mallika khwanmuang phatcharapol udomluck jitsupa litleangdej

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Mallika Khwanmuang Phatcharapol Udomluck Jitsupa Litleangdej ---------------------------------------------------------- --------- 5 th year medical students of Naresuan university, Phitsanulok , Thailand The Correlation between Mild Head Injury and Positive CT Scan of the Brain in the Patients with Moderate Risks at Naresuan University Hospital

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Mallika Khwanmuang Phatcharapol Udomluck Jitsupa Litleangdej ------------------------------------------------------------------- 5 th year medical students of Naresuan university, Phitsanulok , Thailand. - PowerPoint PPT Presentation

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Page 1: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Mallika Khwanmuang Phatcharapol Udomluck

Jitsupa Litleangdej -------------------------------------------------------------------

5th year medical students of Naresuan university, Phitsanulok , Thailand

The Corre la t ion between Mi ld Head In ju ry and Pos i t i ve CT Scan o f the Bra in in the Pat ients w i th Moderate R isks a t Naresuan Un ivers i ty Hosp i ta l

Page 2: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Magn i tude o f p rob lem Casualty due to accident is the third cause of

death following to cancer and cardiovascular disease

Head injury is the most common site (30%) of all injuries. Mortality rate of severe head injury is 29% and is increasing steadily

CT brain is gold standard for diagnosis of intracerebral hemorrhage which requires specialized instruments and only available in tertiary center

Page 3: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Magn i tude o f p rob lemThere is increasing trends of screening

patient before performing CT brain based on clinical characteristics of patient because of its availability , cost and specialist requirements .

The study objective is to define clinical characteristic criteria for screening patient who is at risk of intracerebral hemorrhage , which is insight for diagnosis , treatment , referral to reduce morbidity , mortality rate and cost for health on source section

Page 4: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Mild head injury

patients with GCS score of 13-15

Positive CT scan one that demonstrated an acute pathological state in the skull or brain attributable to head injury (Epidural hematoma, Subdural hematoma, Subarachnoid hemorrhage, Intracerebral hemorrhage, Hemorrhagic contusion, Hydrocephalus).

Basal skull fractures

Evidence of basilar skull fracture including Raccoon’s eyes: periorbital ecchymoses, Battle’s sign: postauricular ecchymoses (around mastoid air sinuses), CSF rhinorrhea/otorrhea, Hemotympanum or laceration of external auditory canal

Opera t i ona l defin i t i ons

Page 5: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Head injuryMild head injury

(GCS 13-15)Low risk criteria

Moderate risk criteria

High risk criteria

Moderate head injury(GCS 9-12)

Severe head injury(GCS ≤ 8 )

Gap of Knowledge

Page 6: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Research Quest ion

Clinical characteristic findings for abnormal CT brain results

Page 7: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Li terature ReviewThe relevant literature contains many studies

on the use of CT scan in patients with minor head injury, yet no consensus has been reached.

Page 8: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Li terature ReviewA study by Haydel et al. suggested that CT

scan is indicated only in patients with minor head injury with any one of seven risk factors, the New Orleans Criteria. A similar study by Stiell et al. identified a different set of factors, the Canadian CT Head Rule. Both decision rules had 100% sensitivity for identifying patients with traumatic brain injury, but both rules had low specificities.

Page 9: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Li terature ReviewServadei et al. classified patients with minor

head injury as low-, medium-, or high-risk They evaluated patients with a GCS score of 15 requiring surgical intervention in these patients as 0.2%.

Patients with one or more of these four symptoms (temporary loss of consciousness, amnesia, vomiting, or widespread headache) were classified as medium-risk head injury, and the risk of intracranial hemorrhage in these patients was determined to be 1–3%. They recommended CT scan for medium-risk patients.

