HEAD TRAUMA


I. Classification approaches for head injuries

  1. Several schemes exist; most based on presence and/or duration of loss of consciousness, confusion, and/or amnesia.
  2. "Minimal head injury" = No LOC or other neurologic alteration
  3. "Minor Head Injury" a.k.a. "Concussion" = History of LOC, amnesia, or disorientation but Glasgow Coma Scale (GCS) 13-15.
    1. Some of these patients will turn out to have intracranial hematomata requiring neurosurgical intervention (craniotomy).
    2. 80-90% will have resolution of symptoms over 2wks but some may have persistent symptoms for months or even years
    3. Neuroimaging generally shows no abnormalities
  4. Another scheme, from Nelson et al. (Phys Sportsmed 12:103, 1984)
    1. Grade 0: no initial confusion, subsequent c/o HA and difficulty concentrating
    2. Grade 1: "Stunned or dazed" initially but < 1 min, no LOC or amnesia
    3. Grade 2: "Stunned or dazed" > 1 min, no LOC, may have amnesia, irritability, HA, dizziness, or tinnitus
    4. Grade 3: LOC < 1 min but not comatose; grade 2 sx after regaining consciousness
    5. Grade 4: LOC > 1 min but not comatose; grade 2 sx after regaining consciousness

II. Decision rules for use of head CT in minor head trauma

  1. "New Orleans Criteria"
    1. Validated in a study using 520 pts 3-94yo presenting < 24h after minor head trauma (LOC with normal neurologic exam and GCS of 15). None of the pts with none of the following 7 criteria had any sig. findings on head CT; specificity of this decision rule was 25% (NEJM 343:100, 2000--AFP, JW)
  1. Short-term memory deficits (LR 15)
  2. Drug or alcohol intoxication (LR 11)
  3. Physical evidence of trauma above clavicles (LR 11)
  4. Age > 60yo (LR 3)
  5. Seizure (LR 3)
  6. Headache (LR 2)
  7. Vomiting (LR 0.2)
  1. "Canadian CT Head Rule"
    1. Validated in a study in 3,121 pts with minor head injry and GCS 15
    2. CT required if any one of the following are present:
      1. GCS < 15 at 2h after injury
      2. Suspected open or depressed skull fracture
      3. Any sign of basal skull fracture (hemotympanum, racoon eyes, cerebrospinal otorrhea or rhinorrhea, or Battle's sign
      4. 2 or more episodes of vomiting
      5. > 65yo
      6. Amnesia before impact of 30min or more
      7. Dangerous mechanism (pedestrian struck by a motor vehicle, occupant ejected from a motor vehicale, or a fall from elevation of 3' or more or 5 stairs or more)
  2. Comparisons between decision rules for minor head injury
    1. In a prospective cohort study in 1,822 adults with minor head injury and GCS of 15, all of whom underwent assessment with the New Orleans Criteria, the Canadian CT Head Rule, and head CT, both decision rules had 100% sensitivity; specificity of Canadian rule was sig. better (76.3% vs. 12.1%) for need for neurosurgical intervention; ditto for "clinically important brain injury" (specificity 50.6% vs. 12.7%) (JAMA 294:1511, 2005--abst)
    2. In a prospective cohort study in 3,181 adults with minor head injury and GCS 13-15, all of whom had head CT, the NOC had higher sensitivity than the CCHR for neurocranial traumatic findings on CT (97.7% vs. 83.4%); NOC had sig. lower specificity, however (3.0% vs. 37.2%) (JAMA 294:1519, 2005--abst)
III. Diagnosis of concussion-Sports Concussion Assessment Tool 2 ("SCAT-2", 2010)-Endorsed by multiple organizations
  1. For sideline diagnosis; No explicit cutoff though
  2. Suspect concussion with any of the following symptoms:
  1. Loss of consciousness
  2. Seizure
  3. Amnesia
  4. Headache or head pressure
  5. Neck pain
  6. Nausea or vomiting
  7. Dizziness
  8. Blurred vision
  9. Balance problems
  10. Photophobia
  11. Sonophobia
  12. Feeling of being "slowed down" or "in a fog" or otherwise vaguely unwell
  13. Confusion, or difficulty with concentration or memory
  14. Fatigue, drowsiness, or low energy
  15. Emotional instability including irritability, sadness, or anxiety
  1. Suspect concussion if memory function is impaired as assessed by ability to answer all of the following questions correctly:
  1. Where are you?
  2. Which half is it now?
  3. Who scored last in this game?
  4. What team did you play last?
  5. Did your team win the last game?
  1. Suspect concussion if, with tandem stance testing, makes more than 5 errors occur in 20 seconds
  1. Stand heel-to-toe with non-dominant foot in back, weight evenly distributed across both feet, with hands on hips and eyes closed.
  2. Count # of times athlete moves out of position
  3. Error = removing hands from hips, opening eyes, lift either foot, step, stumble, or fall.
IV. Management of Pediatric Patient with minimal or minor head injury (concussion)-Guidelines on management of sports-related concussions published in: Pediatrics  2010 Sep; 126:597.
  1. General approach to clinical management
    1. Pay attention to airway management
    2. Head CT if appropriate (see above)
    3. Consider neurosurgical consultation
  2. Predictors of abuse in children presenting with head injury
    1. In a retrospective review of 287 cases in children 1wk-6yo, the following were significant predictors of a final diagnosis of trauma by abuse: subdural hematoma, subarachnoid hemorrhage, and retinal hemorrhage (Arch. Pediat. Adol. Med. 154:11, 2000--AFP)
  3. Note that returning to play too soon puts pt at risk for "second impact sd." in which rapid cerebral edema can lead to death.  It is generally advised that athletes with concussion should not return to play the same day of injury.  
  4. Management guidelines of "minor closed head injury" in kids per AAP 1999 (Peds 104:1407, 1999--JW):
    1. "Minor closed head injury" defined as
      1. No LOC > 1min and
      2. Normal neurologic, fundoscopic, and mental status exam and no physical findings on skull fracture (hemotympanum, Battle's sign, palpable bone depression)
      3. History of seizure immediately after injury, vomiting, headache, and lethargy are allowed
    2. If no LOC, recommend:
      1. "Observation" x 24h ("regular monitoring by a competent adult who would be able to recognize abnormalities and to seek appropriate assistance")
      2. No imaging recommended
    3. If brief (< 1min) LOC occurred:
      1. "Observation" as above is recc'd, even if CT is normal
      2. Cranial CT scanning "may also be used" (imaging modality "of choice")
        1. Skull x-rays recc'd only if CT not available; may not be as sensitive for intracranial injury
        2. MRI is less sensitive than CT for acute intracranial hemorrhage
  5. Seizure prophylaxis in children with head injury
    1. In a trial in 102 children < 16yo with acute head injury and GCS < 10 (or Children's Coma Scale < 9 if < 4yo) who had NOT had a seizure randomized to phenytoin (18mg/kg then 2mg/kg Q8h x 48h) vs. placebo, over 48h observation, there was no sig. diff. in the incidence of seizure between the groups (Ann. Emerg. Med. 43:435, 2004--AFP)
IV. Predictors of serious intracranial injury in pts < 2yo-not all may need CT!
  1. Predictors of intracranial injury from a prospective study of 608 pts < 2yo presenting to an ED w/head trauma; Peds. 104:861, 1999--JW/AFP)
    1. Young age--prevalence 13% in < 3mo vs. 2% in > 12mo
    2. History of fall from > 3ft
    3. Scalp hematomas (OR 22.4)
    4. Depressed mental status (OR 4.90)
    5. Bulging fontanel (OR 22.1)
    6. Lethargy (OR 9.19)
    7. Irritability (OR 2.41)
    8. Vital signs suggestive of increased intracranial pressure (OR 20.57)
    9. Not found to be sig. ass'd with risk of intracranial injury
      1. Loss of consciousness
      2. Seizures
      3. Vomiting > 1x
  2. Predictors of intracranial injury from a retrospective study of 278 pts (Arch. Pediatr. Adol. Med. 153:15, 1999--AFP)
    1. Young age--prevalence 29% in < 12mos vs. 4% in > 12mos
    2. Height of fall > 3ft
    3. Scalp abnormality (94% pos. predictive value!)
    4. Depressed level of consciousness
    5. NO predictive value to sz, emesis, behavior changes, and loss of consciousness!

