Minor Head Injury ================= þ Criteria for Head CT: - New Orleans Criteria (NOC): 2000 - Canadian CT Head Rules (CCHR): both equally sensitive for significant injury, CCHR more specific Ottowa study comparing two: CGX 15 after minor head injury: observed LOC, confusion, amnesia. Study of 1822 patients. Neuro invervnetion, clinically-important brain injury: both 100% senstive clinically-unimportant: CCHR less sensitive. CCHR much more specific. [Stiell et all, SAEM 2004.] þ Bleeds from Minor Head Injury - It has been shown repeatedly that significant intracranial pathology can be present in patients with nonfocal neuro exams and GCS scores of 13 - 15. Furthermore the presence of a normal head CT scan is associated with a zero short term incidence of the need for neurosurgical intervention: No surgical interventions in 1170 patients with normal CT: [Shackford et al. The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma 1992;33(3):385-394.] and none in 1339 patients: [Stein et al. Mild head injury: a plea for routine early CT scanning. J Trauma 1992;33(1):11-13.] none in 497: [Harad et al. Inadaquacy of bedside clinical indicators in identifying significant intracranial injury in trauma patients. J Trauma 1992;32(3):359-363.] and none in 542: [Stein et al. Is routine computed tomography scanning too expensive for mild head injury? Ann Emer Med 1991;20:1286-1289.] - Head injury instruction sheets protect both you and the patient from an outcome that, in general, would be appropriate material for a case report. [Snoey et al. Delayed diagnosis of subdural hematoma following normal computed tomography scan. Ann Emer Med 1994;23:1127-1131.] --H. Louzon MD þ Management of Minor Head Trauma Head Injury management guidelines are in a state of flux, and studies have shown good outcomes for the management of minor head injury (GCS 13-15) by means of routine CT(1), routine observation (2), or skull XR and observation(3). However, the "four-hour rule", still relatively common in this country, is based on the work from Glascow (4) showing that the majority of extradurals will have symptoms/signs within four hours of injury. It seems to be a consensus (5) view and does not appear to have been subjected to a clinical trial. Many of us have moved on to routine CT for other than trivial head injuries (as defined by Masters (3)) on the grounds that normal CT excludes significant pathology and enables discharge. (no, Harvey, please don't tell me about the handful of chronic subdurals after normal CT in the literature). As for the codeine myth, I thought it had died but it does appear to be alive and well. Give the patient whatever they need symptomatically, and never believe that morphine impairs consciousness, but codeine does not (they are both narcotics). Drew -- Dr Drew Richardson Director of Emergency Medicine Princess Alexandra Hospital Ipswich Road Wooloongabba (Brisbane) Queensland Australia 4102 Ph +61 7 3240 2654 Fax +61 7 3240 5870 email: richard@citec.qld.gov.au Emergency Dept URL: http://www.uq.edu.au/~mddricha/index.html 1. SteinSC RossSE Minor Head injury: A proposed strategy for emergency management. Ann Em Med 1993;22:103-6 2. DuusB et al The role of neuroimaging in the initial management of patients with minor head injury. Ann Em Med 1994;23:1279-1283 3. MastersSJ et al Skull XRay examination after head trauma. NEJM 1987;316:84-91 4. MendelowAD et alRisks of intracranial haematoma in head injured adults. BMJ 1983;287(6400):1173-6 5. BriggsM et al Guidelines for the initial management after head injury in adults. Suggestions from a group of neurosurgeons. BMJ 1984;288:983-985 --------------- It has been shown repeatedly that significant intracranial pathology can be present in patients with nonfocal neuro exams and GCS scores of 13 - 15 (1,2,3,4). Furthermore the presence of a normal head CT scan is associated with a zero short term incidence of the need for neurosurgical intervention: No surgical interventions in 1170 patients with normal CT (1), none in 1339 patients (2), none in 497 (3) and