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NEUROLOGIC OBSERVATION

DISCLOSURES

• No relevant disclosures

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CASES

• 52 y.o. with R sided weakness for 1 day. History of HTN and DM. NIHSS of 2.

CT head negative.

• 20 y.o. sent from eye clinic for “pressure behind her eye”

• 27 y.o. assaulted with + LOC. Head CT shows questionable punctate

hyperdensity. Can’t exclude hemorrhage. GCS 15

PROTOCOLS

• Transient Ischemic Attack

• Minor Stroke

• Minor Traumatic Brain injury

• Papilledema

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http://obsprotocols.org/tiki-index.php

WHY DO THIS?

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TIA/MCVA

ED WORK-UP

•Head CT

•Level C

•1.2%

•Neuro consult

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EARLY DISCHARGE?

•ABCD-2

•Level B – not recommended

•ABCD3, ABCD2-I

• Insensitive

PATIENT SELECTION FOR OBS

• Non-disabling stroke

• NIHSS ≤ 3

• Individual subscore ≤ 1

• Swallow Study

• Able to ambulate in ED

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EDOU WORK-UP

• Coordination of radiology services

• PT/OT

• Smart use of Echo

• Outpatient TTE OK for patients with

• No previous cardiac disease or stroke

• Normal EKG and telemetry

• Normal cardiac exam

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DISPOSITION

• Depends on Neurology presence

MTBI

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ED WORK-UP

•Cleared of other injuries

•C-collar cleared

•Able to ambulate

•Neurosurgery consult?

INCLUSION

•Concussion

• Small traumatic ICH

•Negative HCT on anticoagulants

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Efficient management of alert patients with traumatic

intracranial hemorrhages in an emergency department

observation unitMatthew Wheatley1, Timothy Moran1, Jonathan R. Ratcliff1, Alex Hall1, Shikha Kapil1, Bryan Morse2, Peter Rhee3, Hany

Atallah1, Rondi Gelbard2, Brooks Moore1, Faiz Ahmad4, Michael Frankel5, David W. Wright1

1Emergency Medicine, Emory University, Atlanta, GA/US, 2Department of Surgery, Emory University, Atlanta, GA/US, 3Department of Surgery,

Grady Memorial Hospital, Atlanta, GA/US, 4Neurosurgery, Emory University, Atlanta, GA/US, 5Neurology, Emory University, Atlanta, GA/US

Background

Patients with small traumatic intracranial

hemorrhages (ICH) are usually managed in

the ICU. Using the Brain Injury Guideline

(BIG) Criteria Joseph et al (2013) reported

that small and moderate hemorrhages

could be safely managed without ICU care,

repeat head CT or neurosurgery

consultation. The goal of this project to

quantify the reduction in LOS that results

from managing small and moderate ICH in

an Emergency Department Observation

Unit (EDOU)

Methods

This is a retrospective analysis of ED

patients with blunt head trauma and CT

showing confirmed or suspected intracranial

hemorrhage that met BIG 1 or 2 criteria.

Patients were eligible for EDOU

observation if they were not clinically

intoxicated, had no other injuries or co-

morbid conditions and were able to

ambulate. All patients received q2 h neuro-

checks. Repeat head CT and neurosurgical

consultation were at the discretion of the

ED and trauma surgery attendings. Patients

were deemed stable for discharge if had

stable neuro exams and symptoms and they

were able to ambulate without assistance.

Patients whose symptoms worsened were

admitted to the hospital.

Results

The intervention group is patients placed in

EDOU from 9/1/16-1/14/2018; average age

43.5 years; 58% male. Median total LOS of

the intervention group was 25.15 hrs (95%

CI: 22.5 - 27.5). 24 patients in this group

received repeat HCT. 75 patients were

discharged home after a period of

observation. 4 admissions were due to

continued or worsening symptoms

attributable to the head injury. One

admission was due to persistent tachycardia.

None of the 5 patients admitted required

neurosurgical intervention. The comparison

group is 233 patients with similar injuries

admitted to the ICU in 2016; average age

48.4 years 72% male. Median total LOS in the

control group wads 71.92 hrs (95% CI: 48.13

- 73.98) p < 0.001.

Conclusion

Using BIG criteria, we were able to efficientlyand safely manage patients with small andmoderate traumatic ICH in an EDOU setting.Future studies will determine overall costsavings to the system, as well as longer termoutcomes (3 and 6 month trajectories) forthese complicated mild TBI patients.

Table 1: Modified Brain Injury Criteria

Variable BIG 1/2 BIG 3

Neuro exam Normal Normal

Anticoagulation No Yes

Skull fracture

None/non-

displaced Displaced

SDH, mm ≤7 ≥8

IPH ≤7, 2 locations

>8, multiple

locations

SAH Trace/Localized Scattered

IVH No Yes

EDH No Yes

Treatment Area EDOU ICU

Table 2 EDOU Pre-EDOU

N 80 233

Average age 43.5 48.4

% male 58 72

Repeat HCT 24 233 0

10

20

30

40

50

60

70

80

Pre-EDOU EDOU

Median LOS

22

27

18

13

Hemorrhage type for EDOU patients

SDH

SAH

IPH

Atifact/overread

EDOU WORK-UP

•Neuro checks

•Repeat HCT?

•What is the plan if someone rules in?

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PAPILLEDEMA

PRE-WORK

• Discussion with other services

• Ophtho

• Neuro

• Radiology

• Coordinate work-up

• CT

• CTV/MRV

• LP

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INCLUSION

• Diagnostic protocol for new diagnosis

• No optic neuritis

• Not for established Dx with symtpoms

• Avoid work-up creep

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WORK-UP

•ED

•Labs

•CT/CTV

•LP

•Neuro consult

•EDOU

•MRI

•MRV

•LP

CONCLUSIONS

• Neuro protocols can help decompress simple admissions

• EDOUs efficient in coordinating work-ups

• Coordinate with other services first

• RN ability to perform neuro checks is key

• Careful examination of LOS and conversion rate