The Dangers of Missed Head Injuries
By Andrew D. Perron, MD, Chief Resident, Department of Emergency Medicine, Carolinas Medical Center; Michael A. Gibbs, MD, FACEP, Clinical Instructor of Emergency Medicine, University of North Carolina at Chapel Hill, Department of Emergency Medicine, Carolinas Medical Center, Medical Director, MedCenter Air; Daniel J. Sullivan, MD, JD, FACEP, Chairman, Department of Emergency Medicine, Ingalls Memorial Hospital, Harvey, Illinois
Malpractice cases related to traumatic brain injury (TBI) are focused on a wide range of issues including: failure to diagnose the injury through physical examination or CT scan; missed head injury in children; failure to provide adequate discharge instructions; failure to adequately manage the alcohol-impaired patient; and recognition of the nature of the injury in the emergency department (ED), but failure to adequately treat through aggressive management, consultation, or transfer. In general, these cases involve dramatic injury with severe, permanent disability and/or death; thus, settlements and verdicts are quite large.
Avoiding patient injury and malpractice related to patients with TBI require a current working knowledge of the literature, the exercise of sound clinical judgment, and attention to the details of risk management. In this high-risk area, research does not provide all the answers. Some patients with apparent mild head injury will develop an intracranial lesion, and some develop an intracranial bleed two or more weeks after the injury and initial visit.
In recent years, researchers have focused on helping the clinician decide which head-injured patients require a CT in the ED to rule out significant injury. Most studies warn that there is a small but significant number of patients with apparently minimal head trauma, a Glasgow Coma Score (GCS) of 13-15, and a paucity of positive historical or physical findings who ultimately are found to have significant cerebral injury.
Epidemiology and Definition of Minor Head Injury
It has been estimated that there are 2 million cases of TBI in the United States each year, with approximately 500,000 requiring admission.1 Head injury is predominantly a disease of productive young adults, with more than 50% of victims between the ages of 15 and 34 years, and a 2:1 male predominance.2,3 While patients presenting with evidence of moderate-to-severe head injury generally present little diagnostic or treatment dilemma for the emergency physician, there is considerable variation in the evaluation and management of those with perceived minor injuries. The goal in the evaluation of this patient population is to identify which patients are in the small subset harboring a significant intracranial lesion requiring neurosurgical intervention.
Mild TBI is a common neurologic condition with estimates that suggest an incidence of up to 180/100,000 population.4 There is considerable variation among authors as to what constitutes "minor" TBI. It has most commonly been described as existing in any patient with the history of a head injury and a GCS score of 13-15.5,6,7,8 Some authors also require a loss of consciousness to have occurred or post-traumatic amnesia to be present.9,10 There is a more recent trend to categorize those with GCS of 13 and 14 as having "moderate injuries," and to consider those with GCS of 15 as a separate entity.11 This strategy seems the most useful to today's practicing emergency physician, as this is the sub-group that presents to the emergency physician with the greatest frequency (65-85% of patients with TBI presenting to the ED have a GCS of 15).12,13
Essentials of the Neurologic Evaluation
The GCS score should not be thought of as a substitute for a precise neurological examination, which is a critical step in the initial evaluation of all patients suffering a traumatic brain injury. The level of consciousness is the single most important factor in assessing the head-injured patient. Somnolence, irritability, and inattention are all subtle clues as to which patient may harbor intracranial pathology. Orientation, concentration, and memory should all be evaluated. Pupillary size, reactivity, and symmetry need to be assessed bilaterally in addition to a standard cranial nerve examination. Motor strength should be documented, with special attention focused on asymmetry. Pronator drift, where both hands are extended palms up with the eyes closed and held for 30 seconds, is an excellent test for subtle motor weakness. Light touch and pain sensation in all four extremities serves as an adequate sensory evaluation in the setting of head injury. Coordination is tested with finger to nose or tandem gait ambulation.
The general physical examination also needs to be oriented toward discovering occult intracranial pathology. Scalp lacerations need to be examined and palpated for depressed skull fractures, the presence of which increases the likelihood of a TBI by 25-45%.12,14,15 Hemotympanum, CSF rhinorrhea, Battel's sign, and raccoon eyes are all indicative of basilar skull fracture. Throughout the history and physical examination, the emergency physician must remain vigilant for risk factors that can mask serious intracranial pathology, including alcohol intoxication and current drug usage.
The patient should also be carefully evaluated for the presence of associated spinal injury. Minor TBI is not in and of itself an indication for cervical spine radiography. Several studies have shown that the incidence of cervical spine injury does not increase with maxillofacial and head injuries.16,17,18,19 Cervical radiography can be safely deferred in patients who are alert and have no spinal tenderness, neurologic deficit, or major distracting injury.20 It should be remembered, however, that altered mental status as a result of a TBI is a clear indication for cervical spine radiographs. Failure to obtain cervical radiography in the latter situation is a major risk factor for missed spinal injury.21,22,23 The presence of a head injury may impair the evaluation of other injured organ systems. The clinician should have a low threshold for a more aggressive evaluation of other organ systems in the multiply injured patient with TBI.
