EBQ:Canadian Head CT Rule: Difference between revisions
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| fulltexturl=http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04561-X/fulltext | | fulltexturl=http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04561-X/fulltext | ||
| pdfurl=http://www.mcgill.ca/files/emergency/CCHR.pdf | | pdfurl=http://www.mcgill.ca/files/emergency/CCHR.pdf | ||
| status=Complete | |||
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#Amnesia before impact >30 min | #Amnesia before impact >30 min | ||
#Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs) | #Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs) | ||
==Design== | ==Design== | ||
*Prospective cohort study in 10 Canadian community and teaching institutions | *Prospective cohort study in 10 Canadian community and teaching institutions | ||
*N=3121 | *N=3121 | ||
==Population== | ==Population== | ||
Line 60: | Line 59: | ||
*Pregnant | *Pregnant | ||
===Baseline Characteristics=== | ===Baseline Characteristics=== | ||
* Mean age: 38 years | |||
*Age range 16-99 | |||
* Men: 69% | |||
* Mean time between injury and physician assessment: 3.1 hours | |||
* Arrival by ambulance: 73% | |||
* Transfer from outside hospital: 13% | |||
* Witnessed loss of consciousness: 46% | |||
* Amnesia: 87% | |||
* Initial GCS score: | |||
** 15: 80% | |||
** 14: 17% | |||
** 13: 4% | |||
* Mechanism of injury: | |||
** Fall: 31% | |||
** MVA: 26% | |||
** Assault: 11% | |||
** Sports: 10% | |||
** Bicycle: 7% | |||
==Interventions== | ==Interventions== | ||
*Patients underwent standard CT of the head according to the judgment of the treating physician. | |||
*The reliability of the radiography interpretations was assessed by having abnormal CT scans, and 5% (randomly selected) of normal scans reviewed by a second radiologist who was unaware of the first interpretation. | |||
*Patients were classified as having no clinically important brain injury if af 14 days they had: | |||
**no complaints of memory or concentration problems | |||
**no seizures | |||
**NO focal motor findings | |||
**Score ≤ 10 on the Katzman Short Orientation-Memory-COncentration Test | |||
**Returned to normal daily activities | |||
==Outcomes== | ==Outcomes== | ||
''High risk by decision rule, requiring neurological intervention:'' | |||
Sensitivity '''100%''' (95% CI 92-1000) | |||
Specificity '''68.7%''' (95% CI 67-70%) | |||
''With 2 moderate risk criteria added in (consisting of 7 criteria):'' | |||
Sensitivity '''98.4%''' (95% CI 96%-99%) | |||
Specificity '''49.6%''' (95% CI 48-51%) | |||
==Criticisms== | ==Criticisms== | ||
==Funding== | ==Funding== | ||
Funded by peer-reviewed grants from the Medical Research Council of Canada (MT-13699) and the Ontario Ministry of Health Emergency Health Services Committee (11896N) | |||
==See Also== | |||
*[[Head CT in Trauma (Clinical Decision Rules)]] | |||
==CME== | ==CME== | ||
<quiz display=simple> | |||
{Besides the Canadian Head CT Rule, which other clinical decision rules in adults are available to emergency physicians? (more than one answer possible) | |||
|type="[]"} | |||
+New Orleans Criteria (NOC) | |||
||[http://www.ncbi.nlm.nih.gov/pubmed/10891517 Haydel et al. NEJM, July 2000] | |||
||CT indicated if: GCS 15 and loss of consciousness in the setting of trauma AND… | |||
||1. Headache, | |||
||2. Vomiting, | |||
||3. Age > 60 years, | |||
||4. Drugs/ EtOH, | |||
||5. Short term memory deficit, | |||
||6. Visible trauma above clavicles, or | |||
||7. Seizure | |||
||[http://www.wikem.org/wiki/Head_CT_(New_Orleans_rule) NOC WikEM review] | |||
-Ottawa Head CT Rule | |||
-San Francisco CT Head Rule | |||
+NEXUS II | |||
||[http://www.ncbi.nlm.nih.gov/pubmed/16374287 Mower et al. J Trauma, 2005] | |||
||CT indicated if any of following: | |||
||1. Age ≥ 65 years old | |||
||2. Evidence of significant skull fx | |||
||3. Scalp hematoma | |||
||4. Neurologic deficit | |||
||5. Altered level of alertness | |||
||6. Abnormal behavior | |||
||7. Coagulopathy | |||
||8. Recurrent or forceful vomiting | |||
-PECARN | |||
