Discharge form for patients with MTBI

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Discharge form for patients leaving the ER after suffering a mild head trauma

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بسم الله الرحمن الرحيم ﴿ وَمَا أُوتِيتُمْ مِنَ الْعِلْمِ إِلَّا قَلِيلًا ﴾ صدق الله العظيم الإسراء ٨۵

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A thesis Submitted to Faculty of Medicine University of Alexandria In partial fulfilment of the requirements of the Master Degree of Emergency Medicine b y Marwan Gamal El Din

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A PROPOSAL FOR AN EVIDENCE-BASED EMERGENCY DEPARTMENT DISCHARGE INSTRUCTIONS FORM FOR PATIENTS WITH MILD TRAUMATIC BRAIN INJURY

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INTRODUCTION

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1- What is MTBI? 4- How should these instructions be delivered? INTRODUCTION 2- What are the instructions that should be given to patients with MTBI upon discharge from the ED? 3- To what extent these instructions are compatible with EBM?

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INTRODUCTION What is MTBI? A patient with MTBI is a person who has had a traumatically induced physiological disruption of brain function manifested by at least one of the following: 1. Any period of LOC. 2. Any loss of memory for events. 3. Any alteration in mental state. 4. Focal neurological deficit. The severity of the injury should not exceed: a. LOC of 30 minutes. b. An initial GSC of 13-15 after 30 minutes. c. Amnesia not greater than 24 hours.

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INTRODUCTION Symptomatology of patients with MTBI 1-Physical symptoms of brain injury (e.g. nausea, vomiting, dizziness, headache, blurred vision, sleep disturbance, lethargy….etc.) 2-Cognitive deficits ( involving attention, concentration, memory, speech/language) 3- Behavioral changes or emotional instability (e.g. irritability, disinhibition, emotional lability)

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INTRODUCTION MTBI……..is it really mild? Emergency physicians see a large number of patients with MTBI and routinely discharge them home with instructions for observation. This large number of patients causes an increased cost burden for healthcare facilities manifested in radiological work up, variable duration of observation in hospital.

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INTRODUCTION MTBI……..is it really mild? 10% -up to 20% in some studies- of patients with MTBI will have positive findings on CT scans and about 1% may require neurosurgical intervention. On the other hand,

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INTRODUCTION What are the instructions that should be given to patients with MTBI upon discharge from the ED? Early recognition of symptoms and signs known to raise the suspicion of presence of intracranial haemorrhage is the key issue and is the most important take home message for patient or the caregiver.

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INTRODUCTION What are the instructions that should be given to patients with MTBI upon discharge from the ED? The responsibility rests with the caregiver to monitor the patient for a life-threatening cerebral pathology requiring surgery or hospital observation. It is the responsibility of the emergency physician to inform the family what to observe and what actions to take if the patient deteriorated after discharge from the ED.

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INTRODUCTION To what extent these instructions are compatible with EBM ? There is considerable research on factors associated with neurologic complications following MTBI. There is no true consensus on which factors are most predictive. Several evidence-based studies found certain factors to be most consistently associated with the presence of haemorrhage or intra-cranial pathology following MTBI.

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INTRODUCTION To what extent these instructions are compatible with EBM ? 1- Vomiting (especially if repeated). 2- Headache (especially a worsening headache). 3- Amnesia with or without LOC. 4- Worsening mental status (GCS <15). 5- Neurologic deficit (motor, vision or speech) 6- Seizures.

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INTRODUCTION How should these instructions be delivered ? Parents watching over individuals with MTBI should be informed of these factors and the best means to inform them is with a discharge instruction form. The written word is superior to verbal explanation in terms of compliance and for retaining the information.

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INTRODUCTION How should these instructions be delivered ? A simple and evidence-based discharge instruction form for mild head injuries will help caregivers to properly monitor post-MTBI patients after discharge from the ED.

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INTRODUCTION How should these instructions be delivered ? The development of such a form will sequentially lead to: Better care for MTBI patients. Avoiding medical pitfalls and conflicting opinions of discharge Vs observation. Limiting unnecessary follow up radiological workup. Decreasing the duration of admission and observation.

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INTRODUCTION How should these instructions be delivered ? Lowering the cost burden for healthcare services without sacrificing the patient’s rights. and finally the ultimate goal:

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AIM OF THE WORK

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To propose the first easy-to-understand discharge instructions form for patients with MTBI in Alexandria University Hospital Emergency Department depending upon evidence-based factors predictive of haemorrhage or traumatic lesions. AIM OF THE WORK

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PATIENTS 100 patients fulfilling the inclusion criteria for MTBI were enrolled in the study.

