Clinical decision rules for head CT in trauma: Difference between revisions
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==Background== | ==Background== | ||
Clinical decision rules to guide providers when determining which patients require urgent CT neuroimaging. | |||
===Decision Rule Performance=== | ===Decision Rule Performance=== | ||
{| class="wikitable" | |||
|- | |||
! !! Canadian Head CT Rule<ref>[[EBQ:Canadian Head CT Rule]]</ref> !! New Orleans !! NEXUS II !! ACEP Clinical Policy | |||
|- | |||
| Sensitivity || 99% || 99% || 97% || Unknown | |||
|- | |||
| Specificity || 47% || 33% || 47% || Unknown | |||
|} | |||
==Canadian Rule== | ==[[EBQ:Canadian Head CT Rule|Canadian CT Head Rule]]<ref>[[EBQ:Canadian Head CT Rule]]</ref>== | ||
===Inclusion Criteria=== | ===Inclusion Criteria=== | ||
*GCS 13-15 | *Blunt head trauma causing loss of consciousness, amnesia, or disorientation | ||
*[[GCS]] 13-15 | |||
*Age ≥ 16yr | *Age ≥ 16yr | ||
*No coagulopathy nor on anti-coagulation | *No coagulopathy nor on anti-coagulation | ||
*No | *No seizure | ||
===Rule=== | ===Rule=== | ||
''[[Head CT]] not required if NONE of the following are present'' | |||
*Age ≥ 65 years | |||
*[[Vomiting]] > 2 episodes | |||
*Suspected open or depressed [[Skull Fracture]] | |||
*Signs suggesting basal skull fracture: | |||
**Hemotympanum | |||
**Racoon eyes | |||
**CSF otorrhea or rhinorrhea | |||
**Battle's sign (bruising around mastoid process) | |||
*[[GCS]] < 15 at 2 hours post injury | |||
*Retrograde Amnesia > 30min | |||
*Dangerous mechanism | |||
**Pedestrian struck by vehicle | |||
**Ejection from motor vehicle | |||
**Fall from elevation >3 feet or 5 stairs | |||
==New Orleans Rule== | ==New Orleans Rule== | ||
===Inclusion Criteria=== | ===Inclusion Criteria=== | ||
*Age >18 | *Age >18 | ||
*GCS 15 | *[[GCS]] 15 | ||
*Blunt head trauma occurring within previous 24hr causing LOC, amnesia, or disorientation | *Blunt head trauma occurring within previous 24hr causing LOC, amnesia, or disorientation | ||
===Rule=== | ===Rule=== | ||
''[[Head CT]] not required if NONE of the following are present'' | |||
*[[Headache]] | |||
*[[Vomiting]] | |||
*Age >60yr | |||
*Drug or [[Alcohol Intoxication]] | |||
*Persistent anterograde amnesia (deficits in short-term memory) | |||
*Visible trauma above the clavicles | |||
*[[Seizure]] | |||
==Nexus II Rule== | ==Nexus II Rule== | ||
===Rule=== | ===Rule=== | ||
''[[Head CT]] not required if NONE of the following are present'' | |||
*Age ≥ 65yr | |||
*Evidence of significant [[Skull Fracture]] | |||
*Scalp hematoma | |||
*Neurologic deficit | |||
*[[Altered Level of Alertness]] | |||
*Abnormal behavior | |||
*[[Coagulopathy]] | |||
*Recurrent or forceful vomiting | |||
==[[ACEP clinical policies|ACEP Clinical Policy (2008)]]== | |||
{{ACEP TBI policy}} | |||
==Pediatrics== | ==Pediatrics== | ||
See [[Head Trauma (Peds)]] | *See [[Head Trauma (Peds)]] | ||
*See [[EBQ:PECARN Pediatric Head CT Rule|PECARN Head CT Rule]] | |||
==See Also== | ==See Also== | ||
*[[Head trauma (main)]] | |||
*[[CT Before Lumbar Puncture]] | *[[CT Before Lumbar Puncture]] | ||
*[[Head CT]] | *[[Head CT]] | ||
*[[Head Trauma (Peds)]] | |||
*[[EBQ:Canadian Head CT Rule]] | |||
== | ==Resources== | ||
<References/> | |||
*Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting; Ann Emerg Med, 2008 | |||
*Annals of Emerg Med 2009; 53, 2:180-188. | *Annals of Emerg Med 2009; 53, 2:180-188. | ||
*http://www.ohri.ca/emerg/cdr/cthead.html | *http://www.ohri.ca/emerg/cdr/cthead.html | ||
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[[Category:Trauma]] | [[Category:Trauma]] | ||
[[Category:Featured]] |
Latest revision as of 20:13, 7 December 2019
Background
Clinical decision rules to guide providers when determining which patients require urgent CT neuroimaging.
