Head Injury

The most common type of injury we see in emergency department.   We treat patients with various degree of head injury. Most commonly we see simple falls in paediatric patients who requires only observation for a period of time.

The most common cause of head injury is road traffic accident, falls and assaults followed by sports related injuries and penetrating injuries.

Our brain is an amazingly sensitive structure.  It is anatomically placed in a cushion of tissue to prevent damage from certain velocity of impact.  When the force disrupts these layers, the impact reaches the brain tissue.  Normal cerebral blood flow necessary for a 100g of brain tissue is 55ml for a minute.  Any decrease in this blood flow could cause significant injury to brain tissue.

When there is an injury to head, our brain has some mechanism to adopt itself to sudden changes.  During an injury, any increase in the normal mass of the brain could cause increase in pressure in the brain. The brain compensates it by displacing the cerebrospinal fluid and venous blood out of the cavity. When there is an additional increase to the mass, the brain loses its capability to adopt and results in increase intracranial pressure, brain herniation and quick fall in patient’s consciousness.                                                 

Classification of Head injury:

Classification of Head Injury is based on different factors.

Primary:   Injury to brain occurring at the time of impact. This damage includes any injury to brain tissue.

Secondary:  Injury to brain tissue following a trauma after certain period time could be a result of decreased oxygen to brain, decreased blood pressure, increased intracranial pressure, low cerebral perfusion pressure, pyrexia, seizures and metabolic  disturbances.

It can also be classified according the severity of injury and it is determined by the 

Glasgow coma scale.

Minor head injury: GCS 15 with no loss of consciousness.

Mild head injury: GCS 14 or 15 with Loss of consciousness

Moderate head injury: GCS 9-13

Severe Head Injury: GCS 3-8

According to the force of injury

Blunt

Penetrating

The   effect of an injury is usually based on the mechanism of injury.  As a doctor we could identify the nature of the impact the patient has had with just considering the following questions:

1.   Mechanism of Injury

2.   Loss of consciousness

3.   Level of consciousness at scene and on transfer

4.   Seizure

5.   Probable hypoxia or hypotension

6.   Pre existing medical condition

7.   Medications

8.   Illicit drugs and alcohol.

For example, a person is brought in to the hospital after a fall from a height or after a high impact accident where the other person involved in the accidents GCS is still low. Here you would expect a multiple injuries.

How do we begin to examine a person with head injury?

It is always easy to resuscitate a patient if we follow the principles of

ABCDE

A-AIRWAY

B-BREATHING

C-CIRCULATION

D-DISABILITY

E-EXPOSURE

We perform a primary survey which itself is assessing ABCDE and then a secondary survey which includes head to toe survey looking for any signs of injury.  We should assess GCS which includes eye response, verbal response and motor response.

The pupilary size is an excellent mirror of the occulomotor nerve. Any change in size or any variation of light response suggests a dysfunction of the third nerve.

Management of Head Injury:

1.   Mild Head injury:

When there is no significant impairment in patient’s health and the GCS has always been 15/15, then the patient can be discharged home after a period of observation.

In certain condition, patient’s age and other medical condition may play important factors. In that case we might need a CT scan. It is unnecessary to scan everyone that not to miss any intracranial hematomas.

NICE GUIDELINES FOR CT SCAN IN HEAD INJURY:

GCS <13 AT ANY POINT

GCS 12 OR 14 AT 2HOURS

FOCAL NEUROLOGICAL DEFICIT

SUSPECTED OPEN, DEPRESSSED OR BASAL SKULL FRACTURE

SEIZURE

VOMITING >ONE EPISODE

URGENT CT SCAN IF NONE OF THE ABOVE

AGE >65

COAGULOPATHY

DANGEROUS MECHANISM OF INJURY (CT WITHIN 8HOURS)

ANTEGRADE AMNESIA >30MIN

2.   Moderate to severe Head injury:

The main aim of resuscitation of severe head injury is to prevent any secondary brain injury, so it is important to maintain normal oxygen supply to brain and the blood pressure.  CT scan should be done and intracranial hematomas should be reduced which will decrease the pressure in the brain.  If any hematomas found, then we always discuss it with the neurosurgery specialists.