none in 542 (4). And the list goes on. Head injury instruction sheets protect both you and the patient from an outcome that, in general, would be appropriate material for a case report (5). H. Louzon MD (1) Shackford et. al. The Clinical Utility of Computed Tomographic Scanning and Neurologic Examination in the Management of Patients With Minor Head Injuries. J. Trauma 1992;33(3):385-394 (2) Stein et. al. Mild Head Injury: A Plea for Routine Early CT Scanning. J. Trauma 1992;33(1):11-13 (3) Harad et. al. Inadaquacy of Bedsie Clinical Indicators in Identifying Significant Intracranial Injury in Trauma Patients. J. Trauma 1992;32(3):359-363 (4) Stein et. al. Is Routine Computed Tomography Scanning Too Expensive for Mild Head Injury? Ann Emer Med 1991;20:1286-1289 (5) Snoey et. al. Delayed Diagnosis of Subdural Hematoma Following Normal Computed Tomography Scan. Ann Emer Med 1994;23:1127-1131 -------------------- In the UK the guidelines used are those described by a group of neurosurgeons (British Medical Journal 1984;288:983-5). Patients can be sent home with supervision if they are fully orientated, have no skull fracture, no abnormal neurology, can be assessed properly e.g. not drunk, and have no other confounding factors e.g. pre-existing neurological disorder. We do not routinely CT those being admitted for observation. CT is undertaken in those with neurological deficit, decreased conscious level, penetrating injury, depressed fracture, fits post injury, clinical basal skull fracture and progressive headache. I am relatiuvely lucky in having 24 hour instant CT access but many UK A&E departments still have office hour CT only. -------------------- þ "CT Scans are Cost-Effective in Minor Head Injury" - There was a paper presented at the ICEM in Sydney last year by G Wilkes and S Brown entitled Minor Head Injury: Routine CT Scanning is Cost-Effective. Abstract: Approximately 3-4% of patients with 'minor' head injuries (GCS 14-15, post-traumatic amnesia and no focal neurological signs, penetrating injury or evidence of basilar fracture) have clinically silent, potentially lethal, surgically treatable intracranial haematomas. Cranial CT scanning will detect all clinically significant lesions. Patients with normal CT scans and no neurological deficit can be safely discharged home. The principle argument against routine CT scanning is the cost associated with investigation. Following the introduction of a policy of routine CT scanning for all patients with minor head injuries in a tertiary Australian emergency department the percentage of these patients undergoing CT scanning increased from 49% to 91%. Increased average length of stay (1.38 days to 1.53 days), reduced annual admission rate (564/year to 450/year) and reduced overall costs during the transition phase, all returned to previous levels. There was no significant change in overall (bed and CT) cost per admission for this group of patients despite an 80% increase in the annual incidence of CT scanning. In the first year, three patients underwent craniotomy within 24 hours of admission on the basis of the CT findings alone. No patient discharged home with a normal CT scan required a subsequent craniotomy. þ References: - Wolfson & Paris, Diagnostic Testing in Emergency Medicine. Ch. 59: Imaging after Head Trauma. - Schynoll w, et al. A Prospective Study to Identify High-Yield Criteria Associated With Acute Intracranial Computed Tomography Findings in Head-Injured Patients. Am J Emerg Med. 1993;11:321-326. - Stein S, et al. The Value of Computed Tomographic Scans in Patients with Low-Risk head Injuries. Neurosurgery. 26:638-640, 1990. - Miller E, et al. Utilizing Clinical Factors to Reduce Head CT Scan Ordering for Minor Head Trauma Patients. J Emerg Med. Vol 15 4:453-357, 1997. - Madden C, et al. High-yield Selection Criteria for Cranial Computed Tomography after Acute Trauma. Acad Emerg. Med. 1995; 2:248-253. - Stiell I, et al. Variation in ED Use of Computed Tomography for Patients With Minor Head Injury. Ann Emerg Med. July 1997;30:14-22.