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Brain Inj 1999 Mar;13(3):173-89
Department of Emergency Medicine, University of Rochester Medical Center, NY 14642, USA. jeff_bazarian@urmc.rochester.edu
[Medline record in process]
OBJECTIVE: To determine if clinical variables or neurobehavioural test (NBT) scores obtained in the ED within 24 hours of minor head injury (MHI) predict the development of postconcussive syndrome (PCS). METHODS: Prospective, observational study of 71 MHI patients and 60 orthopaedic controls. MHI defined as loss of consciousness < 10 minutes or amnesia, GCS 15, no skull fracture or new neurologic focality on PE, and no brain injury on CT (if done). All patients received a seven part NBT battery in the ED. Telephone follow-up was done at 1, 3 and 6 months to determine if patients met the DSM IV definition of PCS. ANALYSIS: Stepwise, multivariate, logistic regression. RESULTS: Predictors of PCS at 1 month were female gender (OR = 7.8; 95% CI = 41.6, 1.98), presence of both retrograde and anterograde amnesia (OR = 0.055; CI = 0.002, 0.47), Digit Span Forward Scores (OR = 0.748; CI = 0.52, 1.03) and Hopkins Verbal Learning A scores (OR = 0.786; CI = 0.65, 0.91); at 3 months, presence of both retrograde and anterograde amnesia (OR = 0.13; CI = 0.0, 0.93), Digit Span Forward Scores (OR = 0.744; CI = 0.58, 0.94). No variables fit the model at 6 months. 92% of males scoring > 25 on Hopkins Verbal Learning A did not have PCS at 1 month, and 89% of females scoring < 9 on Digit Span Forward did have PCS at 1 month. CONCLUSIONS: Gender and two NBTs can help predict PCS after MHI.
PMID: 10081599, UI: 99181440
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J Trauma 1999 Jan;46(1):122-8
Department of Trauma/EMS, Hartford Hospital, CT 06102, USA.
OBJECTIVE: To define those physiologic and clinical variables that have a positive or negative predictive value in discriminating survivors from nonsurvivors with traumatic injuries and a Trauma Score of 5 or less. METHODS: A retrospective review of 2,622 trauma patients transported by an air medical service from the scene of injury to a Level I trauma center was performed. Demographic, physiologic, and clinical variables were evaluated. RESULTS: One hundred thirty-six patients were studied; 14 patients survived trauma resuscitation. Survivors had statistically significant improvement in the Glasgow Coma Scale from the field to arrival in the emergency room. Revised Trauma Score, probability of survival, pulse, respiratory rate, cardiac rhythm, central nervous system activity, and signs of life were statistically more favorable in survivors. CONCLUSION: In patients who survived to discharge, signs of central nervous system activity in the field was a positive predictor of survival, and severe head injury served as a negative predictor of survival.
PMID: 9932694, UI: 99129474
Arch Pediatr Adolesc Med 1998 Dec;152(12):1176-80
Department of Pediatrics, University of Washington, Seattle, USA. maitken@care.ach.uams.edu
OBJECTIVE: To describe variation in the clinical management of minor head trauma in children among primary care and emergency physicians. DESIGN: A survey of pediatricians, family physicians, and emergency physicians drawn from a random sample of members of the American Academy of Pediatrics, the American Academy of Family Physicians, and the appropriate American Medical Association specialty listings, respectively. Physicians were given clinical vignettes describing children presenting with normal physical examination results after minor head trauma. Different clinical scenarios (brief loss of consciousness or seizures) were also presented. Information was gathered on initial and subsequent management steps most commonly used by the physician. RESULTS: Surveys were returned by 765 (51%) of 1500 physicians. Of these, 303 (40%) were pediatricians, 269 (35%) family practitioners, and 193 (25%) emergency physicians. For minor head trauma without complications, observation at home was the most common initial physician management choice (n = 547, 72%). Observation in office or hospital was chosen by 81 physicians (11%). Head computed tomographic (CT) scan was chosen by 7 physicians (1%) and skull x-ray by 24 physicians (3%) as the first management option. Most physicians (n = 445, 80%) who initially chose observation at home would obtain a CT scan if the patient showed clinical deterioration. In the original scenario, if the patient had also sustained a loss of consciousness, 383 physicians (58%) altered management. Of these, 120 (18%) chose CT, 13 (2%) chose skull x-ray, 1 (1%) chose magnetic resonance imaging, 141 (21%) chose inpatient observation, and 125 (19%) chose a combination of CT scanning and observation. With seizures, 595 (90%) altered management, with 176 physicians (27%) choosing CT scan, 5 (1%) skull x-ray, 60 (9%) inpatient observation, and 299 (45%) a combination of radiological evaluation and observation. CONCLUSIONS: Most physicians surveyed chose clinic or home observation for initial management of minor pediatric head trauma. Clinical management was more varied when patients had sustained either loss of consciousness or seizures. Further study of the appropriate management of minor head trauma in children is needed to guide physicians in their care.
PMID: 9856425, UI: 99072245
Pediatr Neurosurg 1998 Aug;29(2):96-101
Department of Neurological Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, MO, USA.
OBJECTIVE: This study was undertaken to determine the necessity for routine hospital admission of children with skull fractures, a normal neurological exam, a normal head CT, and no other injuries ('uncomplicated skull fracture'). METHODS: A prospective study of closed-head injuries in children was done over a 2-year period at St. Louis Children's Hospital. All patients with closed head injuries underwent skull radiographs and a head CT scan. From this cohort, children with uncomplicated skull fractures were identified and studied. For comparison, a retrospective analysis was also performed of the hospital admission records of children admitted over a 5-year period (1990-1994) with the diagnosis of epidural hematoma (EDH) to identify the typical time intervals between injury and documentation of the lesion in these cases. RESULTS: Forty-four patients with uncomplicated skull fractures were identified; all had been admitted for observation. Mean age was 1.8 years. Average time between injury and hospital admission was 6.35 h with half of this time being spent in the emergency room. Average LOS was 35 h, but 50% of patients were hospitalized less than 24 h. No patient in this study group suffered a complication related to their inury. Twenty-three patients with EDH had been admitted during the 5-year review period. Slightly more than one-half of patients had their EDH detected within 6 h of injury. The others were diagnosed more than 6 h after injury due to a delay in medical evaluation or a delay in obtaining a computed tomographic (CT) scan after an initial medical evaluation. CONCLUSIONS: Patients with uncomplicated skull fractures, in the absence of recurrent emesis and/or evidence of child abuse, can be considered for discharge home. The definition of an uncomplicated skull fracture requires that a head CT be performed on these patients.
PMID: 9792964, UI: 99011302
J Neurosurg 1998 Oct;89(4):526-32
Department of Neurosurgery, Royal London Hospital, United Kingdom.
OBJECT: This study was designed to investigate the incidence of early abnormalities in the cerebral circulation after head injury by relating the results of the initial computerized tomography (CT) scan with transcranial Doppler (TCD) ultrasound readings to see if the side of injury and the outcome can be predicted by using these modalities. METHODS: Transcranial Doppler ultrasound measurements were obtained in the emergency room in 22 head-injured patients less than 3 hours after injury. The middle cerebral artery (MCA) was insonated using a standard technique. The TCD measurements in each MCA were examined individually; of 39 measurements, 22 (56%) showed a low mean blood flow velocity, 27 (69%) demonstrated a high pulsatility index (PI), and 18 (46%) showed both abnormalities. The side of the cerebrovascular abnormality measured by TCD ultrasound did not appear to be an accurate predictor of the side of the injury as determined on the initial CT scan. Of 13 patients in whom either a space-occupying hematoma or signs of swelling were shown on the initial CT scan, 10 (77%) had an increased PI in one or both MCAs, which is an indication of high flow resistance. CONCLUSIONS: Transcranial Doppler ultrasound examinations performed while patients are in the emergency room may have a role in determining treatment priorities, especially in those with multiple injuries.
PMID: 9761044, UI: 98432188
J Emerg Med 1998 Sep-Oct;16(5):709-13
Department of Emergency Medicine, Massachusetts General Hospital, and the Harvard Medical School, Boston 02114, USA.
Falls in the elderly leading to closed head trauma represent a significant cause of morbidity and mortality in that population, but are not well-characterized. The purpose of this study was to determine the mechanism of fall, outcome, and additional risk factors in elderly patients who require cranial computed tomography (CT) scan after a fall. We conducted a retrospective case series of patients age 60 years and older with closed head trauma secondary to falling who underwent CT scan in the emergency department (ED). Data were gathered from ED and hospital records. The setting was an urban Level I trauma center. Our series consisted of 189 patients, of whom 31 (16%) had an abnormal head CT scan and four (2%) required neurosurgery. Cerebral contusions (38%) and subdural hematomas (33%) were the most common lesions seen on CT scan. Falls from standing (76%) were more common than falls on stairs (19%) or from height (5%), but the latter two were more likely to result in an abnormal CT scan (stairs 42%, height 40%). An abnormal neurologic examination was associated with a higher risk of the need for neurosurgery (risk ratio 11.5). We conclude that among elderly patients who fall and present to an ED with evidence of closed head trauma, a significant percentage will have abnormal CT scans but only a small minority will require neurosurgery. While falls from standing are more common, falls on stairs or from height are associated with a higher risk of having an abnormal CT scan. A focal neurologic examination is a strong predictor of the need for neurosurgical intervention.
PMID: 9752942, UI: 98423864
J Digit Imaging 1998 Aug;11(3 Suppl 1):131-3
University of Alabama Hospitals, Birmingham, USA.
This paper details our experience in developing and implementing an automated DICOM Image Router. This workstation serves as a gateway between image acquisition devices and image display and storage devices. Images are checked for demographic input errors and data format inconsistencies between the source and destination devices. Based on the configured rules, and image may be held for manual correction and/or distributed to multiple locations. Distribution is based on easily configured environmental variables and rules files which may be changed as needed. For example, CT images are typically sent to the archive and to a radiologist's display workstation. If the patient came from the Emergency Department, a copy of the images are sent to a clinician display workstation located in the Emergency Department. If the patient has suffered trauma to the head, a copy of the images are sent to a display workstation in the Neurosurgery Department for possible consultation. The software was developed on a UNIX-based platform and utilizes a Fast Ethernet network. To date, images from a variety of devices have been acquired: General Electric HiSpeed CT/I scanner, General Electric Signa MRI scanner, Philips Thoravision Digital Chest unit, and Fuji AC-3CS Computed Radiography (CR) unit. Each device has presented new challenges in providing a uniform look to patient demographics in the PACS archive. The workstation also provides a buffer in the event of network outages, storing images for later transmission when the network and/or a workstation recover.
PMID: 9735450, UI: 98406411
Acad Emerg Med 1998 Jul;5(7):678-84
Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston 02114, USA. nagurney.john@mgh.harvard.edu
OBJECTIVE: Little is known about the circumstances surrounding closed head trauma (CHT) in elders, and how they differ from nonelders. The study objective was to compare the 2 populations for outcome (positive cranial CT scan depicting traumatic injury, or the need for neurosurgery), mechanism of injury, and the value of the neurologic examination to predict a CT scan positive for traumatic injury or the need for neurosurgical intervention. METHODS: A retrospective study was conducted by collecting a case series of patients with blunt head trauma who underwent CT scanning, and comparing elder (aged > or =60 years) with nonelder patients. The setting was the ED of a university-affiliated Level-1 trauma center. RESULTS: Twenty percent of the elders and 13% of the nonelders had CT scans positive for traumatic injury, which conferred a risk ratio of 1.58 (95% CI 1.21-2.05). Older women were more at risk for the need for neurosurgery than were younger ones (3.1 vs 0.3%, RR 10.66, 95% CI 1.26-90.46). Among the elders, falls were the dominant mechanism of closed head trauma, followed by motor vehicle collisions (MVCs), then being struck as a pedestrian. In the nonelders, MVCs, falls, and assaults were the most important mechanisms of injury. A focally abnormal neurologic examination imparted an increased risk for both a CT scan positive for traumatic injury (elder 4.39, 95% CI 2.91-6.62; nonelder 7.75, 95% CI 5.53-10.72) and the need for neurosurgery (elder 35.68, 95% CI 4.58-275.89; nonelder 142.58, 95% CI 19.11-1064.22) in both age groups. CONCLUSIONS: Significant differences exist between elder and nonelder victims of CHT with respect to mechanisms of trauma and outcomes (CT scan positive for traumatic injury, or the need for neurosurgery).
PMID: 9678391, UI: 98341531
Radiology 1998 Jul;208(1):125-8
Department of Radiology, Allegheny University Hospital, Philadelphia, PA 19129, USA.
PURPOSE: To determine the rate and clinical outcome of discrepancies in interpretation by radiology residents and staff neuroradiologists of posttraumatic cranial computed tomographic (CT) scans. MATERIALS AND METHODS: Prospective evaluation was performed for 419 consecutive emergency posttraumatic cranial CT studies that had been interpreted by radiology residents on call over a 16-month period. Discrepancies between the interpretations made by residents and those made by staff radiologists were divided into two groups: failure to recognize an abnormality (false-negative finding) and interpretation of normal as abnormal (false-positive finding). Discrepancies were considered major if they could affect patient care in the emergency setting and minor if they could not. RESULTS: Major and minor discrepancies were 1.7% and 2.6%, respectively, among interpretations made by residents and those by staff radiologists. Major discrepancies were four subdural hematomas, one pneumocephalus, one hemorrhagic contusion, and one subarachnoid hemorrhage. Minor discrepancies included six skull and five facial fractures. The discrepancy rate was statistically significantly higher (12.2%) when CT findings were abnormal than when they were normal (1.5%). No change in treatment was attributed to the delay in diagnosis. CONCLUSION: A low discrepancy rate was found between interpretations made by radiology residents and those made by staff neuroradiologists of posttraumatic cranial CT scans. There were no adverse clinical outcomes.
PMID: 9646802, UI: 98310770
Neurophysiol Clin 1998 May;28(2):121-33
Service d'explorations fonctionnelles du systeme nerveux, CHRU, hopital Nord, Marseille, France.
After initial loss of consciousness following brain injury, background EEG may show slowing and posterior slow waves are observed, consistent with the existence of commotio cerebri, particularly in children. However, discrepancies between cerebral electrogenesis and the clinical condition may also persist for several weeks. As EEG is correlated with the stage of posttraumatic coma, its reactivity to stimuli is of value. While important EEG impairment with paroxysmal abnormalities is frequent in children, the patients' outcome is poorly correlated with initial EEG record. In intensive care units, the use of continuous digitized EEG techniques has opened new avenues. Though in case of mild risks, EEG and clinical follow-up may be sufficient after brain injury, EEG recording is recommended when computerized tomography (CT-scan) is normal in case of severe risks. When consciousness impairment is unexplained by the importance of the brain injury, emergency CT-scan is recommended, searching for intracranial hematoma. If CT-scan proves to be normal EEG should then be recorded, searching for local injury. EEG may uncover non-convulsive status epilepticus, mainly in elderly patients. In case of early seizures, EEG recording should be done within the first 24 hours following brain injury. In the post-ictal period, EEG should be recorded in emergency in case of confusional state lasting more than 30 minutes, as potential non-convulsive status epilepticus should not be underestimated. EEG is not of good predictive value for posttraumatic epilepsy; however, the existence of paroxysmal, local abnormalities is a risk factor. Recording of abnormalities may be useful for the medico-legal expert.
Publication Types:
PMID: 9622805, UI: 98286008
Can J Neurol Sci 1998 May;25(2):154-8
Department of Neurology, Washington Hospital Center, Washington, DC 20010, USA.
OBJECTIVE: We reported a possible risk factor which could identify patients with chronic hydrocephalus who are risk for sudden death. METHODS: A retrospective review of medical records and computed tomographic (CT) scans was conducted on three patients with chronic hydrocephalus who suffered acute cardiorespiratory arrest without those signs which are normally associated with a progressive worsening of hydrocephalus. RESULTS: All three of these patients were awake and communicative shortly before the life threatening or terminal event. All had experienced some recent worsening of neurologic signs or symptoms, but none had shown a progressive impairment of consciousness or major neurologic decline ordinarily associated with life threatening elevation of intracranial pressure. Absence of the perimesencephalic cisterns on head CT scans done prior to or just after the life threatening event was the only new radiologic finding common to all these patients. CONCLUSIONS: The absence of the perimesencephalic cisterns in an awake and alert patient with severe hydrocephalus indicates that the patient may be at risk for neurogenic cardiorespiratory failure. In such cases, (especially when there has been a recent, albeit mild, change in neurologic signs or symptoms), the neurologist should urge emergency ventriculostomy or shunting for the hydrocephalus.
