Minor head injury : Classification, Presentation.investigation and management CT criteria,Discharge criteria

1. APPROACH TO PATIENTS WITH
MINOR HEAD INJURY
Dr SAMEEP KOSHTI

2. MILD TRAUMATIC BRAIN INJURY
(M-TBI)
• Definition
• Scales
• Signs and symptoms
• Prehospital management of traumatic brain injury
• Management in ED/Triage
• Requirement of Imaging :?:
• Admission or safe discharge?
• Treatment
• Sequelae
• Post injury Neuropsychology and rehabilitation

3. WHO DEFINITION
• Mild TBI is an acute brain injury resulting from
mechanical energy to the head from external physical
forces.
• Operational criteria for clinical identification include:
– (i) 1 or more of the following:
• confusion or disorientation,
• loss of consciousness for 30 minutes or less,
• post-traumatic amnesia for less than 24 hours, and/or
• Other transient neurological abnormalities such as focal signs,
seizure, and intracranial lesion not requiring surgery;
– (ii) Glasgow Coma Scale score of 13-15 after 30 minutes
post-injury or later upon presentation for health care.

4. Contd..
• These manifestations of MTBI must not be due
to :
– drugs, alcohol, medications,
– caused by other injuries or treatment for other
injuries (e.g. systemic injuries, facial injuries or
intubation),
– caused by other problems (e.g. psychological
trauma, language barrier or coexisting medical
conditions) or
– caused by penetrating craniocerebral injury.

5. Concussion definition
• A complex pathophysiological process affecting the brain, induced by biomechanical forces.
• Several common features that incorporate clinical, pathologic and biomechanical injury
constructs that may be utilized in defining the nature of a concussive head injury include:
• 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on
the body with an “impulsive” force transmitted to the head.
• 2. Concussion typically results in the rapid onset of short-lived impairment of neurological
function that resolves spontaneously. However, in some cases, symptoms and signs may
evolve over a number of minutes to hours.
• 3. Concussion may result in neuropathological changes, but the acute clinical symptoms
largely reflect a functional disturbance rather than a structural injury and, as such, no
abnormality is seen on standard structural neuroimaging studies.
• 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss
of consciousness. Resolution of the clinical and cognitive symptoms typically follows a
sequential course.
• However, it is important to note that in some cases symptoms may be prolonged.

6. Scale

7. (8-19%)
(Hallmark of concussion)

10. PREHOSPITAL MANAGEMNT

11. As per BTF(Brain trauma foundation)

14. MANAGEMENT IN ED /TRIAGE

15. Primary Survey
• Airway
– Clear and maintain airway
• Breathing
– Supply oxygen (target PaCO2 30-35 mmHg)
– Look for and treat injuries
• Circulation
– P/BP/Neck veins/external haemorrhage
– Temperature /capillary refill
• Disability
– Assess GCS
• The GCS score that has the most prognostic importance is referred to as the
postresuscitation GCS, obtained after the patient's airway and hemodynamic status have
been stabilized.
– Pupillary size and response
– Other brainstem reflexes: Corneal /Cough /gag reflex
– Signs of Spinal cord injury and Other lateralizing signs of injury
• Exposure
– After adequate collar immobilization of neck and log roll for back examination
– For Adequate complete examination
– Prevention of hypothermia

16. Secondary Survey
• History:
– Allergy
– Medication
– Past medical history (Including pregnancy)
– Last meal
– Events relating to injury
• Examination:
– Head
– Eyes
– Face
– Neck
– Chest
– Abdomen
– Pelvis
– Extremities
• Detailed Neurological reassessment:
– GCS/Pupils /Motor /Sensory
• Adjuvant Test
– CT Scan (“MAN SCAN”—tomogram from head to knee)

17. Requirement of Imaging
• ATLS guidelines :
– a goal of 30 minutes between initial assessment and CT
scan.
• The Canadian CT Head Rule is useful for indication of
CT scan: includes the following high-risk factors and
two additional medium-risk factors
• Other Imaging:
– MRI BRAIN
– CT ANGIOGRAPHY OF CEREBRAL VESSELS

20. CLASSIFY THE SEVERITY
• ONCE
– INITIAL ASSESSMENT AND
– RESUSCITATION
– IMAGING
THEN
Classify as per GCS scoring and management of
1. GCS score of 3 to 12 -- (moderate and severe TBI) and an abnormal CT
scan will require :
– Neurotrauma intensive care unit specialized care.
2. GCS scores of 13 to 15 (mild TBI) depends on the :
– degree of injury and
– the cause of the depressed GCS score (e.g., alcohol, illicit drugs, hypoxia).