Case # 1
At 5:20 a.m., a 35-year-old male presented to the ED with a complaint of injury to the right orbit. He stated that he was struck in the early hours of the morning while sleeping. He was intoxicated. The physician noted that he was in no apparent distress. According to the patient history, there was no documented loss of consciousness, lethargy, weakness, dizziness, or vomiting. The patient had gross edema and echymoses around the right eye and was unable to open the eye without assistance. Pupils were equally reactive to light. Extraocular movements were grossly intact, and there was a laceration under the right eye. There was no documented evaluation of the skull, ENT, or neurologic examination.
The physician repaired the laceration and discharged the patient with wound care instructions and a head injury sheet, with orders to return to the ED if there were any signs of head trauma. On the ED nursing flow sheet, the RN noted a Neuro check. "Alert, ++ ETOH. PERL. Ambulates with assistance. Speech slurred." The nursing progress notes indicate that the patient was seen by the EP at 5:30 a.m., was sutured at 5:45 a.m., and took a Tylenol for pain at 6:05 a.m. At approximately 7:00 a.m., the patient called a friend for a ride, but there was no answer. At 7:15 a.m. patient was sleeping, and at 8:15 a.m. he was moved out to the triage area in a wheelchair pending his ride home. At 8:20 a.m. the patient was brought back into the department. He was cyanotic and not breathing. He slid out of the wheelchair and arrested on the floor in the ED.
At that point the physician ordered a CT scan that showed a large right subdural hematoma with midline shift and tonsillar herniation. The alcohol level was 0.226 mg/dL. The patient was intubated and transferred to another institution. The history at the second institution indicated that the patient had been on an alcohol binge and was apparently kicked in the face. A surgical consultant noted that the patient had been in a bar altercation the prior evening and received blows to the head.
In his deposition, the physician said he did a neurologic exam and did a skull evaluation. The physician indicated that he did not ask the patient about loss of consciousness (LOC), and further testified that even though the patient was intoxicated he felt like he was getting a good history. They physician did not consider a closed head injury, only a facial bone fracture.
The plaintiff's attorney asked, "Can't head injury give slurred speech?" The physician answered, "Yes, but in this particular case I had no reason to think it was anything but the ETOH [ehtyl alcohol consumpion]."
It is impossible to know in the head-injured intoxicated patient whether abnormal speech and gait is secondary to alcohol or a traumatic brain injury. The clinician should consider TBI in the differential and image the brain.
The physician did not document a neurologic examination. If there is one organ system the physician would want on this chart, it is the neurologic system. In this case, there was only one patient in the ED. The physician had plenty of time to document the relevant organ system. In high-risk cases, the physician should consider which system is the most important to document fully and write that one first. It may be out of order, but at least it gets done. The clinician must think of charting not only as documenting a patient encounter, but also as `creating a record' that may be reviewed by a malpractice litigant, a Medicare fraud and abuse review officer, o,r perhaps, a member of the state disciplinary review board.
Who is at Highest Risk for Traumatic Brain Injury Following Seemingly Minor Closed Head Injury?
A number of studies have attempted to quantitate the risk of harboring intracranial pathology despite having a seemingly minor mechanism of injury and a GCS of 13-15. Estimates from these studies indicate that 18-21% of patients with a GCS of 13-15 will have pathologic findings on their CT scans, and that 4-10% will need neurosurgical intervention.7,12,24,25 The three highest risk groups, the intoxicated, the very young (age < 2), and the elderly (age > 65), deserve special mention.
The Alcohol Impaired Patient
Intoxicated patients are at high risk because they do not have a reliable neurologic exam, and rarely do they have a responsible party with whom they can be discharged home. Chronic alcoholics are at risk for brain atrophy, which puts them at increased risk for subdural hematomas.26 Finally, chronic alcoholics can also harbor unrecognized coagulopathies due to liver disease, which again puts them at increased risk for deterioration.
The detection of intracranial lesions among intoxicated patients is particularly difficult.27 In one study, 42% of patients with minor head trauma had positive blood alcohol tests. A recent prospective study evaluated consecutive patients presenting to the ED with minor head trauma and serum ethanol levels higher than 80 mg/dL.27a The study group consisted of 107 patients. Intracranial injuries were noted on CT in nine of the 107 patients (8.4%). In comparing the characteristics of the group with intracranial injury to that without injury, there were no differences in GCS or neurological evaluation either upon arrival or at one hour. The groups did not differ by mechanism of injury, historical factors, or by physical examination findings.
Intracranial injury was detected even in patients with minor-appearing mechanisms of injury and minimal external evidence of trauma. The authors concluded that in alcohol-intoxicated patients, the presence of intracranial injuries cannot be detected by neurological testing, historical factors, or physical findings. A subset of patients who can be managed safely without CT scan of the head could not be identified. The authors conclude that a very low index of suspicion is necessary for obtaining a CT of the head in intoxicated victims of minor head trauma.