PMID: 9604139, UI: 98267498
J Trauma 1998 May;44(5):868-73
Division of Neurosurgery, Ospedale Maurizio Bufalini, Cesena, Italy. servadei@mbox.queen.it
BACKGROUND: Patients who have an acute subdural hematoma with a thickness of 10 mm or less and with a shift of the midline structures of 5 mm or less often can be treated nonoperatively. We wonder whether the knowledge of the clinical status both in the prehospital determination and on admission to the neurosurgical center can predict the need for evacuation of subdural hematomas as well as the computed tomographic (CT) parameters. METHODS: From January 1, 1994, to May 31, 1996, 65 comatose patients harboring an acute subdural hematoma of 5 mm or more and not brain dead were admitted to our intensive care unit. Of the 65 patients, 15 patients were initially managed conservatively according to a protocol based on clinical, CT, and intracranial pressure parameters. During the study period, the use of long-lasting paralytic agents has been eliminated to allow detection of clinical deterioration in the Glasgow Coma Scale (GCS) score from the prehospital determination to the hospital admission assessment. RESULTS: Of the 15 patients initially managed conservatively, two were subsequently operated on because of evolving parenchymal hematomas. When comparing demographic, clinical, and CT parameters between the surgical group of patients and the patients initially conservatively treated, hematoma thickness (mean, 17.1 mm vs. 7.5 mm, p < 0.0001) and shift of the midline structures (mean, 12.8 mm vs. 4.7 mm, p < 0.008) were predictive of the need for surgery. A statistically significant change in the GCS score between prehospital determination and admission assessment was shown in the surgical group of patients (mean GCS score, 8.4 vs. 6.7, p < 0.01), and it was not present (mean GCS score, 7.3 vs. 7.2) in the patients initially conservatively treated. Functional outcomes were present in 23 cases (35.4%); functional outcomes in the initially conservatively treated patients were reached by 10 patients (66.7%). CONCLUSIONS: Nonoperative management for selected cases of acute subdural hematomas is at least as safe as surgical management. GCS scoring at the scene and in the emergency room combined with early and subsequent CT scanning is crucial when making the decision for nonoperative management. This strategy requires that administration of long-lasting sedatives and paralytic medications be avoided before the patient arrives at the neurosurgical center.
PMID: 9603091, UI: 98264230
Pediatr Emerg Care 1998 Apr;14(2):89-94
Department of Pediatrics, University of Washington, Tacoma, WA, USA.
OBJECTIVE: To determine whether differences exist between general emergency physicians (GEMs) and pediatric emergency physicians (PEMs) in the emergency care of children with common pediatric emergencies. METHODS: We carried out a survey study of all members of the American Academy of Pediatrics Section of Emergency Medicine and the Washington State American College of Emergency Physicians. We identified current therapeutic interventions for croup, asthma, bronchiolitis, seizures, febrile infant, conscious sedation, head trauma, and coin ingestion, and compared the practice patterns of GEMs and PEMs. RESULTS: A total of 66% of the surveys were returned, including 211 GEMs and 329 PEMs. The majority of PEMs practice in children's hospitals, whereas most GEMs practice in general community hospitals. Slightly over half (51%) of PEMs are PEM fellowship-trained versus 1% of GEMs. CROUP: The majority of GEMs and PEMs use racemic epinephrine (RE) in the treatment of a child with stridor at rest; approximately one-third admit to the hospital after RE (39 vs 30%, NS). PEMs are more likely to observe the child for >2 hours after RE (94% vs 79%, P < 0.01). The majority of PEMs and GEMs use steroids in these patients (94 vs 88%, NS). ASTHMA: There is no significant difference in the use of albuterol, aminophylline, or steroids. Steroids are more likely to be given orally by PEMs than GEMs (74 vs 50%, P < 0.01). BRONCHIOLITIS: The majority of both groups of physicians routinely use nebulized beta-agonists; however, significantly more GEMs than PEMs use steroids (68 vs 45 %, P < 0.01). SEIZURES: Half of GEMs vs 78% of PEMs use lorazepam as a first line drug in the treatment of seizures (P < 0.01). There is no significant difference with respect to the use of rectal diazepam in the pre-hospital setting. FEBRILE INFANT: GEMs are less likely than PEMs to admit the febrile infant <4 weeks of age (68 vs 87%; P < 0.01). Admission of older febrile infants (four to six weeks and eight weeks of age) is not significantly different between PEMs and GEMs. CONSCIOUS SEDATION: Both groups use a wide array of drugs alone or in combination to sedate children for complex facial laceration repair, closed fracture reduction, and cranial computed tomography (CT). GEMs are more likely to use ketamine for laceration repair (28 vs 16%, P < 0.01). Both GEMs and PEMs use midazolam plus a narcotic for fracture reduction. For further sedation for cranial CT, after an initial dose of midazolam, GEMs are more likely to use additional midazolam (64 vs 47%, P < 0.01), and PEMs are more likely to add pentobarbital (15 vs 4%, P < 0.01). HEAD TRAUMA: Most GEMs (87%) and PEMs (81%) would obtain a cranial CT on a neurologically normal two year old who had fallen down the stairs with a six-minute loss of consciousness. COIN INGESTION: Most GEMs and PEMs would obtain radiographs on an asymptomatic two year old with a recent coin ingestion. CONCLUSION: With some notable exceptions, GEMs and PEMs have similar pediatric practice patterns despite differences in training and practice environments.
Comments:
PMID: 9583386, UI: 98242688
An Esp Pediatr 1998 Feb;48(2):122-6
Departamento de Pediatria, Hospital de Cruces, Baracaldo, Vizcaya.
OBJECTIVE: The objective of this study was to assess the clinical features that might reliably identify the presence of an intracranial injury. PATIENTS AND METHODS: A prospective study of 1,128 children with head injury over a one year period was carried out. Information regarding each patient was documented, including demographic data, physical examination findings, neurologic status, diagnostic studies and the patient's outcome. RESULTS: Of the 1.128 patients, traumatic intracranial abnormalities identified on CT of the head was found in 11 (1%). Four patients of this group (36%) required surgery. Two children subsequently died. Loss of consciousness, amnesia. Glasgow Coma Scale less than 15 and focal neurological deficits were significantly more common in the group with intacranial injury. The negative predictive values were high for all features. CONCLUSIONS: Patients with symptoms of head injury should undergo head CT because a small number will require surgery. After a minor head trauma, children who are neurologically normal and without symptoms may be discharged from the emergency department and sent home after careful physical examination alone.
PMID: 9577018, UI: 98237868
Pediatrics 1998 Apr;101(4 Pt 1):575-7
Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.
OBJECTIVE: Children with a question of occult head injury are routinely hospitalized despite having both normal central nervous system (CNS) and computed tomographic (CT) scan examinations. We determined the incidence of significant CNS morbidity after occult head injury to determine whether or not hospital admission was necessary in children after minimal head trauma. METHODS: We reviewed the records of children admitted to a level I trauma center with a question of closed head injury, an initial Glasgow Coma Scale equal to 15, a normal neurologic exam, and a normal head CT scan. Children with associated injuries requiring admission were excluded. The endpoints were deterioration in CNS exam, new CT findings, and the need for a prolonged hospital stay. RESULTS: Sixty-two patients were studied with a mean age of 7 years (range, 1 month to 15 years), and 65% were male. The primary mechanisms of injury were fall (45%) and vehicular crash (23%). The mean injury severity score was 4 +/- 2. The mean length of stay was 1.2 days (range, 1 to 3 days). Prolonged hospitalization occurred in 9 patients (15%). No child developed significant CNS sequelae warranting hospital admission. Total charges for these hospitalizations were $177 874. CONCLUSIONS: Children undergoing emergency department work-up of occult head injury, who have a normal CNS exam and a normal head CT scan, do not seem to be at risk for significant CNS sequelae. These patients can be discharged home with parental supervision and avoid unnecessary and costly hospitalization.
PMID: 9521936, UI: 98190110
Acad Emerg Med 1998 Feb;5(2):134-40
Ottawa Civic Hospital, Ontario, Canada. igraham@civich.ottawa.on.ca
OBJECTIVES: 1) To assess Canadian emergency physicians' (EPs') use of and attitudes toward 2 radiographic clinical decision rules that have recently been developed and to identify physician characteristics associated with decision rule use; 2) to determine the use of CT head and cervical spine radiography by EPs and their beliefs about the appropriateness of expert recommendations supporting the routine use of these radiographic procedures; and 3) to determine the potential acceptance of clinical decision rules for CT scan in patients with minor head injury and cervical spine radiography in trauma patients. METHODS: A cross-sectional anonymous mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians using Dillman's Total Design Method for mail surveys. RESULTS: Of 288 eligible physicians, 232 (81%) responded. More than 95% of the respondents stated they currently used the Ottawa Ankle Rules and were willing to consider using the newly developed Ottawa Knee Rule. Physician characteristics related to frequent use of the Ottawa Ankle Rules were younger age, fewer years since graduating from medical school, part time or resident employment status, working in a hospital without a CT scanner, and believing that decision rules are not oversimplified cookbook medicine or too rigid to apply. Eighty-five percent did not agree that all patients with minor head injuries should receive a CT head scan and only 3.5% stated they always refer such patients for CT scan. Similarly, 78.5% of the respondents did not agree that all trauma patients should receive cervical spine radiography and only 13.2% said they always refer such patients for cervical spine radiography. Ninety-seven and 98% stated they would be willing to consider using well-validated decision rules for CT scan of the head and cervical spine radiography, respectively. Fifty-two percent and 67% of the respondents required the proposed CT and C-spine to be 100% sensitive for identifying serious injuries, respectively. CONCLUSIONS: Canadian EPs are generally supportive of clinical decision rules and, in particular, have very positive attitudes toward the Ottawa Ankle and Knee Rules. Furthermore, EPs disagree with recommendations for routine use of CT head and cervical spine radiography and strongly support the development of well-validated decision rules for the use of CT head and cervical spine radiography. Most EPs expected the latter rules to be 100% sensitive for acute clinically significant lesions.
PMID: 9492134, UI: 98151098
Acta Neurochir (Wien) 1997;139(12):1143-51
Department of Neurology, Massachusetts General Hospital, Boston, USA.
We report management and outcome data on 118 patients that presented to our emergency room over a 4 year interval (1990-1994) in poor neurological condition after subarachnoid hemorrhage. All patients were treated following a strict protocol. After initial evaluation, patients underwent a head computerized tomography (CT) scan to try to understand the mechanism of coma. If CT did not show destruction of vital brain areas, a ventriculostomy was inserted and ICP measured. If ICP was less than 20 mm Hg, or if standard treatment of increased ICP was able to lower the ICP to a value less than 20 mmHg, patients were evaluated with cerebral angiogram to determine the location of the ruptured aneurysm. The lesion was then treated by craniotomy for aneurysm clipping or endovascular obliteration. Postoperative monitoring for vasospasm with clinical exam and transcranial doppler studies was performed routinely. If vasospasm developed, this was managed aggressively with hypertensive, hypervolemic and hemodilutional therapy and, at times, endovascular treatment with angioplasty or papaverine. Outcome was measured at 1 year or more after treatment. Among patients who met criteria for aneurysm treatment, 47% had excellent or good neurologic outcome. There was a 30% mortality rate in these patients. In patients with high ICP, poor brainstem function or destruction of vital brain areas on CT, comfort measures only were offered and almost all died. It is concluded that an approach of early aneurysm obliteration and aggressive medical and endovascular management of vasospasm is warranted in patients in poor neurological conditions after subarachnoid hemorrhage.
PMID: 9479420, UI: 98140033
J Neurosurg Sci 1997 Jun;41(2):215-7
Neurological and Neurosurgical Sciences Institute, University of Messina, Italy.
A case of large fronto-temporo-parietal epidural hematoma associated with ipsilateral retrobulbar hematoma is reported. A 24-year-old man soon after a head injury due to a traffic accident became comatose with anisocoria and hemiplegia and developed exophthalmos, conjuctival chemosis, downward and lateral displacement of the eyeball. CT scan of the brain and the orbit showed the large epidural clot communicating with an ipsilateral retrobulbar hematoma through a sphenoid bone fracture. The patient underwent emergency surgery. Postoperatively, he improved and was discharged in good conditions. On follow-up one month later he was symptoms free. The available literature is reviewed: our case seems to be the fifth reported.
PMID: 9385574, UI: 98046684
Acad Emerg Med 1997 Dec;4(12):1107-10
Department of Medicine, University at Buffalo, NY, USA. dr2277@po2.bgh.edu
OBJECTIVE: 1) To examine the ordering of head CT scans in elder patients with delirium and cognitive impairment; and 2) to report CT scan findings associated with these conditions. METHODS: This was a 2-part study. Part 1 was a prospective, observational study of 560 adults > 70 years of age evaluated at 3 separate EDs using a 200-hour stratified sampling process at each ED. During Part 1, the frequencies of specific findings (i.e., delirium, impaired consciousness, and impaired cognition) and CT scan rates for these groups were determined. Part 2 was a retrospective analysis of CT scan reports and medical records (n = 279) for patients > 70 years of age in the prospective sample (n = 79) and from a sample (n = 200) of CT scans obtained at a fourth ED. Part 2 examined clinical findings detected in the ED to determine those factors that were associated with acute findings on CT scan. RESULTS: Part 1: There were 333 (59.4%) patients prospectively classified as having impaired cognition, impaired consciousness, or delirium; 79 (23.7%) of these patients had a head CT scan. Of these 3 groups, delirious patients were more frequently scanned (p < 0.001). Part 2: Of 279 CT scans, 42 (15.0%) were positive for an acute condition (hemorrhage, hematoma, space-occupying lesion, infarct). Of 42 positive scans, 40 (95.1%) were found in the 102 (36.6%) patients with either impaired consciousness or a new focal neurologic finding detected in the ED. CONCLUSIONS: Considerable variability in ED CT scan ordering exists for elder patients with neurologic findings. Impaired consciousness and/or new focal neurologic signs are associated with acute findings on CT scan in elder patients. Acute CT abnormalities are uncommon in elder ED patients with other neurologic findings. Additional prospective evaluation is warranted prior to guideline development for CT scans in this patient population.
PMID: 9408423, UI: 98072703
J Emerg Med 1997 Nov-Dec;15(6):793-810
University of California, San Diego Medical Center, USA.
The purpose of this article is to provide a guide to assist the Emergency Physician in examining the eye. The evaluation of a patient with eye problems consists of a history, visual acuity, pupil examination, external examination, extra ocular movements, visual fields, and color vision. The patient is then examined at the slit lamp. After the slit lamp examination, the fundus and optic nerve is examined with a direct ophthalmoscope and intraocular pressure is measured. Special tests such as a plain film study and computed tomography (CT) scan may be obtained when indicated and, finally, referral to an ophthalmologist can be made for a dilated fundus examination, ultrasound studies of the eye and orbit, and surgical treatment.
PMID: 9404796, UI: 98067300
Surg Neurol 1997 Sep;48(3):213-9
Institute of Neurosurgery, University of Milan, Maggiore Hospital, Italy.
BACKGROUND: The management of head-injured patients admitted to emergency departments is not standardized. METHODS: The authors performed a retrospective analysis of 10,000 head-injured patients admitted to the Emergency Department of our hospital in a 21-month period and, on the basis of a statistical correlation between each clinical parameter (symptoms and signs upon arrival at the hospital or risk factors) and the presence of intracranial lesions, they propose a practical protocol in an attempt to avoid the overuse or radiologic examinations and yet identify patients with possible life-threatening complications. RESULTS: On the basis of this correlation the patients have been divided into four groups. In the first group (called group alpha) are patients with: no history of loss of consciousness, no vomiting or amnesia, a normal neurologic examination, and minimal if any subgaleal swelling. They can be released into the care of relatives who are given a special instruction sheet (X rays unnecessary). No patient in group alpha had complications of any kind. The second group (group beta) is made up of patients with at least one of the following features: transient loss of consciousness, post-traumatic amnesia, a single episode of vomiting or significant subgaleal swelling. They undergo a computed tomography (CT) scan and if this is normal, only a short period of observation is needed. If CT scan is not available, the skull is X rayed and, if this X ray is negative, the patient is sent home with the warning sheet after an observation period. If a fracture is found, CT scan should be performed promptly. No patient in group beta with normal skull X rays developed intracranial lesions. The third group (group gamma) contains patients with at least one of the following symptoms: impaired consciousness, repeated episodes of vomiting, neurologic deficits, otorrhagia, otorrhea, rhinorrea, signs of basal skull fracture, seizures, penetrating or perforating wounds, lack of cooperation for varying reasons, patients who have undergone previous intracranial operations or been affected by coagulopathy or submitted to anticoagulant therapy, and finally, epileptic or alcoholic patients. They receive a CT scan immediately and, if necessary, again prior to discharge. Six patients in group gamma with GCS = 15 upon admission were operated on for intracranial hematoma. The fourth group (group delta) is composed of comatose patients. Immediately following resuscitation maneuvers and prior to any surgical intervention, they undergo a CT scan. A linear association between the severity groups and the presence of intracranial lesions has been demonstrated. CONCLUSIONS: The present protocol stresses the importance of the patient's clinical and anamnestic evaluation upon arrival in the Emergency Department, especially in minor head injuries.
PMID: 9290706, UI: 97436039
Clin Pediatr (Phila) 1997 Aug;36(8):461-5
Pediatric Emergency Services, University Medical Center of Southern Nevada, University of Nevada School of Medicine, Las Vegas, USA.