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METHODS

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METHODS Recognizing symptoms & signs most consistent with intracranial lesion following head trauma Reviewing & comparing some of the available samples of similar instruction forms The development of the current instruction form was carried out by two main pathways:

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METHODS Recognizing symptoms & signs most consistent with intracranial lesion following head trauma Using the study done on our patients. Reviewing similar studies.

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Reviewing & comparing some of the available samples of similar instruction forms Keeping in mind the critical signs and symptoms of haemorrhage that the best evidence in the literature says should be observed. METHODS

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All patients were subjected to the following 1-Patient data: Age, sex, occupation 2-History related to injury: RTA, fall, assault 3-Physical Examination: 1ry & 2ry surveys 4-Investigations: Lab Ix & CT brain METHODS

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RESULTS

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RESULTS Distribution of the studied cases according to sex Distribution of the studied cases according to mechanism of trauma Demographic Data

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RESULTS No % Sex Male 53 53.0 Female 47 47.0 Age Range 1.0 – 64.0 Mean ± SD 23.86 ± 17.66 Median 25.0 Distribution of the studied cases according to demographic data

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RESULTS Distribution of the studied cases according to the admission GCS

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RESULTS Distribution of the studied cases according to presenting symptoms

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Distribution of the studied cases according to CT finding which was + ve in 22 % of the cases RESULTS

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Relation between duration of admission and CT finding RESULTS

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RESULTS GCS MCp 13 14 15 No % No % No % CT No 0 0.0 5 45.5 73 85.7 0.001 * Yes 4 100.0 6 54.5 12 14.3 SIGNIFICANT Relation between admission GCS and CT finding

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RESULTS Relation between GCS and CT finding

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CT Test of sig. Sensitivity Specificity PPV NPV Accuracy - ve + ve No. % No. % Symptoms LOC -ve 55 88.7 7 11.3 FEp = 0.001 * 68.18 70.51 39.47 87.10 63.0 +ve 23 60.5 15 39.5 Headache -ve 53 80.3 13 19.7 p = 0.439 40.91 67.95 26.47 80.30 62.0 +ve 25 73.5 9 26.5 Vomiting -ve 32 71.1 13 28.9 p = 0.152 40.91 41.03 16.36 71.11 41.0 +ve 46 83.6 9 16.4 Neurological deficit -ve 78 80.4 19 19.6 FEp = 0.010 * 13.64 100.0 100.0 80.41 81.0 +ve 0 0.0 3 100.0 Seizures -ve 77 82.8 16 17.2 FEp <0.001 * 27.27 98.72 85.71 82.80 83.0 +ve 1 14.3 6 85.7 Relation between CT finding and symptoms RESULTS SIGNIFICANT SIGNIFICANT SIGNIFICANT

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Relation between CT finding and symptoms RESULTS

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CONCLUSIONS & RECOMMENDATIONS

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CONCLUSIONS Patients in the current study were evaluated for symptoms and signs suggestive of presence of intracranial pathology . RTA is the most common cause of traumatic brain injuries. Males are more prone to TBI than females. 10-20% of patients with MTBI may have + ve CT findings & only 1-2% may require urgent neurosurgical intervention

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CONCLUSIONS Six evidence based factors are proven to be good predictors of intracranial lesion following MTBI which are: GCS <15. Focal neurological deficit. Seizures. Loss of consciousness with or without amnesia. Headache. Vomiting.

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RECOMMENDATIONS A dditional studies including a larger group of patients with + ve CT findings to clarify the significance of each factor shoul d be carried out. A special instruction form for the pediatric age group should be devised.

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Five more factors are added criteria suggestive of post-traumatic intracranial lesion and we recommend them to be indications of performing CT brain in cases of MTBI together with the proven predictors. Dangerous mechanism of injury. Coagulopathy. Old age. Trauma above the clavicles. Drug/alcohol intoxication. RECOMMENDATIONS

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RECOMMENDATIONS We recommend using the following discharge instruction form in Alexandria Main University Hospital. Lastly,

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ALEXANDRIA UNIVERSITY ALEXANDRIA MAIN UNIVERSITY HOSPITAL EMERGENCY DEPARTMENT Discharge instruction form for patients with mild traumatic brain injury This person had a head injury and must be watched closely by another person for 24 hours and checked up during sleep every 2 hours. If this person shows any of these symptoms or signs after his head injury, you should call your doctor or go to the Emergency Room: • Any fainting or failure of arousal from sleep • Cannot remember new events, increased confusion (acting strange, saying things that do not make sense) • A constant headache, mainly a worsening headache • repeated vomiting or throwing up • Cannot move parts of the body or persistent numbness in any limb • Seizure (any jerking of the body or limbs) The person may use paracetamol, but do not take any strong pain pills or aspirin for the first 24 hours. The person must not do any sports until a doctor says it is safe to do so.

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THANK YOU