Early management of head injury: summary of updated NICE guidance

As an anaesthetic trainee, I would like to raise the issue regarding clearing the immobilised (cervical) spine in an intubated or unconscious patient as there is no specific consensus in this area that exists.

I understand this article is primarily interested in the early management of a head/cervical spine injury but prolonged immobilisation and use of a cervical collar are associated with many problems including death secondary to necrotic pressure sores in the occipital, sacral and heel areas. The risks of prolonged immobilsation could potentially outweigh a serious missed cervical spine injury. [1]

As no single investigation will completely exclude a cervical spine injury. Clinicians must decide what investigation, or combination of investigations, provides them with enough evidence to either diagnose a cervical spine injury or exclude it. [2] As no consensus exists, and local guidelines that are being produced with inevitable variation I think a good place for a national guideline in this specific area would be in these particular NICE head injury guidelines.

I look forward to discussion on what I predict is a topic of much interest to those involved in the management of immobilsed patients in a critical care setting.

References:
1. Morris C, McCoy W, Lavery G.
Spinal immobilisation for unconcious patients with multiple injuries.
BMJ. (2004) 329(7464): 495–499.

2. Harrison P, Cairns C.
Clearing the cervical spine in the unconsious patient
CEACCP (2008) 8 (4): 117-120.

Immediate CT scan in the coagulopathic elderly with a minor brain injury is a must

Dear Madam,

The NICE head injury guidelines 2014 now consider the use of warfarin alone, as an indication for CT-head scan (CT) within 8 hours, after a minor brain injury (GCS >12). The guidelines state that warfarin and anti-platelet agents equally affect the coagulation system. However, a distinction is made on that only the use of warfarin mandates imaging (INR >2 by some authors) and excludes the use of anti-platelet agents.1 2 NICE guidelines are based on the Canadian CT Head Rules (CCHR), which excluded patients who had a bleeding disorder or used oral anticoagulants (ie, Coumadin). The CCHR also differ from NICE on that it considers age >65 years alone, as a high risk factor and recommends immediate CT.3 Although the search for evidence in head injury studies is a complex task, NICE could have also appraised the following publications on the use of clopidogrel in the elderly with a minor brain injury:

Nishijima et al observational cohort multicenter study reported immediate traumatic intracranial haemorrhage or contusion (TICH) in 24 of 217 patients >65 years of age with evidence of trauma above the clavicle, who were on clopidogrel (11.1% 95% CI 7.2 to 16). This is a much higher incidence that the 33 of 594 patients (5.6%), who were taking warfarin. The majority did not have loss of consciousness or amnesia at anytime and 6 out of 33 patients with an initial GCS of 15, had intracranial hematomas without evidence of trauma above the clavicles.4 These are recognized presentations, which may result in missing injuries and preventable delays.

Fabbri et al recently reported that patients with GCS 14-15, who were on clopidogrel, not only had an increased incidence of TICH, but also had a two-fold risk for deterioration within 7 days, when the number of lesions was <2, at the first CT scan (6.90% versus 3.70%, RR 1.86, 95% CI 1.06 to 3.30; P = 0.032). The risk further increased when the number of lesions was ≥3 (34.8% versus 10.4% not treated; RR 3.34, 95% CI 1.74 to 6.40, P = 0.003). The lesions included traumatic subarachnoid haemorrhage, subdural and epidural haematoma, intra-cerebral haemorrhage/contusion, depressed skull fracture and intra-ventricular haemorrhage.5 Multiple lesions are a common presentation in the elderly.

A coagulopathy (clotting or bleeding disorder) is an impairment of the blood’s ability to clot, which can cause prolonged or excessive bleeding. Therefore, every patient on anti-platelet agents is coagulopathic. Very small amounts of additional intracranial bleeding may result in catastrophic consequences to the patient. Clopidogrel and aspirin inhibit platelet function for at least 5 days after discontinuation of the drug. Aspirin doubles the bleeding time and clopidogrel is considered to be equally effective, if not more potent. Many of the new anti-platelet agents have similar effects on the coagulation system.6 The treatment of the bleeding complications is difficult, as there are no specific reversal agents, contrary to warfarin. Bleeding during antithrombotic therapy is associated with high morbidity and mortality.7