Case # 2
A young man in his twenties was brought to the ED by the police after he suffered blunt head injury during an assault. He was uncooperative and initially refused treatment but eventually consented to an x-ray of the skull. The x-ray was read as normal by the emergency physician.
The patient was released against medical advice to the custody of the sheriff's department. The defendant physician claimed that the patient was legally intoxicated but was lucid enough to make an "against medical advice" (AMA) decision. The radiologist read the x-ray later that day and noted a markedly depressed left parietal skull fracture. The plaintiff was taken from jail to a hospital, monitored for several hours, and then taken to surgery where the depressed fracture fragments were elevated. The plaintiff suffered a brain injury with associated cognitive deficits that "prohibit gainful employment."
The plaintiff claimed that the emergency physician failed to recognize the skull fracture and improperly released him while he was intoxicated, and that the delay in treating the fracture contributed to approximately half of his neurological deficits. The defendants contended that although the fracture was present, it was not negligence to miss it, and that any injuries to the plaintiff were caused by the blow itself, and the delay in treatment was inconsequential.
According to reports, a $200,000 settlement was reached, with the emergency physician paying the entire amount.28
The injury was probably caused by the blow itself and any delay in treatment was inconsequential. Therefore, this case should have failed on the causation issue. That is, if the plaintiff can't prove that a breach in a standard of care caused the injury, the lawsuit must fail. The physician did not cause this injury, the accident did. However, this case never made it to the jury; it was settled prior to arguments over the causation issue.
Review of recent against medical advice (AMA) cases indicates that the AMA defense is an extremely strong defense when used in the appropriate circumstances. (See ED Legal Letter, October 1996.) If a patient has a normal mental status and makes an informed refusal of care, then the AMA defense wins in almost every case. Although these issues must go to a jury, the jury tends to support the physician. However, if there is a question about the individual's ability to provide an informed refusal, and, thus, an informed AMA, juries are not nearly as lenient.
Case # 3
The patient was a 16-year-old boy who was taken to the defendant Spectrum Emergency Care Center after his friends found him abandoned in a parking lot. He was disoriented, lethargic, semi-comatose, and unresponsive except to painful stimuli. His blood alcohol level was 53 mg/dL. The patient exhibited poor verbal skills, sluggish pupils, contusions on the back of his skull, upper back abrasions, and an inability to communicate rationally.
The defendant emergency physician examined the patient at midnight. The primary diagnosis was alcohol abuse with possible head injuries. The emergency staff checked on the patient periodically through the night. The patient's condition deteriorated between 5 a.m. and 6 a.m., and he was transferred to the Washoe Medical Center. In route, the patient died as a result of a massive epidural hematoma.
The plaintiff claimed that the defendant should have immediately transferred the decedent to the medical center for a CT scan for further evaluation that was not available at the emergency clinic. The defendants contended that the decedent had been treated appropriately given his conditions and symptoms. They also maintained that immediate transfer of a patient in the decedent's condition for a CT scan was not within the standard of care.
The jury returned a verdict for the defendants.29
This was a gift. The physician perceived that this was an alcohol-impaired patient, but it was not. It appears there was a delay in diagnostic evaluation. Remember, however, that the jury is asked to measure the physician's conduct not against the highest quality practitioner, but against the reasonably trained practitioner. The jury believed here that it was reasonable to observe rather than aggressively evaluate.
This is a typical alcohol/head trauma case. Most are similar in that the presence of an alcohol level results in a delay of a more serious diagnosis. In this particular case, an alcohol level of 53 mg/dL does not explain the long list of neurologic signs and symptoms. The facts of the case suggest that more rapid diagnostic evaluation would have been wise.
Case # 4
The patient was a 23-year-old named Shawn Davis. Mr. Davis went to a concert and had been drinking beer. Upon leaving the concert, the patient was struck by an automobile and knocked to the ground. He was taken to an emergency department where the defendant emergency physician, Dr. W., examined him and noted that he was unsteady on his feet. Mr. Davis was sent home with head injury instructions.
Several hours after arriving home, Mr. Davis aspirated and was revived by his parents. CT revealed a skull fracture with a subdural hematoma. The patient underwent an emergency craniotomy and evacuation of the hematoma. As a result of the delay, Mr. Davis is blind in one eye and has a loss of peripheral vision in the other eye.
The plaintiff alleged that the defendant was negligent in attributing his symptoms to alcohol and in failing to diagnose the skull fracture and subdural hematoma. The defendant contended that he conformed to the standard of care in sending the plaintiff home with head injury instructions. The parties reached a structured settlement of $120,000 cash plus $1000/month for life.30
In this case, the emergency physician documented that the patient was not steady on his feet. The clinician should consider that this may represent a focal neurologic deficit. This case required more aggressive management, probably CT, and continuing observation until the patient was no longer intoxicated. Sending this type of patient home with head injury instructions is inadequate.
