Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update

Johan Undén,Tor Ingebrigtsen,Bertil Romner

doi:10.1186/1741-7015-11-50

Abstract

BackgroundThe management of minimal, mild and moderate head injuries is still controversial. In 2000, the Scandinavian Neurotrauma Committee (SNC) presented evidence-based guidelines for initial management of these injuries. Since then, considerable new evidence has emerged.MethodsGeneral methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Systematic evidence-based review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, based upon relevant clinical questions with respect to patient-important outcomes, including Quality Assessment of Diagnostic Accuracy Studies (QUADAS) and Centre of Evidence Based Medicine (CEBM) quality ratings. Based upon the results, GRADE recommendations, guidelines and discharge instructions were drafted. A modified Delphi approach was used for consensus and relevant clinical stakeholders were consulted.ConclusionsWe present the updated SNC guidelines for initial management of minimal, mild and moderate head injury in adults including criteria for computed tomography (CT) scan selection, admission and discharge with suggestions for monitoring routines and discharge advice for patients. The guidelines are designed to primarily detect neurosurgical intervention with traumatic CT findings as a secondary goal. For elements lacking good evidence, such as in-hospital monitoring, routines were largely based on consensus. We suggest external validation of the guidelines before widespread clinical use is recommended.

Highlights

The management of minimal, mild and moderate head injuries is still controversial
Following a normal computed tomography (CT) scan after mild head injury, consensus is generally to discharge patients from the hospital [13,14], subgroups of patients may still be at risk of developing delayed intracranial complications of varying significance [15,16]
Further research is very unlikely to change our confidence in the estimated effect

Summary

Introduction

The management of minimal, mild and moderate head injuries is still controversial. In 2000, the Scandinavian Neurotrauma Committee (SNC) presented evidence-based guidelines for initial management of these injuries. Initial management strategies have become focused on selective CT use based upon presence or absence of specific aspects of patient history and/or clinical examination [6,9,10,11], in order to effectively use health care resources. This selective management has received more attention following reports of increased cancer risks from CT scans, estimated at 1 in 5,000 to 10,000 for a single head CT scan in young adults [12]. Following a normal CT scan after mild head injury, consensus is generally to discharge patients from the hospital [13,14], subgroups of patients may still be at risk of developing delayed intracranial complications of varying significance [15,16]

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