Paul Reading Maurice Curtis, Andrew Naylor, Richard Faull ... - ACNR

More documents

Recommendations

Info

Neurosurgery ArticleThe National Institute of Clinical Excellence Head InjuryGuidelines: A Summary to Assist ImplementationThe National Institute for Clinical Excellence guidelinesaim to improve the quality of healthcare. Theyprovide evidence based recommendations for thetreatment and care of patients with specific disorders. Theguidelines can be used to develop standards of care andprovide a useful tool for auditing clinical practice. In2003, NICE first published guidelines for the managementof head injured patients (Clinical Guideline 4). 1 InSeptember, 2007, an extensive update including amendmentsto existing advice and new recommendations waspublished (CG 56). 2 The guidelines and the update werecompiled by a large panel of interested parties after anexhaustive review of the available literature. This paperaims to summarise the features of head injury care as recommendedby the guidelines.The objective of care for head injured patients is toensure timely recognition and treatment of significantinjuries in an appropriate healthcare setting. The NICEguidelines have led to a shift in management from an“admit and observe” strategy to a “diagnose and decide”approach. The guidelines provide advice on pre-hospitalmanagement, assessment in the emergency department,investigation for brain and cervical spine injuries (seeBox 1 – CT head imaging in adultsCT Head Imaging in adultsImmediate CT (within 1 hour of request):GCS 30 minAge >65 years if any amnesia or loss of consciousnesssince the injuryDangerous mechanism if any amnesia or loss ofconsciousness since the injury (e.g. pedestrian orcyclist hit by motor vehicle; ejected vehicleoccupant; fall >1m or 5 stairs)Box 2 – CT head scanning in childrenCT Head in Children (under 16):Age 5 minSeizure (with no history of epilepsy)Suspicion of open or depressed #Tense fontanelleSigns of basal skull #Focal neurological deficitBoxes 1, 2 and 3), recommendations for referral andtransfer to a neurosurgical unit (see Box 4) and guidelinesregarding the admission, care and discharge of braininjured patients (see Box 5).The key features of the guidelines include the following:• Head injured patients should be transported to a facilitywith the resources to resuscitate, investigate andprovide initial management of multiple injuries. Theinitial assessment and management should follow theprinciples of the Advance Trauma Life Support system.For patients with a GCS 3-8 the paramedic crewshould make a stand-by call to ensure that appropriatepersonnel are available to treat the patient at thereceiving hospital.Box 3Cervical Spine ClearanceIf undertaking urgent head CT the cervical spineshould also be scannedIn patients who are alert it is safe to fully examinethe neck if:• Simple rear end collision• Patient has been ambulant at any time since injuryand there is no midline tenderness• Patient can sit comfortably in emergencydepartment• Patient presents with delayed onset of neck painRequests for cervical spine radiographs in adultsand childrenFor adults and children age 10-16 years use AP,lateral and odontoid peg viewsFor children age 1m or 5 stairs; axial load; highspeed RTA; ejection from vehicle; rollover;bicycle collision; recreational vehicle)• Cervical spine status required e.g. pre-surgeryCT Cervical Spine requests in adults and children 10years or olderCT Cervical Spine should be requested if:• GCS
Neurosurgery Article• The spine should be immobilised for allpatients with GCS < 15, any history of neckpain or tenderness, any extremity paraesthesia,any focal neurological deficit or any othersuspicion of a cervical spine injury.Immobilisation should remain in place untila full assessment has been conducted (Box 3).• Immediate clinical assessment should beconducted in the Emergency Departmentfor all patients with a GCS 4 hours• Deterioration in GCS after admission• Progressive focal neurological signs• Seizure without full recovery• CSF leak• Definite or suspected penetrating injuryThe South West Neurosurgery Centrerecommends that all patients not obeyingcommands after resuscitation and imagingare discussed with on-call neurosurgical SpR.Transfer of Patients to the NeuroscienceUnit• All patients with GCS 13 kPa and PaCO2 4.5-5.0 kPareported improvements in outcome can beachieved across the board.5. Robust clinical decision tools need to bedeveloped to help predict those patientswith mild injury who are likely to developlong term sequelae.ConclusionIn summary, the NICE Head Injury Guidelinesprovide the many clinicians involved in the careof brain-injured patients with a sound foundationupon which to build patient care. The challengefor neurosurgeons is to improve the efficacyof management for patients with intracranialmass lesions and to conduct further work toestablish the best pathway of care for patientswith diffuse brain injury. Neurosurgeons are wellplaced to aid national guideline implementation.References1. CG4. Head injury: triage, assessment, investigation andearly management of head injury in infants, children andadults. http://www.nice.org.uk/nicemedia/pdf/headinjury_full_version_completed.pdf2. CG56. Head injury: triage, assessment, investigation andearly management of head injury in infants, children andadults. http://www.nice.org.uk/nicemedia/pdf/CG56NICEGuideline.pdf3. ERNIE Head injury. http://www.nice.org.uk/usingguidance/evaluationandreviewofniceimplementationevidenceernie/searchernie/resultsummary.jsp?o=109184. Sultan HY, Boyle A, Pereira M, Antoun N, Maimaris C.Application of the Canadian CT head rules in managingminor head injuries in a UK emergency department:implications for the implementation of the NICE guidelines.Emerg Med J 2004;21:420-5.Box 5 – Criteria for admission, observation,medical review and dischargeAdmission Criteria• New, significant abnormalities onimaging• GCS
Page 4 and 5: EditorialPaul Reading in the first
Page 6 and 7: Review ArticleThe Neurological Slee
Page 9 and 10: Review Articledopamine signalling t
Page 11 and 12: Rehabilitation Articleand managemen
Page 13 and 14: Rebif ® New FormulationBalancing P
Page 15 and 16: Neurophysiology Articleresults of S
Page 17 and 18: mother: 365 days a yearms patient:
Page 21 and 22: Neuropathology ArticleTable 2: Path
Page 23 and 24: A positive difference inthe early s
Page 25: Neurogenetics ArticleTable 2: The R
Page 28 and 29: Association of British Neurologists
Page 30 and 31: Neurology in IndiaMultiple Sclerosi
Page 34 and 35: Controversies in NeurologyNICE/SCIE
Page 36 and 37: Roundtable DiscussionCognitive Func
Page 38 and 39: Roundtable DiscussionIdentification
Page 40 and 41: Conference ReportRAatE 2007 - Key t
Page 42 and 43: Conference ReportThe UK Stroke Foru
Page 44 and 45: Conference ReportPREVIEW European A
Page 46 and 47: Events DiaryTo list your event in t
Page 48 and 49: Journal ReviewsEDITOR’S CHOICESte
Page 50 and 51: Journal Reviewsis likely to be for
Page 52 and 53: Book ReviewsIf you would like to re
Page 54 and 55: News ReviewHand-carried ultrasound
Page 56: COPAXONE ® (glatiramer acetate)PRE

Paul Reading Maurice Curtis, Andrew Naylor, Richard Faull ... - ACNR

Create successful ePaper yourself

Delete template?

Save as template?