The goal of this study was to describe a single emergency physician's experience with symptomatic blunt head injury in children and prospectively assess the sensitivity and predictive value of the neurologic examination. The author utilized a prospective patient series comparing neurologic examination with computed tomography (CT) of the head. Nine of 42 patients had intracranial injury for a prevalence of 21%; two patients (5%) had intracranial injury with only subtle neurologic examination findings. Twenty-six patients had a negative neurologic examination, and all had normal-appearing CT scans. Sixteen patients had a positive neurologic examination, of whom nine had a positive CT scan. The properties of the neurologic examination as a diagnostic test, with CT as the gold standard, were as follows: sensitivity = 100%, specificity = 78%, positive predictive value = 56%, negative predictive value = 100%. Normal findings from neurologic examination can be used in some children with symptomatic blunt head injury to delay or eliminate the need for CT of the head.
PMID: 9272320, UI: 97418315
Stroke 1997 Aug;28(8):1530-40
BACKGROUND AND PURPOSE: With the approval by the Food and Drug Administration of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke within 180 minutes of symptom onset, patients and prehospital and hospital systems will now have to treat stroke as a medical emergency. It is thus critical to develop efficient hospital-based methods for hyperacute stroke patient evaluation and intervention at both community-based and tertiary care academic centers. METHODS: We describe how the eight centers in the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial developed systems for enrolling patients within 3 hours of symptom onset. The actual methodology and practical sequence of events are detailed. Deming principles of system organization were applied, and each center developed a flowchart of acute stroke patient screening, assessment, and treatment. We divided the process into the following: clinical center background and preparation, screening, stroke team response, data needed before treatment, CT of the head, pharmacy, patient treatment, and monitored care. Critical features, both unique to a given center and shared by several centers (common at four or more centers), were summarized. RESULTS: Phase I of the trial included several months of preparation with review of every detail involved in the process of acute stroke care at each site. All centers worked closely with emergency medical services. Community stroke awareness and education programs were developed. A stroke team was initiated and worked closely with the emergency department physicians and nurses. Rapid and efficient communication systems and protocols were established to reduce time to complete each task. Standardized stroke examinations and protocols for blood pressure management and intracranial hemorrhage detection as well as nursing flowcharts were used. CONCLUSIONS: Hyperacute stroke treatment can be initiated, often within 55 minutes of patient arrival at the hospital, in both community and academic settings when all aspects of stroke care processes are identified, streamlined, and built into the day-to-day operations of the prehospital and hospital healthcare delivery system.
PMID: 9259745, UI: 97406284
Emerg Med Clin North Am 1997 Aug;15(3):563-79
Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA.
Patients with mild traumatic brain injury constitute the overwhelming majority of head-injured patients seen in the emergency department. The indications for radiologic imaging in these patients are still undergoing study and revision. The Glasgow Coma Scale is a widely used triage score for head injury, but is less useful at identifying which patients with mild head injuries have intracranial pathology. There have been several retrospective studies and a few prospective studies examining the indications for imaging in mild to moderate head trauma. They all show that it is not easy to predict which patients will have CT abnormalities, and that some of these patients do go on to require neurosurgery. No set of clinical predictors have yet been put together that is capable of identifying all patients who are safe to be discharged without a CT scan. Pharmacologic therapy to help reduce axonal damage after head trauma and thus minimize the postconcussive sequelae of mild traumatic brain injury remains a challenge for physicians and neurobiologists into the next century.
PMID: 9255133, UI: 97399004
J Emerg Med 1997 Jul-Aug;15(4):453-7
Division of Emergency Medicine, University of California Davis Medical Center, USA.
Our study objective was to determine whether simple clinical criteria can be used to safely reduce the number of patients who require cranial computed tomography (CT) scan after sustaining minor head trauma. Awake patients (Glascow Coma Scale = 15) who presented to the emergency department with acute head injury associated with a loss of consciousness were evaluated for clinical predictors of head injury prior to CT scan. The studied risk factors included severe headache, nausea, vomiting, and depressed skull fracture on physical examination. Patients with no risk factors present were compared with patients with one or more risk factors with respect to abnormal CT rate and rate of operative intervention for head injury. Of the 2143 patients entered into the study, 1302 (61%) had no risk factor for head injury, whereas 841 (39%) had one or more risk factors present. A total of 138 (6.4%) of those studied had an abnormal CT scan. This number included 3.7% of those patients with no risk factors vs. 11% in patients with one or more risk factors. The CT scan abnormalities in the no-risk-factor group were not clinically significant. All 5 patients who required operative intervention had at least one of the risk factors present. The use of four simple clinical criteria in minor head trauma patients would allow a 61% reduction in the number of head CT scans performed and still identify all patients who require neurosurgical intervention and the majority of patients with an abnormal CT scan. This method could lead to a large savings in patient charges nationwide. Further studies may be helpful in confirming these findings.
PMID: 9279694, UI: 97425644
Acad Emerg Med 1997 Jul;4(7):654-61
Department of Emergency Medicine, Orlando Regional Medical Center, FL 32806, USA.
OBJECTIVES: To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. METHODS: A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection. X2 recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. RESULTS: Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age > or = 60 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94-100%) and 31% specific (95% CI: 28-33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8-13%) and 100% (95% CI: 98-100%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed. CONCLUSION: Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high- and low-risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.
PMID: 9223687, UI: 97366874
Ann Emerg Med 1997 Jul;30(1):14-22
Department of Medicine, Ottawa Civic Hospital, Loeb Medical Research Institute, Canada.
STUDY OBJECTIVE: To determine the frequency of utilization, yield for brain injury, incidence of missed injury, and variation in the use of computed tomography (CT) for ED patients with minor head injury. METHODS: This retrospective health records survey was conducted over a 12-month period in the EDs at seven Canadian teaching institutions. Included in this review were adult patients who sustained acute minor head injury, defined as witnessed loss of consciousness or amnesia and a Glasgow Coma Scale score of 13 or greater. Data were collected by research assistants who were trained to select cases and abstract data in a standardized fashion according to a resource manual. Subsequently, patient eligibility was reviewed by the study coordinator and principal investigator. RESULTS: Of the 1,699 patients seen, 521 (30.7%) were referred for CT, and 418 (79.8%) of these scans were negative for any type of brain injury. Overall, 105 (6.2%) of these patients sustained acute brain injury, including 9 (.5%) with an epidural hematoma Cochran's Q test for homogeneity demonstrated significant variation between the seven centers for rate of ordering CT (P < .0001), from a low of 15.9% to a high of 70.4%. All five cases of "missed" hematoma occurred at the institutions with the highest and third highest rates of CT use. After controlling for possible differences in case severity and patient characteristics at each hospital, logistic regression analysis revealed that five of seven hospitals were significantly associated with the use of CT (respected odds ratios [OR], .4, .5, .5, 3.2, and 4.7). Three of the centers (two with the highest ordering rates) showed significant heterogeneity in the ordering of CT among their attending staff physicians, from a low of 6.5% to a high of 80.0%. CONCLUSION: There was considerable variation among institutions and individual physicians in the ordering of CT for patients with minor head injury. Although emergency physicians were selective when ordering CT, the yield of radiography was very low at all hospitals. None of the cases of "missed" intracranial hematoma came from the lowest ordering institutions, indicating that patients may be managed safely with a selective approach to CT use. These findings suggest great potential for more standardized and efficient use of CT of the head, possibly through the use of a clinical decision rule.
PMID: 9209219, UI: 97352961
Pediatr Emerg Care 1997 Jun;13(3):198-203
University of Pittsburgh School of Medicine, Department of Pediatrics, USA.
BACKGROUND: Emergency department (ED) management of skull fractures in children remains controversial. Because infants incurring head trauma have a high incidence of skull fracture, we chose to describe fractures in this subset of patients and to determine if there are clinical predictors of associated intracranial injury (ICI) that may have utility in developing more efficient management schemes in these patients. METHODS: A retrospective medical record review was conducted on all awake patients < 13 months of age with an acute skull fracture from non-birth trauma, presenting to the ED of a university-affiliated children's hospital during a three-year period. Clinical and radiographic data extracted were used to describe skull fractures in these patients. The ability of various characteristics to determine the presence of ICI was assessed by calculating sensitivity, specificity, positive predictive value, and negative predictive value for each. RESULTS: The predominant mechanism of injury for the 102 infants was falls (91%). Suspicion of abuse was found in only one case. The parietal bone was fractured in 87 infants, and 34 had nonparietal fractures. The most prevalent fracture type was linear (92 infants), and 31 had > 1 cranial bone fractured. CT scans obtained on 32 infants (CT group) revealed 21 ICIs in 15 patients. Two with temporoparietal fractures required emergent evacuation of epidural blood. In the CT group, seven of the 15 (47%) with ICI (ICI group) were lethargic compared to two of the 17 (12%) without ICI (No ICI group) (P = 0.035). Five (33%) in the ICI group had temporal bone fractures compared to 0 in the No ICI group (P = 0.015). The presence of any sign or symptom had a sensitivity and negative predictive value of 100%, but only a specificity of 35%. The presence of lethargy had a positive predictive value of 78%. The presence of temporal and frontal bone fractures had positive predictive values of 100 and 75%, respectively. CONCLUSION: This study reports a high prevalence of fracture characteristics often associated with inflicted injury in other studies when virtually all injuries in our sample were accidental. Several clinical characteristics were demonstrated to be potentially useful in predicting ICI associated with skull fracture; however, prospective study is recommended to validate these findings prior to clinical application.
PMID: 9220506, UI: 97364228
Arch Pediatr 1997 May;4(5):443-59
Departement d'anesthesie reanimation pediatrique, hopital de la Timone-enfants, Marseille, France.
Trauma are responsible for approximately 50% of the deaths of the pediatric population between 1-15 years of age. This high mortality rate, associated with frequent sequelae, leading sometimes to severe handicaps, is a major problem of public health in the developed countries. Pediatric trauma have some particularities, due to anatomical and physiological differences, and to specific injury mechanisms. Management of a patient with severe trauma is best performed by trained physicians, working in a multidisciplinary team with a two steps approach: 1) emergency rapid clinical assessment and resuscitation. 2) a secondary complete clinical evaluation associated with medical imaging, mainly based on CT scan. Head injuries are frequent and represent the main prognosis factor, mass lesions being less frequent and cerebral oedema more frequent in children, than in adult; brain swelling appears to be less frequent than initially reported. Management of head trauma has evolved in recent years, and is now largely directed towards the prevention of secondary ischemic brain injury: new monitoring devices are proposed to pursue that goal: transcranial doppler and continuous jugular vein oxygen saturation monitoring. Spinal cord injuries are rare but may be severe: cervical and spinal cord injuries without radiological abnormality (SC/WORA) appear to be more frequent than in adult. Most often, abdominal plain viscera injuries are treated with a conservative non operative approach. Among chest injuries, pulmonary contusion is the most frequent, with a favorable outcome in most cases within 3-4 days. Child abuse must be suspected in any case where there is no clear injury mechanism or when there is a discrepancy between the severity of the injury and the alleged mechanism.
PMID: 9230995, UI: 97374546
Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 1997 May;166(5):382-8
Klinik und Poliklinik fur Radiologie, Johannes Gutenberg Universitat Mainz.
PURPOSE: The aim of this study was to evaluate the role of a fast whole body helical CT scanner for primary diagnosis in trauma patients. METHODS: 27 severely injured patients (9 women, 18 men; mean age 43 years) were first examined with a helical CT scanner allowing for digital radiograms up to a length of 1024 mm and continuous helical scans of up to 70 seconds (slice thickness 3 to 10 mm, pitch factor up to 2). The primary CT diagnosis was verified either by x-ray after the CT examination or during the subsequent days, by abdominal ultrasound, by additional CT scans in the following days, and by clinical follow-up. RESULTS: CT showed all clinically relevant injuries of the head, spine, chest, abdomen and pelvis. The diagnosis and classification of vertebral fractures was performed immediately. 4% of the fractures of the extremities and the ribs were not seen primarily. 6% of the injuries were outside the CT scan field. CONCLUSION: Helical CT is a reliable and fast method to obtain vital information and to improve management planning in severely injured patients. It reduces the number of conventional x-ray examinations. In certain cases, additional x-rays of extremity fractures may be required.
PMID: 9198509, UI: 97317615
Am J Emerg Med 1997 May;15(3):244-7
Department of Radiology, Hadassah University Hospital, Jerusalem, Israel.
A study was conducted to determine parameters indicating the current use of computed tomography (CT) in the emergency department (ED). Computerized data regarding patients seen in the ED between 1/1/92 and 9/30/95 were retrieved. A rate of 36/1,000 patients underwent CT in the ED (ED CT). Of patients eventually hospitalized, 6.04% had ED CT, whereas 2.81% of the discharged patients had undergone ED CT (P < .001). The most common region examined by ED CT was the head (55.38%), followed by the abdomen (14.19%), pelvis (11.96%), spine (11.46%), and chest (5.57%). The hospitalization rates for patients undergoing head and spine ED CT were 35.99% and 36.84%, respectively. The hospitalization rates for patients undergoing abdomen, pelvis, and chest ED CT were 50.76%, 51.46%, and 55.61%, respectively. The mean number of patients undergoing ED CT increased according to age with a positive linear correlation. Head CT was most common in the very young and the very old. Some parameters about the use of ED CT were identified. The information obtained will allow comparison of practice between EDs in different medical centers and will be useful to hospital administrators, health planners, and clinicians. This retrospective analysis is to be followed by more comprehensive prospective studies involving different EDs in various sections of the country.
PMID: 9148977, UI: 97292924
Surg Neurol 1997 May;47(5):428-31
Division of Neurosurgery, S. Croce Hospital, Cuneo, Italy.
BACKGROUND: Protrusion of the cortex through a bone flap in the course of surgery is a very serious event and, if it persists, the procedure must be suspended, the cause sought, and the problem resolved. CASE DESCRIPTION: We report the case of a 13-year-old boy whose brain underwent sudden swelling during removal of a supratentorial cystic lesion. The operation was suspended at once and an emergency CT scan was performed. It revealed a large contralateral extradural hematoma, which was removed immediately. CONCLUSIONS: We considered the following possible mechanisms of the emergency: bleeding of bone at the site of the supposed piercing by the headrest pin and/or a vacuum mechanism consequent upon removal of the large cystic lesion. Our aims are to emphasize the importance of gauging the thickness of a child's skull before fixing the head in the headrest, especially when chronic intracranial hypertension is present, and the need to suspend the operation for CT scanning in the event of uncontrollable brain swelling.
PMID: 9131023, UI: 97277639
Surg Neurol 1997 Apr;47(4):331-8
Department of Neurosurgery, Sina Hospital, Tehran, Iran.
BACKGROUND: Air-gun pellet injuries (AgPI) of the central nervous system (CNS) are rare but catastrophic events. They occur mostly in children and young adults. The entrance is usually either through the orbit or through the neck and the entry wound is so small that it may be disregarded on physical examination in the emergency room. Early recognition and correct management of the possible complications of AgPIs is important and may prevent a poor outcome. METHODS We intend to present our experience with 16 cases of AgPIs of the head and neck referred to the department of neurosurgery during the last 15 years. The characteristic findings on physical examination of the cases and the imaging studies performed are described. Special management undertaken for the rare complications are mentioned and a short literature review is performed on each entity. RESULTS All our cases happened in the first and second decades of life and only in boys playing with toy guns. There were 12 head and face and four neck wounds. Damaged globe that had to be exenterated was the earliest complication, handled by ophthalmologists (four cases). Cerebrospinal fluid (CSF) leakage, meningitis, brain abscess formation, development of traumatic aneurysm (TA), carotid-cavernous sinus fistula (CCF), wandering intracerebral and intraventricular pellet, and splitting of the pellet after striking hard bone were the complications noted. In addition to plain X-ray films, computed tomography (CT) scanning and angiography were diagnostic procedures of choice. CONCLUSIONS The present series of patients is the largest collection of AgPIs to the head and neck reported in the literature in which nearly all the possible complications of such injuries have been reviewed. Early recognition and awareness of the possible cumbersome complications of such a minor penetrating wound can prevent major catastrophies in this young group of victims.
PMID: 9122835, UI: 97247281
Ann Emerg Med 1997 Apr;29(4):518-23
Department of Pediatrics, University of Washington Emergency Services, Children's Hospital and Medical Center, Seattle, USA.
STUDY OBJECTIVE: To develop a preliminary clinical decision guideline, using characteristics of ED pediatric patients presenting with seizures, that successfully predicts all abnormal results of computed tomography (CT) of the head. METHODS: We assembled a retrospective case series in the ED of a tertiary care children's hospital without trauma designation. The series comprised all patients who presented between January 1, 1992, and December 31, 1994, with seizures (febrile and afebrile) who underwent head CT as part of ED evaluation. RESULTS: Our inclusion criteria were met by 203 patients. Of these patients, who had a median age of 3.1 years, 53% were boys; 18% had been transferred from another facility; 25% had received anti-convulsant medication in the field, at the referring facility, or both; 32% had a history of seizures before the presenting episode; 6% had sustained a closed-head injury (CHI); 15% had a cerebrospinal fluid (CSF) shunt; 4% had an underlying malignancy or neurocutaneous disorder (NCT); and 30% had a documented fever. CT findings were abnormal in 25 patients (12%). CT showed evidence of hemorrhage in eight patients (32%), small focal abnormalities in four (16%), cerebral edema in three (12%), and shunt obstruction in two (8%). chi 2 Recursive-partitioning analysis revealed that CT scan results were always normal when the patient did not have an underlying high-risk condition (malignancy, NCT, recent CHI, or recent CSF shunt revision), was older than 6 months, had sustained a seizure of 15 minutes or less, and did not have a history of a new-onset focal neurologic deficit. Retrospective application of these criteria revealed that 41% of the CT scans could have been deferred. CONCLUSION: In this case series, the absence of defined high-risk factors predicted normal head CT findings. The deferral of emergency CT in this population should be considered.
