Clinical Decision Instruments Research Articles

Characteristics of Intracranial Injuries in Pediatric Patients Following Blunt Head Trauma.

Pediatric head trauma is a frequent reason for presentation to the emergency department. Despite this, there are few reports on specific characteristics and injury patterns in head injured children. The goal of this study was to evaluate head injury patterns in children with blunt head injury and their prevalence by age group. This is a planned secondary analysis of the NEXUS II Head CT validation study. Consecutive patients with blunt head trauma were enrolled between 2006 and 2015. Demographics and criteria from 2 clinical decision instruments (NEXUS and Canadian Head CT rules) were gathered at the time of enrollment. We abstracted and cataloged injuries for pediatric patients based on radiologist report. Frequencies of injuries and severity were analyzed by developmental age group. A total of 1018 pediatric patients were enrolled, 128 (12.6%) of whom had an injury on computed tomography scan. Median age was 11.9 (Interquartile range 4.5-15.5) for all patients and 12 (4.8-15.5) for injured patients. Of injured patients, 49 (38.3%) had a significant injury, and 27 (21.1%) received an intervention. Teenagers had the highest rate of significant injury (50%) and intervention (30%). Injuries were most frequently noted in the temporal (46.1%), frontal (45.3%), and parietal (45.3%) regions. Subarachnoid hemorrhage (29.7%) and subdural hematoma (28.9%) were the most common injuries observed.Intraparenchymal hemorrhage and cerebral edema were more prevalent in older age groups. The most common injury mechanism overall was fall from height (24.7%). Motor vehicle accidents and nonmotorized wheeled vehicle accidents were more common in older patients. Serious injuries requiring intervention were rarely encountered in pediatric patients experiencing blunt head trauma. Mechanisms of injury, type of injury, and rates of intervention varied between developmental age groups.

Effect of the Extended Focused Assessment With Sonography for Trauma on the Screening Performance of the National Emergency X-Radiography Utilization Study Chest Decision Instrument.

Developed to decrease unnecessary thoracic computed tomography use in adult blunt trauma patients, the National Emergency X-Radiography Utilization Study (NEXUS) Chest clinical decision instrument does not include the extended Focused Assessment with Sonography in Trauma (eFAST). We assessed whether eFAST improves the NEXUS Chest clinical decision instrument's diagnostic performance and may replace the chest radiograph (CXR) as a predictor variable. We performed a secondary analysis of prospective data from 8 Level I trauma centers from 2011-2014. We compared performance of modified clinical decision instruments that (1) added eFAST as a predictor (eFAST-added clinical decision instrument), and (2) replaced CXR with eFAST (eFAST-replaced clinical decision instrument), in screening for blunt thoracic injuries. One thousand nine hundred fifty-seven patients had documented computed tomography, CXR, clinical NEXUS criteria, and adequate eFAST; 624 (31.9%) patients had blunt thoracic injuries, and 126 (6.4%) had major injuries. Compared to the NEXUS Chest clinical decision instrument, the eFAST-added clinical decision instrument demonstrated unchanged screening performance for major injury (sensitivity 0.98 [0.94 to 1.00], specificity 0.28 [0.26 to 0.30]) or any injury (sensitivity 0.97 [0.95 to 0.98], specificity 0.21 [0.19 to 0.23]). The eFAST-replaced clinical decision instrument demonstrated unchanged sensitivity for major injury (sensitivity 0.93 [0.87 to 0.97], specificity 0.31 [0.29 to 0.34]) and decreased sensitivity for any injury (0.93 [0.91 to 0.951] versus 0.97 [0.953 to 0.98]). In our secondary analysis, adding eFAST as a predictor variable did not improve the diagnostic screening performance of the original NEXUS Chest clinical decision instrument; eFAST cannot replace the CXR criterion of the NEXUS Chest clinical decision instrument.

EXPOSURE OF PEDIATRIC EMERGENCY PATIENTS TO IMAGING EXAMS, NOWADAYS AND IN TIMES OF COVID-19: AN INTEGRATIVE REVIEW.

