Clinical decision rules for head CT in trauma: Difference between revisions

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==Clinical Question==
==Background==
Among patients with minor head trauma, is it possible to develop a sensitive and specific tool to determine the necessity of CT head imaging?
===Decision Rule Performance===
#Canadian
##Sn 99%, Sp 47%
#New Orleans
##Sn 99%, Sp 33%
#Nexus II
##Sn 97%, Sp 47%


==Bottom Line==
==Canadian Rule==
The Canadian CT head rule is a rapid method of determining which patients need CT imaging upon presentation to the emergency department with head trauma.
===Inclusion Criteria===
 
*GCS 13-15
==Major Points==  
*Age ≥ 16yr
Many experts rely on clinical gestalt to identify patients at high risk who should undergo head CT imaging for trauma. The Canadian rules were designed to identify a set of objective criteria for determining whether trauma patients are likely to require neurological intervention or have clinically important brain injury. The rule identifies two sets of criteria, one for high-risk patients and the other for low-risk patients. The first, a set of high-risk criteria, identifies with 100% sensitivity (95% CI 0.92-1.00) patients at risk for emergent neurological intervention, when any of the following are present:
*No coagulopathy nor on anti-coagulation
# GCS score <15 at 2h post injury
*No obvious open skull fx
# Suspected open or depressed skull fracture
===Rule===
# Any sign of basal skull fracture (raccoon eyes, battles sign, etc.)
*Head CT not required if ALL of the following are absent:
# >1 episode of emesis
#Age >65 years
# Age ≥64 years
#Vomiting >2 times
 
#Suspected open or depressed skull fracture
A second group of patients, identified with 95% sensitivity, is at moderate risk; namely, they are at risk of having clinically important brain injury when any of the following are present:
#Signs suggesting basal skull fracture:
# Have amnesia of 30 minutes or greater prior to trauma
##Hemotympanum
# Trauma from dangerous mechanism (eg, fall greater than 3 feet, MVA with ejection from vehicle, or pedestrian vs. motor vehicle accident)
##Racoon eyes
 
##CSF otorrhea or rhinorrhea
==Design==
##Battle's sign
* Prospective cohort derivation study
#GCS <15 at 2 hours post injury
* N=3121
#Amnesia before impact >30min
* Setting: 10 Canadian emergency departments
#Dangerous mechanism
* Enrollment: 1996-1999
##Pedestrian struck by vehicle
##Ejection from motor vehicle
##Fall from elevation >3 feet or 5 stairs


==Population==  
==New Orleans Rule==
===Inclusion Criteria===
===Inclusion Criteria===
* Blunt trauma to the head
*Age >18
* Witnessed loss of consciousness or disorientation
*GCS 15
* Definite amnesia
*Blunt head trauma occurring within previous 24hr causing LOC, amnesia, or disorientation
* GCS ≥13 in the ED
===Rule===
* Injury within 24 hours
*Head CT not required if ALL of the following are absent:
#Headache
#Vomiting
#Age >60yr
#Drug or alcohol intoxication
#Persistent anterograde amnesia (deficits in short-term memory)
#Visible trauma above the clavicles
#Seizure


===Exclusion Criteria===
==Nexus II Rule==
* Age <16 years
===Rule===
* Minimal head injury (no loss of consciousness, amnesia, or disorientation)
*Head CT not required if ALL of the following are absent:
* Absence of clear history of trauma as inciting event (eg, syncope or seizure as inciting event)
#Age ≥ 65yr
* Penetrating skull injury or depressed skull fracture
#Evidence of significant skull fx
* Acute focal neurological deficit
#Scalp hematoma
* Unstable vital signs
#Neurologic deficit
* Seizure prior to ED assessment
#Altered level of alertness
* Bleeding disorder
#Abnormal behavior
* On oral anticoagulation
#Coagulopathy
* Had returned for reassessment of same head injury
#Recurrent or forceful vomiting
* Pregnancy
 
===Baseline Characteristics===
* Mean age: 39 years
* 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%
** Pedestrian struck: 6%
** Head struck/hit by object: 6%
** Motorcycle: 4%
** Other: 1%
 