Page 10: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Object ive1. Define definitive clinical characteristics

associated with abnormal computed tomographic scan finding in mild head injuries

2. Guideline for appropriate requirement to perform CT brain

3. Guideline for management and referral

Page 11: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Advantages 1. Can predict clinical characteristics of

patients at risk for intracerebral hemorrhage in mild head injuries

2. Can reduce cost for health on source section for performing CT brain

3. Can discharge patients with mild head injuries who do not require CT brain and with no consequences after discharge

Page 12: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

MethodsRetrospective cohort studies

Mild head injury + Moderate risks

+ CT scanModerate risksYes

Abnormal CT

Normal CT

NoAbnormal CT

Normal CT

Page 13: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Reference populationInclusion criteria Patients treated at the emergency

department between January 1, 2008 and May 31, 2011

Mild head injury (GCS score of 13 to 15) CT performed within 3 hours of the admit

Page 14: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Inclusion criteria Moderate risk criteria

Significant subgaleal swelling Post traumatic seizure Retrograde amnesia Alcohol consumption Basal skull fractures Serious facial injury Loss of consciousness Vomiting Progressive headache Multiple traumas

Reference population

Page 15: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Exclusion criteria Bleeding disorder or used anticoagulants

Coumadin Spontaneous intracerebral hemorrhage

Idiopathic thrombocytopenic purpura Leukemia Stroke

Reference population

Page 16: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Data were collected on patient characteristics (age, sex time of injury), mechanisms of trauma and CT scan findings.

Data were analyzed with chi-squared tests.The research ethics committees of the

study hospitals approved.

Methods

Page 17: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Results Medical charts of 64 males and 45 females. An average age of 17-60 years. Mechanisms of trauma were motorcycle

accident, 74; fall 21; and other, 12. Initial CT scan was performed on all 109

patients. Abnormal findings were identified in 28

(25.7%).

Page 18: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

7%

18%

61%

14%

Traumatic findings at CT

Hemorrhagic con-tusion

Traumatic sub-arachnoid hemor-rhageSubdural hematoma

Epidural hematoma

Traumatic findings at CT

Page 19: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Signifi

cant

subg

aleal

swell

ing

Post t

raum

atic s

eizur

e

Retrog

rade

amne

sia

Alcoho

l or d

rug i

ntox

icatio

n

203

65

35

9 114 9

Correlation between moderate-risk criteria and initial abnormal CT scan

in all patientsNumber of patients Abnormal CT scan number

Correlat ion between moderate-r isk cr i ter ia and in i t ia l abnormal CT scan in a l l pat ients

Page 20: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Basal

skull

frac

ture

s

Serio

us fa

cial in

jury

Loss

of co

nscio

usne

ss

Vomitin

g

16 15

68

277 3

219

Correlation between moderate-risk criteria and initial abnormal CT scan

in all patientsNumber of patients Abnormal CT scan number

Correlat ion between moderate-r isk cr i ter ia and in i t ia l abnormal CT scan in a l l pat ients

Page 21: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Univariable analysis from this study was found that age and sex were not significant risk factor associated with intracranial hemorrhage

Clinical characteristics that had significant associated with abnormal CT brain scan (p<0.05) was significant subgaleal swelling

Discussion

Page 22: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

All patients who had significant subgaleal swelling were found that accompanied with other symptoms.

Therefore, we used the Crude analysis to find the potential confounder by choose co-symptoms which had p-value<0.2.

There were loss of consciousness, basal skull fracture, and multiple traumas. But, from analysis, these symptoms did not affect the relation.

Discussion

Page 23: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

We cannot certainly conclude that the patients who had subgaleal swelling symptom were also associated with abnormal CT brain scan everyone. Because of Small size of sample Incomplete medical record some patients did not perform the CT brain scan

Discussion

Page 24: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

This research was studied only at Naresuan university hospital that can not refer to another population of patients with mild head injury.

Design of this study would be better in prospective cohort study design

Suggestion

Page 25: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Patients with mild head injury who had significant subgaleal swelling and other symptoms which were risk to intracranial hemorrhage should perform computed tomography brain scan.

Current study findings demand future researches in larger population by prospective cohort study design in the future.