{All are criteria for the Canadian Head CT Rule EXCEPT? (more than one answer possible) | |||
|type="[]"} | |||
+Age <15 | |||
-Basilar skull fx signs | |||
-Auto vs. Peds | |||
-Ejection | |||
+Children | |||
||[http://www.ncbi.nlm.nih.gov/pubmed/19758692 Pediatric Emergency Care Applied Research Network] (PECARN) Pediatric Head Injury/Trauma Algorithm for evaluating pediatric head injury. | |||
||Largest study ever done on pediatric head injury patients. It was developed to help physicians determine which children do or do not require brain imaging after head trauma. | |||
||[[File:Pecarn.png|200px|]] | |||
||[http://www.wikem.org/wiki/PECARN_Head_Trauma WikEM Review] | |||
</quiz> | |||
[[Category: Trauma]][[Category: EBQ]] | [[Category: Trauma]][[Category: EBQ]] |
Latest revision as of 12:11, 19 December 2016
PubMed Full text PDF
Clinical Question
Can a decision rule be used to determine which patients require CT imaging after head trauma?
Conclusion
The Canadian CT head rule is a effective method for determining the need for a patient to receive a non contrast brain CT after head trauma.
Major Points
The trial found that the following criteria had 100% sensitivity for identifying patient at risk for neurologic intervention with minor head injury
- GCS score <15 at 2h post injury
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (hemotympanum, ‘racoon’ eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle’s sign)
- Vomiting ≥ 2episodes
- Age ≥ 65 years
- Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patients with a GCS score of 13–15
The moderate risk group (for brain injury on CT) was identified with 95% sensitivity if any of the following were present:
- Amnesia before impact >30 min
- Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs)
Design
- Prospective cohort study in 10 Canadian community and teaching institutions
- N=3121
Population
Inclusion Criteria
- Blunt Trauma to the head causing witnessed loss of consciousness, definite amnesia, or witnessed disorientation)
- GCS ≥ 13 on ED arrival
- Head injury within the last 24 hours
Exclusion Criteria
- Less than 16 years old
- Minimal head injury (no loss of consciousness, amnesia, or disorientation)
- No clear history of trauma as the primary event (eg, primary seizure or syncope)
- Obvious penetrating skull injury or obvious depressed fracture
- Acute focal neurological deficit
- Unstable vital signs associated with major trauma
- Seizure before assessment in the ED
- Bleeding disorder
- Using oral anticoagulants
- Returned for reassessment of the same head injury
- Pregnant
Baseline Characteristics
- Mean age: 38 years
- Age range 16-99
- Men: 69%
- Mean time between injury and physician assessment: 3.1 hours
- Arrival by ambulance: 73%
- Transfer from outside hospital: 13%
- Witnessed loss of consciousness: 46%
- Amnesia: 87%
- Initial GCS score:
- 15: 80%
- 14: 17%
- 13: 4%
- Mechanism of injury:
- Fall: 31%
- MVA: 26%
- Assault: 11%
- Sports: 10%
- Bicycle: 7%
Interventions
- Patients underwent standard CT of the head according to the judgment of the treating physician.
- The reliability of the radiography interpretations was assessed by having abnormal CT scans, and 5% (randomly selected) of normal scans reviewed by a second radiologist who was unaware of the first interpretation.
- Patients were classified as having no clinically important brain injury if af 14 days they had:
- no complaints of memory or concentration problems
- no seizures
- NO focal motor findings
- Score ≤ 10 on the Katzman Short Orientation-Memory-COncentration Test
- Returned to normal daily activities
Outcomes
High risk by decision rule, requiring neurological intervention: Sensitivity 100% (95% CI 92-1000) Specificity 68.7% (95% CI 67-70%)
With 2 moderate risk criteria added in (consisting of 7 criteria): Sensitivity 98.4% (95% CI 96%-99%) Specificity 49.6% (95% CI 48-51%)
Criticisms
Funding
Funded by peer-reviewed grants from the Medical Research Council of Canada (MT-13699) and the Ontario Ministry of Health Emergency Health Services Committee (11896N)
See Also
CME