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head injury

Etiology: - falls (most common in children < 13 years of age) [1] - assault, sports injury, motor vehicle accidents common among teens [2] Pathology: - subdural hematoma, epidural hematoma - subarachnoid hemorrhage - cerebral contusion - among patients with traumatic brain injury, 48% with more than one type of brain injury [1] Radiology: 1) computed tomography (head CT, non-contrast) a) Glasgow coma scale < 13 [10]; < 15 [13] b) focal neurologic deficits c) anticoagulation - routine repeat head computed tomography imaging in anticoagulated patients with a negative scan on admission is not cost-effective [11] d) severe headache [6] or persistent headache > 71 hours e) suspected skull fracture f) vomiting [6] g) dangerous mechanism of injury [6] - ejection from a motor vehicle - vehicle-pedestrian motor vehicle collision [6] - falling from height > 3 feet h) anterograde amnesia [9] i) witnessed loss of consciousness [9] j) imaging modality of choice in acute setting [6] k) sensitivity - 5% with mild head injury - 27 with moderate head injury - 65% with severe head injury [1] l) 3 clinical decision rules reduce unnecessary CT - PECARN (Pediatric Emergency Care Applied Research Network) - CATCH (Canadian Assessment of Tomography for Childhood Head Injury) - CHALICE (Children's Head Injury Algorithm for the Prediction of Important Clinical Events) [4] m) Florida Geriatric Head Trauma CT Clinical Decision Rule 2) CT angiography of the head & neck for suspected intracranial arterial injury 3) CT venography for suspected intracranial venous injury [10] 4) noncontrast maxillofacial CT, noncontrast temporal bone CT for suspected CSF leakage [10] 4) magnetic resonance imaging (MRI) Complications: - benign paroxysmal positional vertigo can result from head trauma [8] - traumatic brain injury - < 1% of older patients with initial negative head CT have delayed intracranial hemorrhage [5] - a single head injury is linked an increased risk of all-cause mortality [12] Management: - minor head injury in adults - acetaminophen - normal neurologic examination with 99.6% sensitivity for ruling out need for neurosurgery increased to 99.9% after 4-6 hours [2]* - minor head injury in children & infants - normal neurologic examination with 99.1% sensitivity for ruling out need for neurosurgery increased to 99.8% after 4-6 hours [3]* - Pittsburgh Infant Brain Injury Score to assess abusive head trauma in infants [3] - glucocorticoids worsen outcomes in severe head injury [6] * distinguish from traumatic brain injury

Related

anoxic/hypoxic encephalopathy Mayo Portland Adaptability Inventory

Specific

craniofacial trauma facial trauma; maxillofacial trauma intracranial hemorrhage pneumocephalus severe head injury skull fracture (cranial fracture) traumatic brain injury (TBI)

General

trauma

References

  1. Quayle KS et al Epidemiology of Blunt Head Trauma in Children in U.S. Emergency Departments. N Engl J Med 2014; 371:1945-1947. November 13, 2014 PMID: 25390756 http://www.nejm.org/doi/full/10.1056/NEJMc1407902
  2. The NNT: Risk Assessment: Minor Head Injury in Adults in the Emergency Department. http://www.thennt.com/risk/minor-head-injury-in-adults/ - The NNT: Risk Assessment: Minor Head Injury in Infants and Children in the Emergency Department. http://www.thennt.com/risk/minor-head-injury-in-infants-and-children/
  3. Berger RP, Fromkin J, Herman B et al. Validation of the Pittsburgh Infant brain Injury score for abusive head trauma. Pediatrics 2016 PMID: 27338699 http://pediatrics.aappublications.org/content/138/1/e20153756
  4. Babl FE, Borland ML, Phillips N et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: A prospective cohort study. Lancet 2017 Apr 11; PMID: 28410792 - Mower RW. Paediatric head imaging decisions are not child's play. Lancet 2017 Apr 11; PMID: 28410793
  5. Chenoweth JA, Gaona SD, Faul M et al. Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. JAMA Surg 2018 Feb 14; PMID: 29450470 https://jamanetwork.com/journals/jamasurgery/article-abstract/2672215
  6. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018
  7. Rincon S, Gupta R, Ptak T. Imaging of head trauma. Handb Clin Neurol. 2016;135:447-477. Review. PMID: 27432678
  8. NEJM Knowledge+ Question of the Week. Feb 19, 2019 https://knowledgeplus.nejm.org/question-of-week/1346
  9. Mori K, Abe T, Matsumoto J et al Indications for Computed Tomography in Older Adult Patients with Minor Head Injury in the Emergency Department. Acad Emerg Med. Aug 20, 2020 PMID: 32815620 https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.14113
  10. American College of Radiology (ACR) Evaluation of Head Trauma Clinical Practice Guidelines (ACR, 2021). Medscape. May 28, 2021 https://reference.medscape.com/viewarticle/951966 - Expert Panel on Neurological Imaging Shih RY, Burns J, Utukuri PS et al ACR Appropriateness Criteria Head Trauma: 2021 Update. J Am Coll Radiol 2021 May 21 PMID: 33958108 https://www.jacr.org/article/S1546-1440(21)00025-9/fulltext
  11. Borst J, Godat LN, Berndtson AE et al. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery 2021 Aug; 170:623. PMID: 33781587 https://www.surgjournal.com/article/S0039-6060(21)00117-3/fulltext
  12. Anderson P Even One Head Injury Boosts All-Cause Mortality Risk. Medscape. Jan 27, 2023 https://www.medscape.com/viewarticle/987621 - Elser H, Gottesman RF, Walter AE et al Head Injury and Long-term Mortality Risk in Community-Dwelling Adults. JAMA Neurol. Published online January 23, 2023 PMID: 36689218 https://jamanetwork.com/journals/jamaneurology/fullarticle/2800331
  13. Silverberg ND, Iaccarino MA, Panenka WJ, et al; American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group Mild TBI Task Force. Management of concussion and mild traumatic brain injury: a synthesis of practice guidelines. Arch Phys Med Rehabil. 2020;101:382-393. PMID: 31654620