI) is the most common cause of death in children. Even mild concussions can cause some degree of functional impairment. Many clinicians believe that the degree of impairment correlates with the initial Glasgow Coma Scale score (GCS), although this has only been shown in adults. This has led many hospitals to perform cognitive screening selectively, usually on adolescents with lower GCS scores.

A recent study by Goold and Vane at the Cardinal Glennon Children’s Medical Center in St. Louis, and the University of Vermont College of Medicine in Burlington looked at the correlation between GCS and level of impairment, and ways to determine which groups of adolescents need more sophisticated cognitive testing to evaluate deficits.

A total of 609 young adults age 13-21 with brain injuries were identified, and a cognitive screening test was performed (Occupational Therapy Head Injury Mini Screen [OT HIMS]). There was no correlation between GCS and the components of the OT HIMS. Interestingly, the GCS did not predict which patients were discharged to rehab centers either.

The Bottom Line: Adolescents can develop significant cognitive deficits or behavior issues after any degree of head injury. Because of this, it is not possible to selectively screen for cognitive deficits. All adolescents age 13-21 should undergo screening with an instrument like the OT HIMS after head injury.

At our Level I Pediatric Trauma Center, we consider a child to have a TBI if:

  • the mechanism involves head impact and
  • any of the following apply:
    • known or suspected loss of consciousness
    • cannot remember the event
    • parents detect any change in behavior

All of these children undergo a TBI screen performed by Gillette Children’s Specialty Hospital physiatry, occupational and physical therapy services. If needed, they receive followup in the Gillette Minor Neurotrauma Clinic.

Reference: Goold D, Vane DW. Evaluation of Functionality After Head Injury in Adolescents. Journal of Trauma 2009;67:71-74.

General

Motorcycle Helmets and Reduction of Head Injury and Mortality

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There are more than 4000 motorcyclist deaths each year. Per mile traveled, there are 27 times more motorcycle deaths that automobile fatalities. This is primarily due to the lack of protection available to motorcyclists, including failure to use a helmet. About 50% of motorcycle deaths are due to head injury.

Helmet use by motorcyclists varies widely across the US. Only 20 states and the District of Columbia have mandatory helmet laws for all motorcyclists. 27 states require helmets on some riders, usually those less than 17 or 18 years old. Three states (Illinois, Iowa and New Hampshire) do not have any helmet law.

Do helmets work? Do helmet laws work? Many studies have been done, and now the evidence is convincing that the answer to both questions is yes! The Eastern Association for the Surgery of Trauma has just released an evidence based review on motorcycle helmet use. They looked at 45 of the best scientific studies available to reach their conclusions. Following is a summary of their findings:

  • The use of motorcycle helmets decreases the overall death rate of motorcycle crashes as compared to non-helmeted riders
  • The use of motorcycle helmets decreases lethal head injuries as compared to non-helmeted riders
  • The use of motorcycle helmets decreases the severity of non-lethal head injuries as compared to non-helmeted riders
  • Mandatory universal helmet laws reduce mortality and head injury in geographical areas with the law as compared to those without it

Based on this data, the EAST document makes the following recommendations:

  • Level I (supported by highest quality research): All motorcyclists should wear helmets to reduce the incidence of head injury after a crash
  • Level II (supported by high quality research): All motorcyclists should wear helmets to improve overall survival and reduce head-injury related mortality after a crash
  • Level II: Mandatory universal motorcycle helmet laws should be introduced or re-enacted to reduce morality and head injury after a crash

The full text of the EAST review can be downloaded by clicking the link below.

Reference: EAST Evidence Based Review on Helmet Efficacy to Reduce Head Injury and Mortality in Motorcycle Crashes

General

A Quick and Dirty Test for Traumatic Brain Injury

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Traumatic brain injury (TBI) is an extremely common diagnosis in trauma patients. The majority are minor concussions that show no evidence of injury on head CT. Despite normal findings, however, a short conversation with the patient frequently demonstrates that they really do have a TBI.

Scoring systems can help quantitate how significant the head injury is. The Glasgow Coma Scale (GCS) score is frequently used. This scoring system is not sensitive enough for minor head injuries, since a patient may be perseverating even with a GCS of 15.

The Short Blessed Test (SBT) is a 25 year old scoring system for minor TBI that has been well-validated. It takes only a few minutes to administer, and is very easy to score.

The most important part of the administration process is choosing a threshold for further evaluation and testing. We administer this test to all trauma patients with a suspected TBI (defined as known or suspected loss of consciousness, or amnesia for the traumatic event). If the final score is >7, we refer the patient for more extensive evaluation by phsyical and occupational therapy. If the score is 7 or less but not zero, consideration should be given to offering routine followup in a minor neurotrauma clinic as an outpatient. In all cases, patients should be advised to avoid situations that would lead to a repeat concussion in the next month.

Reference: Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983 Jun;140(6):734-9.