PMID: 9095014, UI: 97249109
Lancet 1997 Mar 22;349(9055):821-4
Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK.
BACKGROUND: The value of routine skull radiography as a method of predicting intracranial injury is controversial. We aimed to assess the effectiveness of skull radiography by prospectively studying head-injured children admitted to a children's hospital that serves an urban population. METHODS: Over a 2-year period, 9269 children attended our accident and emergency department with head injury, and 6011 were referred for skull radiography. All children who were admitted to hospital or had a skull fracture (n = 883) were included in the study. Computed tomography (CT) was done in children with skull fractures on radiography and in those without fractures if there were neurological indications. FINDINGS: Radiographs showed 162 fractures (2.7% of all radiographs and 18% of study group radiographs). Staff in the accident and emergency department missed 37 (23%) fractures. CT scan was done on 156 children, of whom 107 had a skull fracture. 23 children were found to have intracranial injuries on CT. The presence of neurological abnormalities had a sensitivity for identification of intracranial injury of 91% (21 of 23) and a negative predictive value of 97%. The corresponding values for skull fracture on radiography were 65% (15 of 23) and 83%. Four children died, of whom only one had a skull fracture. INTERPRETATION: In children, severe intracranial injury can occur in the absence of skull fracture. Skull radiography is not a reliable predictor of intracranial injury and is indicated only to confirm or exclude a suspected depressed fracture or penetrating injury, and when non-accidental injury is suspected, including in all infants younger than 2 years. Clinical neurological abnormalities are a reliable predictor of intracranial injury. If imaging is required, it should be with CT and not skull radiography.
PMID: 9121256, UI: 97236857
J Intern Med 1997 Mar;241(3):237-43
Department of Internal Medicine, St Vincent Hospital, Worcester, MA, USA. pmarik@ultranet
OBJECTIVES: Cranial CT scans are amongst the most frequently performed radiological investigations performed in most developed countries. However, these tests are relatively expensive and economic realities should compel physicians to re-evaluate the utilization of this technology. The aim of this study was to review the utilization pattern and effect on management decisions of cranial CT scanning. DESIGN: Retrospective chart review. SETTING: University-affiliated community teaching hospital. SUBJECTS: The clinical data on 451 consecutive patients undergoing cranial CT scanning in our radiology department were reviewed. Eighty-five patients were referred from outside the hospital and were subsequently excluded from further analysis. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The following data was abstracted from each patient's chart: the presenting clinical syndrome, the physician ordering the scan, details of the neurological examination performed prior to scanning, the CT scan findings and the impact the CT scan findings had on management decisions. RESULTS: The largest percentage of patients were referred from the emergency department (61%). Chronic intracranial lesions were present in 77 (21%) patients. New pathological findings were found in 91 (25%) patients. The commonest new lesions were ischaemic infarcts (43%), followed by intracerebral haemorrhage (13%) and space occupying lesions (11%). Ninety-seven per cent of patients presenting with new focal neurological signs had new findings on the CT scan, compared to 28% of patients with severe headache and 27% with a history of loss of consciousness. Head trauma was the presenting problem in 139 patients. New pathological findings were diagnosed in 24 of these patients. Fifty-four patients had no signs or symptoms referable to the central nervous system. None of these patients had new findings on CT scan. In the vast majority of patients the neurological examination performed prior to CT scanning was incomplete. CT scanning was considered to have altered the management or provided a new diagnosis in 162 (44%) patients; of these patients 61 (67%) were in the group with new findings on CT scanning and 101 (37%) in the group with no new findings. CONCLUSION: In this study cranial CT scanning affected clinical management decisions in less than half of the patients. Furthermore, a careful history and neurological examination was performed in the minority of patients undergoing CT scanning. It would therefore appear that the easy accessability of CT scans largely determines the utilization of this diagnostic tool.
PMID: 9104437, UI: 97257963
Nervenarzt 1997 Jan;68(1):1-10
Psychiatrische Klinik der Universitat, Mainz.
This paper evaluates the role of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of psychiatric disorders according to the "International Classification of Diseases" (ICD-10). Indications for CT/MRI can be derived from ICD-10 for the identification or exclusion of defined cerebral lesions resp. for the etiology in organic disorders. Due to the lack of specific morphological findings, CT/MRI do not contribute to the classification of all other diagnoses. CT/ MRI can only exclude causal organic factors. However, ICD-10 provides only few guidelines for ruling out cerebral pathology (e.g. tumors in bulimic anorexia). Therefore, recommendations for routine CT/MRI-investigations for the exclusion of organic disorders are required and might be developed by the quality assurance. Application of CT or MRI: CT plays an important role in diagnostic imaging in routine as well as in emergency situations (haemorraghe, hamatoma, infaction, head injury, tumour, vascular malformation). MRI on the other hand, is more sensitive in the diagnosis of inflammatory diseases, skull base lesions, degenerative changes of the white matter and in the imaging of hydrocephalus and epilepsy.
PMID: 9132616, UI: 97206207
J Emerg Med 1997 Jan-Feb;15(1):19-22
Department of Emergency Medicine, University of Southern California School of Medicine, Los Angeles 90033, USA.
The case presented offers a demonstration of a rare yet devastating condition that may go unrecognized and incompletely worked up by the emergency physician. Internal carotid artery dissection is seen most often in previously healthy, young patients and thus all efforts toward diagnosing this condition and providing proper stabilization must be made. Unfortunately, little advancement in the therapeutic progress of this frequently fatal condition has been made over the past decades. To date, both medical management and surgical techniques have been utilized with variable success. This case should serve to remind physicians evaluating young patients with stroke symptoms or other neurological findings that a negative head CT scan may not be the last test necessary for the definitive diagnosis.
PMID: 9017482, UI: 97169939
No Shinkei Geka 1996 Oct;24(10):945-8
Department of Neurological Surgery, Ehime University School of Medicine.
We encountered 3 cases of battered children with acute subdural hematoma. In this report, we discuss the difficulties in treating this condition surgically, and we emphasize the importance of early diagnosis and treatment of abused children and their parents. Case 1: A girl, aged 2 months, was brought in by her mother, because the child had become drowsy. The mother stated that the child had been battered by her father. Physical examination revealed tense anterior fontanelle, bruises on her face, consciousness disturbance and retinal bleeding. Marked anemia was revealed on laboratory studies. A computed tomographic (CT) scan demonstrated an interhemispheric subdural hematoma in the parietooccipital region. She was treated conservatively for 2 months. Follow-up CT revealed a bilateral chronic subdural hematoma. Burr hole irrigation and drainage on both sides brought about complete disappearance of these lesions. Case 2: A girl, aged 1 year and 9 months, was brought in by her parents. According to her mother's allegation, the child fell down from the top of an indoor slide and became comatose. Physical examination revealed severe malnutrition, loss of consciousness, dilated pupils and negative light reflex. Numerous areas of subcutaneous bleeding and skin erosions were seen on her back and abdomen. Marked anemia was revealed on laboratory studies. CT scan demonstrated a left acute subdural hematoma and massive brain swelling. Despite an emergency craniotomy, the child died 5 days later. Case 3: A 4-year-old boy was admitted in a comatose state. According to his mother's allegation, he was thrown to the floor from a 1.5m height and struck against a wall by his father. Physical examination revealed severe malnutrition, consciousness loss, dilated pupils and negative light reflex. Many scratches and bruises were seen over his whole body, especially on his back. Marked anemia was revealed on laboratory studies. A CT scan demonstrated a left acute subdural hematoma and massive brain swelling. Three days later, he died despite emergency craniotomy. The incidence of battered children is increasing in Japan, and these cases sometimes involve severe head injuries, such as subdural hematoma. In these cases, successful surgical treatment is difficult after admission to the neurosurgical institute. This may result from late admission as well as marked anemia and malnutrition. Therefore, we conclude that early diagnosis of child abuse and treatment of the abused child and psychological treatment for their parents are very important.
PMID: 8914155, UI: 97071230
Acad Emerg Med 1996 Sep;3(9):853-8
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA. michelle.biros@co.hennepin.mn.us
OBJECTIVE: To determine the frequency of unsuspected minor illness or injury in a group of patients frequently seen in the ED for acute intoxication. METHODS: The medical records of the 20 patients seen most frequently in the ED for acute intoxication in 1993 were reviewed for the number of ED visits for intoxication, the number of associated documented episodes of minor trauma or illness, the extent of ED workup of discovered illness or injury, and patient disposition from the ED. RESULTS: The 20 study patients were evaluated in the ED 1,858 times in 1993 for acute intoxication, a mean of 92.5 visits/patient (+/- 26.6). The most frequent injury was minor trauma above the neck, occurring a mean of 9 times (+/- 3.6) in each of the study patients during 1993. Evaluation included repeated neurologic examinations and frequent radiography of the cervical spine (n = 80), skull (n = 5), facial bones (n = 6), and mandible (n = 5). A limited number of head CT scans also were done (n = 8). The most frequent minor illnesses were gastritis (n = 7), managed with hydration, and mild hypothermia (n = 6), managed with passive rewarming. CONCLUSIONS: The incidence of unsuspected minor illness or injury in this patient group was substantial. While most unsuspected medical problems had little clinical significance, some were potentially dangerous, and some necessitated hospitalization (e.g., hypothermia, hematemesis, and respiratory depression).
PMID: 8870757, UI: 97024529
Acad Radiol 1996 Aug;3(8):678-82
Department of Radiology, University of California, San Diego, USA.
RATIONALE AND OBJECTIVES: Before a computed tomography (CT) scanner was installed in the emergency department, this hospital had no dedicated CT scanner for patients in the emergency department, and transporting these patients to the CT scanners in the radiology department took approximately 8-10 min each way. We sought to determine whether the presence of a CT scanner within the emergency department would lead to an increase in the number of emergent cranial CT examinations and a decrease in the diagnostic yield of these examinations. METHODS: More than 8,000 records of cranial CT examinations were reviewed for the 12 months before and the 12 months after the installation of the CT scanner in the emergency department. A positive case was defined as one that showed acute abnormality such as ischemia, hemorrhage, edema, or mass effect. RESULTS: Our results show a 30.1% increase in the number of CT scans of the head ordered by physicians in the emergency department after the installation of a CT scanner (p < .0001). This is compared with the background 1.8% increase in the total number of emergency department visits. However, in both periods, 12% of the total number of head scans done were positive. CONCLUSION: The convenience of having a CT scanner in the emergency department leads to greater use of CT examinations. However, the increase in the number of emergent CT studies is justified because the number of positive CT examinations increases proportionately.
PMID: 8796732, UI: 96389435
Am J Emerg Med 1996 Jul;14(4):373-6
Department of Emergency Medicine, Duke University Medical Center, Durham, NC 27710, USA.
Vomiting of gastric contents is common among multisystem trauma patients and may cause significant morbidity. A study was conducted to examine whether metoclopramide (Reglan), an antiemetic and promotility agent, could decrease vomiting after administration of oral radiographic contrast in stable multisystem trauma patients undergoing computed tomography (CT) of the abdomen ("trauma CT patients"). The charts of 193 patients listed in the Duke Trauma Registry who underwent abdominal CT scanning from January, 1992 until February, 1993 were reviewed. The emergency department record was reviewed for documentation of vomiting, use of intravenous metoclopramide, and other potential confounders of vomiting such as age, pharmacologic paralysis, and head injury as measured by the Glasgow Coma Scale (GCS). Patients who received intravenous metoclopramide were six times less likely to vomit after administration of oral radiographic contrast than those who did not receive the drug. This effect increased to a twelvefold protective effect after correcting for age, pharmacologic paralysis, and GCS. These preliminary findings strongly suggest that routine use of metoclopramide may prevent vomiting of gastric contents after administration of oral radiographic contrast in trauma CT patients. A future prospective study is recommended to confirm these results.
PMID: 8768158, UI: 96331141
Pediatr Emerg Care 1996 Jun;12(3):160-5
Primary Children's Medical Center, Emergency Department, Salt Lake City, UT 84113, USA.
Head injury is a frequent cause of morbidity and mortality in pediatric trauma. Guidelines for obtaining computed tomographic (CT) scans in the child with mild head injury are poorly defined. This study investigated the utility of head CT scanning in the pediatric patient presenting with normal neurologic examination. All patients undergoing head CT scanning for trauma in the emergency department (ED) at a tertiary care pediatric trauma center during 1992 were identified (508). Charts were reviewed for historical and physical examination findings, CT results, and need for neurosurgical intervention. Patients were excluded if they had an abnormal neurologic examination (179), known depressed skull fracture (11), bleeding diathesis (3), age older than 18 years (1), or developmental delay (1). Included were 313 patients (median 5.5 years) who presented with clinical variables including sleepiness (38%), vomiting (34%), headache (30%), loss of consciousness (LOC) (25%), irritability (22%), amnesia (20%), and seizures (8%). An abnormal head CT was noted in 88 cases (28%); 79 (25%) were traumatic abnormalities involving the skull and/or contents. Thirteen patients (4%) had intracranial injuries (ICI); all had either a linear (10), basilar (2), or depressed (1) skull fracture noted on CT. Four patients required neurosurgery, three for epidural hematoma, and one for a complicated orbital fracture (without ICI). No clinical variables (seizure, LOC, vomiting, headache, confusion, irritability, sleepiness, amnesia) were associated with ICI (P > 0.05). In pediatric head trauma patients, with normal neurologic examinations in the ED, ICI occurs < 5% of the time and neurosurgery is needed in 1% of the cases. Commonly used clinical variables are not associated with ICI in these children.
PMID: 8806136, UI: 96399678
Semin Ultrasound CT MR 1996 Jun;17(3):185-205
University of California, San Francisco 94110, USA.
This article reviews the neuroradiological evaluation of acute head injury with an emphasis on CT and MR imaging. Subacute and chronic head injury are not discussed. CT remains the modality of choice in the emergency setting, permitting rapid, comprehensive assessment of the great majority of head injuries. MR is most useful in patients in whom there is a discrepancy between clinical symptoms and CT findings. In addition, MR is the imaging modality of choice in the subacute and chronic setting. The superior contrast resolution of MR permits optimal evaluation of nonhemorrhagic (and hemorrhagic) white matter shearing injuries, and the lack of beam-hardening artifact permits a more thorough evaluation of the brain stem, posterior fossa, and cortical surface.
PMID: 8797246, UI: 96390167
Acad Emerg Med 1996 Apr;3(4):304-11
Division of Emergency Medicine, Northwestern University Medical School, Chicago, IL 60611-2914. sadams@casbah.acns.nwu.edu
OBJECTIVES: 1) To assess the relationship between types of injuries incurred and training and protective equipment worn by adults injured while in-line skating; 2) to observe the type and amount of protective equipment worn by in-line skaters while skating; and 3) to survey active in-line skaters about formal training, protective equipment, and history of injuries incurred, and the effect of such injuries on the protective equipment subsequently worn. METHODS: A prospective study of consecutive adult patients presenting to the ED for evaluation of in-line skating injuries; a consecutive-series observational study of active in-line skaters to assess protective equipment worn; and a survey of selected active in-line skaters. Eighty-five adult patients were included who presented with a history of injury related to in-line skating to the EDs of an urban academic medical center, a suburban academic-affiliated hospital, and a community hospital. Four hundred eleven active in-line skaters on the Chicago lakefront were observed for protective equipment worn, 91 of whom participated in the survey. RESULTS: Of those presenting to the ED with injuries, only 15% indicated that they had received formal in-line skating instruction. Of the ED patients, 50% wore no protective equipment; overall, 6% wore a helmet; 44%, wrist protection; 23%, knee protection; and 19%, elbow protection. Only 2% wore all of the above equipment. The primary mechanism of injury reported was a loss of balance (58%); others included collision with objects (25%), collision with bicycles (11%), and collision with cars (5%). Fractures or dislocations occurred in 48% of the patients; 6% had head injuries necessitating CT scans. Those who wore no protective gear were more likely to require hospital admission (p < 0.05). Of the 411 in-line skaters observed, 157 (38%) wore no protective equipment. Compared with the injured group presenting to the ED, fewer observed participants were without protection (p < 0.05). Among those surveyed, prior injury was not associated with the subsequent use of protective gear. CONCLUSION: Patients who present to the ED for evaluation of in-line skating injuries have a high incidence of fractures/dislocations. Few injured or surveyed in-line skaters had formal training. Use of protective equipment by injured skaters was associated with a decreased likelihood of hospitalization. Observed in-line skaters more commonly wore protective gear than did those who presented to the ED with injuries.