Decision Rule Performance
Canadian Head CT Rule[1] | New Orleans | NEXUS II | ACEP Clinical Policy | |
---|---|---|---|---|
Sensitivity | 99% | 99% | 97% | Unknown |
Specificity | 47% | 33% | 47% | Unknown |
Canadian CT Head Rule[2]
Inclusion Criteria
- Blunt head trauma causing loss of consciousness, amnesia, or disorientation
- GCS 13-15
- Age ≥ 16yr
- No coagulopathy nor on anti-coagulation
- No seizure
Rule
Head CT not required if NONE of the following are present
- Age ≥ 65 years
- Vomiting > 2 episodes
- Suspected open or depressed Skull Fracture
- Signs suggesting basal skull fracture:
- Hemotympanum
- Racoon eyes
- CSF otorrhea or rhinorrhea
- Battle's sign (bruising around mastoid process)
- GCS < 15 at 2 hours post injury
- Retrograde Amnesia > 30min
- Dangerous mechanism
- Pedestrian struck by vehicle
- Ejection from motor vehicle
- 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 NONE of the following are present
- Headache
- Vomiting
- Age >60yr
- Drug or Alcohol Intoxication
- Persistent anterograde amnesia (deficits in short-term memory)
- Visible trauma above the clavicles
- Seizure
Nexus II Rule
Rule
Head CT not required if NONE of the following are present
- Age ≥ 65yr
- Evidence of significant Skull Fracture
- Scalp hematoma
- Neurologic deficit
- Altered Level of Alertness
- Abnormal behavior
- Coagulopathy
- Recurrent or forceful vomiting
ACEP Clinical Policy (2008)
- Inclusion:
- Non-penetrating trauma to the head
- Presentation to ED within 24 hours of injury
- GCS 14 or 15 on initial evaluation in ED
- Age ≥ 16
- Exclusion:
- Penetrating trauma
- Patients with multi-system trauma
- GCS < 14 on initial evaluation in the ED
- Age < 16
- Level A:
- A noncontrast head CT indicate in head trauma patients with LOC or post-traumatic amnesia only if ≥ 1 of following is present:
- Headache
- Vomiting
- Age> 60
- Drug or alcohol intoxication
- Deficits in short-term memory
- Physical evidence of trauma above the clavicle
- Post-traumatic seizure
- GCS < 15
- Focal neurological deficit
- Coagulopathy
- A noncontrast head CT indicate in head trauma patients with LOC or post-traumatic amnesia only if ≥ 1 of following is present:
- Level B:
- A noncontrast head CT should be considered in head trauma patients with no LOC or post-traumatic amnesia if there is:
- Focal neurological deficit
- Vomiting
- Severe headache
- Age ≥ 65
- Physical signs of basilar skull fracture
- GCS < 15
- Coagulopathy
- Dangerous mechanism of injury
- Patients with an isolated TBI who have a negative head CT scan result are at a minimal risk for developing an intracranial lesion and therefore may be safely discharged from the ED.
- A noncontrast head CT should be considered in head trauma patients with no LOC or post-traumatic amnesia if there is:
- Level C:
- In mild TBI patient with significant extracranial injuries and a serum S-100B level ≤ 0.5ℳg/L measured w/in 4 hours if injury, consideration can be given to not performing a CT.
- Mild TBI patients discharged from the E should be informed abut post-concussive symptoms.
- No specific recommendation for use of head MRI in patient with mild TBI
Pediatrics
See Also
Resources
- Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting; Ann Emerg Med, 2008
- 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