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Head Injuries

Head injuries are a common reason for attending the Emergency Department (1). They are also a common situation to be called about when a patient falls on the ward whilst you are on ward cover, especially at night when you have less immediate support. How do you assess these patients? Who needs a CT scan? What medication do we need to be concerned about?

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Dr Mike Aisbitt is a Consultant in Emergency Medicine and Paediatric Emergency Medicine at Southport and Ormskirk Hospital NHS Trust. The episode focuses mainly on the initial assessment of head injuries, discusses NICE Head Injury guidance including those on anticoagulation alongside emerging evidence about anti-platelet medication. If you want to know more about dealing with a patient who has fallen or is at risk of falls, check out our previous discussion here. We use a case example to aid discussion.

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Case Discussion

You are the FY2 on ward cover overnight. It’s 3am and your bleep goes off. The nurse tells you that their patient, Fred, has fallen over on the ward. Fred is 78 and was admitted 2 days ago for urosepsis. His past medical history includes coronary artery disease and hip arthritis. His medication history includes:

  • Bisoprolol
  • Aspirin
  • Clopidogrel
  • Rampipril

When you ask what happened, the nurse tells you they heard a bang and attended Fred immediately. He is alert but dazed.

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Initial Assessment

As for any patient where there is a concern, your assessment intially should follow an ABCDE structured approach.

When you get to Fred, he is sitting on the floor, appears dazed but is alert. A quick ABCDE reveals no immediate resuscitation concerns and you decide to attempt a more in depth head injury assessment.

The salient points to pick up in your assessment include:

  • Amnesia – how long, retrograde or antegrade?
  • Vomiting – how many discrete episodes? Continuous vomiting for 3 minutes would be one discrete episode.
  • Loss of conscioussness – may be difficult to ellicit and often elderly patients do not know or have a degree of cognitive impairment
  • Confusion – don’t be caught out by the “it’s normal for them” statement. Any possible new change in mental state should be ascribed to the head injury unless you are absolutely certain it is unrelated
  • Post-traumatic seizure
  • Consider the mechanism of injury – it will point you towards likely injuries to be looked for
  • Look at the drug chart for potentially dangerous medication in this context, especially those that alter coagulation (warfarin etc)
  • Obvious injuries – these include the head injury itself and any other injuries, truncal and bony. A previously mobile patient who does not mobilisse has a fracture until proven otherwise.
  • Brief neuro exam – with practice, this can be slick and efficient
    • This may include GCS or if you struggle with remembering these point, a simple AVPU will suffice initially. Part of the neuro obs the nursing staff undertake is GCS so it may have been done for you.
    • Gross motor and sensory deficit should be examined for.
    • Pupils for size and reactivity
    • Eye movements
    • Facial movements and sensation
  • Signs of open, depressed or basal skull fractures – see later

Following your assessment, Fred is alert, answers questions appropriately and appears orientated. He has no gross motor or sensory deficit. Towards the back of his head you find a slowly bleeding 3cm wound. Fred is uncertain of the exact events but says he was asleep, got up to go to the toilet so stood up but can’t remember falling and the next he knew the lights were on and the nursing staff were in the room.

An important point to make is not to fixate upon the wound itself. Blood usually grabs our attention and holds it. But you don’t want to be distracted and miss the deteriorating patient. If you haven’t undertaken an Emergency Medicine placement or Surgical Speciality placement then suturing a bleeding wound may be outside your comfort zone. Apply pressure and call someone who can deal with it.

A neat technique for bandaging is the turban technique as demonstrated by St Emlyn’s:

http://stemlynsblog.org/turban-technique-scalp-bandage/

NICE Guidance

Screenshot (2)

NICE have robust and clear guidance when it comes to head injuries (1). These are designed for patients attending the Emergency Department and so do not necessarily apply to patients who fall on the ward. However, in lieu of guidance that does apply to this patient set, it is the best we have.

The important part of this guidance to consider is the criteria for undertaking a CT head:

1.4.7 For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:

  • GCS less than 13 on initial assessment in the emergency department.
  • GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
  • Suspected open or depressed skull fracture.
  • Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
  • Post-traumatic seizure.
  • Focal neurological deficit.
  • More than 1 episode of vomiting.

    A provisional written radiology report should be made available within 1 hour of the scan being performed.

1.4.8 For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury, perform a CT head scan within 8 hours of the head injury:

  • Age 65 years or older.
  • Any history of bleeding or clotting disorders.
  • Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
  • More than 30 minutes’ retrograde amnesia of events immediately before the head injury.