In general, the clinician should consider the intoxicated patient as high risk for traumatic injury. The physician's approach in the first moments with the alcohol-impaired patient is critical. These are not the most pleasant patients, and it is easy to do a superficial examination or put these patients lower on the priority list. Do the exam as soon as possible after arrival; don't delay the exam while waiting for the patient to sober up. Manage your risk by doing a careful focused history and physical. Head and spinal injuries are common problems in this patient population.
Head Injuries in Children
Patients at the extremes of age are also at higher risk. Children under the age of two do not have reliable neurologic exams, and they cannot follow commands necessary to establish a GCS. A modified coma score may be useful in this population. (See Table 1.) Additionally, their skulls are not fully formed, so a seemingly minor mechanism can cause significant injury to the underlying brain.
Because cranial sutures are still open, the young child's skull is more elastic than an adult's, allowing proportionately greater accumulation of edema and hemorrhage before elevated ICP causes brain damage. However, this also allows for more direct damage to the brain since there are large areas unprotected by bone. Young children (age < 5) have a higher mortality from head trauma than adults, most likely due to the delayed presentation of child abuse and the difficulty in obtaining an accurate neurologic exam.31 Children younger than 2 years with head injury have an especially poor prognosis.
Concussion is the most minor brain injury and is generally characterized by posttraumatic transient loss of consciousness and amnesia. No consistent associated pathologic lesion in the brain has been identified. The child may have a depressed level of consciousness, pallor, and vomiting; however, the clinical picture usually normalizes within several hours without specific therapy. If symptoms are persistent and the CT scan is negative, the child can be discharged with reliable parents and head injury instructions.
Simple linear fractures require no therapy. Skull fractures that cross the grooves of the middle meningeal artery or the venous sinuses may result in intracranial bleeding. A skull x-ray would confirm the fracture, but would not address the more important issue of intracranial injury. Thus, the clinician may want to consider a CT to determine if there is an intracranial hematoma. If the scan is normal, the child may be discharged safely.32
If the head injury has resulted from blunt trauma, it must be determined whether an intracranial injury is likely. Suggestive historical or physical features included a prolonged LOC (longer than a few minutes), seizure, or deteriorating or persistent altered level of consciousness, unremitting vomiting or progressive headache, full fontanelle, or underlying abnormalities, such as a ventricular shunt or coagulopathy. (See Table 2.)
Table 1
Modified Coma Score in Infants
Activity Best Response Score
Eye Opening Spontaneous 4 To speech 3 To pai2 None 1
Verbal Coos, Babbles 5 Irritable, Cries 4 Cries to pai3 Moans to pai2 None 1
Motor Normal spontaneous movements 6 Withdraws to touch 5 Withdraws to pi4 Abnormal flexio3 Abnormal extensio2 None 1
Case # 5
The patient was a 12-year-old female who fell off her bike and landed on her head. She was taken to the local ED where, after three hours, she was sent home by the EP. There was some indication from a witness to the accident that there may have been a loss of consciousness. There was also a history of headache prior to arrival in the ED, and one episode of vomiting in the ED. The family's testimony during trial was that there were several episodes of vomiting in the ED.
After a history and physical examination, the emergency physician concluded that there had not been an LOC. According to testimony, the child's condition improved over several hours in the ED, and the patient expressed that she wanted to go home. The emergency physician did not document a neurologic examination. The child was discharged to the care of her parents with head injury instructions.
She died in bed one week later of an epidural bleed. She was apparently fine through the course of that week without apparent neurologic symptoms.
The parents alleged that the defendant EP was negligent in failing to detect the skull fracture and in not consulting a specialist. The physician contended that during the examination, the girl improved remarkably, and continued to do so until the time of her death. The physician further testified that he did a neurologic examination. There was also some question as to whether the physician had performed testing to rate the child on the GCS.
The jury rendered a verdict for the plaintiff. According to reports, two factors were important in the jury's decision: sympathy for the family and the fact that the physician did not document a neurologic examination.
The plaintiff's verdict totaled $625,000.33
There is a critical risk management lesson for the clinician here. The jury's decision turned in part on the fact that there was no documentation of a neurologic examination. Even though the physician testified he did an exam and observed the child for "several hours," the jury apparently concluded that the evaluation was inadequate. High quality patient care and meticulous documentation of the relevant exam are the highest priority in high-risk acute care.
This is an unusual case. The only indication of possible significant head injury was the family's history of persistent vomiting. In the best light for the defendant, there was no LOC or a brief LOC, one episode of vomiting, a headache that improved in the ED, and a bleed that did not become symptomatic until one week after discharge. Based on these facts and an extended observation period in the ED, it seems that this should have been a defense verdict. Perhaps meticulous documentation of the child's neurologic exam, her GCS, and her condition over time in the ED could have changed the outcome.
Delayed bleeds are an unusual but well reported complication of head injury. The discharge instructions should include a mandatory follow-up with a private physician, and, perhaps, a warning that symptoms may occur in a delayed fashion.
