A Quick and Dirty TBI Screen

Traumatic brain injury (TBI) is an extremely common diagnosis in trauma patients. The majority are minor concussions that show no evidence of injury on head CT. Despite normal findings, however, a short conversation with the patient frequently demonstrates that they really do have a TBI.

Scoring systems can help quantitate how significant the head injury is. The Glasgow Coma Scale (GCS) score is frequently used. This scoring system is not sensitive enough for minor head injuries, since a patient may be perseverating even with a GCS of 15.

The Short Blessed Test (SBT) is a 25 year old scoring system for minor TBI that has been well-validated. To download a copy of this test instrument, click here. It takes only a few minutes to administer, and is very easy to score.

The most important part of the administration process is choosing a threshold for further evaluation and testing. We administer this test to all trauma patients with a suspected TBI (defined as known or suspected loss of consciousness, or amnesia for the traumatic event). If the final score is >7, we refer the patient for more extensive evaluation by phsyical and occupational therapy. If the score is 7 or less but not zero, consideration should be given to offering routine followup in a minor neurotrauma clinic as an outpatient. In all cases, patients should be advised to avoid situations that would lead to a repeat concussion in the next month.

Reference: Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983 Jun;140(6):734-9.

Evaluation After Head Injury in Adolescents

Traumatic brain injury (TBI) is the most common cause of death in children. Even mild concussions can cause some degree of functional impairment. Many clinicians believe that the degree of impairment correlates with the initial Glasgow Coma Scale score (GCS), although this has only been shown in adults. This has led many hospitals to perform cognitive screening selectively, usually on adolescents with lower GCS scores.

A recent study by Goold and Vane at the Cardinal Glennon Children’s Medical Center in St. Louis, and the University of Vermont College of Medicine in Burlington looked at the correlation between GCS and level of impairment, and ways to determine which groups of adolescents need more sophisticated cognitive testing to evaluate deficits.

A total of 609 young adults age 13-21 with brain injuries were identified, and a cognitive screening test was performed (Occupational Therapy Head Injury Mini Screen [OT HIMS]). There was no correlation between GCS and the components of the OT HIMS. Interestingly, the GCS did not predict which patients were discharged to rehab centers either.

The Bottom Line: Adolescents can develop significant cognitive deficits or behavior issues after any degree of head injury. Because of this, it is not possible to selectively screen for cognitive deficits. All adolescents age 13-21 should undergo screening with an instrument like the OT HIMS after head injury.

At our Level I Pediatric Trauma Center, we consider a child to have a TBI if:

• the mechanism involves head impact and
• any of the following apply:
• known or suspected loss of consciousness
• cannot remember the event
• parents detect any change in behavior

All of these children undergo a TBI screen performed by Gillette Children’s Specialty Hospital physiatry, occupational and physical therapy services. If needed, they receive followup in the Gillette Minor Neurotrauma Clinic.

Reference: Goold D, Vane DW. Evaluation of Functionality After Head Injury in Adolescents. Journal of Trauma 2009;67:71-74.

Forensic Nursing

A recent article in USA Today has focused interested in a little-known area of nursing involving forensics. Click here to see the article.

Forensic Nursing combines nursing science with the investigation of injuries or deaths that involve accidents, abuse, violence or criminal activity. Sexual Assault Nurse Examiners (SANE nurses) are one of the most recognized types of forensic nurses, but they have special training in one type of injury. Forensic nursing typically involves a broader set of skills, encompassing some or all of the following:

• Interpersonal violence, including domestic violence, child and elder abuse/neglect, psychological abuse
• Forensic mental health
• Correctional nursing
• Legal nurse consulting
• Emergency/trauma services, including auto and pedestrian accidents, traumatic injuries, suicide attempts, work-related injuries, disasters
• Patient care facility issues, including accidents/injuries/neglect, inappropriate treatments & meds
• Public health and safety, including environmental hazards, alcohol and drug abuse, food and drug tampering, illegal abortion practices, epidemiology, and organ donation
• Death investigation, including homicides, suicides, suspicious or accidental deaths, and mass disasters

Forensic nurses find that their additional training improves their basic nursing skills, and allows them to derive greater career satisfaction from helping patient in another rather unique way.

Approximately 37 training programs exist, ranging from certificate programs that require a specific number of hours of training, to degree programs (typically Masters level programs). Many of the certificate programs are available as online training. Click here for information on these programs. http://www.iafn.org/displaycommon.cfm?an=1&subarticlenbr=50

Source: International Association of Forensic Nurses (http://www.iafn.org/)

Cervical Spine Clearance

Cervical spine clearance can be challenging in trauma patients. I will review simple algorithms for clearing the c-spine in the emergency department, and for clearing it in an inpatient.

Clearing the c-spine requires two things: evaluation of the bones and evaluation of the ligaments. There is some new literature that suggests that it may be possible to clear based on a high quality cervical CT scan only. However, there is not yet enought data to adopt this as a standard of care.

A copy of a clearance algorithm for use in the ED will be available shortly.
Click here to download a copy of our clearance algorithm for inpatients with normal mental status.

A complete evaluation of both bones and ligaments can be performed in a few patients by a clinical exam alone. However, this requires several things:

1. Awake and alert
2. Not intoxicated
3. No "distracting injuries." These are painful injuries that may preclude the patient being aware of discomfort in their neck.

If these conditions are met, then a careful exam of the neck can allow spine clearance. The exam consists of:

• Palpation of the cervical spine in neutral position
• Gentle flexion and extension to the limits of comfort
• Left and right rotation to the limits of comfort
• Gentle compression by pressing on top of the head

If at any point the patient experiences pain or tenderness in the posterior midline, then the clearance process is terminated and the collar replaced. Pain or tenderness in the paraspinous muscles is common and is not a contraindication to clearance. If all maneuvers are successfully completed, then the collar can be removed and clearance documented in the medical record.

For patients who are not eligible for clinical clearance, the vertebrae must be evaluated radiographically. Although standard cervical views can be obtained with conventional radiography, helical CT has become the standard. Once radiographic clearance is complete, clinical clearance can be performed using the guidelines listed above.