PMID: 8881538, UI: 97035890
J Neurosurg Sci 1996 Mar;40(1):11-5
The study group on Head Injury of the Italian Society for Neurosurgery suggests the following guidelines for minor head injured patients management. Patients either oriented to time, space and person (GCS 15) or confused (GCS 14) are included among the group of minor head injury. Criteria of exclusion are the presence of focal neurological deficits, open injury and a GCS < or = 13. Six categories of risk factors (coagulopathies, alcoholism, drug abuse, epilepsy, previous neurosurgical treatments and disabled elderly patients) relevant to the clinical course are identified. Three group of patients are distinguished. Patients in the Group 0 (GCS 15, without loss of consciousness, amnesia, diffuse headache, vomiting) could be sent home from Emergency Department after at least 6 hours period of observation with an information sheet. Patients in the Group 1 (GCS 15, with loss of consciousness and/or amnesia and/or diffuse headache and/or vomiting) require clinical observation (> or = 6 hours) and neuroradiological assessment. According to hospital availability, either skull-X rays or CT scan is obtained. In the presence of a skull fracture a CT scan is mandatory. In the presence of intracranial lesions, neurosurgical consultation is requested. In the absence of skull fractures or intracranial lesions the patient is admitted for observation (> or = 24 hours). Patients in the Group 0 and in the Group 1 with a risk factor (R) are admitted to the hospital (> or = 24 hours) and submitted to a CT scan. In patients with coagulopathies or in treatment with anticoagulants a CT scan should be repeated before discharge even in the absence of intracranial lesion on the first CT. In patients in the Group 2 (GCS 14) a CT scan is obtained in all cases independent of the presence of a risk factor.
PMID: 8913956, UI: 97071030
J Accid Emerg Med 1996 Mar;13(2):80-5
Department of Accident and Emergency Medicine, Bristol Royal Infirmary, United Kingdom.
The aim was to reconsider the "Guidelines for initial management of head injury in adults"--particularly with respect to the indications for computerised tomographic (CT) scanning--suggested by "a group of neurosurgeons" over a decade ago and still followed in some accident and emergency (A&E) departments. These recommendations are placed in the context of more recent research and the increased number of A&E departments with on-site rapid access to a CT scanner but without a resident neurosurgical facility. A case can be made for an updated policy with more liberal indications for CT scanning of acutely head injured adults in peripheral A&E departments. However, calculating the cost-efficiency of more frequent use of what is now a common but relatively expensive resource would remain a challenge.
PMID: 8653255, UI: 96243993
Ann Emerg Med 1996 Mar;27(3):290-4
Division of Emergency Medicine, University of California, Davis, Medical Center, Sacramento, CA 95817, USA.
STUDY OBJECTIVE: To determine the clinical value of routine computed tomography (CT) of the head in patients with normal mental status after minor head trauma. METHODS: We carried out a prospective study of a consecutive series of patients of all ages who presented to our urban university Level I trauma center emergency department with a Glasgow Coma Scale score of 15 and underwent CT of the head after loss of consciousness (LOC) or amnesia to event. A data form was filled out for each patient before CT. Patients with abnormal CT results were followed to discharge. We analyzed data with the chi 2 and student t tests. RESULTS: Of 1,382 patients, traumatic intracranial abnormality was identified on CT of the head in 84 (6.1%). Three patients in this group (.2%) required surgery. The subgroup of patients with history of LOC/amnesia but no symptoms or signs of a depressed skull fracture had a rate of abnormal CT findings of only 3% (24 of 789), and no patient in this group required medical or surgical intervention. Nausea and vomiting and signs of head trauma were significantly more common in the group with abnormal CT findings. CONCLUSION: Routine CT of the head in patients with history of LOC/amnesia but no symptoms or signs of depressed skull fracture has minimal clinical value and is not warranted. Patients with symptoms of head injury or apparent depressed skull fracture should undergo head CT because a small number will require surgery.
PMID: 8599485, UI: 96178188
Rev Chir Orthop Reparatrice Appar Mot 1996;82(3):201-07
Service de Chirurgie Infantile, CHU Charles Nicolle, Rouen.
PURPOSE OF THE STUDY: Skull X-rays are systematically performed on children after head injuries in most hospitals. However, the discovery of a skull fracture as an isolated finding rarely warrants intervention. In february 1994, we stopped performing systematical skull X-rays in children after head injuries. We report the results of this experience. MATERIALS AND METHODS: Since February 1994, only children with possible skull penetration, depressed fracture, or presenting signs of basilar fracture had X-ray examination. Facial injuries were excluded in this study. In case of focal neurologic signs, neurosurgical consultation, or emergency CT examination, or both were performed. In case of change of consciousness at the time of injury or subsequently, the child was hospitalised for clinical observation for 48 hours, but no X-ray examination was performed. Children without any neurological signs or change of consciousness were discharged to their homes after they were given a head-injury instruction sheet, and if a second person could observe them for signs indicating that they belong to a higher risk group, but no X-ray examination was performed. RESULTS: An average of 241 children per month were presented at the Children Emergency Unit after head trauma. An average of twenty-one X-ray examinations per month were performed instead of 194/month before february 1994. This represented a decrease of 2000 X-ray examinations per year. There was no undiagnosed neurological complication, and the number of children staying in the hospital for clinical supervision did not increase. DISCUSSION: Skull radiographies only show fractures and do not afford visibility of either brain or blood to demonstrate an intracranial injury. The presence of a skull fracture without neurological abnormalities is of little significance. Harwood-Nash reported that 60 per cent of the children with extradural hematoma, 85 per cent of the children with subdural hematoma and 35 per cent of the children with brain damage did not have any associated skull fracture. Clinical examination is essential, and it would be a mistake to be reassured about the severity of a head trauma because skull X-rays are normal. CONCLUSION: Routine skull X-rays after head trauma are not justified either for financial or radioprotection reasons. In this study, more than half of the children were less than five years old and ran a higher risk of irradiation.
PMID: 9005457, UI: 97104520
Acad Emerg Med 1996 Jan;3(1):16-20
Joint Military Medical Centers, San Antonio, TX, USA.
OBJECTIVE: To determine the sensitivity of the initial new-generation CT (NGCT) scan interpretation for detection of acute nontraumatic subarachnoid hemorrhage (SAH) and to decide whether lumbar puncture (LP) should follow a "normal" NGCT scan. METHODS: A retrospective chart review was performed of patients admitted between March 1988 and July 1994 with proven SAH. Exclusion criteria were age < 2 years, diagnosis other than acute SAH, history of head trauma within 24 hours before symptom onset, NGCT scan not done before diagnosis, and records not available. Patients were placed into two groups: symptom duration < 24 hours (group 1) and > 24 hours (group 2) prior to CT scan. The resolution of each NGCT scanner was recorded. An NGCT scanner was defined as a third-generation scanner or more recent. RESULTS: Of 349 SAH patients, 181 met inclusion criteria. The sensitivity of NGCT scans for SAH was 93.1% for the group 1 patients (n = 144) and 83.8% for the group 2 patients (n = 37). The overall sensitivity was 91.2%. All the patients who had SAH not detected by NGCT scans were diagnosed by LP. There was no significant relationship between NGCT scanner resolution and sensitivity for SAH. CONCLUSION: Initial interpretation of NGCT scans to detect SAH does not approach 100% sensitivity. A "normal" NGCT scan does not reliably exclude the need for LP in patients who have symptoms suggestive of SAH.
PMID: 8749962, UI: 96363165
Injury 1995 Dec;26(10):667-9
Accident and Emergency Department, Leicester Royal Infirmary NHS Trust, UK.
To determine the access to and use of computed tomography (CT) scanning by Accident and Emergency (A&E) departments a questionnaire was sent to all major A&E departments in the UK. Although CT scanners were present in over 80 per cent of the 225 responding hospitals, many centres (including 15.8 per cent of those with a CT scanner on site) did not have 24 h scanning facilities for emergency cases. Few departments (26 per cent) have agreed protocols with their radiology departments with regard to CT scanning and some departments transferred cases for emergency CT scans at another hospital. There are deficiencies in access to CT scanning in a significant number of hospitals. This results in some patients undergoing hazardous and in our view unnecessary transfer for scanning. Little use is made of agreed protocols between A&E and Radiology departments to simplify and speed up the process of arranging CT scans. We feel that the deficiencies identified need to be addressed particularly in the assessment of head injury.
PMID: 8745802, UI: 96287073
Neuroradiology 1995 Oct;37(7):551-2
Department of Neurosurgery, Faculty of Medicine, Kyushu University 60, Fukuoka, Japan.
We report a patient with calcification of the convexity dura mater and an acute epidural haematoma. CT revealed a calcified layer between the haematoma and brain parenchyma, which mimicked acute bleeding into a calcified chronic subdural haematoma. The appearance of a calcified haematoma does not always mean a "chronic" lesion, and that emergency operation should not be foregone, when there is a history of acute head trauma and progressive impairment of consciousness.
PMID: 8570052, UI: 96131395
Neurosurg Clin N Am 1995 Oct;6(4):741-51
Department of Emergency Medicine, University of Southern California School of Medicine, Los Angeles, USA.
The prehospital and emergency department management of the patient with a penetrating cranial injury can be summarized by the following tenets: 1. Assume any alteration in level of consciousness to be a result of the brain injury and not from alcohol or illicit drug intoxication. 2. Have a low threshold to protect the patient's airway with endotracheal intubation and chemical paralysis if a surgical lesion is suspected, there is seizure activity, or the patient is too combative to obtain the necessary studies. 3. Always protect the cervical spine and do not remove the hard collar and spine board until adequate radiographs have been obtained and the patient is lucid enough to complain of any neck pain. 4. Do not delay CT scanning to obtain other studies in the presence of lateralizing neurologic findings. 5. Do not delay in obtaining neurosurgical consultation or in arranging transfer to a facility where definitive care can be provided. 6. Remember, first do no harm. The primary brain injury has already been done. The clinician maximizes preservation of viable brain tissue by preventing secondary injury.
PMID: 8527915, UI: 96123873
J Neurosurg 1995 Sep;83(3):438-44
Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
Delayed intracranial hematomas are an important treatable cause of secondary brain injury in patients with head trauma. Early identification and treatment of these lesions, which appear or enlarge after the initial computerized tomography (CT) scan, may improve neurological outcome. Serial examinations using near-infrared spectroscopy (NIRS) to detect the development of delayed hematomas were performed in 167 patients. The difference in absorbance of light (delta OD) at 760 nm between the normal and the hematoma side was measured serially during the first 3 days after injury. Twenty-seven (16%) of the patients developed a type of late hematoma: intracerebral hematoma in eight, extracerebral hematoma in six, and postoperative hematoma in 13 patients. Eighteen of the delayed hematomas caused significant mass effect and required surgical evacuation. The hematomas appeared between 2 and 72 hours after admission. In 24 of the 27 patients, a significant increase (> 0.3) in the delta OD occurred prior to an increase in intracranial pressure, a change in the neurological examination, or a change on CT scan. A favorable outcome occurred in 67% of the patients with delayed hematomas, which suggests that early diagnosis using NIRS may allow early treatment and reduce secondary injury caused by delayed hematomas.
PMID: 7666220, UI: 95395622
J Neurotrauma 1995 Aug;12(4):591-600
Baylor College of Medicine, Houston, Texas, USA.
Clinical studies have documented the importance of secondary brain insults in determining neurologic outcome after head injury. Delayed intracranial hematomas are one of the most easily remediable causes of secondary injury if identified early, but can cause significant disability or death if not promptly recognized and treated. Early identification and treatment of these lesions that appear or enlarge after the initial CT scan may improve neurological outcome. Serial examinations using near-infrared spectroscopy (NIRS) to detect the development of delayed hematomas were obtained in 167 patients. The difference in absorbance of light (deltaOD) at 760 nm between the normal and the hematoma side was measured serially during the first 3 days after injury. Twenty-seven (16%) of the patients developed some type of late hematoma: an intracerebral hematoma in 8 patients, an extracerebral hematoma in 6 patients, and a postoperative hematoma in 13 patients. Eighteen of the delayed hematomas caused significant mass effect and required surgical evacuation. The hematomas appeared between 2 and 72 h after admission. In 24 of the 27 patients, a significant increase (>0.3) in the deltaOD occurred prior to an increase in intracranial pressure or a change in the neurological examination, or a change on CT scan. Early diagnosis using MRS may allow early treatment and reduce secondary injury caused by delayed hematomas.
PMID: 8683610, UI: 96116225
Ann Emerg Med 1995 Jun;25(6):731-6
STUDY OBJECTIVE: To determine the prevalence of abnormal computed tomography (CT) scans and define high-risk clinical variables in patients with mild head injury. DESIGN: Retrospective descriptive study of patients with Glasgow Coma Scale (GCS) scores of 13 or greater who presented to the emergency department with blunt head trauma and who underwent cranial CT. SETTING: Level I trauma center, university ED. RESULTS: During the 15-month study period, 1,448 patients underwent CT scanning for mild head injury. Abnormalities resulting from the trauma were found in 119 (8.2%), and 11 patients (.76%) required neurosurgical intervention. Patients with higher GCS scores had a greater chance of having a solitary CT abnormality (P = .004). Bicyclists and pedestrians struck by cars were more likely than others to sustain intracranial injury. High-risk clinical variables included the presence of cranial soft-tissue injury, a focal neurologic deficit, signs of basilar skull fracture and age older than 60 years. A strategy using those variables had a sensitivity of 91.6% and a specificity of 46.2% for detecting a CT abnormality. None of the patients missed by this strategy required medical or neurosurgical management for the CT finding. CONCLUSION: Abnormalities on CT scans in patients with mild head trauma are fairly common, although the need for neurosurgical intervention is rare. Clinical decision rules can be used to identify those patients with more serious intracranial pathology. Such strategies should be validated prospectively in various ED settings.
PMID: 7755192, UI: 95274834
Acad Emerg Med 1995 Jun;2(6):523-6
Department of Emergency Medicine, Cook County Hospital, Chicago, IL, USA.
A child who presented with hemiparesis secondary to a delayed non-hemorrhagic pontine infarction following mild head trauma is described. The results of the child's workup, including computed tomography (CT), were negative. The diagnosis of nonhemorrhagic pontine infarct was made by magnetic resonance imaging (MRI). The diagnostic evaluation excluded other possible etiologies of cerebral infarction, including vasculitides, CNS infection, congenital heart disease, hypercoagulable states, and demyelinating diseases. Although trauma cannot be proven as the cause of the infarct, other known causes of infarct were excluded. There are few cases of traumatic nonhemorrhagic cerebral infarction among children in the literature; none describes diagnostic MRI findings. MRI is important in these cases, because it may reveal delayed infarction from small-vessel injury, which is not apparent on CT. This article discusses the etiology of and the diagnostic evaluation of pediatric cerebrovascular accidents and suggests the need for emergency physicians to consider trauma as a potential cause of delayed nonhemorrhagic cerebral infarct in children.
PMID: 7497054, UI: 96121901
Pediatr Emerg Care 1995 Apr;11(2):86-8
Case Western Reserve University, Department of Pediatrics, Rainbow Babies and Childrens Hospital, Cleveland, OH 44106, USA.
The objective of this study was to identify a group of patients with mild closed head injury, lack of other significant trauma, and normal head computerized tomograph (CT), who could be safely observed at home by a reliable caretaker. Data were from a retrospective chart review of pediatric emergency department (PED) and hospital course of an urban university children's hospital. The pediatric trauma registry was used to identify patients one to 17 years old seen in the PED with closed-head injury and normal head CT between June 1991 and August 1992. A total of 746 patients with heads injury were seen in the PED, and 161 patients with closed-head injury were admitted during the study period. Sixty-two patients (mean age = 8.5 +/- 5 years) met inclusion criteria with hospital admission, mild head injury, Glasgow Coma Scale > or = 13, and normal head CT. Of the patients 63% (34) were male and 37% (23) were female, with 74% (46) African-American and 26% (16) Caucasian. The most frequent mechanisms of injury were 27% (17) fall from height (mean height = 6.7 +/- 4.6 feet) and 18% (11) passenger in a motor vehicle accident. Patients had a median Glasgow Coma Scale of 15 (mean 14.8) and median abbreviated injury score of 2 (mean = 1.8). Thirty-seven percent of patients (23) had a history of loss of consciousness (range one to five minutes) and 6% (4) had generalized tonic-clonic seizure after the injury.
PMID: 7596884, UI: 95320001
J Trauma 1995 Mar;38(3):338-42; discussion 342-3
Department of Surgery, Tulane University, New Orleans, LA, USA.
The use of computed tomography (CT) has helped revolutionize the process and accuracy of diagnosis of the trauma patient. We have noted a striking increase in the use of CT scanning early in the management of trauma patients at our trauma center and sought to assess our experience. METHODS: All trauma patients admitted to our trauma center from February 1991 to February 1992 who received any CT scan within the first 12 hours after arrival were enrolled in the study. A positive (+) CT scan was defined as a scan that demonstrated a significant finding consistent with the injury and a negative (-) CT scan was one in which there were either no abnormalities or only incidental findings unrelated to the injury. Each patient was followed daily by one of the authors (A.G.R.). Patient records were reviewed and treating surgeons were interviewed to determine whether the CT scan improved the process of therapy. Morbidity incident to the performance of the CT scans was assessed. RESULTS: 1609 trauma patients underwent 2047 CT scans (1.3 CT scans per patient). Sixteen percent (n = 260) had scans of more than one part of the body. Thirty-eight percent (n = 770) of scans were positive but 29% (n = 225) of these were not helpful to the patient care process. Overall, 29% of scans, either because they were positive or negative, assisted in the clinical care of the patient. Six percent (n = 45) of CT scans were falsely positive. Sixty-five percent of scans were true negatives. Two patients died in the CT suite, 6 died shortly after completion of the scan, and 12 required emergency trips to the operating room from the CT suite. CONCLUSIONS: A large number of CT scans are being performed in our trauma patient population. Less than 30% contributed to patient management. Because of morbidity and cost, strict surgeon and radiologist oversight of CT for trauma is essential.