Patients without loss of consciousness (LOC) or post-traumatic amnesia (PTA) need to be carefully evaluated and may need imaging in the presence of another risk factor.8 A reliable history of LOC or PTA is not always available. Elderly patients on antithrombotic medication can present with brief or prolonged brain dysfunction. Any alteration of consciousness, whether momentary confusion, agitation, vacant stare, delayed verbal or motor responses, slow to answer questions or follow commands, abnormal behaviour, incoordination or unsteady gait may be early signs of TICH. Significant subgaleal swelling has also been considered, as an indication for CT.9 The prevalence of dementia (5% in the >65s and 20% in the >80s) adds further complexity to the management of TMBI in the elderly.10

It is estimated that 10% to 15% of patients with GCS >12 have clinically significant findings on CT and up to 1% may require neurosurgery. An immediate CT allows for an early diagnosis, treatment and emergency department discharge and prevents missing a potentially life threatening injury. A delay of several hours could result in subtle bleeding progression until sudden deterioration occurs. Furthermore, the window of opportunity for early intervention to stop haematoma expansion, manage secondary brain injury and to obtain specialist haematological treatment is narrow and it could be missed. Coagulopathic patients may even require anticoagulation reversal before imaging.

Correction of the coagulation disorder is not required in patients that appear to be well with a normal CT scan, who can be discharged from the emergency department with appropriate written and verbal instructions for the patient and the carer.

The purpose of the NICE head injury guidelines is to enable for early detection and treatment of life- threatening brain injury and early discharge of patients with negligible risk of brain injury. However, this cannot be achieved without an immediate CT in the coagulopathic elder with a mild brain injury. Those patients with TICH may not only require timely in-hospital management and neurologic observation but also rapid correction of the coagulopathy or emergency neurosurgery. Otherwise the outcomes will be very poor and the mortality rates very high.

Plutarco Chiquito-Lopez senior education fellow in emergency medicine, Royal Hospitals, Belfast BT12 6BA plutarco.chiquito-lopez@belfasttrust.hscni.net
Oliver Bannon consultant in emergency medicine, Royal Hospitals, Belfast BT12 6BA

1. Hodgkinson S, Pollit V, Sharpin C. Early management of head injury, summary of updated NICE guidance. BMJ 2014;348:g104
2. National Institute for Clinical Excellence. Head Injury. Triage, assessment, investigation and early management of head injury in children, young people and adults. http://guidance.nice.org.uk/CG176/Guidnace/pdf/English. Accessed February 2014
3. Stiell I, Wells G, Vandemheen C, et al. The Canadian Head Rule for patients with minor head injury. Lancet 2001,357;1391-1396
4. Nishijima D, Offerman S, Ballard D, Vinson D, Chetipally U, Rauchwerger A, et al. Immediate and delayed traumatic intracranial haemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel. Ann Emerg Med. 2012;59(6):460-8
5. Fabbri A, Servadei F, Marchesini G, Stein S, Vandelli A. Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study. Critical Care. 2013,17:R53
6. Brunton L, Chabner B, Knollman B. Goodman & Gildman’s. The Pharmacological Basis of Therapeutics. 12th Edition. McGraw-Hill; 2011
7. Makris M, Van Veen J, Tait C, et al. Guideline on the management of bleeding in patients on antithrombotic agents. British Journal of Haematology. 2012;160:35-46
8. Smits M, Hunik M G M, Nederkom P , Dekker HM, Vos PE, Kool DR, et al. A history of loss of consciousness or post-traumatic amnesia in minor head injury: “conditio sine qua non” or one of the risk factors?. J Neurol Neurosurg Psychiatry. 2007;78(12):1359-1364
9. Greenberg M S. Handbook of neurosurgery. 7th Edition. Thieme; 2010
10. Bracewell C, Gray R, Rai G. Essential facts in geriatric medicine, 2nd edition. Radcliffe Publishing; 2010

Thank you for this update.

I note that NICE has included warfarin therapy as an indication for the CT scanning of adult patients in its own right. I concerned, however, that no mention is made of other anticoagulant strategies incuding those on long-term low molevular weight heparins or the new oral agents such as apixaban which are incresingly being used for thromboprophylaxis following elective orthopaedic surgery or as an alternative to warfarin in atrial fibrillation.

My fear is that the use of the term "patients on warfarin" in the published guideline rather than "patients on anticoagulant medications" may inhibit a number of anticoagulated patients from receiving CT imaging at an appropriate time.