Conclusion

Page 26: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

Bahner J, Don R, Stein S, Ross S. The value of computed tomographic scans in patients with low-risk head injuries [Online]1990 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/073646799190431E.

Cattamanchi S, Siva A, Raja A, Thiagarajan NR, Trichur RV. 86: Comparison of the Canadian CT Head Rule and the New Orleans Criteria In Minor Head Injury Patients With Glasgow Coma Scale 15/15.[Online]2010 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0196064410007134.

de Andrade AF, de Almeida AN, Bor-Seng-Shu E, Lourenço L, Mandel M, Marino JR. The value of cranial computed tomography in high-risk, mildly head-injured patients.[Online]2006 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0090301905007937.

Falimirski ME, Gonzalez R, Rodriguez A, Wilberger J. The need for head computed tomography in patients sustaining loss of consciousness after mild head injury. [Online] 2003 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12855873 2003

Havdel M, Preston C, Mills T, al. e. Indications for computed tomography in patients with minor head injury [Online]2001 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S073567570180111X.

References

Page 27: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

References Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce

head CT scan ordering for minor head trauma patients.[Online]1997 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S0736467997000711.

Murshid WR. Management of minor head injuries: admission criteria, radiological evaluation and treatment of complications.[Online]1998 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9522909.

Ratanalert S, Kornsilp T, Chintragoolpradub N and Kongchoochouys. The impacts and outcomes of implementing head injury guidelines: clinical experience in Thailand. [Online] 2007 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17183038

Royal college of surgeons of Thailand. Head injury. [Online] 2008 [cited 29 July 2554]. Available from: http://www.surgeons.or.th/view.php?group=8&id=208

References

Page 28: Mallika Khwanmuang  Phatcharapol Udomluck  Jitsupa Litleangdej

References Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, et al.

External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury.[Online]2005 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16189365.

Stein SC, Ross SE. Mild head injury: a plea for routine early CT scanning.[Online]1992 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1635094.

Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. . [Online] 2001 [cited 29 July 2554]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11356436

Süleyman Türedi MD , Altug Hasanbasoglu MD, Abdulkadir Gunduz MD ,Mustafa Yandi MD. Clinical Decision Instruments for CT scan in Minor Head Trauma. [Online] 2008 [cited 29 July 2554]. Available from: http://www.sciencedirect.com/science/article/pii/S0736467907006117

References

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References Voss M, Knottenbelt J, PEEDEN M. Patients who reattend after head

injury: A high-risk group [Online]1995 [cited 29 July 2554 ]. Available from: http://www.sciencedirect.com/science/article/pii/S073646799785175X.

Yavuz MS, Asirdizer M, Cetin G, Gunay Balci Y, Altinkok M. The correlation between skull fractures and intracranial lesions due to traffic accidents.[Online]2003 [cited 29 July 2554 ]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14634472.

กองพฒันาการจราจรและบรกิารประชาชนสำานักงานตำารวจแห่งชาติ, เอกสารประกอบโครงการสมัมนาการกวดขนัวนัิยจราจรและลดอุบติัเหตทัุ่วประเทศ. 2008.

ดำานาคแก้ว, ก., การบาดเจบ็รุนแรงจากอุบติัเหตขุนสง่ พ.ศ.2550. 2008, สำานักระบาดวทิยา กรมควบคมุโรค กระทรวงสาธารณสขุ.

อัตราตายปรบัฐานอายุ (age-adjusted death rate) ต่อประชากร 100,000 คน ด้วยกลุ่ม โรคหัวใจ หลอดเลือด กลุ่มโรคมะเรง็ และการบาดเจบ็ และโรคในกลุ่มโรคหัวใจหลอดเลือดและ โรค เบาหวาน ปี 2539-2548. 2548, ศูนยข์อ้มูลโรคไมติ่ดต่อ สำานักโรคไมติ่ดต่อ กรมควบคมุโรค

กระทรวงสาธารณสขุ.

References