A knock to the head

Tuesday, September 18, 2007

It should be football that would provide an opportunity to talk about minor head injuries and concussion, but instead I get to turn to baseball and the Yankee – Red Sox series. Eric Hinske ran over Juan Posada at the plate and while he held onto the ball, Posada headed to the hospital after the game to be evaluated for headaches. It’s a cryptic message, isn’t it…heading to the hospital for further evaluation.

Patients are brought to the hospital after being hit in the head and the question asked is whether a concussion occurred. Then there is the other question, under the surface, whose words are too frightful to ask: “Is there bleeding in the brain?” This is quickly followed by: “We thought he should be checked because we were afraid for him to go to sleep.” So who needs a CT scan to make sure there is no bleeding and who gets to go home and sleep well in their own bed.

While in today’s medical arms race of technology, CT scans are almost everywhere, their use should be limited to those who actually need them. Aside from the cost of the test, there is a want to limit radiation to those people who really need it. For those with minor head trauma, research has set some guidelines as to who needs what, when. Minor head injury, or concussion, can be defined as a patient with a short loss of consciousness, amnesia or disorientation who is now conscious, talking and normal.

The Canadian Head CT Rules came out the winner when they we compared with the New Orleans rules (even medical decision making rules can complete against each other). There are 5 high risk and 2 medium risk signs that can predict whether bleeding exists in the brain that will need an operation:

High risk: Not neurologically normal after 2 hours, a depressed skull fracture, a fracture of the base of the skull, vomiting more than twice and being older than 65.

Medium risk: more than 30 minutes of amnesia and dangerous mechanism like being thrown from a car.

These risk factors seem pretty self evident. If you’re not normal after a couple of hours, or the doc thinks you’ve broken your skull then it’s wise to look at the brain and make certain that it’s OK. If you’re old, your body tends to break more than bounce and looking at the brain again seems pretty reasonable. And why two vomits and not three? That’s statistics taking. More importantly, since the rules predict who may be injured, they also predict who can go home and sleep the rest of the night in their own bed. They answer those questions that people are afraid to ask.

Returning to the field of play is a different question. The brain needs time to recover from minor injuries and symptoms of concussion can be pretty subtle, from difficulty concentrating to irritability to insomnia. Until stuff has settled down, it’s hard for the brain to protect itself against another injury. And while guidelines exist to help decided when to return play and work, repeat evaluation by a doctor before making that decision is a must.

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