Medical

Statistics

Assistant professor
Dr. Hiwa Omer Ahmed
Medical Statistics
• Good history taking
• Good Examination
• Precise Recording
• Good selection of
Investigations & imaging
• Good followup
Types
of
researches
Qs
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AUDIT OF MANAGEMENT OF
HEAD TRAUMA
IN SLEMANI TEACHING
HOSPITAL 2001 – 2002
DR. HIWA OMER AHMED
MB.CHB. C.A.B.S
CONSULTANT SURGEON STH
PROF. ASSIST – COLLEGE OF
MEDICINE– UNIVERSITOF SLEMANI
SUMMARY:

• Trauma remains the leading killer of

children and young adults, specially
head trauma injuries of different
types from fall from height (FFH) in
children to road traffic accident (RTA)
and quarrelling in adolescence and
young adults.
•
• Every day many victims with head trauma
will arrive the Surgical Casualty
Department of STH, managed first by
house officer and senior house officers in
general Surgery.
• As long as there is no uniform method
for management of these cases the author
is trying in this paper to audit the lines of
management for these victims in two
different surgical unites, each using away
of management different in many aspects.
Aiming that the conclusions may help in
promoting the practice in this field
INTRODUCTLON

• Trauma in general is the most

common cause of death in children,
adolescence and young adults. Minor
head injury is common in modern
society (1). Care of the head injured
patients begins with assessment of
severity and protection of the brain
from further insult. Outcome
depends on recognition, severity and
treatment of two fundamentally
distinct types of head injury: diffuse
• To achieve correct management of this
common problem, we need accurate
medical data recording and detailed and
repeated neurosurgical examinations;
including records of repeated evaluation of
the level of consciousness by Glasgow
Coma Scale (GCS), to assess the severity
of the injury, diagnosing the life
threatening conditions, to protect the
brain from second trauma. This
recognition needs precise clinical
evaluation and imaging to differentiate the
type of the injury: is it focal or diffuse,
which need different methods of treatment
• On the other hand (GCS) will help in
classifying the head injury into minor
(13,14,15 scores), moderate (9,10,11,12
Scores) and severe (8 or less scores)(2),
which have different outcome & may need
different levels of care and treatment. The
objective of scoring is to provide a uniform
way of describing injuries, which can only
be achieved by obeying the rules, this still
requires practice, as there are many
pitfalls for the unwary, clinical outcome in
patients with minor head injury, might
have been predicted from history & clinical
examination alone, and less than (1%) of
these patients will develop an intracranial
complication.
• The aim of this study is to audit two
different methods of management of
head trauma patients in two surgical
unites, to assess methods, which
may improve the outcome.
PATIENTS AND
METHODS:
• The retrospective study was carried out at
Slemani Teaching Hospital (STH), in two surgical
unites on (160) consecutive patients who were
admitted between 1st of April 2001 to 1st April
2002, with acute trauma to the head, of these
(80) patients (Group- A) managed in the authors
surgical unit and the rest (Group B) managed by
a colleague surgeon in another surgical unit.
• Demographic details were extracted from
action taken on basis of the finding was noted.
• Comparative analysis between the two groups
through multiple variables was done to identify
any different between them in the aspect of
management and outcome.
RESULTS

• Most of the patients in both groups

(A & B) were males as in (Group A);
male/ female ratio was 5/3 and in
(Group B); was 5.1/2.9. Majority of
the patients was in the age group of
(0-19 years) as shown in table I
 No. of patients No. of patents
Age groups in years
Group A Group B

0 - 9 25 38

10 + 19 14 15

20 - 29 9 14

30 - 39 13 6

40 - 49 7 3

50 - 59 6 2

60 - 69 2 -

70 - 79 4 2

Table I: Showing age groups in both groups (A &B) of patients

The most common type of trauma was fall from height as shown in
table II

Types of the No. of patients No. of patients

trauma Group A Group B

Fall From height 48 43

Road traffic accident 21 29

Quarrelling 11 8

Table II: showing types of the trauma in both groups (A&B) of patients
Most of the injuries were mild (64patients in group-A), (52patients in group-B), as showed in table III,
which is clarifying the GCS of the patients on arrival.

No. of
Glasgow Coma
patients No. of patients
Severity Scale
Group Group -B
Scores
-A
15 60 43
Minor 14 4 4
13 - 5
12 6 7
11 1 12
Moderate
10 2 -
9 2 1
8 - 1
7 - 1
Severe
6 2 6
5 3 -
Table III. Showing GCS scoring in both groups (A&B) of patients
 Most of the patients (63 patients in group-A, 56 patients in group –B)
remained in hospital for up to 47 hours as shown in table IV. .