Case # 6
A 4-year-old Massachusetts child fell from a high stool at his father's video store. He was brought to the nearest hospital where he showed obvious symptoms of intracranial injury. He had vomited, he was unconscious without spontaneous respirations, and his pupils were nonreactive. A CT scan was read as showing there was no ongoing acute intracranial process. The physician felt that the child was having seizures from an underlying brain abnormality. The child was transferred to Boston for treatment.
Ground transport during rush hour was used rather than Med Flight. When the child arrived at the Boston hospital about four hours later, another CT scan was performed followed by emergency surgery for evacuation of a massive intracranial hemorrhage. The child suffered a severe neurologic injury. He is now ventilator dependent and incapable of purposeful movement. The parents claimed that the defendant doctors departed from the standard of care in their failure to perform emergency surgery, failure to adequately stabilize the patient before transfer, and failure to use air transport, and were thus responsible for the child's massive injuries. The defendants argued that the child was so damaged at the time he first arrived at the hospital that nothing could be done to alter the catastrophic brain damage.
The case settled for $2.2 million.34
This case is included in order to point out that head injury litigation runs the gamut from the failure to diagnose to improper management once the injury has been diagnosed and everything in between. Once the diagnosis is made, attention must be paid to state-of-the-art management and timely intervention, whether that is intubation and hyperventilation, specialty consultation, or transfer. Given the facts in this report, it is difficult to determine if the transport was reasonable, but in retrospect it is likely that a jury would question the wisdom of the chosen mode of transportation.
Table 2
Indications for CT in Children
· Prolonged LOC (> 1 min)
· Deteriorating or persistent altered level of consciousness
· Focal neurologic abnormality
· Seizure
· Unremitting vomiting (> 6 hours) or progressive headache
· Full fontanelle
· Consider for suspected linear fracture if it crosses a vascular path 32
The Elderly
The elderly can develop brain atrophy, which can allow them to harbor pathology for a longer time before it becomes clinically evident. Additionally, as with the alcoholic, brain atrophy places them at increased risk for subdural hematoma accumulation. The elderly should be considered at high risk for TBI.
Are There any Low-Risk Patients in Whom CT Scanning Can be Excluded?
The goal of any ED management protocol should be to minimize morbidity and mortality at reasonable cost and effort. Yet emergency medicine practice is driven by high patient load, brief doctor-patient encounters, uncertain follow-up, and fear of medico-legal repercussions. For the management of mild TBI then, the challenge becomes seeking factors that will help the practitioner place the patient into low-risk or high-risk categories.
For this purpose, a large number of studies have been conducted over the past decade by neurosurgeons,7,12,24,35 emergency physicians,25,36,37 and radiologists13 to risk stratify patients into low or high risk for intracranial lesions. Despite the large number of studies and relatively large numbers of patients collectively studied, no consensus has yet been reached as to what constitutes high- or low-risk criteria. This variability in results is explained by a number of factors. Different authors have used widely varying inclusion and exclusion criteria. In the past, patients with GCS of 13 and 14, especially in the neurosurgical literature, have been analyzed along with patients of GCS 15. Newer studies, especially in the emergency medicine literature, do not consider any patient with a GCS of less than 15 as having a normal examination. Many studies have suffered selection bias, looking only at neurosurgical referral populations. Finally, the definition of a "positive scan" and even a "neurosurgical lesion" have changed over time. In the past, every epidural, subdural, and depressed skull fracture went to the operating room for surgical repair. Now, many more of these lesions are watched and managed in a non-operative manner.
In evaluating the patient with mild head trauma, the physician needs to define the goals that are to be achieved. If the goal is to identify just those patients who need neurosurgical intervention, then one may reasonably omit the CT scan in those with a GCS of 15 and a normal neurological examination, based on a 0.1-0.3% prevalence.35,38,39 It is even less likely that they will have a neurosurgical lesion if they are older than 2 years and younger than 65 years, are not intoxicated, and have no focal neurological deficits. However, if the goal of the emergency physician is to identify all patients with an abnormal CT scan, it appears unlikely that these patients can be identified using a clinical decision algorhythm. We recommend neuroimaging in all patients with a GCS of less than 15. Clinical judgment will play a major role in the decision to perform a CT scan in the patient who is alert with a GCS of 15.
Case # 7
A 62-year-old California antique dealer hit his head during a car accident, suffering a 5 cm skull laceration. He was initially treated by a passing physician and by paramedics who felt he was stable and that he had suffered only minor injuries. However, as a precaution, he was taken to a nearby medical center where he was examined by the defendant primary care physician. X-rays were taken. The patient reported that he had blacked out during the accident and complained of a headache. The LOC was brief, and the headache was not progressive.
