Delayed presentation to the Emergency Department following a head injury : current care and the risks of intra-cranial pathology

Marincowitz, Carl

August 2015

Thesis or dissertation

© 2015 Carl Marincowitz. All rights reserved. No part of this publication may be reproduced without the written permission of the copyright holder.

Background: Head injury is a common reason for Emergency Department attendance. The clinical dilemma is differentiating between patients who have mild/minor head injuries into those that can be discharged following clinical review and those that require a CT head scan to rule out neurosurgical pathology. Clinical decision rule research to aid this risk assessment has been conducted almost exclusively on patients presenting within twenty-four hours of injury. Delayed presentation head injury patients may be a distinct sub-population with a different risk profile.

Methods: Three studies were undertaken. A systematic review was conducted to identify and assess existing evidence regarding the risk assessment in delayed presentation head injury patients. A survey of emergency physicians using clinical vignettes was used to assess variation in the investigation of this patient group. Lastly, six months of audit data were analysed to assess the size of the population of delayed presentation head injury patients, and the use and sensitivity of existing NICE guidelines in their risk assessment.

Results: Few existing studies of poor methodological quality were found. A large degree of variation in clinical practice was identified in the investigation of this group. Head injury patients presenting after twenty-four hours of injury were found to account for 15.5% of CT head scans for the investigation of adult head trauma. In patients presenting after twenty-four hours of injury 30% of identified intra-cranial injuries were in patients without a NICE indication for a CT head scan compared to only 2.2% of intra-cranial injuries in patients presenting within twenty-four hours of their injury.

Conclusions: Head injury patients presenting more than twenty-four hours after injury represent a significant clinical sub-population. A different approach to that recommended in the current NICE guidelines may be required in the risk assessment of this group.

Hull York Medical School, The University of Hull and the University of York
Townend, William; Allgar, Victoria
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