PMID: 7897711, UI: 95205468
Pediatrics 1995 Mar;95(3):345-9
Department of Pediatrics, University of Washington, Seattle 98195.
OBJECTIVE. Recent evidence suggests that patients with a normal cranial CT scan after head injury can be safely discharged home from the emergency department. However, supporting data from previous studies has relied on incomplete patient follow-up. We utilized a statewide comprehensive hospital abstract reporting system (CHARS) to assess whether children with normal CT scans after head injury subsequently developed intracranial sequelae in the month following their initial injury. DESIGN. Retrospective case-series study, with comprehensive statewide follow-up for 1 month. SETTING. The emergency department of a Level 1 Trauma Center in Seattle, Washington. PARTICIPANTS. All children (n = 400) with head injury, Glasgow Coma Score of 13 to 15, and initial normal CT scan seen over a 4.5-year time period. All were matched against CHARS to evaluate admissions within 30 days after emergency department disposition. For readmissions, International Classification of Diseases (9th revision) discharge and procedure information was collected. All children were also matched against the state death files. RESULTS. Four children were readmitted for neurologic reasons within 1 month following injury. One child on coumadin for heart disease developed a symptomatic subdural hematoma 5 days after head injury, requiring neurosurgical drainage. One child developed a symptomatic hemorrhagic contusion 3 days after injury, requiring observation only. Two children were readmitted 1 day after injury for concussive symptoms; both were discharged home after observation only. There were no deaths among the study population. CONCLUSIONS. Among children with a normal cranial CT scan after mild head injury, delayed intracranial sequelae requiring intervention are extremely uncommon. In otherwise stable patients, a normal cranial CT scan can identify patients to be safely discharged from the emergency department, and would be more cost-effective than 1 to 2 days of hospital observation.
PMID: 7862471, UI: 95166583
Ann Emerg Med 1995 Feb;25(2):169-74
Department of Emergency Medicine, Alameda County Medical Center, Oakland, CA.
STUDY OBJECTIVES: To determine the concordance of emergency physicians and radiologists in interpreting cranial computed tomography (CT) scans. The study also sought to determine the clinical significance of misinterpretations of cranial CT scans by emergency physicians. DESIGN: Prospective cohort study. SETTING: A county hospital emergency medicine residency program. PARTICIPANTS: Five hundred fifty-five patients undergoing CT scanning during emergency department evaluation. RESULTS: Forty-nine percent (272) of the indications for CT scanning were for trauma, 14.2% (79) were for cerebrovascular accident, 25.1% (139) were for headache, 15.1% (84) were for seizure, and 13.7% (76) were for miscellaneous reasons. The radiologists interpreted 46.1% (256) of the CT scans as abnormal. The most frequent abnormalities were scalp hematoma, 15.2% (39); infarction, 14.1% (36); calcification, 6.3% (16); contusion, 6.3% (16); parenchymal hemorrhage, 5.1% (13); and mass, 5.1% (13). Nonconcordance between radiologists and emergency physicians was found in 38.7% (206) of the cases. Potentially clinically significant misinterpretations were found in 24.1% (131) of the total sample. These misinterpretations included 62 missed major findings (11.4% of total sample): 25 new infarcts, 10 mass lesions, 8 cases of cerebral edema, 8 parenchymal hemorrhages, 5 contusions, 4 subarachnoid hemorrhages, 1 epidural hematoma, and 1 subdural hematoma. However, on chart review, only three patients (0.6%) were found to have been managed inappropriately, and none had an adverse outcome. CONCLUSION: The misinterpretation rate of cranial CT scans by emergency physicians is of potential clinical concern. However, clinical mismanagement is rare. We recommend that more formal education in CT interpretation be included in residency training and continuing medical education programs for emergency physicians.
PMID: 7832342, UI: 95133745
Pediatr Emerg Care 1995 Feb;11(1):1-4
Department of Pediatric Emergency Medicine, Children's Hospital Medical Center of Akron, OH 44308, USA.
Children commonly seek attention in emergency departments following head injury. Head computed tomography (CT) is often used to decide subsequent disposition. Clinical criteria predicting CT abnormalities would allow effective and timely treatment and minimize unnecessary procedures depleting overburdened medical resources. We prospectively compared presenting clinical features with subsequent emergent head CT in 300 children less than 19 years old over a nine-month period. The disposition of patients following imaging was also recorded. Only suspected abuse was more than 50% positively predictive in children below age two and those above age two. Two signs were more than 67% positively predictive in both age groups: focal motor deficit and pupillary asymmetry. Patients with abnormal CTs were the only children to undergo emergent neurosurgery (30%) and were nearly five times as likely to be intensively monitored. Children with normal CTs were nearly five times as likely to be observed in a routine department or at home. We conclude that no single clinical feature can predict with certainty an abnormality on immediate head CT. However, children suspected of being abused, and those with focal motor deficits or pupillary asymmetry, should be imaged. Finally, emergent CT when judiciously ordered likely reduces unforeseen morbidity and minimizes costly intensive care observation.
PMID: 7739953, UI: 95258387
Acta Neurochir (Wien) 1995;137(3-4):151-4
Department of Neurosurgery, Chang Gung Memorial Hospital, Taiwan, Republic of China.
The incidence and clinical significance was studied in 2574 closed head injury patients, each of them having a Glasgow Coma Scale (GCS) 9 to 12 after trauma. All patients underwent computerized tomography (CT) after being admitted to the emergency service. One hundred and six patients (4.1%) experienced seizures within 1 week after head injury; 46 of these (1.8% of the series) had seizures within 24 hours after trauma. There was no statistically significant difference between the early seizure and seizure free group of patients in gender, age and GCS with the exception of cause of injury (p < 0.01). The incidence of intracerebral parenchymal damage was found to be higher with seizures developing between day 2 and day 7 (80%) than those with seizures developing within 24 hours (54.3%). Analysing the data revealed that early posttraumatic seizures were not related to the presence of intracerebral parenchymal damage on CT scan. The occurrence of early seizures did not affect the mortality and outcome of moderate closed head injury patients.
PMID: 8789655, UI: 96381642
Acta Neurochir (Wien) 1995;133(3-4):116-21
Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey.
Patients defined as having a moderate head injury on the basis of Glasgow Coma Scale scores within the ranges of 9 to 13 after acute nonsurgical procedures were selected. Almost 1600 cases were hospitalized in the Neurosurgery Department. The cases were admitted through the Emergency Unit of Gaz University Medical School, Ankara, Turkey during the period between 1979 and 1992. The group studied consisted of 231 selected patients assessed separately in paediatric, adult and elderly age groups. Possible risk factors such as: GCS score, anisocoria, unilateral or bilateral fixed pupils, impaired oculocephalic reflexes, presence of multiple systemic injuries, aetiology of head trauma, presence of linear or depressed skull fractures, space occupying mass on CT or operation was also assessed. Subarachnoid haemorrhage turned out to be the only independent significant risk factor in predicting mortality. The data about the patients who have "talked and deteriorated" were also reported so as to assisst physicians charged with the care of trauma victims.
PMID: 8748753, UI: 96352768
Am Surg 1995 Jan;61(1):24-9
Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
OBJECTIVE: To identify complications and interventions resulting from fiberoptic ICP monitoring in a large series of patients with closed head injury (CHI). SETTING/DESIGN: Level I trauma center/Consecutive case series. METHODS: Of 11,962 consecutive trauma admissions from 1984-1991, 279 patients underwent fiberoptic ICP monitoring for CHI. We identified the last 100 consecutive blunt trauma patients who had received ICP monitoring. Ninety-eight of these patients had charts available and constitute the study group. We examined mortality, Glasgow Coma Score (GCS), and admission CT findings for the group. Indications, interventions, and complications (bleeding, meningitis, and wound infections) associated with ICP monitoring were identified. RESULTS: Mortality for the group was 24%. Reasons for ICP monitoring included GCS < or = 8 and/or abnormal CT findings; 83% had GCS < or = 8. Admission CT findings included subarachnoid hemorrhage (48%), intracerebral hemorrhage (47%), edema (31%), intraventricular hemorrhage (20%), subdural hematoma (18%), and epidural hematoma (9%). Eighty-one per cent of patients had interventions based on ICP monitoring: osmolar therapy (81%), emergency CT (22%), surgical decompression (3%), or pentobarbital coma (2%). No complications resulted from ICP monitoring. Mean duration of monitoring was 4 days (maximum 13 days). Twenty patients (20%) required two or more monitors. Reasons for placing a second monitor included duration > 5 days (50%), questionable accuracy (20%), and accidental removal of the first monitor (10%). CONCLUSIONS: 1) Fiberoptic intracranial pressure monitoring leads to specific interventions in the majority of patients. 2) The procedure is safe. 3) Prospective studies are needed to determine the impact of coagulopathy on the safety of fiberoptic intracranial pressure monitoring and to define those factors responsible for the low infection rate.
PMID: 7832377, UI: 95133781
J Trauma 1995 Jan;38(1):70-8
Department of Trauma Surgery, Hannover Medical School, Germany.
The quality and progress of treatment for 3406 multiple trauma patients was reviewed retrospectively. Two periods (1972 to 1981, the first decade, and 1982 to 1991, the second decade) were compared. Sixty-nine percent of patients with multiple trauma had cerebral injuries, 62% thoracic trauma, and 86% fractures (40% open fractures). Concerning injury combinations, there was an increase of head/extremity injuries and thoracic/extremity injuries, whereas all combinations with abdominal injuries decreased. The relation between severity of injury as well as number of injured body regions and the mortality rate was significant. In the second decade prehospital care became more aggressive with an increase in use of intravenous fluid resuscitation (from 80% to 98%), intubation (from 84% to 91%), and chest tube insertion (from 37% to 76%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal hemorrhage, ultrasound (89%) nearly replaced peritoneal lavage (10%) and led to earlier surgical approach. For diagnosis of head injury, CT scan was used more frequently. Primary stabilization of long bone fractures, especially of the lower limb, is recommended. Concerning complications, the change in volume therapy helped to nearly eliminate acute renal failure (from 8.4% to 3.7%), the modification of respirator treatment led to a decrease of pulmonary insufficiency (ARDS; from 18.2% to 12.0%), whereas the rate of multiple organ failure increased. The mortality rate declined from 37% in the first decade to 22% in the second decade. The incidence of lethal multiple organ failure increased from 13.8% in the first decade to 18.6% in the second decade, whereas the mortality rate of ARDS decreased from 32.4% to 15.9%. Further reduction of incidents of death is only possible with causal therapy of posttraumatic organ failure immediately after injury.
PMID: 7745664, UI: 95264404
Ann Emerg Med 1994 Dec;24(6):1108-14
Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance.
STUDY OBJECTIVES: To determine which adult patients with new-onset seizures require admission and whether those who require admission can be identified in the emergency department. DESIGN: Retrospective chart review of patients seen during a 5-year period. SETTING: Urban county teaching hospital in southern California. PARTICIPANTS: Three hundred thirty-three adult patients with new-onset seizures. Patients were excluded if they had acute head trauma, hypoglycemia from diabetic therapy, or alcohol- or recreational drug-related seizures. INTERVENTIONS: Standardized medical evaluation including physical examination, CBC, SMA-7 (electrolytes, blood urea nitrogen, creatinine, glucose), calcium, cranial computed tomography (CT), lumbar puncture if indicated, and admission to the hospital. RESULTS: Forty-six percent of patients (136 of 294) admitted to our hospital required admission as judged by a retrospective evaluation of the ED and hospital course. The numbers of patients who had a clinically significant result with each part of the evaluation were: physical examination, 75 of 333 (23%); CBC, 25 of 319 (8%); SMA-7, 21 of 329 (6%); calcium, 2 of 208 (1%); CT, 134 of 325 (41%); and lumbar puncture, 19 of 227 (8%). Ninety-five percent of patients requiring admission (129 of 136) were detected by the standardized medical evaluation. CONCLUSION: One half of patients with new-onset seizures require admission. Patients with new-onset seizures who require admission can usually be detected by a standardized medical evaluation in the ED.
PMID: 7978592, UI: 95069278
J Accid Emerg Med 1994 Dec;11(4):218-22
Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK.
Head injuries are commonly seen in accident and emergency (A&E) departments and within this group a small proportion will have a temporal bone fracture. Thirty-four such cases were identified from a 7-year period and their case notes were reviewed. The mechanisms of injury included:falls outdoors (15 cases), falls in the home (eight cases), road traffic accidents (RTAs; seven cases), missiles (three cases) and non-accidental injury (one case). In 20 cases the fracture involved more than one cranial bone, and the implications of this with regard to non-accidental injury are discussed. CT scans were carried out in 14 cases and 11 of these showed intracranial haematoma. The criteria for CT scan following head injury in general, and temporal bone fracture in particular are discussed. Outcome measures indicated that those injured as a result of RTAs had the poorest outcome, followed by those who fell outdoors and then those who fell in the home.
PMID: 7894805, UI: 95202182
Ann Emerg Med 1994 Oct;24(4):640-5
Department of Pediatrics, University of Washington, Seattle.
STUDY OBJECTIVE: To assess the need for cranial computed tomography (CT) in the emergency department evaluation of children with Glasgow Coma Scale (GCS) score of 15 after mild head injury with loss of consciousness. DESIGN: Retrospective case series of children aged 2 to 17 years with documented loss of consciousness after head injury from January 1, 1988, to July 31, 1992. All had a GCS score of 15 on initial ED evaluation and were further categorized according to physical examination findings, neurologic status, and whether the head injury was isolated or nonisolated. Recursive partitioning was used to identify variables predictive of the presence and absence of intracranial hemorrhage. SETTING: ED in two settings: a regional tertiary care trauma center and a community children's hospital. RESULTS: Of the 185 patients who met study criteria, 17 had evidence of depressed or basilar skull fractures on physical examination or had a ventriculoperitoneal shunt in place before head injury. In the remaining 168 patients, recursive partitioning identified two variables (neurologic status and head injury type) associated with intracranial hemorrhage. Overall, 12 of 168 patients (7%) had intracranial bleeding. However, none of the 49 neurologically normal children with isolated head injury had intracranial hemorrhage (95% confidence interval, 0.0 to 6.0). CONCLUSION: The prevalence of intracranial hemorrhage in children with mild closed-head injury appears to vary with the presence of neurologic abnormalities and other noncranial injuries. After isolated head injury with loss of consciousness, children older than 2 years who are neurologically normal and without signs of depressed or basilar skull fracture may be discharged home from the ED without a cranial CT scan after careful physical examination alone.
PMID: 8092590, UI: 94379534
AJR Am J Roentgenol 1994 Sep;163(3):667-70
Department of Radiology, Jewish Hospital, Mallinckrodt Institute of Radiology, St. Louis, MO 63110.
OBJECTIVE. The purpose of this study was to evaluate the utility of cranial CT performed emergently in patients with neurologic deficits of acute onset that had resolved by the time of presentation to an emergency department. MATERIALS AND METHODS. Data were evaluated from 1518 patients presenting to level I (967 patients) and level II (551 patients) emergency departments. All patients underwent cranial CT during their visit to the emergency department to exclude potential intracranial hemorrhage or life-threatening mass effect from other causes. Of the 1518 patients who had CT done in one of these two departments and were entered into this study, 71 had histories compatible with resolved neurologic deficits, including 62 with apparent cerebrovascular disease, six with trauma, and three with seizure. The data collected included demographic information, medical history, physical and neurologic examinations, relevant laboratory data, results of CT, and information regarding patients' disposition from the emergency department. RESULTS. All CT scans in patients with resolved deficits were normal except for one in a patient who had had trauma. The scan of this patient showed a left frontal bone fracture and a subtle underlying subdural hematoma. These required no therapy. The rate of abnormal findings on CT scans was significantly lower in the 71 patients in whom acute neurologic deficits had resolved than in the other 1447 patients who underwent CT for other reasons (chi 2: p < .001). CONCLUSION. Immediate cranial CT is not indicated in the evaluation of patients with resolved neurologic deficits, except possibly when the patient has a history of trauma.
PMID: 8079865, UI: 94361005
J Emerg Med 1994 Sep-Oct;12(5):597-601
Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts 02115.
The efficacy of using unenhanced head computed tomography (CT scans) as a routine screening procedure prior to lumbar puncture in the emergency department is studied retrospectively by comparing opening pressure during lumbar puncture to CT scan diagnosis in 42 patients. No correlation was found between CT scan findings and opening pressure.
PMID: 7989684, UI: 95081517
Am Surg 1994 Jul;60(7):533-5; discussion 535-6
Department of Surgery, Wright State Univeristy School of Medicine, Dayton, Ohio.