21. MILD TBI
• commonly associated with transient
confusion, temporary loss of consciousness,
and amnesia without significantly poor GCS
scores.
• GCS: 13-15
• Watch for “Talk and Die” patient (ask for lucid
interval)
• WHO definition : Concussion and Mild TBI
• CDC guidelines

22. CDC Guidelines for Mild TBI
1. Any period of observed or self-reported transient
confusion, disorientation, or impaired
consciousness
2. Any period of observed or self-reported
dysfunction of memory (amnesia) around the time
of injury
3. Observed signs of neurological or
neuropsychological dysfunction

23. Neuropsychology testing
• ImPACT (Immedicate Post concussion
Assessment and cognitive testing) program
– measures verbal and
– visual memory,
– information processing time, and
– reaction time
• Other Computerized test
– (CogSport, and Headminders)

24. Post Imaging
• Patients with mild TBI and negative head CT scans :
– Can be safely discharged
– except those on anticoagulant or antiplatelet therapy or
– who have undergone prior neurosurgical procedures.
• Patients with head CT scans showing small contusions
and hemorrhages, but with GCS scores of14 or 15,
– inpatient observation for 24 to 48 hours with frequent
neurological examinations in a monitored setting (e.g.,
every 2 to 4 hours) and
– repeat imaging

25. Adjunct testing
• fMRI
• PET
• MR Spectroscopy-- (NAA : Cr) Ratio
• DTI
• HD Fibre tracking
• Serum markers:
– S100B Calcium binding protein
– GFAP
– By immuno assay:
• NSE
• MBP
• Tau Protein
• Neuropsychhologic assessment
• Post concussion SCAT 3

26. Concussion Management
• COGNITIVE
• PHYSICAL REST FOR first 48 hours
• Stepwise approach:
– period of no activity,
– followed by light aerobic exercise,
– sport-specific exercise,
– noncontact training drills,
– full-contact practice, and
– finally return to play/ Full activity
• with a period of 24 hours at each level
• In the event that postconcussion symptoms occur at any step:
– another 24-hour period of rest is completed, and the
– Patient /athelete drops back to the previous step in the program.
• Because of evidence that RTP(return to play) on the day of injury may be
associated with prolonged neuropsychological deficits with delayed onset,
same-day RTP should never be permitted.

27. Pharmacological treatment
– Not used for TBI deficit
– but useful for patients with postconcussion syndrome
or prolonged postconcussion syndrome
– during the recovery phase
• It is best to avoid medications
– that lower the seizure threshold or
– that cause confusion or contribute to cognitive
slowing, fatigue, or daytime drowsiness

28. In patient management
• strict monitoring
– GCS
– Vital
– Pupils
– Newer neurological defcit
• Cerebral protection
• Other systemic injuries to be ruled out and
managed accordingly

29. Drugs
• Symptoms specific management :which are grouped into four
categories
– somatic complaints,
• Headache :
– Acetaminophen
– Amitryptiline
– Limited: DHE / Calcium channel blockers/Anticonvulsant : valproate
,Gabapentin,Topiramate/Beta blockers
– sleep disturbance
• Trazodone (serotonin antagonist )
• Zolpidem
• Prazosin
• Melatonin
– Emotional (TBI associated depression)
• SSRI
– Cognitive
• Amantadine

30. Post Head injury disease (Post
concussion)
• Post concussion syndrome (6weeks – 3 months)
– ICD 10 Diagnosis of PCS:
• requires the presence of three or more of the following symptoms:
– headache,
– dizziness,
– fatigue,
– irritability,
– insomnia,
– concentration difficulty, and
– Memory difficulty.
• Prolonged post concussion syndrome (>3 months)
• Mild cognitive deficit
• Chronic traumatic encephalopathy

31. NICE GUIDELINE