The patient did not have a focal neurologic deficit on physical examination. The GCS was 15. He was observed for two and a half hours, and was then discharged with instructions to seek medical help if his headache worsened or if he suffered a seizure. Twenty-two hours later, he suffered what appeared to be a petit mal seizure in a parking lot. A pool of blood six inches in diameter was found emanating from the area of his earlier wound. He was taken to the hospital and diagnosed with a subdural hematoma, which was surgically evacuated. He subsequently showed signs of dementia and mood disorders.
The plaintiff argued that the defendant primary physician should have ordered a CT scan, which would have revealed the hematoma. The defendant physician denied that he had fallen below the standard of care, denied that the seizure in the parking lot was caused by a slow-growing subdural hematoma, and argued that the plaintiff's psychiatric symptoms preceded the accident. Verdict for the defense.40
To scan or not to scan. So what is the standard of care? Do you need to do a CT scan on any patient with a loss of consciousness? The standard of care is what the jury says it is. Clearly, both sides could make arguments in this case, but the jury believed that this physician's care was adequate under the circumstances.
This patient had a brief LOC, normal neurologic examination, and a GCS of 15. The medical literature simply does not give us all the answers. The clinician's judgment must fill in the gaps. In this case, a jury felt that a period of observation and good discharge instructions met the standard of care.
Case # 8
Plaintiff was assaulted by an unidentified individual when he was hit with a bottle against the left eyebrow. The 31-year-old man suffered a one and one-half inch laceration. The blows also caused LOC, both at the time of injury and five more times later on. The plaintiff went to the ED at Olive View Medical Center. The EP interviewed the patient and sutured his wound. He did not order a CT scan.
Eighteen days later the patient developed focal neurologic signs, abnormal gait, and left sided weakness. CT revealed a large intracranial hematoma. The patient suffered from seizures and left sided weakness as a result of the injury.
The plaintiff alleged that the brain injury occurred from the negligence of the emergency physician in failing to perform a CT scan. The defendant contended that there was insufficient evidence at the time of the first emergency room visit for any need of CT scanning, and that the hematoma, although huge when discovered, had no connection with the assault or the lack of a CT scan. The defendant physician maintained that the hematoma came up independently, probably because the patient had taken cocaine after the assault. The defendant maintained that drug usage, superimposed over an existing but occult arteriovenous malformation with a cocaine-produced transient hypertension, allowed a blow out in the brain's white matter and produced the hematoma and disability.41
If the history of the multiple episodes of LOC was correct, then CT scan was clearly warranted. At issue in this section is whether there is a group of patients in which the clinician can safely discharge the patient without a CT scan. When indications for CT are clearly present, CT scanning is the standard of care.
Case # 9
A 34-year-old Illinois man presented to an ED stating that he had been in a fight, and complained of nausea, headaches, and vomiting. The physician found no physical or neurological deficit and concluded that the patient, an IV drug user, was soliciting drugs after he requested Tylenol with codeine and Dilaudid for his migraine headaches. The physician carefully documented the patient's conduct related to drug seeking. From the trial testimony it was not clear that the patient had been in a physical altercation. The physician discharged him with over-the-counter painkillers and instructions to follow up with a neurologist.
The next day, the patient was beaten by five men, and left unconscious on the scene. Four days later, he lapsed into a coma and was rushed to the hospital where an acute subdural hematoma was diagnosed and evacuated, but he died four days later. On autopsy, a second, non-acute subdural hematoma was discovered. The plaintiff claimed the physician was negligent in failing to order a CT scan, which would have revealed the hematoma.
The physician contended that the cause of death was the hematoma the patient sustained after he was discharged from the ED. In the first trial, the jury deadlocked eight to four in favor of the defendant. In the second trial the jury rendered a defense verdict.42
It is interesting to note that the only apparent difference between the first and second trial is that in the first trial, the defense EM expert was not available, and her deposition transcript was read to the jury. In the second trial, she gave live testimony to the jury. The take home point is that the ultimate result of malpractice litigation depends in part upon the quality of experts and their appearance and manner before a jury. In what appears to be an obvious case for the defense, it took a live personal appearance by a strong defense expert to convince the jury.
The clinician should also recognize that a certain population of patients who present with head injury are at high risk for additional injury post discharge. Make sure that you carefully document a textbook neurologic exam and a well patient on discharge. When the subsequent traumatic event occurs, make sure it is clear that no part of that injury was present during your encounter with the patient.
Case # 10
A 48-year-old sheet metal assembler/welder was working when he experienced a seizure, which caused him to fall and strike his head (left parietal temporal area) on the corner of a large metal work bench. The blow to the head caused a laceration that immediately started to bleed, and the patient fell to the floor with a seizure. His seizure continued for 4-10 minutes while he was attended by co-workers and evaluated at the scene by his employer's medical staff.
The patient was transported to the El Camino Hospital in Mountain View, and was met by a triage nurse and the EP. The patient was noted to be conscious and responsive, but was disoriented as to time and event. The patient had a history of alcoholism and seizure disorder, but had not experienced a seizure in six years.
