BRITISH JOURNAL OF PSYCHIATRY 2000), 177, 177, 540^545 540^545 Unconsciousness, amnesia and psychiatric the accident they were also sent postal follow-up questionnaires, which included symptoms following road traffic accident injury the Post-Traumatic Stress Symptom PSS) scale FoascaleFoa et aletal, 1993), the Hospital Anxiety and Depression HAD) scale Zigmond & RICHARD A. MAYOU, JOHN BLACK and BRIDGET BRYANT Snaith, 1983) and questions about phobic travel anxiety derived from previous re- search Mayou et aletal, 1993).,1993). Measures Unconsciousness This was rated by an emergency medicine Background Although road traffic This paper presents findings from a prospec- physician J.B.), who examined all available tive study of consecutive attenders at an emer- accidentinjuryis the mostcommon cause information from the medical records for gency department following a road traffic of traumatic brain injury, little is known of all patients for whom there was any indica- accident Ehlers et al, 1998), who were re- tion that they might have been unconscious, the prevalence of psychiatric complications cruited for a self-report study of psychological reported impaired memory of the accident, or the significance of unconsciousness and consequences. It considers two main issues: or had been recorded as suffering an injury amnesia.amnesia. a)a)thethe prevalence of head injury and features to the head above the hairline) or face. Three categories were devised: Aims Todescribe amnesia and of possible traumatic brain injury such as unconsciousness and amnesia; unconsciousness following a road traffic a)a)definitelydefinitely unconscious: a witnessed accident and to determine whether they b)b)thethe prevalences of immediate psycho- statement of unconsciousness; logical distress and of psychological are associated withlaterwith later psychological b)b)probablyprobably unconscious; not witnessed; complications at 3 months and 1 year ± the nature of the injury and other symptoms. post-traumatic stress disorder PTSD), reports strongly suggested that the travel anxiety, anxiety and depression, patient was unconscious ± a high MethodMethod Information was obtained post-concussional symptoms ± in those degree of probability; from medical and ambulance records for who were briefly unconscious minor 1441consecutive attenders at an head injury) as compared with those c)c)notnot unconscious: no evidence for who did not lose consciousness. emergency department aged17^69aged 17^69 who unconsciousness, and in many cases specific comments that the patient had had beenbeeninvolvedin involvedin a road traffic not been unconscious. accident. Atotal of1148 $80%) subjects METHOD completed a self-report questionnaire at The sample was based on 1534 consecutive Head injury baseline andandwere were followedfollowedup up at 3 months patients aged 17±69 who attended the Having excluded major head injury, we and1year.and1year. emergency department of the John Radcliffe classified all cases with head injury and un- Hospital, Oxford, after a road traffic acci- consciousness of less than 15 minutes as ResultsResults Altogether,1.5% suffered dent. We excluded those who were minor. The emergency physician also noted major head $and traumatic brain) injury unconscious for more than 15 minutes. whether patients had suffered a soft tissue and 21% suffered minor headheadinjury.Post- injury.Post- or fracture head injury. Injuries to the head traumatic stress disorder $PTSD) and Data collection above the hairline were distinguished from those to the face. Evidence of brain injury Information about the accident and injuries anxiety and depression were more from abnormal computed tomography was collated on standard data sheets from common at 3 months in those who had CT) scans was noted. ambulance, triage and emergency depart- definitely been unconscious than in those ment records, and any in-patient notes, by who had not, butthere were no Self-report rating of loss of consciousness a research worker who had previously been and memory of the accident differences at1year.at 1year. a senior trauma nurse in the department. Where possible, subjects were approached On the questionnaire, subjects were asked to Conclusions PTSD and other by a nurse and invited to take part; the say whether they thought they had been un- psychiatric complications are as common remainder were sent information and conscious or not, or were not sure. Similarly, they were asked to rate their memory of the inthosewhowerebrieflyunconscious asin questionnaires by post. Patients completed a questionnaire accident as `clear', `patchy' or `no memory'. those who were not. which included questions on their initial Psychological outcome measures Declaration of interest The emotional reactions to and memory of the accident, whether they thought they had research was supported by a grantgrantfrom from a)a)PTSD:PTSD: this was the minimum number of been unconscious, or to blame for the acci- symptoms on the PSS scale required by the WellcomeTrust. dent, previous travel, and emotional and DSM±IV American Psychiatric Associ- social adjustment. At 3 and 6 months after ation, 1994) criteria. 