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Table of Content - Volume 12 Issue 3 - December 2019


 

A study of cases of conservative treatment of head injury

 

Jignesh P Dave1, Dhaval R Vadodaria2*, Shivendra padhiyar3, Lakshya Kumar4, Parth Parikh5,

Devendra Rathore6

 

1Associate Professor, 2,3,5,6Junior Resident, Department of General Surgery, PDU Government Medical College, Rajkot, Gujarat, INDIA.

4Medical Officer, Kadivar Multispeciality Hospital, Rajkot, Gujarat, INDIA.

Email: drdhavalvd@gmail.com

 

Abstract               Background: Traumatic brain injury is one of the most devastating types of injury. It affects all ages, however majority of road traffic injuries occurs in young adults of productive age group. Material and Method: The present study was conducted in General Surgery Department of P.D.U. Medical College and Hospital, Rajkot. Clinical study of a total 100 Patient in duration July 2017 to July 2019 will be included in the study that have head injury with taking consideration of all inclusion and exclusion criteria. This was an observational study, Study will be done with patient profile. Mode of injury: fall down, Road traffic injuries, assault. Type of injury: scalp hematoma, skull fracture, nasal bleeding, ear bleeding, ecchymoses over mastoid (battle sign), CSF rhinorhea/otorrhoea, radiological findings and conservative management details. TBI severity was scored according to GCS. Result: It included 100 cases of TBI were admitted during the study period. The mean age of the patient was 34.5 years. 80% were male and 20% were female, The most commonly involved age group was 27-48 years 47% and the most common mode of injury was road traffic accident 77%. 85% of patient to reach hospital within 6 hours, 42% of patient prominent symptom was vomiting, 64% of patient had mild head injury (GCS 13-15), 31% of patient had moderate head injury(GCS 9-12) and 5% of patient had severe head injury(GCS≤8), conservatively management of EDH up to 24 mm. 48% of patient had start orally on first day of admission and patient complain after discharge at end of one month 17% had vertigo, 8% had headache. Conclusion: TBI predominantly affects young male population and most of these are preventable. Early transportation to the hospital and first aid results in good outcome. Radiologically significant EDH, SDH, SAH, Cerebral contusion and Cerebral Oedema can be treated conservatively. This depends on the neurological state of the patients rather than the size of lesion.

Key Words: Head injury, GCS score, CT Brain.

 

 

INTRODUCTION

Traumatic brain injury (TBI) is one of the most devastating types of injury. It affects all ages; however majority of road traffic injuries (RTA) occurs in young adults of productive age group. TBI also associated with significant socioeconomic losses in India as well as in other developing country. Due to rapid surge in urbanization, motorization and economical liberation, many Asian countries have increased risk for TBI. Similarity in many low and middle income countries, non-communicable disease including injuries are becoming a leading cause of mortality and morbidity. Most common clinical presentation in TBI patient is headache and vomiting followed by skull fracture with history of loss of consciousness (LOC).Associated clinical findings suggestive of basal skull fracture are nasal bleed, ear bleed, ecchymosis over mastoid (battle’sign) and CSF rhinorrhea/otorrhea. Neurological assessment for assessing severity of TBI is commonly done by Glasgow coma scale (GCS) but low score of GCS do not necessarily predict bad outcome. The computed tomography (CT) Classification for TBI yields important prognostic information. It provides an objective assessment of the structural damage to brain following TBI. Individual CT characteristics are important predictors of outcome in TBI. Despite various advances in radiology, CT remains the investigation of choice in case of suspected TBI. Treatment plan and prognostication can also be done easily. Cases of head injury with fracture tend to have more complication and are more often fatal than those without fracture. The quality of pre-hospital and emergency room care is an extremely important determinant of outcome in trauma patients. Trauma presents with variety of injuries and problems that demand rapid evaluations, discussion, improvisation and interventions to save life and prevent permanent disabilities. There are numerous factors that determine the outcome in head injury patients namely age, sex, severity of injury, intracranial pressure and associated injuries. The objective of present study was to determine epidemiology of TBI correlation of clinical status, severity of head injury with final outcome and how a multimodality management can change the prognosis.

MATERIALS AND METHODS

The present study was conducted in General Surgery Department of PDU Medical College and Hospital, Rajkot.

Clinical study of a total 100 Patient in duration July 2017 to July 2019 will be included in the study that have head injury with taking consideration of all inclusion and exclusion criteria.

This was an observational study.

Study will be done with patient profile.

Mode of injury: fall down, Road traffic injuries, assault.

Type of injury: scalp hematoma, skull fracture, nasal bleeding, ear bleeding, ecchymoses over mastoid (battle sign), CSF rhinorhea/otorrhoea, radiological findings and conservative management details.

TBI severity was scored according to GCS.

Each patient given conservative treatment including anti-convulsion drug phenytoin. And additional drug including mannitol, ehysamsulate, dexona and methyl prednisolone according to patient’s CT brain finding.

Each patient was discharge at GCS 15 out of 15 and taking full diet tolerated.

