Recomendados
Más contenido relacionado
Destacado
Destacado (20)
Similar a Ct head, nz_guidelines,_ed_presentation
Similar a Ct head, nz_guidelines,_ed_presentation (11)
Más de chricres
Más de chricres (20)
Ct head, nz_guidelines,_ed_presentation
- 1. Head trauma: When to CT adults and kids in ED NZ guidelines Anna Waterfield ED RMO June 2014
- 2. Alternative guidelines ● Canadian CT head rules Stiell IG et al, Ann Emerg Med 2001 ● New Orleans Haydel et al, NEJM 2000 ● NEXUS II Mower et al, J Trauma, 2005 ● PECARN Lancet 2009
- 3. Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation, ACC evidence- based best practice guideline summary, March 2007, updated 2013 NZ Guidelines ● NZ Guidelines Group, ACC funded ● Includes pre-/post-hospital care ● Clinically significant: ‘need for intervention/care/support’ ● Classification: Severity of TBI GCS Mild 13-15 Moderate 9-12 Severe 3-8
- 4. Traumatic Brain Injury Acute brain injury for external force with one or more of: ● Confusion or disorientation ● Loss of consciousness ● Post-traumatic amnesia ● Focal neurological signs ● Seizure ● Intracranial lesion 4
- 5. When to CT adults Any TBI TBI + LOC/anterograde amnesia GCS<13/GCS 13-14 2h post- injury Age >65 Any deterioration in GCS Coagulopathy Suspected open/depressed/basal # High risk MOI e.g. pedestrian vs car, ejected from vehicle, fall > 1m / 5 stairs Seizure (unless recovery is prompt and complete) Focal neurology >1 vomit Retrograde amnesia >30min .“The decision to CT scan should be applied regardless of the influence of intoxication”
- 6. When to CT kids 0-16 years <2 years – additional risk factors Post-injury adverse features e.g. focal neurology/seizure (except immediate seizure) Occipital/temporal/parietal soft tissue injury – swelling/haematoma GCS<13 or any decrease Skull # NAI Fall >1m or >5 stairs (less if younger) Lethargic/irritable
- 7. 7
- 8. 8
- 9. Repeat CT in adults/kids? ● New severe/increasing headache or persistent vomiting ● New agitation/abnormal behaviour ● >30 min 1 point drop in GCS ● >2 GCS points drop ● New/evolving neurology ● First CT NAD + GCS<15 after 24h
- 10. Summary ● All guidelines similar ● Instinct ● Resources incl. seniors/specialists ● Beware: ◦ Iatrogenic anticoagulation ◦ Infants ◦ Insidious deterioration ◦ Intoxication
Notas del editor
- National Emergency X-radiography Utilisation Study II Various trials comparing decision rules for detecting significant intracranial injury – all have sensitivity 97-100%, specificity low (Canadian & NEXUS ~50%, Orleans 10-30%) MDCalc, Life in the Fast Lane, ALiEM (Academic Life in Emergency Medicine) PECARN – paediatric emergency care applied research network low risk clinical decision rules
- Traumatic brain injury Long document from July 2006 but shorter summary from March 2007 helpful
- High risk mechanism of injury: pedestrian struck by motor vehicle, occupant ejected from a motor vehicle, fall from a height of >1 metre or >5 stairs. Open # - bone exposed through broken skin. Basal # - haemotympanum, Battle’s (mastoid ecchymosis, middle cranial fossa #, extravasation of blood along posterior auricular artery, may only develop after a few days), raccoon eyes (purple discoloration around eyes, frontal #), CSF oto/rhinorrhoea.
- Paeds GCS – Eyes: none/pain/voice/spontaneous; Motor: none/extension/flexion/withdraws/localises/obeys command; Verbal: grimace to pain: none/mild/vigorous/less than usual/normal OR verbal: none/moans/cries inappropriately/reduced or irritable cry/usual
- Consider MRI if last point applies Consider repeat CT if any of the above