IV. Management of adult patients with minimal or minor head injury

  1. General approach to clinical management
    1. Pay attention to airway management
    2. Head CT if appropriate (see above)
    3. Consider neurosurgical consultation
  2. Corticosteroids for prevention of complications of head injury
    1. 10,000 pts > 16yo with GCS < 15 at < 8h s/p head trauma randomized to methylprednisolone 2g bolus thn 0.4g/h x 48h vs. placebo; 2wk incidence of death was sig. higher in methylprednisolone recipients (21.1% vs. 17.9%) (Corticosteroid Randomisation After Significant Head injury ("CRASH") Trial; Lancet 364:1321, 2004--JW)
  3. Pts with normal head CT
    1. In a series of 2152 pts with "minimal head injury" (LOC or post-traumatic amnesia and GCS 14-15 in ER but no focal neurologic findings, open skull fx, or serious underlying medical disorders--Note this is not consistent with the definition above; would count as "minor head injury" in that schema), no pts with normal head CT showed any neurologic deterioration over 20h of observation (Ann. Surg. 232:126, 2000--JW)
  4. Pts with mild head CT abnormalities
    1. In a case series of 202 pts > 16yo presenting to an ED with " minimal head injury" (LOC and/or posttraumatic amnesia and GCS 14-15) and an intracranial injury on initial CT but not felt on neurosurgical consult to require immediate neurosurgical intervention, all of whom had repeat CT at 24h, none of those pts with normal or improving neurological exam at 24h required neurosurgical intervention (Am. J. Surg. 187:338, 2004--AFP)
(Sources include Core Content Review of Family Medicine, 2012)