Monday, September 19, 2011
While the NFL reigns on Sunday and college football rules on Saturday, It’s high school football that is the king of Friday nights. Teams play, students and parents cheer and eventually, there is a stream of injured players that present to the Emergency Department for care. These are an unusual group of patients because most have been seen on the field by a trainer or team physician and initial opinions and plans have been discussed with the athlete and their family. Unfortunately, what is promised on the field may not necessarily be delivered at the hospital.
After a summer of listening to the pro football talk about their concussion initiatives, it must be frustrating to parents when an emergency physician they may not know, suggests that a CT scan isn’t recommended for their injured son. The disconnect between patient expectation and physician assessment is one that can sour the communication that is key to providing medical care.
Minor head injuries have long been worrisome. Prior to CT scanning, history and physical examination was the only way of deciding who might be bleeding in their head and who might be safe to go home. Observation was often relegated to family members at home, waking patients up hourly for fear that they just might not. CT scans allowed medicine to peer inside the skull, but required a fair amount of radiation to provide the images. They were expensive and most scans were negative. Ian Stiell and his Ottawa colleagues developed rules to guide decisions about using CT scans to image patients with minor head injuries, just like those who get dinged on the football field. Stiell’s study allowed doctors to use their history and physical examination skills to care for patients instead of relying solely on technology. Armed with data, the physician caring for a seemingly normal football player could reassure parents that all was well inside the skull…maybe.
There is a small caveat with the Canadian CT Head Rules. It is 100% sensitive that there are no intracranial lesions that require neurosurgical intervention but there can be small bleeding or swelling areas in the brain that presumably have no clinical significance. Perhaps another historical perspective is required. Initially, Head CT scans showed images that were reconstructed approximately 10mm (1 cm) apart. When TPA was introduced as a therapy for stroke, the technical guidelines for head CT scanning allowed the slices to be only 5mm apart. This gave the images greater accuracy at the cost of more radiation but it also uncovered small bleeds that would have been previously missed with the less sensitive scans. Finding the tiny brain bleeds are tremendously important for stroke patients who could bleed aggressively if given TPA, but how would they affect the care of the concussed patient? The CT rules have been repeated validated by further research.
The Canadian CT Head rules are pretty simple.
A patient is at high risk of neurosurgical intervention if:
1. The Glasgow Coma Scale is less than 15 after 2 hours
2. There is a suspected open or depressed skull fracture
3. There are signs of basilar skull fracture
4. There are two or more vomiting episodes
5. The patient is older than 65
There is medium risk for brain injury on CT if:
1. There is amnesia before impact greater than 30 minutes
2. There is a dangerous mechanism injury (eg. pedestrian hit by car, ejected from car, fall greater than 3 feet or 5 stairs)
The rules do not apply to kids younger than 16 or patients who are anti-coagulated with Coumadin (warfarin).
Aside from knowing the rules, it is important that the physician perform a solid neurologic examination searching for the subtle findings of an early basilar skull fracture, looking for hemotympanum (blood behind the eardrum), Battle’s sign (blood behind the earlobe) and raccoon eyes and the skull needs to be palpated feeling for a depressed skull fracture. Ideally, the exam is done in front of family. It is reassuring and the time it takes allows for education and conversation that can calm a potentially inflammatory visit.
The decision to CT or not CT a concussed patient often needs to be delayed for a couple of hours. The player who is markedly confused on the field may have his thinking clear by the time he presents to the Emergency Department. The on field recommendation sometimes ties the hands of the emergency physician and it is easier to agree to order a test that may not be needed, than to spend the time and emotional effort to undo the patient and parent mindset.
Doctors get frustrated and angry when their colleagues tell them what to do either directly or by patient proxy. Most physicians presume that they have some expertise that is useful for patient care and want the ability to offer opinions that matter. Even a surgeon who is consulted to see a patient with CT confirmed appendicitis should be allowed the opportunity to tell the patient that an operation is needed. When an athlete is sent from the playing field to the ED, perhaps the trainer or field doctor should allow the emergency physician the courtesy to assess the patient before presuming care scenarios. And perhaps the emergency physician should return the courtesy by letting the field provider how the athlete fared.