Head trauma case
23-01-2020 -By Lucia van Vliet, general practitioner committee of inquiry into incidents and calamities
Not long ago, the Commission of Inquiry into Incidents and Emergencies Faced with a Case concerning head trauma in an elderly lady. This lady passed away because the possibility of a subdural hematoma was not recognized in time. There there seems to be a lack of clarity about the interpretation of the standard head trauma of the NHG. When should someone with a head trauma be sent in? become? Which symptoms are sufficient on their own or which combination of factors leads to submissions?
The NHG standard makes a classification into:
- Head trauma with a greatly increased risk of intra-cranial injury: This is the case with reduced consciousness, a seizure, suspected skull base fracture or high energy trauma (IT). These are referred as a matter of urgency .
- Head trauma with an increased Risk of intracranial injury, at age>16 years:
- persistent vomiting, or
- coagulation abnormalities or
- severe antero- or retrograde anmesia
- These symptoms are separate enough to send in or at least consult with the neurologist.
- a combination of 3 symptoms or more, (serious accident mechanism, but no IT, age> 60 years, once vomiting, severe, unrecognizable headache, any loss of consciousness, clinically relevant external injury, alcohol and/or drug intoxication).
- For this combination: send in or consult with neurologist.
Concerning The patient did not have a greatly increased risk, but she did have an increased risk, namely: >60 years old, vomited several times, unrecognizable headache and clopidogrel use. Because of this combination of symptoms, she had sent in should be addressed. See also: https://www.nhg.org/standaarden/volledig/nhg-standaard-hoofdtrauma
Additions on NHG standard:
- In the NHG standard, TARs are (platelet aggregation inhibitors) not counted as anticoagulation; i.e. they would not increase the risk of intracranial injury. There are more and more indications that the bleeding risk does appear to be increased by This group of drugs (clopidogrel, acetyl salicylic acid). Adv: consider this group as an anticoagulant.
- The guideline of the RAV and NVN are both more proactive than those of the NHG. They assume higher percentages as a priori risk of intracranial injury. As a result, when the patient After a head trauma 112 calls the chance He will be transported to the hospital. It is also more likely to that he gets a CT scan. The NVN calls vomiting a major criterion (regardless of how often), together with some minor criteria, this leads to a CT more quickly.
Takeaways:
- Think more in risk (of intracranial injury) than in neurological abnormalities; that are often not there (yet).
- Take the family’s concerns are very serious.
- Bee Doubt, combination of symptoms: consult with neurologist, even at night.