You are asked to review a 48 year old man with a moderate head injury following a bicycle accident 1 hour ago.
a) What do you understand by the term moderate head injury?
b) List the major determinants of prognosis in moderate traumatic brain injury?
c) What additional factors would warrant admission of these patients to an intensive care or a high dependency unit?
A moderate head injury has a presenting coma score in the range 9 to 12 or 13, and is the best score in the absence of sedation and post non-surgical resuscitation.
a) Age > 60
b) Pupillary abnormalities
c) Presence of hypotension and hypoxia
d) CT scan abnormalities – intracranial collections, presence of traumatic subarachnoid haemorrhage
Factors warrant admission in intensive care :
i) Presence of a skull fracture,
k) influence of any drug including alcohol, anticoagulation,
l) presence of other injuries
Well, from one's feeble memory one may be able to extract the recollection that "mild" head injury is one with a GCS of 14-15, and "severe" head injury is a GCS of less than 8, which would mean that "moderate" head injury should have a GCS between 9 and 13.
The major determinants of prognosis are
- GCS on admission
- Pupillary abnormalities
- CT scan abnormalities
- Medical comorbidities
Prognosis in severe brain injury is discussed elsewhere.
What factors would warrant admission of these patients to an intensive care or a high dependency unit? Well. The semiconscious patient in general should be managed in the ICU or HDU. But more precisely, I would use the following criteria:
- Need for airway control
- Seziures and the sedating consequences of benzodiazepines
- Multiple traumatic injuries
- Multiple medical comorbidities
- Influence of illicit substances, distorting the level of consciousness and decreasing the accuracy of physical examination though incooperation.
Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.
MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.
Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.
Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.
Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.
Scherer, R., et al. "Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients." Acta anaesthesiologica scandinavica 37.4 (1993): 370-374.
Kapral, Stephan, et al. "The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism." Anesthesia & Analgesia 88.2 (1999): 402-406.