WHAT TYPE OF HEAD INJURY REQUIRES SURGICAL MANAGEMENT?

1.   EXTRADURAL HEMATOMA:

                   It occurs between the skull and the duramater. It is commonly seen in young male patients.  The hematomas usually occur after the tear of meningeal artery and a mass forms in between the skull and duramater.

It usually causes secondary brain injury.  Immediately after the injury, patients complain of headache, but there will be no focal neurological deficit, but after minutes or hours patient starts to deteriorate. Early recognition and treatment is vital in case of extradural hematoma.  Immediate evacuation of the mass is significant for a better prognosis of patient’s condition.

2.   ACUTE SUBDURAL HEMATOMA:

It occurs between duramater and arachnoid.  As it involves the layer nearer to the brain tissue, we would expect some degree of damage to the brain and blood supply. It causes significant primary brain injury.  Patients with acute subdural hematoma have impaired level of consciousness from time of injury.  Treatment is usually evacuation via a craniotomy.

       

3.   SUBARACHNOID HAEMORRHAGE:

Aneurysms are the most common cause of subarachnoid haemorrhage. Traumatic subarachnoid haemorrhage is managed conservatively.

  

4.   CHRONIC SUBDURAL HEMATOMA:

It is usually seen in elderly, particularly in patients on blood thinners.  There is usually a history of trauma but sometimes it occur without one.  It can present with headaches, cognitive impairment, focal neurological deficit and seizures.  Treatment is usually evacuation of the mass via a burr hole.

5. CEREBRAL CONTUSION:

It occurs when the brain tissue has an impact against skull either at the point of impact or on the other side of the head.  It is usually bruising to the brain tissue which involves micro haemorrhages.  A patient with cerebral contusion requires observation for a period of time and in rare cases might need surgical evacuation.

If you have anyone you know has had a head injury and you think they are acting strangely or complaints of severe headache, discomfort to light, vomiting or drowsy,  then it is time for them to be taken to the hospital immediately.

In elderly and children with a head injury, it would be sensible to get it checked by your general practitioner or at the nearest hospital.

 

Readers

I am writing after a long time. In this article I would like to describe about the place and the people where I work. After a break of one year after my medical studies, I decided to move to Ireland to begin my career.

I applied for jobs and I had three telephone interviews and I got selected in two if it. One of it was St. Vincent University Hospital, Dublin. The consultant of Emergency Department interviewed me. He was very certain about me and was pleased with my blog. I was selected for the post in Emergency Department in St. Vincent University Hospital, Dublin. I felt he had a great opinion about me and my fear of not being able to fulfil his expectation made me reject the offer. I do regret not being able to work with him who was very hopeful and would have been supportive in all aspects.

In the meantime, I had another telephone interview for Emergency Department Portiuncula Hospital.

I was selected and now I am here in Ireland working as a Senior House Officer in Emergency Department in one of the regional hospitals in Ballinasloe, Galway. I was very alarmed as it was my first job after completing my medical degree, which was a year ago. I thought it was going to be very hard for me to work in the Emergency Department with no prior proper clinical experience.

First day was my induction at Galway University Hospital. I thought I would not be able to do it. I felt I was going to ruin everything. Medicine seemed to be far in advance in miles from me, but somewhere in the corner of my heart I knew I could do it.

I was very nervous on the first day in Portiuncula Hospital. I stepped into the Emergency Department and the nurses were glad to have me in there. I was taken to the consultant room and I had a short chat with her. I told her about my limited clinical abilities and she made it certain that I work with comfort and gave me the confidence that I will be able to do it. I think her support and her lack of restrictions towards young doctors like me have made me adore my job.

My consultant took me around the Emergency Department. The first nurse whom I met was a wonderful lady. She explained me about everything in detail. First day and my first patient was with cardiac arrest. I did not have a big role in it as it was my first day. The protocol in the hospital makes it uncomplicated and now I can handle critical cases with ease. I haven’t learnt the whole thing but now situations seem not to be complicated as I thought.

Nurses are very pleasant and supportive considering you to be a young doctor who is in the path of your new journey. Nowadays even if I am on a weekend off I miss being there at work.

I realise I am born to be a doctor and has now brought a hunger in me which would reach satiety only after I achieve something in this field.