Period of No. of patients No. of patients

admission Group -A Group -B

0 - 23 hours 19 23

24 - 47 hours 44 31

3 - 9 days 14 23

13 days - 1

21 days 1 0

39 days 0 1

42 days 1 0

45 days 1 0

Table IV: showing period of admission in both groups (A-B) of patients.

GCS scoring was full (15 scores) in most (64patients in group-A) of the patients Within 24 hours of
admission, while there was no any records of this in the files of the (group-B) as shown in Table V.

Day in which GCS scores No. of patients No. of patients in

became full (15) Group –A Group -B

Same day of admission 64

2nd day of admission 5

3rd day of admission 5

NO RECORD
4th day of admission 2

8th day of admission 1

16th day of admission 1

44th day of admission 1

45th day of admission 1

Table V: showing time when the GCS became full scored

 Minority of the patients had positive physical finding as shown in
table VI:

Physical Findings No. of patents Group A No. of patents Group B

Cranial nerve palsy No. Record

5

Black eye due to Ant. cranial fossa #

14 10

Rhinorrhea, Rhinorrhagia 4
4

Otorrhagia 3
1

Battle Sign 1
1

Table VI: Showing physical findings in both groups (A & B) of patients.

Skull radiographs were taken routinely for every patient in both groups, but revealing
skull # just in 9 and 5 patients in Group A and Group B respectively, and there was no
any correlation between # skull and physical findings as most of the patients with
physical findings like (black eyes, rhinorrhea …etc), has no # in the skull radiographs,
as shown in table VII.

No. of patients No. of patients

Findings # on skull X ray
Group A Group B

- 4 3
Rhinorrhia
+ - 1

- 1 2

Otorrhia

- - 1
Battle sign
+ 1 -

Table VII: Showing correlation Between # skull and physical findings

Minority was sent for CT scan, it was normal in 3, 2 of the scans in group A, grope –B respectively.

No. of patients No. of patients

CT scan
Group -A Group- B

Not done
76 75

Normal 3 1

Done 4
Extradural
1 No. recording or
haematoma
paper

Table IIX: Showing results of the CT scans in patients form both groups (A, B).
These patients were managed in the casualty department and later in the surgical unite on follow up as showing in
table IX.

No. of
patients No. of patients
Management
Group- Group-B
A
Elevation of the head
80 60
of the patient
IVF 21 39
Craniotomy 2 No Record
Phenobarbiturate 10 7
Steroids - 61
Diuretic 1 4
Antibiotics 2 72
Analgesia - 63
Diazepam 1 4
Antiemetic - 3
Blood 2 6
Tracheostomy 2 -

Table IX: lines of the treatment in the both groups (A & B)

 DISCUSSION:
• We may notice from the results, that majority of
the victims were children, adolescence, sustaining
minor head trauma (64.4% =116 patients) as
shown in table I, with GCS Scoring of (13,14,15).
Majority were kept under observation for necessary
time (48) hours (table II), but routinely expressed
to two views of skull radiographs with only (14
patients) positive skull radiographs findings (table
IV), while the majority of the patients (64.4%) with
minor head trauma may be evaluated clinically
alone & skull radiographs adds no further
information to the decision weather to admit or
send home patients with a minor head injury and
there in a report from Annals of Royal college of
Surgeons of England claiming that “ not to take
skull radiographs routinely, “specially for patients
who are able to walk and talk when they reached
medical contact”(3).
• On the other hand there was no hard correlation
between findings in the skull radiographs and the
physical findings for example (table VI), there was
seven cases of rhinorrhea and rhinorrhagia which
means anterior cranial fossa #, with only
radiological finding in one of them. Also there was
four cases of otorrhagia with only one radiological
report of # in one of them.
• These may be either due to the fact that most of
the # usually are in the base of skull, which are
not evident on AP & lateral skull views, but need
Special (Town view) which in not in practice at
least in Surgical Casualty Department or there is
a gush of routing skull X-rays (100%) which will
put a have burden on radiological staff who is
alone on duty personal, the result will be bad
quality skull radiographs which add nothing to the
clinical evaluation and decision
• Few patients (9 patients) send selectively for CT-
scanning of the skull & brain (Table IIX), with (4)
normal results, one extradural haematoma, and
unfortunately there is no paper or report or data
recording in the files of the patents with the rest
(5 patients in group B). Majority of our patients
were with minor hand injury which need just
observation and elevation of the head,
unfortunately we found the elevation of the head
not practiced for all the patients in group-B (Table
IX). Different drugs used in most of the patients
which is not necessary for patients with full GCS
scoring for example patient with file number
(21211) had full Scoring (15), had no any injury,
but received all the types of the drugs & lines of
treatment which you will see in (Table IX).
ELEVATION OF THE HEAD
• Now it is clear that cerebral edema &
hemorrhage within the cranial vault will
rapidly increase intracranial pressure
(ICP), because the brain, unlike other
organs is rigidly confined with the skull (4)
and in trauma the Brain Blood Barrier
(BBB) will disrupt. So elevation of the head
will help in facilitation of venous drainage,
which is the only way, as there are no
lymphatic vessels in the brain, and the
veins are thin walled, containing no
muscle fibers in their wall which make
them capable to distend considerably.
IVF
• It is better not to give intravenous fluid
(IVF) routinely for head injured patients,
specially when there is no vomiting & the
patient is conscious, and able to take
orally. When IVF is indicated, it is better to
restrict the IVF therapy at least to 2/3 of
that of normal maintenance. Also it is
better to avoid 5% glucose in water as it
enhances the edema process. So IVF
“Should be administered Judiousely to
prevent overhydration which augments
cerebral edema as mild dehydration wile
protect the brain from insult secondary to
fluid over load (5).
PHENOBARBITONE:

• It will help in decreasing agitation,

controls Seizures and decreases
brain edema.
STEROIDES:

•Are not
recommended for
the treatment of
acute head injury.
DIURETICS:
• In the emergency department should be
administered only with the consent of a
neurosurgeon or to gain time when neurosurgical
capabilities will be delayed and the patient’s
condition is deteriorating, because its beneficial
effect is transient, the drug can severely alter
serum electrolyte and osmolarity
• Patients who are given Steroid, osmotic
diuretics, anticonvulsant & hyperosmolar feeding
are prone to develop hyperosmolar state, some
times leading to hyperglycemic nonketotic coma
(6).
• when may be analyzed as deterioration of the
neurosurgical condition of the patient.
ANTIBIOTICS

• Prophylactic antibiotics are not used

routinely because recent prospective
studies have failed to demonstrate
any benefit from their use (7), so
rarely indicated
ANALGESIA

• Aspirin & other nonsteroidal

Analgesia all increase the risk of
upper GIT bleeding and peptic stress
ulcers, so it is better not to be used
routinely.
DIAZEPAM

• Sedation reduces posturing &

combat activity, both of which
elevate ICP
ANTIEMETIC

• When used, it has symptomatic

benefit but also may induces
occulogyric crises, which will be
misinterpreted for unwary personal.
There is a large difference between
the line of treatment in these two
groups, but the mortality was same
in both groups (A&B), one patient in
each group
CONCLUSION

• We may conclude from this audit, that

skull radiographs and many drugs with
steroid, antibiotics, IVF, diuretics were
used routinely without any additional
benefit to the standard management of
the head injured patients, we need a
uniform standard revised updated
schedule for management of head injured
patients in our casualty, aiming in saving
lives and time of the physician, nursing
and radiological Staffs
AKWOWLEAAEMENT

• I would like to thank all the house

officers & nursing staffs in my
surgical unite & statistical staffs in
STH, Forensic medicine for their
valuable technical help
REFERENCES
• B. R. Duns, T. Boesen, prognostic Signs in the
evaluation of patients with minor head injuries,
British journal of surgery. 1997, Vol. 80, No. 8 ,page
(989)
• American College of Surgeons Committee on Trauma:
Head trauma in Advanced Trauma life Support, Ed.6,
American College of Surgeons. 1997. Chap 6, pp.184.
• F. W. cross: Care of RTA victims in district general
hospital: Annals of the Royal college of England, Nov
1992, Vol. 74, No 6, Page 438.
• Nigel. We6ster. Monitoring the critically ill patients:
Journal of College of Surgeons of Edinburgh. 1999,
Vol. 44, No.6, page 395.
• Robert H. Wilkins, Settee S. Rengachary. Text book
of Neurosurgery 1st edition Vol. I, McGraw Hill
company New York, 1985, page 404.
• 6. Spencer, Shires, Neurosurgery cited in Schwartz,
Spencer, Shires & Daleys Principles of Schwartz,
1999, Vol. 3, (1879), McGraw Hill
• 7. Raymond H. Alexander, Herbert J, Advanced
Trauma life Support, 1st edition American College of
Surgeons, 1993, Page 179.
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