SIGN has produced evidence-based guidance for GPs and A&E teams on managing head injuries, which sets out when to refer patients for specialist assessment and treatment.

Trauma is the main cause of mortality in the under-45s in Scotland, with up to 50% of these deaths caused by head injuries. Head injury is a common problem with a potentially high morbidity. The patients are often young with many years of life ahead of them. Early management is a key factor in determining outcome in head injury. Management should be guided by clinical assessments and protocols based on the Glasgow Coma Scale and Score, the guideline says.

The guideline reminds GPs who, and when, to refer with head injuries. It also recommends a holistic approach, taking into account medical co-morbidity and social factors, It is a guideline not a protocol, and needs to be interpreted locally,

Indications for referral to hospital for adults include: impaired consciousness, i.e. Glasgow Coma Score <15/15, amnesia, neurological symptoms, clinical evidence of a skull fracture, significant extra-cranial injuries, a high energy injury, or possible penetrating brain injury. Where the diagnosis is still uncertain after the first assessment or there is co-morbidity or adverse social factors, referral is also indicated.

Special attention is given to the assessment and management of children. Paediatric practice points are highlighted throughout the guideline, and are also summarised for easy reference.

The guideline points out that the Glasgow Coma Scale is difficult to apply to children under the age of five, and needs to be interpreted in these patients by someone with the relevant expertise. Specific guidance on when to refer children is also included.

Ref (web)

Aspirin was compared with placebo or no treatment, for a minimum of one year. The main outcome measure was the incidence of gastrointestinal haemorrhage.

Gastrointestinal haemorrhage occurred in 2.47% of patients taking aspirin compared with 1.42% taking placebo (odds ratio 1.68; 95% confidence interval 1.51 to 1.88); the number needed to harm was 106 (82 to 140) based on an average of 28 months’ therapy. At doses below 163 mg/day, gastrointestinal haemorrhage occurred in 2.30% of patients taking aspirin compared with 1.45% taking placebo (1.59; 1.40 to 1.81). Meta-regression showed no relation between gastrointestinal haemorrhage and dose. For modified release formulations of aspirin the odds ratio was 1.93 (1.15 to 3.23).

Back to top

The National Institute for Clinical Excellence (NICE) has recommended that zanamivir (Relenza) should be used to treat “at risk” adults when influenza is circulating in the community and if they present within 36 hours of developing symptoms. The institute defines such patients as those with chronic respiratory disease, significant cardiovascular disease, diabetes, or a compromised immune system, and those who are aged over 65.

The recommendation by NICE, whose remit covers England and Wales, reverses the institute’s ruling last year that there was insufficient evidence of the drug’s efficacy in high risk individuals to make it worth prescribing on the NHS.

The recommendations were triggered by an overall pooled analysis of eight trials involving 800 adults at high risk and by new research by GlaxoWellcome. The pooled analysis showed a reduction in the duration of flu symptoms by 1.2 days from 6 to 5 days, in the high risk group. It also showed, in the same group, a 6% reduction in complications in which antibiotics were needed.

Andrew Dillon, the institute’s chief executive, said: “The new guidance on zanamivir demonstrates the institute’s commitment to ensuring that guidance for treating patients is based soundly on evidence”.

Flu is considered to be circulating in the community when consultations for flu rise above 50 a week per 100,000 population, as monitored by the Royal College of General Practitioners’ weekly returns monitoring service. The Public Health Laboratory Service must also have identified the circulation of a flu virus.

Pharmacists and nurses will be allowed to prescribe zanamivir under the generalised directions of a doctor, provided they are satisfied that the patient needs it and satisfies the criteria. Telephoning triaging by practice nurses may also be set up; the nurses will work to a protocol and ask standard diagnostic questions.

Ref (web)

Back to top

Ref (web)

Back to top