EMed

Head Injury in Adults

General principles

  • Assessment of conscious level is standardised using GCS
  • Check short term memory in all "minor" head injury patients
  • Please see below for a-WPTAS if considering discharge in a "minor" Traumatic Brain Injury (MTBI) case (GCS ≥ 13)

Indication for CT in ADULT Head Injury patients

Notes

  • Clinical judgment is necessary
  • There should be a lower threshold for admission of children in pre-school age
  • Post-traumatic amnesia with full recovery and no skull fracture is not an indication for admission
  • Patients sent home receive advice to return if any deterioration
  • They should be given adults or children HI Advice
  • Older children may benefit from concussion recovery advice
  • Please discuss any cases of doubt with the ED Duty Doctor

Nimodipine

  • Nimodipine is not indicated in traumatic SAH

Cervical spine

  • Consider CT scan of cervical spine in all patients needing CT head for altered level consciousness [BestBets]

Base of skull # ± CSF leak

T/F TBI patients to neurosurgeons

Criteria for transfer of patients with Traumatic Brain Injury (TBI) to the National Neurosurgical Centre (NNC) at Beaumont Hospital:

All patients with TBI and an abnormal CT scan must be discussed with Neurosurgery.

The following patients will be accepted for transfer to Beaumont hospital NNC:

  1. All patients with GCS 3-8
  2. Exceptions: The following situations require case by case discussion between referrer and neurosurgeon and may not be appropriate for transfer:
    1. Completely normal CT scan and high alcohol or drug levels on toxicology who qualify for wake & assess
    2. Bilaterally dilated and unreactive pupils where any intervention is deemed futile
    3. Age > 75 years – the prognosis in this age group with severe TBI (GCS 3-8) is extremely poor and decisions will be made on a case by case basis
  3. All patients with GCS 9-12 except those with a completely normal CT scan
  4. Patients with GCS 13-15 with:
    1. EDH > 5 mm in thickness
    2. SDH > 5 mm in thickness
    3. Contusion > 4 cm (30 cc); midline shift > 5 mm
    4. Open skull fracture with torn dura / exposed brain
    5. Other patients on a case by case basis

Print version T/F criteria.

A-WPTAS

Abbreviated Westmead PTA scale

Date: Time T1 T2 T3 T4 T5
Motor Obeys commands 6 6 6 6 6
  Localises 5 5 5 5 5
Abnormal flexion 4 4 4 4 4
Withdraws 3 3 3 3 3
Extension 2 2 2 2 2
None 1 1 1 1 1
Eye Opening Spontaneously 4 4 4 4 4
  To speech 3 3 3 3 3
To pain 2 2 2 2 2
None 1 1 1 1 1
Verbal Oriented **
Name
Place
Why are you here
Month
Year		 5
☐
☐
☐
☐
☐		 5
☐
☐
☐
☐
☐		 5
☐
☐
☐
☐
☐		 5
☐
☐
☐
☐
☐		 5
☐
☐
☐
☐
☐
  Confused 4 4 4 4 4
Inappropriate words 3 3 3 3 3
Incomprehensible sounds 2 2 2 2 2
None 1 1 1 1 1
GCS Score out of 15 /15 /15 /15 /15 /15
  Picture 1 Show
pictures
        
Picture 2        
Picture 3        
A-WPTAS Score out of 18   /18 /18 /18 /18
** must have all 5 orientation questions correct to score 5 on verbal score for GCS, otherwise the score is 4 (or less).

Administration

Question 1: WHAT IS YOUR NAME? The patient must provide their full name.

Question 2: WHAT IS THE NAME OF THIS PLACE? The patient has to be able to give the name of the hospital. The patient does not get any points for just saying ‘hospital’.

Question 3: WHY ARE YOU HERE? The patient must know why they were brought into hospital. If the patient does not know, give them three options, including the correct reason.

Question 4: WHAT MONTH ARE WE IN?

Question 5: WHAT YEAR ARE WE IN?

Scoring:

PICTURE RECOGNITION. Straight after administering the GCS (standardised questions), administer the A-WPTAS by presenting the 3 Westmead PTA cards. Picture Cards the first time - T1 : Show patients the target set of picture cards for about 5 seconds and ensure that they can repeat the names of each card. Tell the patient to remember the pictures for the next testing in about one hour. Picture Cards at each subsequent time T2-T5: Ask patient, “What were the three pictures that I showed you earlier?”

For patients who free recall all 3 pictures correctly, assign a score of 1 per picture and add up the patient’s GCS (out of 15) and A-WPTAS memory component to give the A-WPTAS score (total = 18). Present the 3 target pictures again and re-test in 1 hour.

For patients who can not free recall, or only partially free recall, the 3 correct pictures, present the 9-object recognition chart. If patient can recognise any correctly, score 1 per correct item and record their GCS and A-WPTAS score (total = 18). Present the target set of pictures again and re-test in 1 hour.

For patients who neither remember any pictures by free call nor recognition, show the patient the target set of 3 picture cards again for re-test in 1 hour.

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A-WPTAS for patients with MTBI

The A-WPTAS combined with a standardised GCS assessment is an objective measure of post traumatic amnesia (PTA).

Only for patients with current GCS of 13-15 (<24hrs post injury) with impact to the head resulting in confusion, disorientation, anterograde or retrograde amnesia, or brief LOC.

Administer both tests at hourly intervals to gauge patient’s capacity for full orientation and ability to retain new information. Also, note the following: poor motivation, depression, pre-morbid intellectual handicap or possible medication, drug or alcohol effects.

This is a screening device, so exercise clinical judgement. In cases where doubt exists, more thorough assessment may be necessary.

Admission and Discharge Criteria:

  • A patient is considered to be out of PTA when they score 18/18
  • Both the GCS and A-WPTAS should be used in conjunction with clinical judgement
  • Patients scoring 18/18 can be considered for discharge
  • For patients who do not obtain 18/18 re-assess after a further hour
  • Patients with score <18/18 at 4 hrs post time of injury should be considered for admission
  • Clinical judgement and consideration of pre-existing conditions should be used where the memory component of A-WPTAS is abnormal but the GCS is normal (15/15)
  • In CUH, consider referring (via iCM) symptomatic patients to the Physio. vestibular clinic
  • Referral to GP on discharge if abnormal PTA was present, provide patient advice sheet

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 4/04/24.