I must not fail to mention about the people in the town. They are very pleasant and are glad to accept you. Being a foreigner in a new town, I thought it would be difficult. People are forthcoming and down to earth. In the contemporary world, there is hastiness in everything and everyone, but here people respect each other and spend time to reciprocate everything. I have travelled to many countries and I would say Ireland is one of the countries with the best people on the earth.

I had like to dedicate this article to my Consultant and the staffs in Portiuncula hospital for being kind and supportive.

Now I am here looking forward for my Monday duty...

Osteoarthritis

Osteoarthritis means degenerative inflammation of the joints which is symbolized by loss of cartilage. It is the most common leading cause of disability among older people. It is very rarely found in people less than 40 years and is widespread in adults older than 60years. It is much more common in women than men.

Most commonly affected joints are cervical (neck region), lumbo sacral joints (back region), hip, knee, first metatarsal phalangeal joint (toe), Distal and proximal interphalangeal joints (which includes joints of small fingers).

What is Osteoarthritis?

Osteo means bones

Arthro means Joints

Itis means Inflammation

Osteoarthritis means inflammation of the joints which is due to degeneration of the hyaline cartilage in the joints. There are several reasons for the malfunction of joints but the most common universal reason which stands on the top of the list is the failure of the protective mechanisms of joints.

What constitutes the defensive mechanism of joints?

Joint capsule & ligaments, muscle, sensory afferents (nerves) and underlying bone are structures that provide support to the joints by limiting the movement of joints.

There is synovial fluid which reduces friction between articulating cartilage and reduces friction induced tear of the cartilage.

The ligaments along with muscle and tendon consist of mechanoreceptor sensory afferent nerve. These nerves provide signals to the spinal cord supplying the tendons and muscle thereby limiting the range of motions.

Muscles and tendons contract together at the appropriate time with proper power and acceleration to fulfil a movement. The muscle contraction decelerates any extra force provided to the joint.

The bone beneath the joint also acts as a shock absorber.

Failure of any of the above mechanism can lead to injury of the joints or osteoarthritis.

What are the risk factors for osteoarthritis?

1. Two main risk factors

Susceptible Joints

Overloading of Joints

Susceptible joints are increased age, female gender, racial/ethnic factors, Genetic susceptibility and nutritional factors & previous damage, developmental abnormality.

Overloading of joints which means the stress given to the joint is much more that the specified limit. But in certain group of people even simple daily activities can be a burden to the bones. Overloading can be occupation related and joints affected depend on the joint that is frequently used. This is because during the long hours of using the joints, the muscle become exhausted and effective protective mechanism is lost.

2. Age

As age increases the natural defensive mechanism of the joints becomes fragile. Women in older age are more prone to increased risk to osteoarthritis which may be due to loss of hormone after menopause.

3. Genetics and heritability

It is a hereditary disease and it also depends on the joint affected. Fifty percent of hand and hip joints have increased risk to pass on to the future generations whereas osteoarthritis of the knee has a risk of thirty percent. Multiple joint involvements i.e. Generalised Osteoarthritis is rather due to aging process.

4. Repeated use of Joints

Though exercise is considered as one of the treatment modality, certain type of exercises can increased risk of joint damage. Compared to non-runners elite runners have high risk of getting osteoarthritis in the later years.

Symptoms of osteoarthritis

Joint pain is usually movement related. Pain appears on joint use and resolves later. During the earlier stage of the disease, pain is episodic i.e. the pain is related to movement. For example, if a patient has osteoarthritis in knee, climbing stairs or running may aggravate the pain and the pain will subside in few days. When the disease progress the pain becomes continuous and troublesome especially at night.

Stiffness of the affected joint becomes prominent and morning stiffness may be present.

Investigations Required

There is no specific blood investigation available.

X-ray is an excellent method of investigation for osteoarthritis, though it is not helpful in the earlier stages of the disease.

Treatment

The main objective of the treatment is to limit the damage of joints and to reduce the level of pain. So it could be non-pharmacologic mode of treatment and pharmacological way of treatment.

Non-pharmacologic treatment

1. Avoid activities that overload the joint.
2. Increase the strength and condition of the muscles
3. Distributing the weight by using cane or crutch.