He was given 800 mg of Dilantin and was observed for seizure and trauma. At about ll:30 a.m., it was noted by the that nurse that the patient was complaining of a headache and his nose was swollen. He was observed for two hours and 40 minutes in the ED, during which time he was assessed three times by the EP and monitored by a nurse. His mentation improved to normal and he was discharged from the hospital with a diagnosis of seizure disorder. He was instructed not to drive a car and to remain in the company of a responsible adult until he could be seen by his doctor.
The patient was being watched by one of his sons when he died in bed at home 4-5 hours later. The plaintiffs contend that the defendant EP failed to diagnose and treat the patient's skull fracture and intracranial hemorrhage; failed to request a neurologist in consultation; failed to hospitalize the patient; prematurely discharged him with inadequate head injury instructions; and failed to follow their own head injury protocol by not treating him as a head injury patient.
The plaintiff contended that the EP failed to appreciate the significance of the head injury and the patient's complaints of headache; took an inadequate history and performed an inadequate physical examination; did not properly monitor the patient and failed to adequately assess his mental status; did not take a CT scan or order other radiographic studies; and that he negligently prescribed Dilantin in subtherapeutic dosages for seizure disorder. The plaintiff also alleged that the nurses were negligent in that they failed to contact the patient's wife to advise her that he suffered a seizure and should not be left at home alone for 48 hours.
The defendant EP and hospital contended that they completely complied with the standard of care in treatment, and that the patient's massive brain injuries occurred from an event (albeit unobserved and unknown) that occurred after his discharge from the hospital.
The EP contended that he did, in fact, consider a head injury, but ruled it out because the plaintiff was properly oriented and coherent during the ED stay; that there were no indications of a severe head injury; that the injuries disclosed in the autopsy report were such that a patient who suffered those injuries would have disclosed some signs or symptoms during the ED stay; and the injuries suffered were probably due to a subsequent seizure or fall while at home and unobserved. The physician testified that the patient's mentation improved during the course of his stay in the ED; that his course was entirely consistent with a postictal patient recovering from a seizure, and was inconsistent with a patient suffering from a serious head injury; that the patient's clinical condition was such that it was appropriate to discharge him after two hours and 40 minutes; that it was sufficient for the physician to rely on the patient to carry out his own discharge instructions; and that it was not necessary to provide him with a preprinted head injury instruction sheet, nor was it required that a family member be contacted.
The jury returned a verdict for the defense.43
This is a fortunate verdict. It appears that it could have gone either way. The differential diagnosis would include a seizure related to a seizure disorder, and a seizure related to a TBI. With both possibilities in the differential, perhaps the diagnostic evaluation should cover both. That is certainly the conservative risk managed approach to this case.
Delayed Intracranial Injuries
There have been a number of case reports of delayed intracranial injuries in traumatized patients, some occurring up to two weeks after the initial injury. Snoey and Levitt reported on three patients who had late development of subdural hematomas after minor head injuries.44 All three had a negative head CT on initial presentation. Alvarez-Sabin et al reported a series of 10 patients who suffered delayed post-traumatic hemorrhage.45 Their representation occurred between days 1-15 following their trauma, and all had a good clinical outcome.
The true incidence of delayed decompensation of patients with minor head injury is unknown. For patients with GCS and a normal neurological exam, however, the incidence appears to be extremely low and in the realm of the case report.
Case # 11
Mr. A was in a car accident on August 6th. The ambulance responded to the location at 2:13 p.m. The paramedics' history of present illness indicates that Mr. A. was involved in a traffic accident and he had a laceration on his nose. Bleeding was under control on their arrival. The patient had no other complaints or apparent injuries. No LOC was reported and patient was ambulatory prior to their arrival. The patient stated that he was restrained with a seat belt. His only complaint at that time was nose pain.
Mr. A. was registered at the ED at 2:45 p.m. The nurse at triage documented that the patient was a 62-year-old man, he was alert and oriented, and was a restrained driver in a car accident. He had a laceration to the bridge of his nose and a nosebleed. The nosebleed was now controlled. There was no LOC, no nausea or vomiting, and the pupils were equal and reactive to light. The nurse documented his vital signs at 3:20 p.m. His blood pressure was 168/104, pulse was 76, and respirations were 16.
The physician's history indicates that Mr. A. was in a car accident, and he hit his nose and glasses on the steering wheel. There was no LOC. The emergency physician noted that the patient felt fine, with no other symptoms except mild stiffness in the mid-thoracic spine. The physical exam indicates the patient was alert and in no apparent distress. There was a one-half inch laceration across the bridge of the nose with a slight amount of blood. The neck was supple with full range of motion. The lungs were clear; the heart examination was normal. The abdominal examination was normal and the back was normal and non-tender.
The physician's impression was "nasal fracture and laceration."
Two and one-half months later, the patient presented to another ED for right facial weakness, speech difficulty, and right arm numbness for 4-5 days. A neurosurgeon was called to evaluate Mr. A. He recounted the history of the car accident two and one-half or three months prior. He found the patient to be awake and coherent with no obvious speech difficulty. There was some right lower facial weakness with a slight drift (weakness) in the right arm. CT of the brain showed a fairly large left high frontoparietal subdural hematoma, subacute, and mostly chronic.