    A provisional written radiology report should be made available within 1 hour of the scan being performed.

The older patient is more at risk of a delayed presentation with an intracranial injury. This is in part due to the impact of brain atrophy. Over time, their skull has stayed the same size but their brain has dereased in size. The bridging veins across the meninges re more likely to rupture and the cranial vault can accommodate more blood before the effet becomes apparent.

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Signs of Skull Fractures

From practical experience, it would be unusual to find an isolated skull fracture without another sign such as vomiting or loss of consciousness. This is simply because in order to break the skull, a bone which by design should dissipate energy away from the impact site, a high amount of focussed energy is needed.

Signs and Symptoms of a Head InjuryA depressed skull fracture is often described as “boggy” when felt. A large number of head injuries may have a scalp haematoma which in itself can feel soft to the touch. The base of the haematoma should feel firm to the touch. A depressed skull fracture will feel as though there is no base or you may be able to feel a step that signifies the edges of the fracture. This will not be the case every time and the mechansim itself will heighten your suspicion if it is one of a direct blow from a small point transmitting a high force over a small cross-sectional area such as a hammer, corner of a table or stone.

A basal skull fracture may be more difficult to distinguish from other injuries. The classical signs include:

“Panda” or “Raccoon” eyes

1.4.12 For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having warfarin treatment, perform a CT head scan within 8 hours of the injury.

A provisional written radiology report should be made available within 1 hour of the scan being performed.

Neuro Observations

How long are these continued and at what frequency? Your own hospital or trust may well have a policy that guides the nursing staff but it is not an infrequent question.

Neuro obs should be continued at half-hourly intervals until the patient’s GCS is 15.

The recommended frequency once the patient is GCS 15 is (1):

  • Half-hourly for 2 hours.
  • Then 1-hourly for 4 hours.
  • Then 2-hourly thereafter

Before you leave the ward, ensure your documentation is clear in the notes. This not only includes the frequency of neuro obs but also what you want the nursing staff to call you about as well.

Such concerning features could include:

  • Agitation, confusion or abnormal behaviour.
  • A sustained (that is, for at least 30 minutes) drop of 1 point in GCS score (greater weight should be given to a drop of 1 point in the motor response score of the GCS).
  • Any drop of 3 or more points in the eye-opening or verbal response scores of the GCS, or 2 or more points in the motor response score.
  • Severe or increasing headache or persisting vomiting.
  • New or evolving neurological symptoms or signs such as pupil inequality or asymmetry of limb or facial movement.

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Medication of concern

We’ve already mentioned Warfarin through the example of the NICE guidelines and their recommendation for CT scanning within 8 hours in any patient on warfarin who has sustained a head injury (1).

The AHEAD study (2) looked to investigate the adverse outcome rate and identify risk factors for adverse outcomes in patients on Warfarin. It is important to note that this data collection was from 2011-13 and was prior to the change in NICE guidelines that recommended a more liberal CT scanning policy.

What did they do? They took 33 EDs in England and Scotland, collecting data on 3534 patients. Their main outcome was a composite one that ranged from death to re-attendance with a head injury-related complication 10 weeks after the original attendance. Their secondary objective was identifying the risk factors for adverse outcome. The fact a composite primary outcome was used is important because it increases the chance that the result may have been inflated. The rate of adverse events in the study was 5.9% (95% CI 5.2-6.7).

Over 80% of patients had a GCS score of 15 and nearly 70% of all participants had no related head injury symptoms.  Those who were GCS 15 were at the lowest risk of adverse outcome (2.7% event rate) and a GCS <15 was a strong risk factor for adverse outcome. Remember that confused patient who you thought may have been “normal for them”? They potentially fit in this category. A GCS less than 15 conveyed an adverse event rate of 20.9%.

One important finding, though a secondary outcome (which would be considered hypothesis generating rather than evidence of causality), is that the level of INR when considered alongside other risk factors had no association with adverse outcomes. What does this mean for practice? Your decision making should be based upon your assessment of the patient and not the numerical INR value.

Pragmatically, a patient with a very high INR on Warfarin would make anyone more concerned about a potentially worse outcome. INR does not need to be part of your initial assessment within the first 30 minutes but should feature in the investigations you organise if you have concerns about the patient.

The other important findings were the symptoms that may convey an increased risk of adverse outcome. These included amnesia, LOC and vomiting. Headache was included but it had the lowest relative risk and did not reach statistical significance. Headache itself presents a diagnositc challenge and some patients with severe headachemay well undergo CT scanning as a result based on clinical judgement.