ABSTRACTObjective: To analyze literature data about unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and during times of COVID-19.Data sources: Between April and July 2020, articles were selected using the databases: Virtual Health Library, PubMed and Scientific Electronic Library Online. The following descriptors were used: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] and [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Inclusion criteria were articles available in full, in Portuguese or English, published from 2016 to 2020 or from 2019 to 2020, and articles that covered the theme. Articles without adherence to the theme and duplicate texts in the databases were excluded.Data synthesis: 61 publications were identified, of which 17 were comprised in this review. Some imaging tests used in pediatric emergency departments increase the possibility of developing future malignancies in patients, since they emit ionizing radiation. There are clinical decision instruments that allow reducing unnecessary exam requests, avoiding over-medicalization, and hospital expenses. Moreover, with the COVID-19 pandemic, there was a growing concern about the overuse of imaging exams in the pediatric population, which highlights the problems pointed out by this review.Conclusions: It is necessary to improve hospital staff training, use clinical decision instruments and develop guidelines to reduce the number of exams required, allowing hospital cost savings; and reducing children’s exposure to ionizing agents.

Prediction of Major Adverse Events After Endovascular Aneurysm Repair Using a Machine Learning Model

Predicting major adverse events (MAE), including type I and III endoleaks (ELs), after endovascular aneurysm repair (EVAR) is essential for clinical decision-making. No clinical decision instruments can reliably predict for MAE after EVAR. We developed a machine learning model (MLM) for predicting MAE within 3 years after elective EVAR using preoperative demographic information and aneurysm geometry. MLMs infer complex interaction without prespecification, possibly increasing the prediction accuracy compared with logistic regression models (LRMs). Patients with intact infrarenal abdominal aortic aneurysms who had undergone EVAR with preoperative M2S reconstruction from 2010 to 2017 at a single institution were analyzed. The MAEs included aneurysm- or intervention-related death within 30 days, aneurysm rupture, the development of type I or III ELs, greater than three reinterventions, or EVAR explantation. Patients with <3 years of follow-up were excluded. Seventy-four preoperative predictors were evaluated. Of these, 30 were geometric factors derived from M2S models. The remaining factors were demographic. The performance of LRMs, random forest models (RFMs), and gradient-boosted models (GBMs) were evaluated using a 75% and 25% training and testing split, fivefold cross-validation, and receiver operating characteristic performance metric. A total of 250 patients were included (mean age, 71.9 ± 8.6 years; 86% male). The abdominal aortic aneurysm diameter was 56.0 ± 10.6 mm, and the infrarenal neck length was 24.6 ± 4.5 mm. Of the 250 patients, 40 (16%) had experienced MAE: 11 had died within 30 days, 3 had experienced aneurysm rupture, 10 had developed a type I EL, 10 had developed a type III EL, 10 had required graft explantation, and 4 had undergone four or more reinterventions. The most significant 45 predictive variables are shown in the Fig. All discrimination and calibration metrics favored the MLM over the LRM. The area under the curve for the LRM was 0.70 compared with 0.83 for the RFM and 0.77 for the GBM. The LRM classification accuracy was 68% compared with 84% for the RFM and GBM. The GBM showed superior calibration performance (Hosmer-Lemeshow P = .201). The removal of the geometric parameters significantly degraded the performance for all the models (likelihood ratio P < .001). The MLM displayed superior discrimination and calibration compared with the LRM in predicting MAE for the first 3 years after elective EVAR, possibly owing to the complex interaction terms in the predictive factors. The anatomic characteristics were more influential than the demographic data in predicting for MAE. Our MLM might predict for MAE after EVAR and thereby aid in selecting patients for EVAR, nonoperative observation, or open repair.

CT scanning in blunt chest trauma: validation of decision instruments

to perform an external validation of two clinical decision instruments (DIs) - Chest CT-All and Chest CT-Major - in a cohort of patients with blunt chest trauma undergoing chest CT scanning at a trauma referral center, and determine if these DIs are safe options for selective ordering of chest CT scans in patients with blunt chest trauma admitted to emergency units. cross-sectional study of patients with blunt chest trauma undergoing chest CT scanning over a period of 11 months. Chest CT reports were cross-checked with the patients' electronic medical record data. The sensitivity and specificity of both instruments were calculated. the study included 764 patients. The Chest CT-All DI showed 100% sensitivity for all injuries and specificity values of 33.6% for injuries of major clinical significance and 40.4% for any lesion. The Chest CT-Major DI had sensitivity of 100% for injuries of major clinical significance, which decreased to 98.6% for any lesions, and specificity values of 37.4% for injuries of major clinical significance and 44.6% for all lesions. both clinical DIs validated in this study showed adequate sensitivity to detect chest injuries on CT and can be safely used to forego chest CT evaluation in patients without any of the criteria that define each DI. Had the Chest CT-All and Chest CT-Major DIs been applied in this cohort, the number of CT scans performed would have decreased by 23.1% and 24.6%, respectively, resulting in cost reduction and avoiding unnecessary radiation exposure.