Routine cerebral CT scanning of patients with minor head injuries has been advocated as a screening procedure for hospital admission. The purpose of this study was to determine whether there were characteristics of the trauma patient with a minor head injury. Glasgow Coma Scale (GCS) of 13-15, that would predict a positive cerebral CT scan. An analysis of 200 patients with potential head injuries transported to our regional trauma center was performed. The following characteristics were analyzed as possible predictors: scene GCS (SC-GCS), emergency room GCS (ER-GCS), a change in GCS from scene to emergency room, loss of consciousness (LOC), and focal neurological deficit. Forty-eight per cent (96/200) of the patients underwent CT scanning of the head. CT scans were positive in 4 per cent (8/200) of the total group and 8.3 per cent (8/96) of those who underwent CT scanning. In the patients without LOC and ER-GCS of 13-15, all CT scans were negative (95% confidence interval 0.0% to 3.4%). In the 93 patients with LOC, eight patients had a positive scan (P < 0.001). Of the nine patients who sustained a skull fracture, five had a positive CT (55.6%; 95% confidence interval 21.2% to 86.3%) (P < 0.0001). Of all the patients with positive CT scans, two underwent emergent craniotomy: one for a depressed skull fracture with underlying contusion, the other for a temporal bone fracture and an epidural hematoma. Both patients had LOC and SC-GCS and ER-GCS of 15.
PMID: 8010569, UI: 94279950
Ann Emerg Med 1994 Jun;23(6):1271-8
Department of Radiology, Jewish Hospital, Washington University Medical Center, St Louis, Missouri.
STUDY PURPOSE: To determine the ability of clinicians to predict the results of emergency head computed tomography (CT) scans. METHODS: Clinicians requesting cranial CT scans from the emergency department prospectively filled out a form detailing their patients' complaints, possible diagnoses, and the likelihood of finding those diagnoses on CT. The results of the scans were catalogued according to diagnosis and classified as acutely abnormal, chronically abnormal, or normal. RESULTS: Analysis of 536 consecutive patients showed a significant direct correlation between clinical prediction of CT abnormality and scan results. No definite differences in the ability to predict scan results were observed among different physician training levels. Thirty-six patients had acute abnormalities on CT despite a clinical prediction of remote or low likelihood. CONCLUSION: Although clinical predictions of CT abnormality correlate with actual CT results, the correlation is not adequately refined to rely on for selection of patients for emergency cranial CT scans.
PMID: 8198300, UI: 94256681
Ann Emerg Med 1994 May;23(5):1127-31
Department of Emergency Medicine, Highland General Hospital, Oakland, California.
We report the cases of three patients with subdural hematoma following minor closed-head trauma in whom the initial neurologic examinations and cranial computed tomography (CT) scans were normal. In each case, the patient was re-evaluated clinically several times (average of four times) due to persistence of post-traumatic symptoms. The development of focal neurologic signs, which eventually led to a correct diagnosis, was significantly delayed in all three cases (average of 47 days). All three patients had large subdural hematomas requiring surgical drainage. The timely diagnosis of subdural hematoma may be difficult despite the appropriate use of CT scan in the immediate post-traumatic period. Repeat CT scan may be indicated in patients suffering minor head trauma with persistent symptoms. These patients seem to recover without deficit following neurosurgical treatment despite a significant delay in diagnosis.
PMID: 8185112, UI: 94241456
Acad Emerg Med 1994 May-Jun;1(3):227-34
Department of Emergency Medicine, Highland General Hospital, Oakland, CA 94602, USA.
OBJECTIVE: To determine whether clinical parameters and neurologic scores can be used to guide the decision to obtain computed tomography (CT) head scans for ethanol- intoxicated patients with presumed-minor head injuries. METHODS: In a prospective cohort analysis, 107 consecutive adult patients who presented to a county emergency department (ED) with serum ethanol levels >80 mg/dL and minor head trauma were studied. Commonly used clinical variables were determined for each patient. Each patient also underwent an abbreviated neurologic scoring examination and a Glasgow coma scale (GCS) score evaluation at the time of presentation and one hour later, after which a cranial CT scan was done. For purposes of analysis, patients with and patients without intracerebral injuries visible on CT scans of the head were compared. RESULTS: Nine of 107 patients (8.4%; 95% confidence interval [CI] = 3.9-15.4%) had CT scans that were positive for intracerebral injury. Two patients (1.9%; 95% CI = 0.2-6.6%) needed craniotomy. Five patients had hemotympanum and two patients had bilateral periorbital ecchymosis, but CT scans were negative for intracerebral injury in these patients. There was no statistically significant difference between the patients with and without CT scan abnormalities, based on the clinical variables, the GCS scores, or the abbreviated neurologic scoring examinations at presentation or at one hour. CONCLUSION: The prevalence of intracerebral injury in CT scans of ethanol-intoxicated patients with minor head injuries was 8.4%. Commonly used clinical parameters and neurologic scores at presentation and one hour later were unable to predict which patients would have intracerebral injuries and evidenced by CT scans. Our low (1.9%) neurosurgical intervention rate supports the need to develop a selective approach to CT scanning in this population.
PMID: 7621201, UI: 95346650
J Accid Emerg Med 1994 Mar;11(1):25-31
Department of Public Health Medicine, Brighton General Hospital.
This paper reports a retrospective criterion based audit which reviewed head injury management in two accident and emergency (A&E) departments. Management was compared with regionally agreed criteria for ordering a skull radiograph (SXR) and a computerized tomogram (CT scan) and for admission, and the quality of medical documentation was assessed. A total of 158 patients were reviewed and 132 patients (84%) satisfied the three key areas of recommended head injury management. Failures to satisfy recommended guidelines were present in 19 patients (12%) for SXR, four (2%) for admission and three (2%) for CT scanning. Three skull fractures (two in young babies) would have been missed if the criteria had been adhered to strictly. There was one adverse outcome when a patient who should have been admitted returned to A&E 8 days after initial attendance with a subdural haemorrhage and died shortly afterwards. Apart from 'loss of consciousness', the quality both in content and legibility of the medical documentation was poor. The result of 84% correctly managed patients may be over-optimistic according to the criteria used. Although criteria have a valuable role to play, there are problems with prescriptive standard setting. A recommendation was made to develop a head injury pro forma to address the poor quality medical documentation and it was also recommended that the SXR, CT scan and admission criteria for babies and young children be reviewed.
PMID: 7921546, UI: 95005770
AJNR Am J Neuroradiol 1994 Feb;15(2):351-6
Department of Radiology, University of New Mexico School of Medicine, Albuquerque 87131-5336.
PURPOSE: To compare CT and MR in the evaluation of acute head injury. METHODS: One hundred seven consecutive patients who were referred to the emergency department and underwent both MR and CT cranial examinations within 48 hours were retrospectively reviewed. The films were interpreted by two neuroradiologists blinded to all patient information. RESULTS: The sensitivity of MR was significantly higher than that of CT for the detection of contusion, shearing injury, subdural and epidural hematoma, and sinus involvement. The sensitivity of CT was significantly higher than that of MR for the evaluation of fracture. The sensitivities of MR and CT were statistically equivalent for the detection of superficial soft-tissue injury. The overall sensitivity of MR for the detection of abnormalities in acute head trauma was 96.4%, and for CT was 63.4%. CONCLUSIONS: CT and MR are complementary studies in the evaluation of acute head trauma. MR is necessary to define or exclude contusions, deep shearing injury, and extraaxial fluid collections in acute head trauma.
PMID: 8192085, UI: 94249611
NIDA Res Monogr 1994;138:161-73
Division of Nuclear Medicine, UCLA School of Medicine, Harbor-UCLA Medical Center, Torrance 90509, USA.
In summary, these data suggest that widespread primary or secondary cerebral vasoconstriction is common in patients with neurological complications from cocaine. In most patients, SPECT showed wide-spread hypoperfusion in regions that had no clear clinical significance (e.g., the periventricular area). In many, the SPECT was performed more than 24 hours after the onset of neurological symptomatology. These findings raise several questions. It has been assumed that these SPECT changes in patients with acute neurological symptoms are temporary, although it will be important to determine whether these areas of hypoperfusion persist after symptoms have abated. Recently, Holman and colleagues (1991) found multifocal and deep areas of hypoperfusion with SPECT in 16 of 18 patients with a history of chronic cocaine abuse. Although most of the subjects tested positive for cocaine, several had abstained from cocaine use for weeks prior to the study. All 18 subjects had neuropsychological deficits, 13 mild and 5 moderate. Similarly, Pascual-Leone and colleagues (1991) have shown that CT scan atrophy strongly correlates with the duration of cocaine abuse, suggesting that brain injury may occur with continued use of cocaine. It is the authors' concern that cocaine abuse might produce permanent changes in cerebral perfusion. In conclusion, brain SPECT was found to be a useful procedure in the evaluation of acute cocaine intoxication. Brain SPECT revealed focal cortical lesions not seen on head CT or MRI, which corresponded to clinical deficits. In addition, [99mTc]HMPAO brain SPECT had a characteristic scalloped appearance, and this may be a marker for acute intoxication with cocaine. This study further supports the contention that cocaine causes neurological disease by its vasoconstrictive action.
PMID: 7603541, UI: 95327163
Brain Inj 1993 Sep-Oct;7(5):425-30
Cooper Hospital/University Medical Center, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden.
The authors have investigated two commonly used methods of assessing neurological status in patients with mild head injury to determine whether they can predict intracranial damage. Of 686 such patients with cranial computed tomography (CT) scans, scan results were recorded, along with total and motor components of the Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85). Despite relatively normal admission neurological examinations, 127 of the 689 patients (18.4%) had intracranial lesions, and 38 (5.5%) required surgery. There was no significant difference in distribution of the GCS in patients with and without intracranial lesions. The RLS85 was superior to the GCS in predicting intracranial pathology, and a significant association between RLS85 and lesions on CT scanning was noted. However, even this test was normal in 19 patients found to have intracranial pathology, including nine who required surgery. The authors conclude that a normal or near-normal mental status examination in a head-injured patient on arrival at the emergency room is inadequate to exclude a potentially serious intracranial lesion. It is unlikely that further refinements in the clinical evaluation will result in diagnostic accuracy comparable with that of CT scanning. Accordingly, we recommend that any patient who has suffered a loss of consciousness or amnesia following head injury have an urgent cranial CT scan.
PMID: 8401484, UI: 94004840
Infect Control Hosp Epidemiol 1993 Aug;14(8):491-9
Hospital Epidemiology and Quality Improvement, Children's Hospital, Boston, MA 02115.
Computed tomography (CT) imaging plays an important role in the acute evaluation and management of children with head trauma. When routine quality improvement (QI) meetings with representatives from the Children's Hospital radiology and emergency departments revealed disagreement regarding the utilization and appropriateness of CT in children presenting with head trauma, an interdepartmental QI team was formed to address this issue. Because formal criteria for obtaining CTs for head trauma were unavailable, internal institutional criteria were developed by consensus after literature review. Contrary to perceptions of some staff members, the majority (95%) of children who received CT met at least one of the established criteria over a one-year study period. There was little relationship between the presence of criteria and abnormal CT results, but decisions whether to admit patients to the hospital or to send them home were influenced by CT results. Follow-up studies suggested that patients who were discharged home with a normal CT or no CT had uniformly good outcomes.
PMID: 8376744, UI: 93389077
J Trauma 1993 Aug;35(2):296-300; discussion 300-2
Department of Surgery, University of Mississippi Medical Center, Jackson 39216.
Computed tomographic (CT) scanning has proved to be valuable in evaluating the head and abdomen of victims of blunt trauma; CT scans of the thorax often are obtained on patients with blunt torso trauma, but their value for this purpose is unclear. We conducted a prospective study to evaluate the role of chest CT scanning in thoracic trauma. Hemodynamically stable patients at least 18 years old with an estimated Abbreviated Injury Scale--Thorax score of 2 or greater underwent a contrast-enhanced CT scan of the chest, usually in conjunction with CT scans of the head, abdomen, or both. Thirteen patients were dead on arrival, 14 required emergency surgical procedures, and 13 were too unstable to undergo chest CT scan. Thirty-three patients were not included because they refused to participate or the protocol was not followed. Forty-six men (69%) and 21 women with a mean age of 42.7 years completed the study. Sixty-one were injured in motor vehicle crashes, four were injured in falls, and one each was injured by assault and by crushing forces. Injury Severity Scores ranged from 4 to 45, with a mean of 20.5. Four patients died (6%), three from head injury and one from multiple organ dysfunction. Chest roentgenography (CXR) was superior to CT scanning in identifying rib fractures, but CT scanning was more sensitive than CXR for pneumothorax, fluid collections, and infiltrates (p < 0.001); CT scanning also was more specific for aortic injury. Despite this quantitative superiority, the abnormalities missed by CXR but identified by CT scanning infrequently led to a change in management.
PMID: 8355312, UI: 93360312
J Trauma 1993 Aug;35(2):271-6; discussion 276-8
Department of Surgery, University of California, Davis, Medical Center, Sacramento 95817.
Setting priorities in the management of patients with suspected injuries to both the head and the abdomen is difficult and depends on the likelihood of different injuries. Eight hundred trauma patients were retrospectively reviewed to determine the likelihood of a surgically correctable cerebral injury. All 800 patients, at the time of initial evaluation, were thought to have potentially correctable injuries to both the head and the abdomen. Of these, 52 had a head injury requiring craniotomy; 40 required a therapeutic celiotomy. Only three patients required both craniotomy and therapeutic celiotomy. There were more cases of delay in therapeutic celiotomy because of negative results of computed tomographic (CT) scanning of the head (13 cases) than there were delays in craniotomy because of nontherapeutic celiotomy (four cases). Need for craniotomy, based on emergency department evaluation, was indicated by the presence of lateralizing neurologic signs. Low Glasgow Coma Scale score, anisocoria, fixed/dilated pupils, loss of consciousness, facial or scalp injuries, and age were of no independent value in predicting the need for craniotomy. CONCLUSIONS: Patients with surgically correctable injuries of both the head and the abdomen are rare. In stable patients with altered mental status and potential injuries to both the head and the abdomen, the abdomen is best evaluated first by diagnostic paracentesis. If paracentesis does not return gross blood, CT scanning of the head should be done.
PMID: 8355308, UI: 93360308
Ann Emerg Med 1993 Jul;22(7):1114-8
Department of Emergency Medicine, University of California, Los Angeles School of Medicine, Harbor-UCLA Medical Center, Torrance.
STUDY OBJECTIVES: To determine the clinical characteristics associated with early post-traumatic seizures in children with head trauma. DESIGN, SETTING, AND TYPE OF PARTICIPANTS: Retrospective chart review; urban trauma center/pediatric emergency department. Trauma patients aged 3 months to 15 years given discharge diagnosis ICD-9-CM codes indicating head trauma and seen from 1988 to 1990 were eligible for the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 194 patients, 96% suffered blunt trauma and 53% had a loss of consciousness. Fifty-one percent of 141 computed tomography (CT) scans of the head were abnormal, most frequently demonstrating skull fractures (34%), subdural hematomas (15%), and cerebral contusions (14%). Eighteen patients (9.3%) suffered post-traumatic seizures. A loss of consciousness, a low Glasgow Coma Scale (GCS) score (3 to 8), and an abnormal CT scan were associated with post-traumatic seizures (P < .02, .001, and .02, respectively). However, only a low GCS score was predictive of post-traumatic seizures when these factors were considered simultaneously (P < .001), with 38.7% of patients with low GCS scores suffering post-traumatic seizures and 3.8% of patients with high GCS scores suffering post-traumatic seizures. In children with low GCS scores, treatment with phenytoin was associated with a decrease in post-traumatic seizures. CONCLUSION: In the pediatric head trauma patient, a GCS score of 3 to 8 appears to be predictive of post-traumatic seizures. The data from this retrospective study are consistent with the hypothesis that prophylactic phenytoin reduces post-traumatic seizures in the pediatric head trauma patient with a low GCS score.
PMID: 8517559, UI: 93297756
Am J Emerg Med 1993 Jul;11(4):321-6
Department of Emergency Medicine, Beloit Memorial Hospital, WI 53511.
We conducted a multicenter, prospective study of head-injured patients to identify high-yield clinical criteria for acute intracranial injuries. Emergency patients with a history of blunt head trauma occurring within 2 weeks and who underwent nonenhanced cranial computed tomography (CT) were entered onto the study during a 12-month period. Of the 264 patients, 32 (12%) had abnormal CT findings. Nine high-yield variables were associated with abnormal CT findings: alcohol use before injury, antegrade amnesia, prolonged loss of consciousness, anisocoria and/or fixed and dilated pupils, abnormal Babinski reflex, focal motor paralysis, cranial nerve deficit, Glasgow coma scale score of less than 15, and clinical signs of basilar skull fracture. Patients 2 years old or younger or older than 60 years of age showed a significantly greater prevalence of abnormal CT findings than patients of other ages.
PMID: 8216509, UI: 94030231
Can Assoc Radiol J 1993 Jun;44(3):189-93
Department of Radiology, Medical College of Wisconsin, Milwaukee 53226.
