To CT head or not to CT head?

• CT head
• Special Education

To CT head or not to CT head?

Festive Edition

Laura Summerfield FY2

Teaching Format

• Basics of head injury

• Criteria for CT head

• Festive themed quiz 

Heady injury: Definition

Trauma to the head resulting in either clinical or radiological changes.

Types:

• Extradural
• Subdural
• Cerebral contusions
• Diffuse axonal injury

Extradural haematoma

Trauma-> brief LoC -> lucid period -> rapid deterioration. Convex hyperdensity  external to the dura

• middle meningeal artery damage
• often associated with a skull #

Subdural haematoma

Concave hypodensity below the dura

• Bridging vein damage: Bridging veins normally are  in the subarachnoid space, puncture the dura mater and empty into the dural venous sinuses. 
• trauma

Classification of head injury

• Mild: GCS 13 or above
• Moderate: GCS 9-12
• Severe: GCS 8 or less 

Cerebral contusions

Generally closed head injury, common mechanisms: RTA, falls, child abuse, blast injury. 

• Usually in temporal or frontal lobes. If temporal may seize
• Areas of hypodensity with some hyperdensities

Diffuse Axonal Injury

A result of rapid movement of the brain inside the skull causing shearing of the axonal tracts of the white matter. 

• Common in RTAs/falls/assault
• Features: :LoC, coma, no neuro recovery
• Can have normal CT

Let's break it down

Criteria for CT head in 1 hour:

• GCS <13 initially
• GCS <15 at 2 hours after injury/assessment
• open/depressed/basal skull #
• post-traumatic seizure
• focal neuological deficit
• More than 1 episode of vomiting since head injury

CT head within 8 hours

• Anticoagulation
• LoC or amnesia +
•  65 and over
• bleeding/clotting disorder
• dangerous mechanism of injury
• > 30 minutes retrograde amnesia immediately before injury

CT- acute bleed... what next?

REFER TO NEUROSURGEONS

But... there's a few things we can do whilst we're sorting that:

• Analgesia and anti-emetics
• Ensuring group and save have been sent
• Reverse warfarin and optimise clotting
• Neuro obs
• Check Na 

Case 1- Harry Lyme

65M Presents to SJUH under police custody 1 hour after shovel slam. His eyes are open spontaneously, speaking in full sentences and following motor commands. He has vomited once since he took the hit. When you asked him what happened he remembers all the details of the attempted burglary and has no amnesia

• PMHx: HTN, T2DM
• O/E: CN in tact, no focal neurological deficit

How urgently does Harry need a CT head?

1. Within 1 hour
2. Within 8 hours
3. No indication for imaging
4. He's a villain who doesn't deserve to be assessed

42M Buddy

Buddy has been brought to LGI after falling down the escalator at Trinity, YAS handover- 42M, seems confused- pointing at inflatable Santa saying 'I know him', and claiming to be from 'The North Pole' witnesses said fell backwards from midway up escalator about 40 minutes ago. No vomiting, remembers event, Nil PMHx. 

O/E: PEARL, eyes open spontaneously, abnormal flexing to pain

What is Buddy's GCS?

1. E4, V4, M3- GCS 11/15
2. E4, V4, M4- GCS 12/15
3. E4, V3, M4- GCS 11/15
4. E2, V4, M2- GCS 8/15

How urgently does Buddy need a CT head?

1. 1 hour
2. 8 hours
3. No indication for CT head
4. Observation and CT head if further deterioriation

33M T Grinch

Mr Grinch self-presented following a fall on the ice at around 2pm in which he fell backwards and hit his head, briefly losing consciousness. He presents 3 hours later, he states he can't remember anything from lunchtime on-wards. Nil PMHx

O/E: nil acute, no focal neurology deficit, CN in tact, no obvious external injuries

How urgently does Mr Grinch require a CT head?

1. 1 hour
2. 8 hours
3. No indication for CT head
4. Admit for observations without imaging

Billy Mack 70M

Billy has been brought to ED by his close friend, after celebrating his Christmas No 1 with a few too many drinks he fell, hitting his head on the way down. He initially LoC but now is orientated, eyes open spontaneously and follows motor commands. He complains of altered sensation... on testing sensation he 'can't feel it in his fingers, or his toes'. .

O/E: CN in tact, reduced sensation and weakness in (bit far but FN)

How urgently does Billy Mack need a CT head?

1. 1 hour
2. 8 hours
3. Not indicated
4. 4 hours

Whats the diagnosis?

1. Chronic subdural haematoma
2. Extradural haematoma
3. Axonal injury
4. Acute subdural haematoma

What's the diagnosis?

1. Acute subdural haematoma
2. Extradural haematoma
3. Axonal injury
4. Chronic subdural haematoma

What's the diagnosis?

1. Acute subdural haematoma
2. Extradural haematoma
3. Axonal injury
4. Chronic subdural haematoma

Summary

• Definition of and types of head injury

• CT head guidelines

• What we can do whilst awaiting that patient pass response