==Interventions==
* Consecutive patients presenting with head trauma with above inclusion criteria were enrolled
* All patients were assessed by study investigator using one-hour session to review 22 different clinical features
* Decision to obtain CT head imaging was made by treating physician (not investigators)
* All patients received follow-up telephone interview at 14 days, evaluated for memory loss, difficulty concentrating, seizure or other neurological deficits, and a score of ≥10 on Katzman Short Orientation-Memory-Concentration Test. Presence of any of these prompted interviewers to advise a return visit to the ED. Absence of all of these features indicated a lack of clinically important brain injury
* Patients who received CT head were compared to those who did not
* Various statistical methods used to determine risk factors for need for neurological intervention and clinically important brain injury
 
==Outcomes==
''Performance of high-risk decision rule, consisting of 5 criteria.''
; High risk by decision rule, requiring neurological intervention
: Sensitivity 100% (95% CI 0.92-1.00)
: Specificity 68.7% (95% CI 0.67-0.70)
 
''Performance of all factors, consisting of 7 criteria.''
; Moderate risk by decision rule, with clinically important injury
: Sensitivity 98.4% (95% CI 0.96-0.99)
: Specificity 49.6% (95% CI 0.48-0.51)
 
==Criticisms==
* 363 patients who did not meet CT criteria were not included in the final statistical analysis, because they were lost to follow-up.
* 1358 patients presented to the study center EDs for minor head trauma, however were not enrolled in the study.
* The 14-day follow-up telephone interview had not been evaluated for precision/reliability in ruling out clinically relevant brain injury.
* The Canadian Head CT Rule allows for minor or clinically unimportant brain injury to go unimaged and without hospital admission, which in some countries, like the United States, is considered important and to many clinicians usually necessitates both imaging and admission.
 
==Funding==
Funding provided by the Medical Research Council of Canada and the Ontario Ministry of Health, Emergency Health Services Committee.


==Pediatrics==
==Pediatrics==
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*Haydel  MJ, Preston  CA, Mills  TJ, Luber  S, Blaudeau  E, DeBlieux  PM.  Indications for computed tomography in patients with minor head injury.  N Engl J Med.  2000;343:100–5.
*Haydel  MJ, Preston  CA, Mills  TJ, Luber  S, Blaudeau  E, DeBlieux  PM.  Indications for computed tomography in patients with minor head injury.  N Engl J Med.  2000;343:100–5.
*Papa L et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States level I trauma center. Acad Emerg Med 2012 Jan; 19:2
*Papa L et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States level I trauma center. Acad Emerg Med 2012 Jan; 19:2
*fulltexturl=http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04561-X/fulltext
 
*pdfurl=http://download.thelancet.com/pdfs/journals/lancet/PIIS014067360004561X.pdf
[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 01:11, 17 September 2013

Background

Decision Rule Performance

  1. Canadian
    1. Sn 99%, Sp 47%
  2. New Orleans
    1. Sn 99%, Sp 33%
  3. Nexus II
    1. Sn 97%, Sp 47%

Canadian Rule

Inclusion Criteria

  • GCS 13-15
  • Age ≥ 16yr
  • No coagulopathy nor on anti-coagulation
  • No obvious open skull fx

Rule

  • Head CT not required if ALL of the following are absent:
  1. Age >65 years
  2. Vomiting >2 times
  3. Suspected open or depressed skull fracture
  4. Signs suggesting basal skull fracture:
    1. Hemotympanum
    2. Racoon eyes
    3. CSF otorrhea or rhinorrhea
    4. Battle's sign
  5. GCS <15 at 2 hours post injury
  6. Amnesia before impact >30min
  7. Dangerous mechanism
    1. Pedestrian struck by vehicle
    2. Ejection from motor vehicle
    3. Fall from elevation >3 feet or 5 stairs

New Orleans Rule

Inclusion Criteria

  • Age >18
  • GCS 15
  • Blunt head trauma occurring within previous 24hr causing LOC, amnesia, or disorientation

Rule

  • Head CT not required if ALL of the following are absent:
  1. Headache
  2. Vomiting
  3. Age >60yr
  4. Drug or alcohol intoxication
  5. Persistent anterograde amnesia (deficits in short-term memory)
  6. Visible trauma above the clavicles
  7. Seizure

Nexus II Rule

Rule

  • Head CT not required if ALL of the following are absent:
  1. Age ≥ 65yr
  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

Pediatrics

See Head Trauma (Peds)

See Also

Source

  • Annals of Emerg Med 2009; 53, 2:180-188.
  • http://www.ohri.ca/emerg/cdr/cthead.html
  • Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343:100–5.
  • Papa L et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States level I trauma center. Acad Emerg Med 2012 Jan; 19:2
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