The post-concussional state: neurophysiological aspects.

BACKGROUND: Twenty-six young men admitted to an Accident and Emergency Department for observation following a minor closed head injury (post-traumatic amnesia (PTA) less than 12 hours) were investigated within 24 hours of admission (day 0) and followed up at 10 days, 6 weeks and 1 year after the trauma. METHOD: Investigations at day 0 included physical examination, completion of post-concussional symptom and stress-arousal checklists, computerised EEG (CEEG) and auditory brainstem evoked potential (BAEP) recordings. These were repeated at ten days and six weeks. At 12 months follow-up, the Present State Examination (PSE) was carried out and a further post-concussional symptom checklist completed. RESULTS: Post-concussional symptomatology declined progressively from day 0 but half had residual symptoms at 1 year. Seventy-two per cent ran an acute course with recovery by 6 weeks, 8% chronic unremitting course and 20% initially improved but had an exacerbation of symptoms between 6 weeks and 12 months. The CEEG alpha-theta ratios decreased significantly between days 0 and 10, reaching a baseline thereafter. Measures of CEEG recovery from all channels correlated with symptom counts at six weeks; the slower the recovery the greater the symptoms. A relative delay in left temporal recovery was associated with residual psychiatric morbidity (PSE ID scores) at 12 months. Prolonged central brainstem conduction times occurred in 27% of patients at day 0. These correlated positively with PTA and degree of psychiatric morbidity (PSE ID scores) at 12 months. CONCLUSIONS: Symptom chronicity was accompanied by continuing brainstem dysfunction, while the degree of transient cortical dysfunction appeared to have a direct influence in the intensity of early organic symptom reaction to the trauma. Levels of perceived stress at the time of the injury, or afterwards, were not related to symptom formation.

The psychobiology of minor head injury.

Twenty-six consecutive admissions to an accident and emergency unit with minor head injury were examined. This was defined as a head injury warranting brief in-patient overnight stay but with a post-traumatic amnesia of less than 12 hours. Each patient had a neurological examination, a post-traumatic symptom check list completed, EEG power spectra analysis and auditory brain stem-evoked potential recordings, and a four-choice reaction-time measurement. These assessments were repeated six weeks later. Six months after the head injury a symptom check list was completed and four-choice reaction time measured again. Post-traumatic symptoms are persistent in half of all patients at six weeks and six months follow-up. The EEG power spectra showed a significant change in theta power between the first recording and the second one at six weeks, with relative reduction being noted. Approximately half of all patients had significant delays in brain stem conduction time at day 0. There was a trend towards a decrease in brain stem conduction time at six weeks, though in almost half the brain stem conduction time still remained abnormal at six weeks. Head-injured patients had prolonged choice reaction times at day 0 with serial improvement between then and six months, though the values at six weeks were still significantly longer than healthy controls. It is suggested that these findings reflect both cortical and brain stem damage following minor head injury, the brain stem damage being more persistent. There appear to be three patterns of recovery, half recovering within six weeks, a minority persisting over six months with persisting brain stem dysfunction and less than a third showing an exacerbation of symptoms with no evidence of brain stem dysfunction, the exacerbation being possibly a consequence of psychological and social factors.

Reception of severely injured patients at hospital: organizational requirements.

All trauma admissions to the Royal Victoria Hospital, Belfast, in 1987 were entered in a computerized trauma register. Analysis of these patients by severity showed that only 3.8 per cent had ISS scores of 16 and over. Of these, 42 per cent arrived at hospital between midnight and 0900. Only 24 per cent arrived in normal office hours. The specialties involved in the treatment of these patients are analysed. It is argued that we cannot instantly leap from the present arrangements to fully developed trauma centres. The most efficient and cost-effective way of initiating better systems would be to appoint sufficient accident and emergency consultants to a number of pilot scheme hospitals so that there would always be a senior doctor present, day or night, in the accident and emergency department to carry out the initial resuscitation and to mobilize the correct trauma team for the severely injured patients.

The place of exercises in disaster management.

This article sets out the personal experience of the author in three types of disaster exercise, acted out exercises carried out at Belfast International Airport, talk-through exercises carried out with personnel at the four Area Boards in Northern Ireland, and a tabletop exercise organized by the Health Emergency Planning Officer of the North West Thames Region in connection with a specific scenario at Heathrow Airport. The advantages and costs of the various exercises are discussed. In order to collect experience from different people carrying out disaster exercises and to increase the professionalism of such exercises, a national centre for disaster teaching and research is recommended.

The medical severity index of disasters.

In 1980 an international working party postulated a definition for a disaster. Later this concept was formulated into a classification and scoring system. This system has now been refined to be used prospectively during the management stage of a calamity. By calculating the medical severity index, which is the product of the casualty load and the severity of the incident, and comparing this figure with the available total capacity of the medical services, which is the medical rescue capacity, the medical transport capacity and the hospital treatment capacity, the dispatcher at the control center can fairly quickly and precisely identify if a calamity is to be regarded as a disaster or not and if the region can cope with the situation. Moreover a calculation of the hospital treatment capacity in the region could serve as a guideline for estimation of the dimensions needed for the medical rescue capacity and medical transport capacity when planning how to deal with a disaster.

An analysis of civil aircrash statistics 1977-86 for the purposes of planning disaster exercises.

Details of 473 aircrashes throughout the world for the period 1977-1986 were obtained from the Civil Aviation Authority. 114 occurred on or near and 359 away from airfields. In 188 there were survivors and in 285 none. On or near airfields it was more common to have survivors, and away from airfields more common to have none, yet crashes with survivors were more common away from airfields. In ten years there were only 3 crashes with more than 50 seriously injured live casualties. Acted out disaster exercises with mock casualties should not have more than 50 injured casualties, of whom not more than 20 should have serious injuries (i.e. need admission to hospital). The problems of crashes with much larger casualty figures should be worked through in table-top exercises.