INCLUSION CRITERIA

All patients admitted in the emergency ward (over duration of 2 years) Age of more than 5 years and less than 70 years with Head injury by RTI, fall down and violence.

EXCLUSION OF CRITERIA

  1. Pediatric patients (≤5 years of age).
  2. Head injury who required surgical intervention.
  3. Pregnant women.
  4. Head injury associated co-morbid condition like Ischemia Heart Disease and Patient on anti-coagulant therapy.
  5. Patients with age more than 70 years.

RESULTS

This study was carried out at P.D.U medical college and hospital Rajkot, Gujarat, India. It included 100 cases of TBI which were admitted between July 2017 to July 2019.

Table 1: Case distribution according to age

AGE GROUP (YEAR)

CASES

5-26

35

27-48

47

49-70

18

TOTAL

100

In my study revealed that the maximum number of patients were in the 27-48 years age group, i.e., 47. The mean age of the patients was 34.5 years.

 

Table 2: Case Distribution according to sex

SEX

CASES

MALE

80

FEMALE

20

TOTAL

100

In my study revealed that male patients (80) have higher chance of TBI than female (20).

 

Table 3: Case distribution according to mode of injury

MODE OF INJURY

CASES

RTA

77

FALL DOWN

15

ASSAULTED

08

TOTAL

100

In my study revealed that the maximaum number of patients due to road traffic accident 77, followed by fall down 15, and assaulted 8 patients.

Table 4: Number of patients on basis of time gap of admission

TIME GAP OF ADMISSION

CASES

≤6 HOURS

85

6-24 HOURS

13

>24 HOURS

2

TOTAL

100

In my study revealed that maximum number of patients to reach hospital from time of injury within 6 hours was 85, followed by 6 hours to 24 hours is 13, and more than 24 hours is 2 patients.

 

Table 5: Number of patients on basis of prominent symptom at time of admission

CRITERIA

CASES

VOMITING

42

ENT BLEED

28

LOC

20

HEADACHE

07

CONVULSION

03

In my study revealed that clinical Prominent symptom at time of admission is maximum number of patients with vomiting is 42, followed by ENT bleed 28, LOC 20, Headache 7 and convulsion 3 patients.

 

Table 6: Number of patients on basis of GCS at time of admission

SEVERITY OF TBI

GCS SCORE

CASES

MILD

13-15

64

MODERATE

9-12

31

SEVERE

≤8

5

In my study revealed that maximum patients were initial GCS at time of admission was 13-15 (64), followed by 9-12 GCS and ≤8 GCS seen in 5 patients.

 

Table 7: Number of patients on basis of CT brain finding

CT BRAIN

SIZE

CASES

EDH

<5MM

21

6-10MM

15

11-15MM

5

>15MM

6

SDH

<5MM

32

6-10MM

7

SAH

MINIMAL

13

MILD

39

MIDLINE SHIFT

≤ 4MM

22

4-8MM

5

8-12MM

1

In my study revealed that CT brain finding in patient having traumatic head injury. Maximum number of patient having SAH (52), mild SAH seen in 39 patients, followed by EDH seen in 47 patients, EDH less than or equal to 5 mm seen in 21 patients, SDH seen in 39 patients, SDH less than or equal to 5 mm seen in 32 patients, MIDLINE SHIFT seen in 28 patients.

 

Table 8: comparison of contusion and oedema on follow up CT brain finding

FOLLOW UP CT BRAIN

SIZE

CASES

Hemorrhage

Increase

4

Decrease

7

Same

3

Oedema

Increase

7

Decrease

2

Same

2

In my study revealed that comparison of contusion and oedema on follow up CT brain after 48 hours. Follow up CT brain done in 14 patients which GCS not improved with duration. On followed up CT brain finding hemorrhage is decreased in 7 patients, increased in 4 patients and same as previous in 3 patients. Oedema is decreased in 2 patients, increased in 7 patients and same as previous in 2 patients.

 

 

 

 

Table 9: Number of patients on basis of orally start

ORALLY STARTED(DAY)

CASES

1

48

2

28

3

13

4

11

 

In my study revealed that maximum number of patients orally started on 1st day after TBI, followed by 28 number of patients orally started on 2nd day, 13 patients orally started 3rd day, 11 patients orally stated on 4th day.

 

Table 10: Number of patients on basis of complains after discharge

COMPLAIN

ONE WEEK

SECOND WEEK

ONE MONTH

Vertigo

47

19

17

Headache

26

43

8

Facial weakness

3

0

0

In my study revealed that follow up patient at end of one week, end of second week and end of one month after discharge from hospital. At the end of one week maximum patient having vertigo 47, followed by headache 26, facial weakness 3 and 24 patient having no any complain. At the end of second week maximum patient having headache 43, followed by vertigo 19, and 38 patients having no any complain. At the end of one month maximum patient having vertigo 17, followed by headache 8 and 75 patient having no any complain.