As per NICE guidelines though, a patient presenting with a head injury on Warfarin requires a CT head within 8 hours of the injury.

What about DOACS?

Depending on the material you read, these may have a lower bleeding risk than Warfarin (3) but the  However, a pragmatic approach is often taken when faced with patients on medications such as apixaban, rivaroxiban or dabigatran. A way of considering it is that a patient on these could be considered as coagulopathic as a result and these patients should be managed the same as those on Warfarin and undergo a CT head.

Antiplatelet Medication

Remember Fred? He takes aspirin and clopidogrel. Both of these drugs interfere with platelt function. The first phase of a clot developing is platelet aggregation. So it makes sense that these medications could have an impact when approaching head injuries.

Emerging evidence suggests that clopidogrel is associated with an increased risk of intracranial haemorrhage (4, 5) and may impart a degree of risk similar to that of Warfarin (5, 6). I could not find any evidence for ticagrelor in this context.

With this in mind, should you come across a patient with a head injury who is on clopidogrel it is worth having a low index of suspicion for an intracranial injury. You might struggle to persuade a radiologist to authorise a CT scan on this alone but there are some places I have worked that already practice in this way.

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The Patient At Home

There is an increasing trend in the UK of older patients presenting to trauma units with what become severe head injuries rather than the trauma centres that they should be taken to. This is often due to the nature of their delayed presentation. The most common reason for presenting in an elderly patient is a simple fall (7). Indeed a national UK audit found that the majority of patients in the group of Traumatic Brain Injury presented to District General Hospitals and not the trauma centres (7). These patients may come in alert, possibly slightly confused and sit in the waiting room or a cubicle, slowly deteriorating. In these situations, patients should still have regular neuro obs in order to detect any change in condition following the head injury.

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A special mention must be made of the patient who attends the acute hospital following a fall at home who is confused and has dutifully had a urine dip performed. Be cautious ascribing the confusion to a simple “UTI” if the patient has a head injury. It could be the head injury. Be UROskeptic! And be skeptical of the patients who attend and you are told their confusion is “normal” for them. The other potential in a recurrent faller with confusion is they could have chronic sub-dural haemorrhages which are potentially reversible.

If you want some help with the patient that falls, check out our falls episode and discussion here.

Risk of Delayed Bleed

It may be suggested from time to time that patients on Warfarin may warrant a repeat CT scan to detect a delayed bleed. However, a recent meta analysis showed that there is a very low risk of this occurring (8). One thing the study does mention is special care given to those presenting whilst taking anti-platelet medication. This may be simply a prolonged period of observation but you should discuss with your local specialists regarding what they feel is appropriate. Indeed, the risk of delayed bleed may extend to 8 days following the injury and we cannot observe people for that length of time in hospital.

Those that we do admit or see on the wards require a period of, as Mike states, masterful inactivity and cat-like observation. 

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Summary

Be aware of the NICE guidelines when it comes to head injuries as these will frame a lot of your assessment and guide further investigations. Be wary of those patients on not only anticoagulation but also antiplatelet medication as they repreent a grouop of patients at higher risk of an adverse outcome. Older people present later with complications following a head injury but it is through good, structured assessments and regular neuro obs we cna detect those deteriorations.

Some of what we have discussed may represent a change in practice for you. I would encourage before introducing a change in practice, as a junior, you read the underlying evidence and speak to you seniors to ensure you are doing the right thing. Do not just take our word for it.

Speak soon,

Gareth

@garEMlyn

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References

  1. NICE Clinical Guideline [CG176], Head Injury: Assessment and Early Management. Published June 2014, updated January 2017.
  2. Mason SAHEAD Study: an observational study of the management of anticoagulated patients who suffer head injury. BMJ Open
  3. Feeney JM et al, Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma. Injury. 2017 Jan;48(1):47-50. Epub 2016 Aug 27.
  4. Levine M et al, Risk of intracranial injury after minor head trauma in patients with pre-injury use of clopidogrel. Am J Emerg Med. 2014 Jan;32(1):71-4. Epub 2013 Oct 8.
  5. Nishkima DK, Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use. Acad Emerg Med. 2013 Feb;20(2):140-5. 
  6. Risk if Intracranial Hemorrhage in Ground-Level Fall with Antipletelet or Anticoagulant Agents. Acad Emerg Med. 2017 Oct;24(10):1258-1266.

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