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Discharge Considerations After Minor Head Injuries

Discharge Considerations After Minor Head Injuries

In elderly patients suffering a fall, long-term anticoagulation has been shown to increase the incidence of intracranial hemorrhage (ICH) and mortality. Patients who receive treatment with anticoagulants have a higher risk for bleeding and can sometimes have serious outcomes after experiencing even relatively minor head injuries. Given the increasing number of elderly patients seen in EDs and the increase in concomitant anticoagulant use, the clinical dilemmas surrounding these patients have become more relevant. Several clinical decision rules have been created to help determine which head injury patients require a head CT scan, but these rules do not apply to anticoagulated patients. “There is some controversy surrounding the utility of head CT in allowing safe discharge dispositions for anticoagulated patients who suffer minor head injuries,” says Samuel M. Keim, MD, MS. Questions remain about whether or not a period of observation or routine serial CT scanning is warranted for these patients. A Closer Look In the Journal of Emergency Medicine, Dr. Keim and colleagues published a critical appraisal study that examined the risks of delayed ICH in anticoagulated patients with minor head injury and a normal initial head CT scan. The researchers reviewed four observational studies that investigated the outcomes of anticoagulated patients who presented to EDs after minor head injuries. In these observational studies, most patients who had a delayed ICH required no neurosurgical intervention and had no adverse outcome documented. The overall incidence of death or neurosurgical intervention ranged from 0% to 1.1% among the patients investigated. However, the studies did not clarify which patients were at highest risk. “Overall, the literature varied greatly but doesn’t support the...
New Evidence-Based Guidelines: 4 Signs of Concussion

New Evidence-Based Guidelines: 4 Signs of Concussion

The first part of new evidence-based guidelines, published in the September 2014 issue of Neurosurgery, sought to identify which signs, symptoms, and neurologic and cognitive deficits have the highest and most consistent prevalence in samples of individuals sustaining a potentially concussive event. The researchers, composed of a team led by Nancy Carney, PhD, Oregon Health & Science University, Portland, and Jamshid Ghajar, MD, Brain Trauma Foundation, New York, New York, sifted through over 5,000 studies and systematically narrowed the stack down to 26 that met their strict criteria. According to the results, the four indicators of concussion, observed in alert individuals (defined as a Glasgow Coma Scale Score, 13 to 15) after a force to the head are the following: 1. Observed and documented disorientation or confusion immediately after the event 2. Impaired balance within 1 day after injury 3. Slower reaction time within 2 days after injury 4. Impaired verbal learning and memory within 2 days after injury The main symptoms experienced by subjects with potential concussive events were headache (93%), blurred vision (75%), dizziness (64%), and nausea (61%). Other key findings from the review include: * Decrements in cognitive function decreased from 58% on day 1 to 8% on day 7, indicating that in the majority of cases, cognitive deficits resolve within 1 week. * Tests of reaction time, memory, and attention/processing speed/working memory most consistently showed deficits in cognitive function within the first week of injury. * Individuals with a history of previous concussions had lower scores on tests from baseline to 5 days after injury, compared to those without previous concussions. The research team hopes...

Uncertain Diagnosis or CT Scan Radiation?

It is so nice to be right. To summarize what I wrote 2 and 3 years ago, here and here—based on my experience, patients and families will accept the theoretical risk of a future cancer if it means they’ll get an accurate diagnosis. A new study validates that opinion. MedPage Today reports that parents of 742 children who arrived at the emergency department with head injuries were surveyed by researchers from Toronto’s Hospital for Sick Children. The parents were queried before receiving any recommendation for CT scanning. Parents, almost half of whom had previously known that CT scanning might cause a cancer to develop in the future, were told of the radiation risks of CT scanning in detail. The authors found that, although the parents’ willingness to go ahead with the CT scan fell from 90% before the explanation of risk to 70% after they were briefed about radiation, at crunch time only 42 (6%) of them refused to let their child be scanned. And of the 42 who initially refused, 8 eventually went ahead with the scan after a physician recommended it. So to put it another way: Even after they were fully informed of the potential risk of CT scan radiation to their child (lifetime risk of cancer is about 1 in 10,000, according to the authors), nearly all parents opted for the scan. Also of note are the following: The median age of the children was 4; 12% of the children in the study had undergone at least one previous CT scan; 97% of the children were diagnosed with only concussions or mild head injuries. An...
Analyzing TBI in Older Americans in the ED

Analyzing TBI in Older Americans in the ED

The management of older adults presenting to the ED is oftentimes complicated by frailty and comorbid chronic conditions. Traumatic brain injury (TBI) has emerged as a leading cause of injury-related morbidity and mortality among adults aged 65 and older in the United States. Previous studies suggest there are differences in both the treatment and outcomes of TBI for older people when compared with younger individuals. Older age has long been thought of as a predictor of receiving more procedures and medications for treatment of TBI in the ED. It is also believed to be a predictor of poorer outcomes after treatment in the ED. “Among older adults, falls are the leading cause of TBI,” says Lisa C. McGuire, PhD. “As age increases, the risk for hospitalization from TBI also rises. This could be due to the increased medical complexity of the patients presenting for treatment as well as other factors. As the U.S. population ages and continues to grow, there will be greater demand for emergency services to treat TBI in older Americans.” To better understand the use of emergency services for TBI among older people, Dr. McGuire and colleagues conducted a study using nationally representative ED data to characterize these visits. The study, published in the August 2012 Western Journal of Emergency Medicine, also compared ED visits for TBI with those made by people younger than 65. In particular, the study team assessed triage immediacy, receipt of a head CT and/or head MRI, and hospital admission by type. Assessing Use of ED Services for TBI The number of ED visits for TBI is increasing among adults aged 65...

The 2012 American Academy of Neurology Annual Meeting

New research was presented at the American Academy of Neurology’s 64th annual meeting from April 21-28, 2012 in New Orleans. The features below highlight just some of the studies that emerged from the conference, including diagnosing Alzheimer’s earlier, an investigational drug to reduce MS lesions, a new drug formulation benefits Parkinson’s, and determining the threshold for head trauma. Diagnosing Alzheimer’s Earlier The Particulars: Alzheimer’s disease (AD) currently can only be confirmed definitively upon autopsies after patients have died or with brain tissue biopsies to detect amyloid plaques, tangles, or both. Florbetaben is an investigational agent that may be beneficial when used as a tracer during PET scans to detect amyloid plaques in patients living with AD. Data Breakdown: In a study, more than 200 patients with and without known dementia who were nearing death and willing to donate their brain to science underwent MRI and florbetaben PET scans. Amyloid plaque levels among those who reached autopsy were compared with scan results. Florbetaben scans were found to have 77% sensitivity and 94% specificity in detecting beta-amyloid. Take Home Pearl: Florbetaben, when used as a PET scan tracer to visualize amyloid plaques in the brain, appears to help diagnose AD in those living with the disease. Investigational Drug May Reduce MS Lesions The Particulars: Patients with multiple sclerosis (MS) who have Gd-enhancing brain lesions have limited treatment options. ONO-4641 is an investigational drug that may help reduce lesions in this patient population. Data Breakdown: Researchers randomized patients with relapsing-remitting MS to placebo or 0.05 mg, 0.10 mg, or 0.15 mg of ONO-4641 once daily for 26 weeks in a study. When...
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