It is advisable to end the activities that precipitate pain. Weight loss in obese may also alleviate the symptoms.

As pain is the main symptom of osteoarthritis, it results in immobility. This immobility can lead to obesity which in turn will have a negative impact on the cardiovascular system. Thus this is a vicious circle. Thus exercise regimens will help in strengthening muscles across the joint. Aerobic exercise and/or resistance exercise will focus on strengthening of the muscles. If an exercise increases the pain, then that particular exercise should be avoided. Patient can contact the general practitioner who can refer you to a physiotherapist. A physiotherapist can advice you about particular exercise that can help to reinforce the strength of muscles.

Pharmacotherapy

Acetaminophen (paracetamol), Non-steroidal Anti inflammatory drugs (NSAIDS) and COX 2 inhibitors are the drugs that control osteoarthritis.

1. NSAIDS are the most familiar drugs to treat osteoarthritis pain. Primarily NSAIDS should be given according to the threshold of the pain. NSAIDS include Naproxen, Salsalate & Ibuprofen. If occasional treatment with NSAIDS is ineffective, daily treatment should be commenced.

NSAIDS has side effects which includes gastrointestinal toxicity, dyspepsia, nausea, and bloating, gastrointestinal bleeding and ulcer disease.

To minimise the effect, the following must be maintained:

a. Take medication after food.

b. Avoid use of two NSAIDs

c. Use a relatively safer NSAIDS.

d. If at risk of gastrointestinal bleeding, prescribe gastro protective agent.

2. Intraarticular injections: Glucocorticoids and hyaluronic acid

In case of severe pain, intraarticular injections with glucocorticoids will be helpful.

Surgery

For knee osteoarthritis, several operations are available which includes arthroscopic debridement and lavage.

Osteoarthritis is not a reversible disease, only the symptoms can be treated. So it is sensible to avoid activities that will provoke the symptoms.

Osteoarthritis ends here and I will see you in the next post with a different topic.

Viral Hepatitis

Hepatitis means inflammation of the liver caused by hepatitis virus. The pathogen involved in this is called hepatitis virus which includes Hepatitis A virus (HAV virus), Hepatitis B virus (HBV virus), Hepatitis C Virus (HCV virus), Hepatitis D virus (HDV virus) & Hepatitis E virus (HEV). There exists Hepatitis G virus and Hepatitis TT virus but it does not cause hepatitis. These agents cause the same similar symptoms, though they all have different route of transmission.

Hepatitis A virus It is RNA virus which belongs to Genus hepatovirus and Family picornavirus. It replicates in the liver and is excreted in the faeces of infected persons for about 2 weeks before the onset of clinical symptoms.

Mode of Transmission Contaminated food or water (Faecal- oral route).

Incubation period 4 weeks

Signs & symptoms Infected patient may have mild flu like symptoms of anorexia, Vomiting, fatigue, malaise, head ache and low grade fever. Later it could be followed by jaundice with dark urine and pale stools. Pain in joints and rash can go together with the jaundice. There may be enlargement of the liver.

Investigation Anti-hepatitis A immunoglobulin M remains for 3-6months after the primary infection and it shows acute infection.

Anti-hepatitis A immunoglobulin stays for many years.

Levels of liver enzymes Alanine aminotransferase and Aspartate aminotransferase are increased. Serum bilirubin level can be increased as well.

There is lecuopenia with a relative lymphocytosis. Prothrombin time is prolonged in severe cases and Erythrocyte sedimentation rate is increased.

Treatment Usually supportive. Your immune system will take care of the offender. You have to make sure you do not drink or eat fatty food.

Prophylaxis If you are travelling to high risk zones of hepatitis A then it is advisable to avoid eating in such conditions especially anything uncooked or raw.

Immunisation One could get vaccinated if he knows that he is travelling to a high risk country 4-6 weeks before travel. A single doses turns out to produce antibodies for one year. When a booster is given, immunity then can lasts for up to 10years.

Prognosis It has excellent with most patients having complete recovery. Death may occur due to fulminant hepatic necrosis. Some cases may occur with prolonged course with 7-20 weeks and is called ‘cholestatic viral hepatitis’. There might be hindrance with weakness following resolution of symptoms and biochemical parameters. This is known as post-hepatitis syndrome.

