Minor Injuries 002

Case Study:

• 17 year old male softball player gets struck to the  temporal region with a soft ball during a game. He falls to the ground, with a brief  ?5-10secs loss of consciousness, witnessed by an off duty aged care nurse.
• He is helped up onto his feet, were he complains of a headache, nausea no vomiting, dizziness and has slight retrograde amnesia and denies neck pain.
• He is then brought to the emergency department for assessment.

Assessment:

• The patient is alert, orientated GCS15, but cannot recall the event or driving to the soft ball game retrograde amnesia) and complains of a mild headache and nausea
• On examination:
  • Pupils 3mm and equal and reactive to light.
  • Patient has 2cmx2cm haematoma to the right temporal area and denies any C-spine tenderness
• Observed in ED for 4 hours, with complete resolution of amnesia, and GCS of 15/15, headache resolved after Panadeine.

Diagnosis and Discharge:

• CT Head scan was performed to rule out extradural haematoma (EDH)
• CT head revelaed no major abnormality
• Diagnosis: mild head injury with associated concussion
• Discharged with head injury advice sheet, competent adult, and oral analgesia for the headaches. Advised to follow up with his GP in 3-4 days before returning to play softball

Minor Head Injury/Concussion:

• Concussion may be defined as a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are hallmarks of concussion.
• Mild head injury is defined as a GCS of 14-15 at the time of presentation to the emergency department. These are patients who can talk and walk providing there is no extracranial injury. Moderate head injury is were the patients GCS is 13/15 and they are drowsy and confused.
• The brief loss of consciousness that characterizes concussion appears to be the result of rotational forces exerted at the junction of the upper midbrain and thalamus that causes transient disruption of the functioning of the reticular neurons that maintain alertness.
• The extent off concussive amnesia roughly correlates with the duration of loss of consciousness and the severity of head injury.
• Some patients with concussive injury will suffer a brief convulsion immediately post injury, this should not be regarded to as epilepsy, and anticonvulsant medications are not indicated. The mechanism that causes this remains unknown.

History and Examination:

Enquire about:

• The nature and speed of impact
• Subsequent loss of consciousness, drowsiness, vomiting or seizures
• The length of post-traumatic amnesia (PTA) from the time of injury to the time of return of memory of consecutive events. This is often underestimated. Over 10 min of PTA is significant.
  

  “Concussion” NEJM 2007;356:166-72

• Associated alcohol or drug intoxication
• Relevant medical conditions and drug therapy including warfarin, clopigrel and aspirin.

Examination

• Record Temperature, pulse, BP, and respirations.
• Assess higher mental functions, including the level of consciousness, using the GCS, assess for retrograde and anterograde amnesia.
• Check pupil size and reactions, eye movements, cranial nerves and the limbs for lateralizing neurological signs.
• Examine the scalp for bruising, lacerations, palpable fractures and haematomas.

Grades of Concussion:

• Grade 1: (mild)
  • Transient confusion without loss of consciousness, symptoms generally resolve within 15mins.
  • Most common symptoms or mental state abnormalities in the immediate post injury period are delayed verbal or motor responses, disorientation, slurred speech, incoordination, memory loss and headaches, nausea, vomiting and vertigo.
• Grade 2: (moderate)
  • Transient confusion without loss of consciousness. Symptoms or mental state abnormalities associated with concussion last more that 15 minutes.
• Grade 3: (Severe)
  • Loss of consciousness of any duration less than 30 minutes.

Signs or symptoms falling outside these criteria, no longer supports a diagnosis of concussion or mild head injury, and should be investigated further.

When is a Head CT indicated?

• The aim of performing a CT head is to rule out subdural, epidural or intracerebral haemorrhage.
• Less than 10% of patients have intracranial bleeding after concussion, and less than 2% require neurosurgical intervention
• The Canadian Head CT Rule for patients with minor head injury is generally referred to when decided which patients require a head CT.
• Overal risk from Head Injury can be calculated

Canadian CT Head Rule:

High Risk (for neurological intervention)

• GCS score <15 at 2hr after injury
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (haemotympanum, ‘racoon eyes’, cerebrospinal fluid ottohoea/rhinorrhoea, battle’s sign)
• Vomiting> 2 episodes
• Age>65 years

Medium Risk (for brain injury on CT)

• Amnesia before impact >30min
• Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height> 3feet or five stairs.