540540 Downloaded from https://www.cambridge.org/core. 23 Sep 2021 at 19:23:13, subject to the Cambridge Core terms of use. UNCONSCIOUSNESS, AMNESIA AND PSYCHIATRIC SYMPTOMS FOLLOWING RTA INJURY b)b)AnxietyAnxiety or depression case: the recom- Neither minor head injury nor loss of con- Unconsciousness was not associated mended cut-off score of 10 or more on sciousness was associated with response. with subsequent involvement in compen- the HAD sub-scales of anxiety and sation proceedings. Claims were pursued depression.depression. by 36% of those definitely unconscious, c)c)PhobicPhobic travel anxiety: a measure Head injury 52% of those probably unconscious and combining increased nervousness and Of the 1148 respondents, 261 23%) were 45% of those not unconscious. avoidance of travel situations, with rated as having a minor head injury and 25 cut-off points consistent with the 2%) had had fractures. Twelve were investi- Amnesia DSM±IV criteria for phobia. gated by computed tomography CT) scan, Many of those for whom there was definite d)d)Post-concussionalPost-concussional syndrome symptoms: of whom four were reported as abnormal. self-ratings of the frequency of loss of medical evidence of unconsciousness concentration or irritability in the reported that they had no memories of the previous two weeks, from 0, `not at Evidence of minor traumatic brain accident 44%), but two 7%) reported that all', to 3, `very often 5+ times a week)'. injury they could remember the accident clearly and 13 48%) described patchy memories Loss of consciousness Table 2). Most reported continuing amne- Statistical analysis There were 124 respondents 11%) who re- sia for parts of the accident at 3 months and The relationship between unconsciousness ported they had been unconscious and 144 1 year Table 4). Emergency department and categorical variables was tested using 13%) who were not sure ± a total of 268. medical records rarely recorded the dura- thethe ww22 test. Analysis of variance was used Review of the records suggested that only tion of post-traumatic amnesia, but review for the continuous variable `age'. Most of two of the 874 patients who indicated on of medical notes and subjects' comments the scores on the variables measuring the self-report questionnaire that they had suggest that amnesia was usually brief and emotional reaction to the accident were not been unconscious had, in fact, been that many subjects had memories for events rather skewed, so the Kruskal±Wallis one- observed by others to be unconscious. Of shortly before and after the road accident. way analysis of variance was used. those who said they had been unconscious, Amnesia was also less frequent in those only 19 15%) had been definitely, and 29 who had not suffered any head injury. RESULTSRESULTS 23%) probably, unconscious as indicated by recorded evidence from bystanders and rescuers. In most of the remainder, rescue Amnesia without traumatic loss Figure 1 shows how many of the consecu- of consciousness tive series were excluded for various reasons, and emergency department notes clearly and how many participated at various cited evidence that subjects had not lost It was common for patients who had not suf- stages. Seven people died in the emergency consciousness although there were some fered any head injury to report that their department. Another 23 1.5%) were ex- comments about `confusion' Table 2). memories of the accident were `patchy'. cluded because they were unconscious for Subjects classified as having been uncon- There were 28 subjects 2% of the eligible longer than 15 minutes; all these subjects scious reported the accident as less frighten- sample) who had no memory of the were admitted, suffered prolonged un- ing, felt less angry and were less likely to accident but who were thought not to have consciousness all more than five days) accept blame for the accident Table 3). suffered any unconsciousness; only two- and satisfied clinical criteria for `major These subjects were also more likely to report thirds were drivers. Five of these had traumatic brain injury'. themselves as numb and dazed in the first suffered head injury above the hairline; of A total of 1441 patients were eligible for questionnaire immediately after the accident. these it is possible that at least two subjects the study and were given the questionnaire; their characteristics are summarised in 15341534 Table 1. There were 309 22%) who were Died in emergency department 77 33 diagnosed as having had minor head injury Excluded by design criteria: 33 which we defined as unconsciousness ofof Unconscious for 15 minutes+ 23 less than 15 minutes), of whom 34% were Excluded for other reasons: 33 admitted and 25% were rated as having Overseas visitors32 been definitely or probably unconscious. Language or psychiatric reasons 8 The great majority of these injuries were Too ill to complete questionnaire 11 abrasions or lacerations, but five people Did not want to take part 12 !! had skull fractures and 21 had facial frac- tures one had both).