Original contribution
Clinical Decision Instruments for CT Scan in Minor Head Trauma

https://doi.org/10.1016/j.jemermed.2007.05.055Get rights and content

Abstract

Previous studies have presented conflicting results regarding the predictive value of various clinical symptoms and signs for performing computed tomography (CT) scan in minor head injury. Moreover, despite the presence in the literature of several similar publications regarding whether or not CT should be employed at the time of presentation of minor head injured patients, data regarding delayed CT are limited. The objective of this study was to determine whether high-risk criteria represent a significant indication for initial CT scan in patients with minor head trauma, and whether or not analysis using delayed CT scan is necessary in patients with high-risk criteria before being discharged. Patients presenting to the Emergency Department with minor head trauma between September 1, 2003 and September 1, 2004 were evaluated prospectively. After being divided into two main groups, low- and high-risk, four separate sub-groups based on age were established. Initial spiral CT examination was done within 3 h of trauma on all patients in addition to a delayed control CT scan in those with high-risk criteria between 16 and 24 h after trauma. The difference between the high- and low-risk groups in terms of abnormal CT findings was statistically significant (p < 0.0005). Among high-risk patients there was a significant difference between patients with a Glasgow Coma Scale (GCS) score of 13 or 14 and those with a GCS score of 15 (p < 0.0005). The relationship between vomiting and abnormal CT scan was significant (odds ratio 4.61, 95% confidence interval 2.20–9.64, p = 0.0001), and the relationship between abnormal CT scan and suspected skull fracture was also significant (odds ratio 3.46, 95% confidence interval 1.52–7.91, p = 0.0032). No significant correlations between other high-risk criteria and abnormal CT scan were determined. The difference between initial and delayed CT scans in patients with high-risk criteria was not significant (p = 0.161). Low-risk patients with a GCS score of 15 may be discharged without initial CT scan being performed. Initial CT scan absolutely must be performed, however, on patients with GCS ≤ 15 in the event of vomiting or suspected skull fracture, even if isolated. Even though the difference between initial and delayed CT scans in patients with high-risk criteria is not significant, it is our opinion that it is still prudent for delayed CT scan to be performed, particularly on patients whose GCS score does not rise to 15, or decreases.

Introduction

Minor head injury is one of the most common injuries in the Western world, with an estimated incidence of 100 to 300 per 100,000 people (1). Minor head injury is commonly defined as blunt trauma to the head, after which the patient loses consciousness for <15 min or has a short, post-traumatic amnesia of <1 h, or both, as well as a normal or minimally altered mental status on presentation (a Glasgow Coma Scale [GCS] score of 13–15) (2). Intracranial complications of minor head injury are infrequent (6–21%) but potentially life-threatening, and may require neurosurgical intervention in a minority of cases (0.4–1.0%) (3).

In cases of head trauma, computed tomography (CT) scan is essential for all patients with a GCS score of 13 or less, whereas only a specific history, symptom, or physical examination finding makes CT scan necessary in patients with a GCS score of 15 or rising to 15 post-resuscitation. These findings, known as high-risk criteria, include: amnesia, loss of consciousness, vomiting, suspected skull fracture, a history of coagulopathy or anticoagulant use, focal neurological findings, post-traumatic seizures, severe or increasing headache, asymmetric pupils, or multiple trauma (4). Algorithms for the management of minor head injury have been proposed for these high-risk criteria (5).

Many studies have been conducted on this subject and algorithms developed with regard to the use of CT scan in patients with minor head trauma (6). The question still remains, however, whether all patients with a clinically significant lesion on CT scan really do require observation and, consequently, whether a CT scan is really indicated (3). Our study was performed to determine whether high-risk criteria represent a significant indication for initial CT scan in patients with minor head trauma, and whether or not analysis using delayed CT scan is necessary in patients with high-risk criteria before being discharged.

Section snippets

Methods

This study was conducted at the Karadeniz Technical University Emergency Department. After approval was obtained from the Local Ethical Committee, minor head injured patients presenting to the Emergency Department between September 1, 2003 and September 1, 2004 were evaluated prospectively. All patients presenting to the Emergency Department within 3 h of minor head trauma were included in the study, without regard to gender or age.

Minor head injury is defined as blunt trauma to the head, after

Results

Included in the study were 240 patients with minor head injury presenting to the Karadeniz Technical University Medical Faculty Emergency Department in the 1-year study period.

Initial CT scan was performed on all 240 patients investigated within the first 3 h. As a result of this initial CT scan, abnormal findings were identified in 47 (19%) patients overall. The number of patients with abnormal CT scan findings in the high-risk group was 39 (32%), and 8 (6%) in the low-risk group. Patients in

Discussion

The relevant literature contains many studies on the use of CT scan in patients with minor head injury, yet no consensus has been reached. A study by Haydel et al. suggested that CT scan is indicated only in patients with minor head injury with any one of seven risk factors, the New Orleans Criteria (7). According to this decision rule, patients without any risk factors would not require CT scan. A similar study by Stiell et al. identified a different set of factors, the Canadian CT Head Rule (8

References (21)

  • I.G. Stiell et al.

    The Canadian CT Head Rule for patients with minor head injury

    Lancet

    (2001)
  • C. Arienta et al.

    Management of head injured patients in the emergency department: a practical protocol

    Surg Neurol

    (1997)
  • P. Riesgo et al.

    Delayed extradural hematoma after mild head injury: report of three cases

    Surg Neurol

    (1997)
  • J. Cassidy et al.

    Incidence, risk factors and prevention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury

    J Rehabil Med

    (2004)
  • L.J. Carroll et al.

    Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury

    J Rehabil Med

    (2004)
  • M. Smits et al.

    External validation of the Canadian CT head rule and the New Orleans criteria for CT scanning in patients with minor head injury

    JAMA

    (2005)
  • J. Dunning et al.

    A meta-analysis of variables that predcit significant intracranial injury in minor head trauma

    Arch Dis Child

    (2004)
  • T.D. Kirsch et al.

    Head injury

  • H.Y. Sultan et al.

    Application of the Canadian CT head rules in managing minor head injuries in a UK emergency department: implications for the implementation of the NICE guidelines

    Emerg Med J

    (2004)
  • M.J. Haydel et al.

    Indications for computed tomography in patients with minor head injury

    N Engl J Med

    (2000)
There are more references available in the full text version of this article.

Cited by (0)

View full text