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Head Injury: Standard of Care

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Head Injury: Standard of Care

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You are handling a case involving a patient who had a head injury, and you wonder if the standard of care was met regarding assessment. Here is a quick overview about diagnostic testing (based on Clinical Guidelines for head injury listed in the National Guideline Clearinghouse)

Adults:
1) Skull x-rays (if a CT scan is not indicated)

2) Immediate CT (Computerized Tomography) scan should be done in an adult with any of the following:
a) Eye opening only to pain or not conversing (Glasgow Coma Score 12 out of 15 or less)
b) Confusion or drowsiness (GCS 13-14/15) followed by failure to improve within one hour of clinical observation or within two hours of injury
c) Fracture of base of skull, depressed skull fracture, and/or suspected penetrating injuries
d) A deteriorating level of consciousness or new focal neurological signs
e) Full consciousness (GCS 15/15) with no fracture, but with other symptoms (e.g. severe and persistent headache or two distinct episodes of vomiting)
f) History of coagulopathy (clotting or bleeding disorder; taking blood thinners) and loss of consciousness, amnesia, or any neurological features

3) CT scan within 8 hours in an adult who is otherwise well, but has any of the following:
a) Age > 65 (with loss of consciousness)
b) Clinical evidence of a skull fracture (e.g.: boggy scalp hematoma) but no clinical features indicative of an immediate CT scan
c) Seizure activity
d) Significant retrograde amnesia (> 30 minutes)
e) Dangerous mechanism of injury (pedestrian struck by motor vehicle. Occupant ejected from motor vehicle. Significant fall from height) or significant assault (e.g.: blunt trauma with a weapon)

4) Skull x-rays should be done only if CT scan is unavailable and the person has a mild head injury

5) In adults with a GCS < 15, who have indications for a CT scan, the cervical spine (neck) should also be scanned. This should include the cervical spine to T4 (Thoracic) images.
Children (<16 years old):

1) Immediate CT scanning for:
a) GCS <= 13 in the Emergency Department b) Witnessed loss of consciousness > 5 minutes
c) Suspicion of open or depressed skull injury or tense fontanelle (space between bones of infant’s skull)
d) Social neurological deficits

Any sign of a basal skull fracture may also warrant an immediate CT scan.

2) CT scanning within 8 hours should be considered for the following:
a) Presence of any bruise, swelling, or laceration > 5 cm on the head
b) Post-traumatic seizure, with no history of epilepsy or reflex anoxic seizure (caused by a temporary interruption in the blood supply to the brain which can be caused by sudden unexpected stimulus, such as pain or fear)
c) Amnesia lasting > 5 minutes
d) Clinical suspicion of non-accidental head injury
e) A significant fall
f) Age < 1 year: GCS < 15 in emergency department g) Three or more episodes of vomiting h) Abnormal drowsiness (slowness to respond) MRI (Magnetic Resonance Imaging) is usually only done when patients have mental status changes that are unexplained by CT scan findings. An MRI can be more sensitive than CT scans in identifying non-hemorrhagic (no bleeding) diffuse axonal lesions.

Indications for admission to the hospital

An adult should be admitted to the hospital if:
a) Level of consciousness is impaired (GCS < 15/15) b) Patient is fully conscious (GCS 15/15) but has any indication for an immediate CT scan (if the CT scan is normal and there are no other indications for admission, the person may be considered for discharge) c) Person has significant medical problems d) Person has social problems and can’t be supervised by a responsible adult
Person may require neurosurgical assessment, monitoring, or other care management if:

a) Persistent coma (GCS <= 8/15) after initial resuscitation b) Confusion persist for more than four hours c) Deterioration in the level of consciousness after admission (a sustained drop of one point on the motor or verbal GCS scales, or two points on the eye opening scale) d) Focal neurological signs e) Seizure without full recovery f) Compound depressed skull fracture g) Definite or suspected penetrating injury h) A cerebrospinal fluid (CSF) leak or other sign of a basal skull fracture Jane Heron MBA RN is employed by Med League as a legal nurse consultant.

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