Also consider head CT when:

• Coagulopathy (includes all patients on warfarin regardless of INR)
• Seizure
• Focal neurological deficit
• Drug or alcohol intoxication
• Physical finding or trauma above clavicle.

What is Post-Concussive Syndrome?

• Postconcussion syndrome consists of a constellation of sometimes disabling symptoms, mainly headache, dizziness, and trouble concentrating in the days and weeks following concussion.
• The frequency and natural history of the disorder is unclear, symptoms often persist for months, are resistant to treatment but eventually will lessen.
• International Classification of Disease, 10^th Revision, Criteria for postconcussion syndrome.
  • Interval between head trauma with loss of consciousness and development of symptoms,<4wk
  • Symptoms in at least three of the following categories:
    • Headache, dizziness, fatigue, noise intolerance
    • Irritability, depression, anxiety, emotional lability
    • Subjective concentration, memory, or intellectual difficulties without neuropsychological evidence of marked impairment
    • Insomnia
    • Reduced alcohol tolerance
    • Preoccupation with above symptoms and fear of brain damage, with hypochondriacal concern and adoption of sick role

What is secondary Impact Syndrome?

• Secondary impact syndrome involves an athlete/patient suffering post-concussive symptoms following a head injury. If, within several weeks, the athlete/ patient sustains a second head injury, diffuse swelling, brain herniation, and death can occur.
• Emergency clinicians need to be aware of this condition and counsel patients accordingly when they sustain the initial injury.

How long should patients be kept in ED?

• Guidelines generally state 4 hours post injury
• Patients in the ED should have hourly GCS, pupillary reactions and vital signs.
• Unsure were the evidence has come from for the 4 hours of monitoring in the ED has come from, maybe the same place as the 4 hour rule evidence?
• Generally if patients are alert and orientated, have a responsible adult to supervise them, and aren’t intoxicated, after a period of observation are fit for discharge.

What are your discharge instructions?

• All patients that are discharged from the emergency department should be given written instruction on when to return, and what symptoms they will experience post head injury.
• Warning signs to return to hospital immediately:
  • Excessive drowsiness or lethargy
  • Confusion or disorientation
  • Abnormal behaviour or irritability
  • Fitting or seizures
  • Blurred vision or slurred speech
  • Severe headache
  • Persistent vomiting
  • Abnormal clumsiness

Patients should also be counseled on postconcussion syndrome, and second impact syndrome.

They should also be warned about driving a vehicle, making important decisions, as concentration could be impaired for the first 24-48hours-post injury.

Patients should avoid NSAID, aspirin and other anti-inflammatory pain relief, to treat headaches post injury, paracetamol, and codeine should be sufficient. If patient not getting relief from simple analgesia for headaches, should also prompt reattendance to the ED or GP for reevaluation.

Reference:

• Adirim, T. (2007). Concussions in Sports and Recreation. Clinical Pediatric Emergency Medicine. 8:2-6
• Bey, T. & Ostick, B. (2009). Second Impact Syndrome. Western Journal of Emergency Medicine. X(1), 6-10.
• Brown, A. & Cadogan, M. (2006). Conscious Head Injury. Emergency Medicine: Emergency and Acute Medicine: Diagnosis and Management. pp. 242-245. London: Hodder Arnold
• Fisher, J. & Vaca, F. (2004). Sports-related Concussions in the Emergency Department. Topics in Emergency Medicine.  26(3). 260-266.
• Gottesfeld, S. & Jagoda, A. (200). Mild Head Trauma: Appropriate Diagnosis and Management.  Emergency Medicine Practice. 2(1)
• Ropper, A. & Gorson, K. (2007).  Concussion. The New England Journal of Medicine. 356(2), 166-172
• Selladurai, B. & Reilly, P. (2007). Mild  Head Injury in Adults. Initial Management of Head Injury: A comprehensive Guide.  pp. 215-227. Australia: McGraw Hill.
• Stiell, I. et.al. (2001).  The Canadian CT Head Rule for patients with minor head injury.  The Lancet. 357, 1391-1396.