The neurosurgeon's impression was that the patient had a subdural hematoma due to a car accident two and one-half to three months prior. The attending physician's impression was that Mr. A. had sustained the intracranial injury as a result of the automobile accident which caused him to go to the first ED on August 6, 1993.
Mr. A. had a frontotemporal craniotomy for evacuation of the subdural hematoma and insertion of a subdural drain. On the fourth postoperative day, the patient was asymptomatic. The face was now symmetrical. There were no neurologic signs and no speech difficulty.
On Mr. A.'s presentation to the first ED, there was absolutely no indication that he may have sustained an intracranial injury. There was no problem with the care and management of Mr. A. during this visit. Arguably, there was no substandard care, and thus no malpractice.
However, the neurosurgeon's note suggests that the injury was missed during the first visit; thus, the family brought suit.
During the first ED visit, Mr. A. was seen first by the triage nurse who noted that the patient had no LOC, no nausea and vomiting, and the pupils were equal and reactive to light. Although the nurse did not do a complete history and physical examination, she certainly documented points that are important in determining neurologic well being. The physician also documented what appears to be a healthy adult other than the presence of a nasal laceration. The physician documented that there was no LOC. However, the physician did not document a neurologic examination.
If a patient has isolated trauma to the head, (e.g., this patient's nose), assume that this represents head injury, and proceed accordingly. The physician should consider this a case not only of nasal trauma, but of closed head injury. If there is one high yield organ system here it is the neurologic examination.
If the injury is limited to the nose, is the failure to document a neurologic exam a breach in a standard of care? Only the jury can answer that question, but it is not worth a roll of the dice.
It is impossible to tell whether the trauma sustained on August 6 actually caused this intracranial bleed. This type of bleed is often caused by head injury, and, in an older adult, the head injury does not have to be severe. There are several possibilities given the facts of this case: 1) this minor injury did result in some intracranial bleeding; 2) the injury resulted in delayed bleeding; 3) there could have been some bleeding on the date of the first ED visit, but the amount was minimal, and the patient was asymptomatic; and 4) the head injury caused no bleeding, either immediate or delayed, and some other insult or injury in subsequent days or weeks caused the injury. For example, some other minor head trauma, a large sneeze, or just spontaneous bleeding could have occurred.
A medical expert will criticize the EP for failure to do a neurologic examination and a failure to repeat a GCS. The plaintiff's medical expert is likely to allege that the neurologic signs are present, but were missed because the physician did not perform a neurologic exam.
This case appeared to the plaintiff's attorney to be an uphill battle, and the family decided not to proceed with the case.
Discharges from the ED
It is known that patients with seemingly minor head injuries may develop late complications. Subdural hygroma, post-traumatic hydrocephalus, and long-term mental impairment can all be seen after injuries thought to be trivial. Even with minor head injuries, some patients will require in-hospital observation and cannot be safely discharged. Among these groups are patients without a relative or guardian who can observe the patient for deterioration, patients who are under the influence of drugs or alcohol, and patients who have progressive symptoms such as intractable nausea and vomiting. In patients who can go home, discharge instructions need to be clear and time-specific. Patients need to return to the ED immediately for increasingly severe headache, seizures, gait abnormalities, pupillary inequality (needs to be explained carefully to patient's observer), progressive lethargy, or change in behavior or personality. The EPshould also make every effort to arrange follow-up for the patient with minor TBI. Many academic centers have minor head injury clinics run by rehabilitation medicine. A general trauma clinic can also meet this need.
Post-Concussive Syndrome
The post-concussive syndrome is described as a constellation of symptoms including headache, dizziness, depression, difficulty with concentration, and memory loss following a minor head injury.46 It is estimated that as many as 50% of patients with mild head injury may suffer from this syndrome.46,47 The majority of patients will recover by 6-12 weeks, but 10-15% may still be symptomatic at one year.48 Those at lowest risk for developing this syndrome are young, well-motivated patients with no LOC. Patients older than 55 years of age and those with prolonged post-traumatic amnesia are most at risk. Cited predictors of prolonged post-concussive syndrome include females, low socioeconomic status, ongoing litigation, other serious illnesses, alcohol abuse, and prior minor TBI.49 Treatment is symptomatic, including psychotherapy and neuropsychological exercises.
Summary
Head trauma is a high-risk clinical entity. Research efforts to clearly identify a group of mild-to-moderately head-injured patients at high risk for TBI have met with limited success. Consider contacting all discharged head-injured patients within a six- to eight-hour time frame. Some type of call back, re-visit, or early follow up to the private physician's office is advisable. The key to good risk management here is recognition of the high-risk presentation; careful documentation of the patient's clinical condition; documentation of the patient's condition over a period of observation; and carefully planned discharge with well written, understandable instructions.
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