Head injury complicating falls and syncope: State of the art Giles Critchley Consultant Neurosurgeon...
-
Upload
pierce-chambers -
Category
Documents
-
view
217 -
download
0
Transcript of Head injury complicating falls and syncope: State of the art Giles Critchley Consultant Neurosurgeon...
Head injury complicating falls and syncope: State of the art
Giles CritchleyConsultant NeurosurgeonHurstwood Park Neurological CentreBrighton and Sussex University Hospitals NHS
Trust
The problem
.....the other silent epidemic – falls and injuries in the home.These accidents increasingly involve our aging population and result in significant disability and death.
The problem
Traumatic brain injury
1. Epidemiology – Socio demographic factors
2. Mechanism of injury – falls and syncope
3. Efficiency of healthcare system –
‘State of the art’
Incidence of traumatic brain injury in different populations (selected studies)
Elderly ratesage range yrs
inc per 100,000
USA Kraus, Nourjah 1989 65-75 200 Cooper et al 1983 60-80 150-200
FinlandKannus et al 2007 male 80-84 465
85-89 61790 > 976
female 80-84 39785-89 60890> 735
Age-specific rates of head injury hospitalization in Ontario, overall 1994/95 through 1998/1999 (from the Minimal Data
Set of the Ontario Trauma Registry)
Socio – demographic factors
• Age – trimodalchildren 0-4 yrs
young adults 15 -19 yrselderly 75 >
yrs
• Gender – male 3: 1
Causes of head injury – all ages
European Brain Injury Consortium – those admitted to neurosurgical units
RTA 51% Falls 12% Assault 7%
CRASH study
RTA 64% Falls 13%
USA, 1995–2001
Causes of head injury – elderly
age yrs distribution
India (Sinha et al 2008) 60> falls 56.3% RTA 44.1%
Singapore(Gan et al 2004) 64> falls 73.8% RTA 21.5%
Ireland (Phillips report 2008) 25%>65 falls 59% RTA 22%
Socio – demographic factors
Falls – 60% at home
Alcohol – 25% falls associated with alcohol
In NSU fall patients :-
Aspirin – 14%
Warfarin – 8%
Mechanism of injury – falls and syncope
Definition of falls: FICSIT, ICD , < 1metre
Classification: explained, unexplainedintrinsic, extrinsic
recurrent, non recurrent
Syncope: a transient loss of consciousness due to cerebral iscaemia
Mechanism of injury – falls and syncope
40-60% of falls lead to injuries.
Low impact injuries
Fewer multiple injuries
BUT
More severe CT findings – mass lesions, SAH, mid line shift
Pattern of injury
diagnosis – CT scanning (MRI)
• Chronic subdural haematoma
• Contusions
• Acute subdural haematoma
Chronic subdural haematoma
Chronic subdural haematoma
• mean age around 71 yrs (74 yrs 20-91)
• head trauma identified in < 50%
• ‘soft’ neurological signs
Chronic subdural haematoma - treatment
• Burr hole drainage – local/ GA
• Twist drill craniostomy
• Mini craniotomy – GA
• Randomised control trial
Use of drains versus no drains after burr-hole evacuation of chronic subdural
haematoma: a randomised controlled trial.T. Santarius et al Lancet. 2009 Sep 26;374(9695):1067-73.
108 patients drain into subdural space107 no drainRecurrences: no drain 24% (26 /107)
with drain 9.3% (10 /108)
Mortality at 6 months: no drain 18.1% (19/105)with drain 8.6% (9/105)
Acute subdural haematoma
Acute subdural haematoma
Trauma craniotomy
Acute subdural haematoma
more common 30% of severe HI manifestation of parenchymal damage
poor prognosis – 45% mortality
in elderly 79% mortality
Management
Conservative – allow to become chronic
Cerebral contusions
Coup/contrecoup
Frontal / temporal
Mass effect
Cerebral contusions
• Supportive management
• In one series of elderly 19.3% of geriatric head injuries
• Mortality 40%
Outcome
• Elderly have a worse outcome, lower admission GCS – more likely unfavourable outcome
• Moderate TBI in elderly similar to severe TBI in younger
• Outcome of mild TBI worse
Outcome
Reasons: decreased functional reserve
loss of elasticity of blood vessels
cerebral atrophy
bridging veins
hypertension
Outcome
• Apoprotein E4 (APOE 4)
• Patients with APOE episilon 4 allelle more than twice as likely to have a poor outcome.
• TBI and APO E increased risk of Alzheimer’s 10 fold.
Factors leading to falls
• Weakness
• Balance deficit
• Mobility limitation
• Visual deficit
• Cognitive impairment
• Postural hypotension
Prevention
• Ward design
• Tai chi
• Stair design
• Lighting
• Helmet use in multiple fallers
The Haddon Matrix
Phase People Vehicle and equipment
Environment
Pre accident (prevention)
Education
Attitudes/behaviour
Impairment (alcohol, drugs, fatigue)
Police enforcement (traffic laws)
Reflective clothing for pedestrians and cyclists
Roadworthiness
Lighting (daytime lights on motorcycles)
Braking and handling
Speed limitation systems
Road design and layout (separation of car, cyclists, and pedestrians; better road marking and lighting)
Speed limits
Provision of transport alternatives
AccidentUse of seat belts
Impairment (drink driving)
Crash-protective design and engineering
Occupant restraints and safety devices (seat belts, air bags, child restraints)
Use of helmets
Crash-protective roadside barriers/objects (centre isle barrier, pedestrian crossing)
Post accidentFirst aid and resuscitation
Access to medical and rehabilitation services
Ease of access
Fire risk
CCTV at danger points
Access for rescue services
(congestion) Adapted from, WHO, Geneva, 2004, Queensland Australia 2004 fall
prevention.
The Haddon Matrix - falls
Phase People Vehicle and equipment
Physical environment
Social
Environment
Pre - fallEducation
Attitudes/behaviour
Impairment (alcohol, drugs, fatigue)
Bone density,
Flexibility, balance and strength
Appropriateness of type of shoe (eg slippers)
Non slip flooring
rails on all stairs
Rationalisation of medications
Lighting
The inevitability of older people falling over and having accidents.
Safe physical activity in older people
Accident - fall
Human tolerances to crash forces.
Use of helmetsProper use of helmets
Height of fall and surface fallen onto.
Contact with other objects
Anti-slip flooring requirements in public places, hospitals and residential elderly care facilities
Post fallFall victims general health, fractures and other injuries
Personal alarm systems Availability of a timely and effective medical response
Public support for trauma care and rehabilitation
Adapted from World report on road traffic injury prevention, WHO, Geneva, 2004. a
Conclusions
• Falls are an increasing cause of head injury ‘silent epidemic’
• Age is an independent predictor in outcome
• This increasing public health problem requires a multidisciplinary approach for prevention, treatment and rehabilitation of elderly patients