 

DISCUSSION

In this observational study where 100 records of patients having TBI at PDUMCH were examined for two year period. As per analysis sex distribution did not have any specific impact on outcome of TBI patients but it is important to note that majority of TBI affected population were male. TBI continues to be a nightmare for both the public as well as for the neurosurgeons due to associated high morbidity and mortality. It is also associated with significant socioeconomic losses in developing countries including India. RTA is an increasing health problem globally and especially in South-East Asia.

In a study from central India reported mean age of TBI cases were 32-64 years. In our study the age of the patients varied from 5 year to 70 years. Out of which 47% patients were found to be adults and age between 27 to 48 years, Mean age noted was 34.5 years. Male:Female ratio was 4:1. Similar observation of male predominance was noted by many other authors also. The probable reason may be that the male population move out of their home more frequently for work. No correlation of sex with treatment outcome is noted in present study. Our observation corresponds with those made by other studies. The reason is that the mobility of male population is higher than their female counter part and they are exposed to more accidental risk factors at various places. As per cause of injury we noted significant relation with outcome. Most common mode of injury was RTI and fall. Injuries other than assaulted showed good outcome as they have different mechanism of action. The IMPACT study has concluded that outcome in TBI cases are dependent on age, but in our study outcome remained to be closely related with the impact of primary injury as shown by the initial GCS.

Pre-hospital care is very necessary for the stabilization of trauma cases in term of adequate airway protection, prevention of excess blood loss and subsequent trauma during transportation to proper hospital setup for definitive care. There is need to create awareness among public regarding how to provide initial care to a trauma patient and need of well trained paramedics on ambulances placed at various strategic location in the city for swift action. In our study hospitalization within 24 hours was 98% case is related to outcome of TBI. In 1978 it was suggested that the GCS be used to assess the seriousness of head injury. A total GSC score of 8 or less for 6 hours be used to set the boundaries of patient study groups and that the GCS be used as the initial end point at a specified time from injury for measuring morbidity and mortality. In the present study good outcome was noted in mild, moderate and severe grades of TBI according to mean hospital stay. Therefore it becomes clear that there is a progressive decrease in good outcome as severity of TBI increases based on GCS. Nutritional support is an integral, though often neglected component of the care of critically injured patient. Nutritional demand in patients with severe TBI is increased due to hypermetabolism and increased protein catabolism. In present study 48% of patient start orally within one day of hospital admission. Therefore it become clear that outcome of TBI related with early as possible to start orally. On CT scan, brain contusion and oedema was noted in 64% and 62% respectively, EDH,SDH and SAH was noted in 41%,39% and 52% respectively, MIDLINE SHIFT was noted in 28% cases of TBI. Follow up CT brain was done which patients not improve according to GCS with conservative management. McLaurin and Towbin mentioned in 1989 that the definitive treatment of EDH should always be surgical removal and delay of this treatment is unacceptable once the diagnosis has been established45. The volume of the EDH is one of the factor which influence the management strategy, in our study the maximum volume of the hematoma was 24 ml but in Dubey et al has recommended a volume of less than 30 ml for conservative management while Bullock et al found the volume of 12-38 ml suitable for conservative management. Temporal EDH as it is nearer to the brain stem carries a high risk to patients life but in 40 of our patients, the hematoma was in the temporal region and they were treated conservatively with satisfactory results. For any hospital with neurosurgeons, CT scan is an important diagnostic tool in planning the management, which dramatically improves outcome of head injury patients. The decision to operate depends on various factors mainly the patient's neurological status, imaging findings and extent of extra cranial injury. Predicting outcome in patients of severe TBI is a challenging task and generates abundant controversy. Apart from clinical parameters at the time of admission, it requires frequent revisits and clinical re-assessment to know about the early deterioration and prompt action with multimodality approach. TBI is possible through environmental improvements and legislative changes. TBI is a significant public health problem worldwide and requires appropriate attention from researchers and policy makers regionally through the development of ongoing surveillance programs and the implementation of effective evidence-based interventions. TBI in children and adolescents is a problem of enormous magnitude and because of improving survival rate; these people later face physical disabilities as well as neurobehavioral problems.

 

CONCLUSION

In India injury patterns/modes are different from the developed nations. We are in a fast transient phase of development with a wide gap between large poor population and rich people. The present health infrastructure is not able to meet the demand of common people, further aggravated with the ever expanding slum population in urban areas. Prevention of Prevention and care of injury is a multidisciplinary area and requires inter-sectoral coordination for planning. By improving our system with better reporting and documentation of cases, we will be able to make a better plan to decrease the incidence of TBI and their timely appropriate multimodality approaches to achieve better outcome of these cases within our limited resources. TBI predominantly affects young male population and most of these are preventable. Early transportation to the hospital and first aid results in good outcome. Mortality increases with the severity of TBI and associated injuries therefore multimodality approach in polytrauma is essential. Radiologically significant EDH, SDH, SAH, Cerebral contusion and Cerebral Oedema can be treated conservatively. This depends on the neurological state of the patients rather than the size of lesion. When conservative treatment is considered, adequate neurological observation is mendatory.

 

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