Hepatitis B Virus It is a DNA virus which belongs to hepadnovirus.

Mode of Transmission Unprotected sexual contact with infected, Sharing of contaminated needles & syringes, vertical transmission from mother to child especially during child birth. All bodily fluids saliva, semen, vaginal secretions and blood contains hepatitis B virus.

Incubation Period 1-6 months

Hepatitis B virus usually can occur in two phases. It can be acute phase when one gets infected and chronic phase when the virus persists in the body.

Signs & Symptoms Patient will feel generally unwell, abdominal pains, vomiting and fever. Later on patient will develop jaundice.

Symptoms usually disappear in few weeks and virus is cleared from the body within 3-6months. In some cases it develops into chronic hepatitis which stays for life long. When a patient is with chronic infection, it might be symptomless and the virus will remain in the body and the patient will be a carrier or a chronic inactive hepatitis B.

In some cases liver is inflamed all throughout and it is called chronic active hepatitis in which patient might experience symptoms or can be asymptomatic.

In later years after infection with hepatitis B virus patient may develop cirrhosis of the liver which is scarring of the liver and it results in deterioration of the function of the liver.

There is risk of developing hepatocellular carcinoma.

Investigation

Blood test shows presence of hepatitis B surface antigen.

Liver function tests which will show the elevation of the liver enzymes

Ultrasound scans of the liver. Biopsy of the liver should be done to check if there is any progressing cirrhosis of the liver.

Various other portions of the virus particles can be seen which shows various stages of infection.

Treatment

No treatment can be helpful but they can ease the symptoms.

In case of chronic hepatitis treatment is given to reduce the progression of liver damage.

Interferon: It is a substance which helps to fight against the immunity. It fights against infection by providing stronger immunity.

Anti-viral drugs: These drugs which help to fight against the infection.

Liver transplantation can be helpful as well.

Diet and Alcohol Normal balanced diet can be continued. It is advisable to avoid cirrhosis.

Prophylaxis Avoid risk factors such as shared needles, multiple male homosexual partners and prostitutes.

Standard precautions must be followed in hospitals to avoid accidental needle punctures and contact with infected body fluids.

Immunisation should be done to people at high risk.

Hepatitis D It is caused by Hepatitis D virus or Delta virus. It is a RNA virus which does not have the capability to replicate on its own but is usually active only in the presence of Hepatitis B virus.

Investigation Ig M anti-delta along with presence of Ig M anti-HBc appears at one week and disappears by 5-6 years when serum Ig G anti-delta is seen.

Hepatitis C

It is a single stranded RNA virus of the Flaviviridae family. It consists of six genotypes. Out of which, genotype one is the most common in U.K.

Mode of transmission Intravenous drug users and blood transfusion (In England from 1991 September blood has been screened for Hepatitis C virus)

Haemodialysis

Sexual contact with infected individual

Needle stick injuries

Perinatal transmission

Signs & symptoms Usually asymptomatic

People will experience malaise, anorexia and weakness with jaundice. Most patient present in later years with abnormal liver function test or with Chronic liver disease.

Extrahepatic manifestations include Arthritis, Glomerulonephritis associated with cryoglobulinaemia and porphyria cutanea tarda.

Investigation HCV RNA can be detected 1 or 2 weeks after infection

Anti-HCV is usually positive 6 weeks from infection

Treatment Patient should be educated about the disease.

Patient should not donate blood, tissue or organ.

Alcohol could accelerate the destruction of the liver; hence excess alcohol intake must be avoided.

Pegainterferon alfa-2a and ribavirin can be prescribed .

Hepatitis E It is a RNA virus which belongs to the family Calicivirus.

Mode of transmission Contaminated water is the main source of infection

Zoonotic spread with dogs, pigs and rodents carrying the virus.

Signs & symptoms Clinical features similar to Hepatitis A virus

It is self limiting.

Investigation

HEV RNA can be detected in the serum or stools by PCR

IgM anti HEV and IgG anti HEV

Treatment Usually supportive

Prevention Good hygiene and sanitation

Avoid tap water in high risk area

No vaccine is available

We will meet in the next blog with another interesting disease.