A study of the effect of legal settlement on post-concussion symptoms.

Forty-four consecutive patients with concussion for whom a medico-legal report had been written were followed up for 3-4 years after their accidents. Three cases were still pending at the end of the study. Fifty-seven per cent complained of symptoms when the medico-legal reports were written (mean interval from accident 12.9 months), 39% had symptoms at the time of settlement (mean interval 22.1 months) and 34% had symptoms one year later. When these results were compared with a general series from the same department some years earlier, it was found that the symptoms at the time of writing the reports were not significantly different from symptoms at 6 weeks in the earlier series, but the symptoms one year after settlement were almost two-and-a-half times greater than the symptoms at 12 months in the general series. No evidence could be found to suggest any organic basis for the higher symptom rate in the litigation series. It is suggested that the litigation process itself is a factor in the persistence of symptoms and this effect continues after legal settlement has been reached. Early settlement of the cases might significantly reduce morbidity.

Unemployment, alcohol and injury in west Belfast.

The relationship of being employed or not to alcohol consumption and subsequent injury which necessitated hospital treatment was evaluated prospectively in 116 patients coming to the Accident and Emergency Department of a large teaching hospital. Details relating to employment, category and situation of injury were collected prospectively on a standard form and breath alcohol content was evaluated in all subjects. Employment or not was related to alcohol consumption and subsequent associated accidents: 40 per cent of unemployed subjects sustained accidents related to alcohol compared with 8 per cent of employed patients (P less than 0.01 by the chi 2 test). Accidents related to alcohol also tended to occur in public places. These findings represent previously unrecognized associations between employment, alcohol consumption and subsequent accidents.

Neck sprain--a major cause of disability following car accidents.

One hundred and thirty-seven patients attending hospital following road traffic accidents were contracted regarding pain in the neck between 1 and 2 years later. Eighty-five (62 per cent) stated that they had suffered pain in the neck at some time following their accident compared with 42 (30.6 per cent) who were noted to have pain in the neck when examined soon after the accident. Thirty-one patients (22.6 per cent) still felt occasional pain 1 year after the accident and 5 had continuous pain at 1 year. Pain in the neck occurred irrespective of the direction of impact but was disproportionately common in rear impact accidents. Patients wearing seat belts experienced pain more frequently than unbelted patients.

The Maurice Ellis lecture for 1986. The responsibility of emergency medicine towards the prevention of road accidents.

It is argued that doctors who work in accident and emergency departments should play their part in road accident prevention. It is suggested that this might be done in the field of research, by direct action, through education of the public and by influencing legislation. Examples are given of both small and simple, and major national research projects based in accident and emergency departments. The type of direct action envisaged is modelled on the work of Dr Hayle Hadeson in preventing accidents to children. Examples of the education of the public are drawn from publicity work in the seat-belt campaign, and experiences of lobbying members of parliament in relation to seat-belt legislation are described. The relative under-funding of trauma research compared with cancer of heart disease research is seen as a measure of society's lack of interest in accident prevention, and colleagues unchallenged to do more to alter this situation.

The resuscitation of the severely injured in the accident and emergency department--a medical audit.

An audit of the medical care of the severely injured was conducted in the Accident and Emergency Department of the Royal Victoria Hospital, Belfast. Over a 6-month period the management of all patients admitted with an Injury Severity Score of 16 or over was critically assessed. Errors of management which occurred in 21 of the 36 patients are discussed. They were mainly related to the fact that 78 per cent of the patients arrived outside normal office hours when only inexperienced junior doctors staffed the department. The findings have drawn our attention to the need for both altering staffing arrangements and improving training in our department.

Myocardial contusion associated with fracture of the sternum: important features of the seat belt syndrome.

Recent legislation has led to increasing numbers of car occupants wearing seat belts and presumably the number of injuries attributable to seat belts will also increase. The commonest such injury is a fracture of the sternum, and blunt myocardial damage is a logical sequel although often unsuspected and therefore unsought. Confirmation is difficult and ECG changes are usually absent or not specific. In three consecutive patients admitted with a fractured sternum we found raised blood levels of CK-MB (creatine kinase-myocardial band) and believe these indicate myocardial contusion. We therefore feel that an isolated fracture of the sternum should be considered a more serious injury than is initially apparent, as these patients are at risk of developing cardiac complications.

Wound infection following surgery in an accident and emergency theatre.

Five hundred and six clean minor surgical procedures were carried out in an emergency theatre. One theatre was used for both clean and septic conditions; clean cases preceding the septic lesions. Sepsis rates were assessed prospectively and complete follow-up was obtained in 491 patients. Four hundred and fifty (91.6%) patients achieved primary healing. Thirty (6.1%) patients developed a mild serous discharge; three developed wound haematomas and eight (1.6%) patients had severely infected wounds with a purulent discharge. From the acceptably low incidence of severely infected wounds with a purulent discharge. From the acceptably low incidence of severely infected wounds we conclude that there is no need for separate clean and septic theatres in an emergency department provided the clean operations are comparatively short and simple procedures.

The definition and classification of disasters.

The universe, we are told, began with a big bang, and ever since, nature has provided a series of unexpected bangs and calamities of one type or another. Since the advent of the industrial revolution, man has been more or less controlling larger and larger amounts of energy. World population has rocketed. The interaction of crowded humanity and escalating energy has added a series of man-made disasters to the continuing natural calamities.

An assessment of the validity of the injury severity score when applied to gunshot wounds.

Injury Severity Scores were calculated for the injuries of 875 patients suffering from gunshot wounds. These scores were plotted against mortality. Increasing ISS is associated with increasing mortality, but the relationship is not linear.