Clinical decision rules for head CT in trauma

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%

ACEP Clinical Policy

• The following patients should have a head CT performed:
  • Patients with loss of consciousness or posttraumatic amnesia AND:
    • Headache OR
    • Vomiting OR
    • Age>60 OR
    • Drug/alcohol intoxication OR
    • Short-term memory deficits OR
    • Evidence of trauma above the clavicles OR
    • Posttraumatic seizure OR
    • GCS<15 OR
    • Focal neurological deficit OR
    • Coagulopathy
  • Patients without loss of consciousness or posttraumatic amnesia AND
    • Severe headache OR
    • Vomiting OR
    • Age>65 OR
    • GCS<15 OR
    • Physical signs of a basilar skull fracture OR
    • Focal neurological deficit OR
    • ^Coagulopathy OR
    • ^Dangerous Mechanism

^Coagulopathy = patient taking anticoagulation (warfarin, fractionated or unfractionated heparin) or has documented coagulation disorder

^Dangerous mechanism = ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs

Canadian CT Head 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 Fracture
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

• CT Before Lumbar Puncture
• Head CT
• Head Trauma (Peds)

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