2024-01-23 10:20:00
In the world there are between 50 and 60 million new cases of head trauma (TCE) per year, of which it is estimated that more than 90 percent are mildand currently the computed tomography Cranial CT is the standard diagnostic tool to evaluate intracranial injury in patients with some degree of traumatic brain injury. However, today there are no universally accepted standards on when urgent head CT should be performed in mild TBI. And the use of these protocols at the Spanish level is center dependent, which implies that there is no homogeneity between autonomous communitieshealth areas and centers of the same region regarding the use of a common consensus, route, protocol, guide or manual of action for the management of patients with mild TBI.
For this reason, from the Spanish Society of Medical Radiology (SCARY), along with its emergency section (Stars), the Spanish Society of Emergency Medicine (Semes), the Spanish Society of Laboratory Medicine (Seqcml), the Spanish Society of Neurosurgery (Haystack) and the Spanish Association of Football Team Doctors, a consensus has been developed, participated in and endorsed on the management of patients with mild head trauma.
Specifically, in Europe it is estimated that at least two and a half million new cases of TBI occur each year and the age-adjusted incidence of patients with TBI admitted to hospitals is between 200-300 per 100,000 inhabitants per yearwith wide variations between countries.
Mild TBI is any trauma to the craniocerebral region that leads to suspicion of acute brain injury using the WHO clinical criteria to identify it. Nowadays, head CT is the standard diagnostic tool for evaluate intracranial injury of patients with some degree of acute head trauma and to identify those who need immediate surgical treatment. Only 7-10 percent of patients with mild TBI present intracranial abnormalities detected by CT, of which less than 1 percent require surgical intervention and mortality could be classified as exceptional (0.1 percent).
There is no agreement on the approach to mild trauma
There is general consensus on performing cranial CT in patients with moderate or severe TBI, but there is no agreement on which patients with mild TBI should undergo this test due to the low prevalence of intracranial anomalies detected by CT and the exceptional mortality linked to mild brain damage.
This lack of consensus added to the need to have more objective tools to determine the neurocognitive status of these patients has led to an exponential increase in requests for cranial CT from the emergency department.
For Agustina Vicente e Inés Pecharrománemergency specialists from SERAM, “there is a need to optimize resources through a more detailed stratification of risk in order to define the best approach for each patient. Furthermore, along with the increase in associated costs, there is a saturation of the services involved and risks of exposure to radiation (especially important in those under 20 years of age), which have led to questioning the widespread use of urgent head CT in TBI and there is a need for optimization.”
Proof of the exponential increase is the recent obtaining of the CE marking (European Conformity) and the approval by the FDA (Food and Drug Administration) of the first rapid serum/plasma test of the specific biomarkers GFAP and UCH-L1 in mild TBI.
The results suggest that this test can be incorporated into the standard of care to help decision making during the evaluation of adult patients with GCS 13-15 in the first 12 hours of injury, to determine the need for CT. “This situation offers the possibility of proposing an updated algorithm to try to standardize the management of mild TBI in emergency situations in Spain,” say Vicente and Pecharromán.
How and when to proceed in the patient assessment
When the patient arrives at the emergency room, by ambulance or on their own, and life-threatening situations, polytraumatization or more severe forms of TBI have been ruled out, for which specific protocols are available, patients with suspected mild TBI are treated with a less urgent category. Its evaluation is carried out, with the aim of identifying the presence of signs, symptoms and/or risk factors for intracranial injury. The realization of neuroimaging testse is limited to those patients in whom the risk is greater, taking into account that in the context of mild TBI, around 90 percent of the head CT scans requested are normal.
The rapid serum/plasma test of the specific biomarkers GFAP and UCH-L1 in the first 12 hours after trauma is a complementary tool during the evaluation that helps decision-making to rule out the need to perform a head CT in patients with GCS 15 with symptoms and/or risk factors, GCS 14 or GCS 13.
A negative test result is associated with absence of intracranial lesions due to its high negative predictive value. Therefore, after a negative result in the determination of GFAP and UCH-L1, patients can be discharged for home observation, as long as the patient is recovered and without symptoms. If more than 12 hours have passed since the trauma or the biomarker result is positive, a blood test is performed. cranial CT. In the event of pathological findings on CT or in the event that the patient’s symptoms do not agree with the radiological results, a consultation is made with the Neurosurgery service to proceed with the patient’s assessment.
Patients with a CT without pathological findings Those who do not have risk factors and who have not experienced clinical deterioration or persistence of symptoms can be discharged for home observation. In addition, the recommended action is specified after the CT results with and without pathological findings.
What are the causes of suffering from trauma?
The causes of TBI are mostly falls and traffic or work accidents, and to a lesser extent blows to the head by/against some object, physical violence and contact sports, among other causes.
In clinical practice, it is estimated that approximately 60-70 percent of cases of mild TBI involve a patient profile aged 60 or 65 years and older with previous comorbiditiesamong which the injury mechanism It is mostly the fall from own height (60-82 percent). The other 30 percent correspond, mainly, to younger patients who suffer a TBI during physical activity.
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