A retrospective study was performed at two teaching hospitals--one in the United States and one in Canada--to determine the results of computed tomography (CT) examinations of the head in patients with nontraumatic headache. Of 1111 examinations performed over a 3-year period, 120 (10.8%) demonstrated an acute intracranial abnormality, such as hemorrhage, infarction or tumour; the frequency of such abnormalities was highest among inpatients and subjects over 40 years of age. Cranial and extracranial abnormalities, such as sinusitis and metastases to the calvarium, were found in 40 (3.6%) of the cases. Chronic abnormalities, such as cerebral atrophy or remote infarction, were the most significant findings in 202 (18.2%) of the cases. The cost of finding each case of acute intracranial abnormality was $5962 (US); for subarachnoid hemorrhage among patients in the emergency department, it was $15,837 (US).
PMID: 8504331, UI: 93278566
Ann Acad Med Singapore 1993 May;22(3 Suppl):410-3
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Twenty-four cases of posterior fossa extradural haematoma constituted 4.16% of all extradural haematomas (576) and 1.12% of all craniocerebral trauma requiring surgery (2150). Five cases were excluded from this study. Of the remaining nineteen cases (the study group), lucid interval was present in eight (42.10%) cases. In half of the cases, the clinical course was acute. Neck stiffness and drowsiness were the commonest clinical signs. Occipital bone fracture was present in 57.89% cases. CT scan was the most valuable investigation in the diagnosis and detection of the associated intracranial injury in 18 cases. Associated intracranial injury was present in seven (36.84%) of these cases. Two (11.1%) of these patients died despite emergency surgery. The Glasgow Coma Scale prior to operation and the presence of associated supratentorial injuries were important prognostic factors. It is concluded that posterior fossa extradural haematoma should be suspected in the presence of a fall on the back of the head, drowsiness, neck stiffness or an occipital bone fracture.
PMID: 8215190, UI: 94028695
J Trauma 1993 Apr;34(4):555-8; discussion 558-9
Section of Neurological Surgery, Yale University School of Medicine, New Haven, CT 06510.
This study evaluated the memory and intellectual function of 32 adults following minimal brain injury. All patients had a Glasgow Coma Scale score of 15 upon evaluation in the Emergency Room, negative findings on radiographic examination, and negative history of prior neurologic disease or injury. Seventeen of these had experienced a loss of consciousness. Patients suffering a loss of consciousness postinjury obtained significantly lower mean verbal intelligence quotients than those obtained by patients who remained conscious following their accidents. Both groups exhibited memory impairments. This could indicate that loss of consciousness predicts intellectual impairment, but not degree of memory dysfunction. An alternative interpretation of these data is that patients referred for examination after a head injury that did not involve a loss of consciousness included a disproportionate number of patients from upper socioeconomic levels who have greater access to medical delivery systems or greater sophistication regarding cognitive function.
PMID: 8487341, UI: 93253827
No Shinkei Geka 1993 Apr;21(4):373-7
Department of Neurological Surgery, Nihon University School of Medicine.
A rare case of penetrating head injury caused by a nail-gun was described. A 24-year-old male was admitted to our hospital due to head injury. He had handled a nail-gun at a construction site. On admission the patient was fully conscious with no neurological defects. A small wound was observed at the left front-temporal region. Skull films showed a large nail embedded in the skull cavity. A computed tomographic (CT) scan, changing level of window, demonstrated intracerebral hematoma, fragment of skull bone and nail. Cerebral angiography (CAG) showed extravasation at the left frontal region. Emergency operation was performed and his recovery was uneventful. Twenty-two craniocerebral injuries caused by nail-guns have been reported in world medical literature but this was the first report in Japan. The characteristics of craniocerebral nail-gun injuries were less damage and better prognosis compared with gunshot injuries. However intracranial infection and vascular injury were possible lethal complications. In this case, preoperative examination, such as CT scan and CAG was valuable and the early operation for the sake of safety was very effective.
PMID: 8474595, UI: 93233885
Surg Gynecol Obstet 1993 Apr;176(4):327-32
Department of Surgery, University of Louisville School of Medicine, Kentucky.
Examination of 462 consecutive patients with blunt trauma suggested reassessment of the timing of head computed tomographic (CT) scanning in the critical care of the seriously injured. Even though potential brain injury was the most common reason for admission, few (5 percent) of the patients required neurosurgical intervention. It is apparent that the more common non-neurosurgical procedures that were used to squelch hemorrhage and provide hemodynamic stability and airway control should not be delayed to obtain "routine" head CT scans.
PMID: 8460407, UI: 93212342
Radiology 1993 Mar;186(3):763-8
Department of Radiology, Jewish Hospital, Washington University Medical Center, St Louis, MO 63110.
Charts from 1,074 consecutive emergency department patients who underwent cranial computed tomography (CT) were reviewed for predictors of a CT abnormality. Twenty-six clinical variables and the results of neurologic examination were compared with cranial CT findings. Patients with focal neurologic deficit, unresponsiveness, and hypertension had an increased risk of a CT abnormality. Blurred vision, trauma, loss of consciousness, headache, and dizziness were each associated with a lower risk of a CT abnormality. Multivariate analysis showed that only focal neurologic deficit and unresponsiveness effectively helped predict a CT abnormality. In patients with negative neurologic findings, only intoxication and amnesia were associated with greater than 10% positive scans and an increased risk for a CT abnormality. The data indicate that positive neurologic findings coupled with intoxication and amnesia would have helped detect 90.7% of the positive scans and provide an effective initial approximation strategy for selecting patients to undergo CT. Although 15 patients with positive scans (1.4%) would have been missed, this strategy would have yielded a negative predictive value of 97.3% and eliminated 53.9% of the CT scans obtained.
PMID: 8430185, UI: 93157588
J Trauma 1993 Jan;34(1):32-9
Department of Diagnostic Radiology, University of Kentucky Medical Center, Lexington 40536-0084.
We retrospectively reviewed the medical records and cervical films, computed tomographic (CT) scans, and tomographic studies of 216 consecutive patients with cervical injuries. A trauma series of roentgenograms--a cross-table lateral (CTL), a supine anteroposterior, and an open-mouth odontoid view--was performed in 100%; CT scanning was performed in 100%; and tomography was done in 9% of cases. We determined what percentage of the patients were asymptomatic initially in the emergency department; the total numbers of fractures, subluxations, and dislocations of the cervical spine in these patients; and what percentage of the cervical injuries were not detected with the plain films. Of the 216 patients in the series, 188 (87%) had known signs or symptoms of cervical injury; however, 28 (13%) of the patients were initially asymptomatic with no neurologic deficit. Of these 28, 17 were intoxicated or had mild closed head injuries; however, in 11 (5%) there was no clinical clue to their cervical injury other than a known injury mechanism. Prospectively, 67% of the fractures and 45% of the subluxations and dislocations were not detected by the CTL films, and 32% of the patients, over half of whom had unstable cervical injuries, were falsely identified as having normal spines. Prospectively, the trauma series improved the sensitivity of plain films for detecting cervical injuries but still did not detect 61% of the fractures and 36% of the subluxations and dislocations, and falsely identified 23% of the patients, half of whom had unstable cervical injuries, as having normal cervical spines.
PMID: 8437193, UI: 93172296
J Trauma 1992 Sep;33(3):385-94
Department of Surgery, Medical Center Hospital of Vermont, Burlington 05401.
The evaluation and management of patients with minor head injury (MHI: history of loss of consciousness or posttraumatic amnesia and a GCS score greater than 12) remain controversial. Recommendations vary from routine admission without computed tomographic (CT) scanning to mandatory CT scanning and admission to CT scanning without admission for selected patients. Previous reports examining this issue have included patients with associated non-CNS injuries who confound the interpretation of the data and affect outcome. We hypothesized that patients with MHI and no other reason for admission with normal neurologic examinations and normal CT scans would have a negligible risk of neurologic deterioration requiring surgical intervention. To validate this hypothesis we studied 2766 patients with an isolated MHI admitted to seven trauma centers between January 1, 1988, and December 31, 1991. There were 1898 male patients and 868 female patients; injury was blunt in 99%. A neurologic examination and a CT scan were performed on 2166 patients; 933 patients had normal neurologic examinations and normal CT scans and none required craniotomy; 1170 patients had normal CT scans and none required craniotomy; 2112 patients had normal neurologic examinations and 59 required craniotomy. The sensitivity of the CT scan was 100%, with positive predictive value of 10%, negative predictive value of 100%, and specificity of 51%. The use of CT alone as a diagnostic modality would have saved 3924 hospital days, including 814 ICU days, and $1,509,012 in hospital charges. Based on these data, we believe that CT scanning is essential in the management of patients with MHI and that if the neurologic examination is normal and the scan is negative patients can be safely discharged from the emergency room.
PMID: 1404507, UI: 93021262
J Trauma 1992 Jul;33(1):11-3
Department of Surgery, Cooper Hospital/University Medical Center, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Camden.
We reviewed the records of 1538 mild head injury patients admitted during a 4 1/2-year period to the Southern New Jersey Regional Trauma Center. All patients had experienced brief loss of consciousness or amnesia, but had a normal or near normal neurologic examination on admission, with Glasgow Coma Scale (GCS) scores of 13-15 and no focal neurologic deficit. Routine urgent cranial CT scans were obtained on all patients, and correlations between skull fractures and intracranial lesions investigated. Two hundred sixty-five patients (17.2%) harbored 340 lesions on CT scans, of which 131 were fractures and 209 were intracranial abnormalities. Fifty-eight patients needed surgery for their intracranial lesions; 23 of them had no skull fractures. None of the 1339 patients without CT evidence of intracranial lesions deteriorated under observation. We conclude that clinical observation with or without skull x-ray films is inadequate to rule out potentially dangerous intracranial lesions in apparently mild head injuries. If there is a history of loss of consciousness or amnesia, an immediate CT scan is indicated. If the results of the CT scan are normal and there are no other indications for admission, these patients may be safely discharged.
PMID: 1635094, UI: 92341394
J Emerg Med 1992 Jul-Aug;10(4):439-43
Ft. Richardson, Alaska.
A 2 1/2-year-old child presented to the emergency department with a wooden stick lodged firmly in her right nares. No nasal discharge or neurological abnormalities were noted at presentation. After plain radiographs failed to demonstrate any evidence of a foreign body, computed tomography (CT scan) was obtained that revealed a hypodense region in the right frontal lobe corresponding to the projected tract of the branch. The patient underwent a right frontal craniotomy with debridement of her contused right frontal lobe. She was discharged 8 days postoperatively without evidence of neurologic sequelae. This case illustrates an unusual presentation of intracranial penetration, with only six similar cases found in the literature. It also highlights the need for the emergency physician to be concerned about intracranial penetration when treating intranasal foreign bodies, particularly those of the nonmetallic type. The literature is reviewed regarding transnasal intracranial penetration by wooden foreign bodies.
PMID: 1430981, UI: 93056322
South Med J 1992 Apr;85(4):348-50
Emergency Medicine Division, St. Louis University Hospital, Mo. 63110-0250.
We retrospectively reviewed 89 noncontrast computerized tomographic scans of the head in trauma patients to determine whether a single midline image could reliably identify intracranial lesions significant enough to warrant emergency surgery. We found that a midline cut was able to detect 92% of all lesions for which emergency neurosurgical evacuation was considered necessary, though it detected only 71% of the more subtle abnormalities.
PMID: 1566132, UI: 92229537
J Neurosurg 1992 Mar;76(3):435-9
Department of Neurosurgery, Taipei Municipal Chung Hsiao Hospital, Taiwan, Republic of China.
The authors review the seizure incidence in 4232 adult patients with mild closed head injury who did not receive prophylactic anticonvulsant agents. One hundred patients (2.36%) experienced seizures within 1 week after head injury; 43 of these (1.02% of the series) had seizures within 24 hours after trauma. Most of the seizures (84%) that developed during the 1st week after injury were of the generalized tonic-clonic type. The incidence of generalized tonic-clonic seizures was higher than that of partial seizures with motor symptoms both within 24 hours (91% vs. 9%) and during the Day 2 to 7 period (79% vs. 21%). No definite intracranial pathological findings were detected by computerized tomography (CT) in 53% of patients with early posttraumatic seizures; six patients had intracranial hemorrhage without intracranial parenchymal damage (three with epidural hematoma and three with subarachnoid hemorrhage). The most common positive CT findings in the early posttraumatic-seizure group were intracerebral hemorrhage (24%), followed by acute subdural hematoma with intracerebral hemorrhage (17%). Intracerebral parenchymal damage could be identified on CT scans in 41 (48.8%) of 84 patients with generalized tonic-clonic seizures and five (31%) of 16 patients with partial seizures with motor symptoms. The intracerebral parenchymal damage was most commonly detected in the frontal lobe (21%) and the temporal lobe (19%). Seven patients with early posttraumatic seizures received emergency craniotomy to remove an intracranial hematoma (epidural in three, subdural and intracerebral in four) because the mass effect resulted in significant midline shift as seen on CT scans. This review suggests that early posttraumatic seizures after mild closed head injury have a high incidence (53%) in patients with normal CT scan findings. Although the possibility of surgically correctable intracranial hemorrhage is low (7%), the condition may be devastating if not treated properly.
PMID: 1738023, UI: 92148524
J Trauma 1992 Mar;32(3):359-61; discussion 361-3
Department of Surgery, Hahnemann University School of Medicine, Philadelphia, Pennsylvania 19107-1192.
During 1987 and 1988, the trauma service at Hahnemann University Hospital, a level I trauma center, evaluated 1,875 consecutive patients. Four hundred ninety-seven consecutive computed tomographic (CT) scans were performed to evaluate intracranial trauma in the emergency department. These patients' records were reviewed to determine the adequacy of loss of consciousness, amnesia, Glasgow Coma Scale (GCS) score, and mechanism of injury in predicting intracranial findings. In 302 patients with a GCS score of 13 or greater, 55 (18%) CT scans showed abnormal findings. Eleven (4%) of these patients required neurosurgical intervention. Furthermore, patients with normal CT scans required no interventions for head trauma. Mechanism of injury directly influenced the incidence of neurosurgical intervention. Current bedside methods to evaluate patients for possible intracranial injury in our trauma patient population are inadequate. Emergency department CT scans should be performed on all patients referred to the trauma service with previously classified mild- or low-risk criteria for intracranial trauma, regardless of GCS score.
PMID: 1548725, UI: 92194376
Radiology 1991 Dec;181(3):711-4
Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104.
A survey was conducted to determine the extent to which skull radiography continues to be used for the evaluation of head trauma. Of 53 hospitals with emergency departments and computed tomography (CT) available full time, only 6% (n = 3) reported that skull radiographs were never a part of the evaluation of acute head injuries. At more than half of the institutions, skull radiographs were obtained always or often in cases of head trauma. High usage rates occurred at teaching and nonteaching institutions and were not related to the availability of CT or the size of the hospitals. CT was always employed in cases of severe head trauma, and skull radiography was frequently used in cases of minor injuries. Magnetic resonance imaging was rarely, if ever, used for evaluating head trauma. Skull radiography continues to be employed at a high rate for the evaluation of head trauma long after it has been demonstrated to provide little or no useful information in such cases.
PMID: 1947086, UI: 92053085
Neurol Med Chir (Tokyo) 1991 Dec;31(13):927-30
Department of Neurosurgery, Oita Nakamura Hospital.
105 patients over a 5-year period underwent emergency evacuation of traumatic intracranial hematomas. Seven (6.7%) developed delayed contralateral extracerebral hematomas (5 epidural and 2 subdural hematomas). These hematomas were insignificant or not present on initial computed tomography (CT) scan, but repeat CT scan after craniotomy showed sizable hemorrhage. In one patient, neurological deterioration heralded the delayed onset. In one case, intraoperative ultrasound imaging disclosed an epidural hematoma. Ultrasound examination is recommended in cases with a skull fracture contralateral to the initial hemorrhage.
PMID: 1726254, UI: 92285004
J Trauma 1991 Oct;31(10):1363-8
Department of Surgery, St. Mary's Hospital, Waterbury, CT 06706.
The psychological effects of nonneurologic trauma on children are poorly recognized. We hypothesized that physical trauma in children, with or without head injury, would result in substantial and persistent psychological and behavioral abnormalities. Using a short telephone survey followed by a detailed behavioral checklist, we studied psychobehavioral dysfunction in children who had experienced trauma either with or without minor head injury (n = 40 each) as well as in a comparative group of children after emergency appendectomy (n = 80). Substantial behavioral disability was identified by the detailed checklist in 35% and 28% of children without and with head injury, respectively, but in none after appendectomy. Dysfunctions included phobias, major scholastic difficulties, rage attacks, and episodic depression that continued for a long period. Even in the 67% of children who eventually fully recovered, the duration of symptoms after the time of injury was an average of 19 months. Demographics, socioeconomic status, severity of injury, and length of hospitalization did not correlate with dysfunction, and these traumatized children's siblings had no reported history of trauma or psychological difficulties. Thus, parental opinion about behavioral dysfunction appears sensitive and specific and is therefore a useful screening index. These results suggest that injured children, even after minor trauma, may suffer substantial and long-lasting behavioral changes to a degree hitherto unrecognized.
PMID: 1942144, UI: 92046191
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