Question 11

Created on Wed, 05/27/2015 - 18:56
Last updated on Thu, 09/24/2015 - 01:36
Pass rate: 75%
Highest mark: ?

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A sixty year old male is brought unconscious to the hospital after a motor vehicle accident. He has an initial GCS of 6 and is intubated at the scene. A non contrast CT head is performed.


a) List the most significant abnormalities that are present on this CT scan?                           ·

b) List the major factors that may adversely affect his prognosis?

c) What is the simplest score in common usage that could be used to describe the patient's outcome?

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College Answer


a) List the most significant abnormalities that are present on this CT 
scan?  
                         ·

a)   R. fronto parietal subdural

b)  Midline shift

c)   Obliteration of R.lateral ventricle

d)  Effacement of sulci

e)   Traumatic subarachnoid hemorrhage

f)   Contusions

b) List the major factors that may adversely affect his prognosis?

a)  Age
b)  ICP control
c)  Severity of injury -  GCS, traumatic SAH
d)  Hypoxia
e)  Hypotension

c) What is the simplest score in common usage that could be used to describe the patient's outcome?

a)  (Extended) Glasgow outcome score

b)  SF-36

Discussion

The image for the CT I have used is obviously not the (missing)image from the college paper, but one which was used in this BMJ paper to illustrate the progression of SAH. On this CT, there is an SDH, an SAH and cerebral contusions which are undergoing haemorrhagic transformation. Certainly, the ventricle and the sulci are effaced, and grey-white differentiation is lost.

As for the prognostic influences on the fate of traumatic brain injury patients - these are well covered elsewhere. I will summarise by saying that they consist of

  • Age over 60
  • Low presenting GCS
  • The presence of pupillary abnormalities
  • An abnormal CT
  • Hypoxia and hypotension
  • Medical comorbidities

The utility of the Glasgow Coma Scale is also discussed in another chapter; and the SF-36 is not in common use. The GCS was actually initially designed with outcome in mind, and the motor components particularly are well correlated with survival.

The college answer mentions the Extended Glasgow Coma Score (which is the eight-point version). This revision was made by Jennett et al in 1981, to better classify patients who had regained consciousness.

References

Chesnut, R. M., et al. "Part 2: Early indicators of prognosis in severe traumatic brain injury." Journal of Neurotrauma 17.6-7 (2000): 555-+.

Fearnside, Michael R., et al. "The Westmead Head Injury Project outcome in severe head injury. A comparative analysis of pre-hospital, clinical and CT variables." British journal of neurosurgery 7.3 (1993): 267-279.

TEASDALE, GRAHAM, and BRYAN JENNETT. "Assessment of coma and severity of brain damage." Anesthesiology 49.3 (1978): 225.

Green, Steven M. "Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale." Annals of emergency medicine 58.5 (2011): 427-430.

Gill, Michelle R., David G. Reiley, and Steven M. Green. "Interrater reliability of Glasgow Coma Scale scores in the emergency department." Annals of emergency medicine 43.2 (2004): 215-223.

Riechers, Ronald G., et al. "Physician knowledge of the glasgow coma scale."Journal of neurotrauma 22.11 (2005): 1327-1334.

Jennett, B., et al. "Disability after severe head injury: observations on the use of the Glasgow Outcome Scale." Journal of Neurology, Neurosurgery & Psychiatry 44.4 (1981): 285-293.