Validation of a preoperative prediction model for mortality within 1 year after endovascular aortic aneurysm repair of intact aneurysms

ObjectiveMost would agree that at least 1-year survival is necessary after intact abdominal aortic aneurysm (AAA) repair to appropriately justify the cost and risk of the procedure. No validated clinical decision instruments exist to predict survival after endovascular aneurysm repair (EVAR) beyond the perioperative period. The purpose of this analysis was to create a preoperative prediction model for 1-year mortality after EVAR for intact AAA in the Society for Vascular Surgery Vascular Quality Initiative. MethodsAll intact EVARs in the Society for Vascular Surgery Vascular Quality Initiative from 2011 to 2015 were randomly divided into training (n = 17,836) and validation (n = 2500) data sets, and 31 preoperative candidate predictors were identified. A logistic regression model for 1-year mortality was created, and bootstrapped stepwise variable elimination was used to reduce this model to a best subset of predictors. Penalized maximum likelihood estimation was used to correct for potential overfitting. The final model was internally validated by bootstrapping the area under the curve (AUC) and the calibration slope and intercept, and its performance when applied to the training and validation data sets was compared. ResultsAfter elective and nonelective (symptomatic, intact) EVAR, 1-year mortality was 5.5% (n = 900/16,411) and 11.4% (n = 162/1425), respectively. The mean probability of 1-year mortality was 6.0% (n = 1062) in the training set and 5.7% (n = 143) in the validation cohort (P = .12). Significant preoperative predictors of 1-year mortality included chronic obstructive pulmonary disease, age, preoperative renal insufficiency (creatinine concentration ≥1.8 mg/dL or on hemodialysis), ejection fraction <50%, transfer status, body mass index <24 kg/m2, preoperative beta-blocker exposure, larger AAA diameter, and lower admission hemoglobin level. Preoperative statin use was found to be protective. The bias-corrected AUC was 0.759 (Hosmer-Lemeshow goodness-of-fit P value of 0.36; calibration intercept, −0.003; slope, 0.999). When applied to the validation data set, the model had AUC of 0.724 (95% confidence interval, 0.676-0.768; calibration intercept, 0.0009; slope, 0.970), which was in excellent agreement with the original data set bias-corrected AUC. Notably, ∼27.5% (n = 4902) had four or more risk factors with a predicted 1-year post-EVAR mortality risk of 10% to 22% despite that 33.2% of these patients had AAA diameters below recommended treatment guideline minimum thresholds. ConclusionsThis validated preoperative prediction model for 1-year mortality identifies patients less likely to benefit from EVAR. Appropriateness of intact AAA EVAR care delivery can be improved by use of this clinical decision aid to determine which high-risk patients have lower probability of mortality within the first postoperative year relative to their predicted annualized rupture risk.

Hot off the Press: Embedded Clinical Decision Support in Electronic Health Record Decreases Use of High-cost Imaging in the Emergency Department: EmbED Study.

This longitudinal before/after study of embedded clinical decision rules assessed the effects of clinical decision support on use of common imaging studies. Among high users, rates of computed tomograhy (CT) scan of the brain and CT of the cervical spine were reduced after implementation of embedded clinical decision instruments, while in low users, rates increased. This article summarizes the manuscript and the Skeptics Guide to Emergency Medicine podcast, as well as the ensuing social media/online discussion.

53 Analyzing the Components of the Wells' Score for Pulmonary Embolus Can Strengthen Unstructured Physician Gestalt

In determining pretest probability for pulmonary embolus (PE) in emergency department (ED) patients, recent studies have shown physician gestalt to be similar or superior to structured clinical decision instruments. Physician gestalt is unique to each practicing emergency physician, developed through clinical practice, knowledge, and experience. Physician trainees often lack that prior clinical experience to develop a gestalt. This study sought to find the predictive value of the individual components of the Wells’ PE score to better delineate the findings that are more predictive of PE, aiding in development of individual gestalt. We conducted a multinational, prospective observational study of adult patients presenting to EDs with suspected PE. Wells’ PE scores were calculated by the treating physicians. D-Dimer assays were performed using a single assay (INNOVANCE D-Dimer, Siemens). Confirmatory imaging (CT angiography of the chest or ventilation/perfusion scan) was obtained at the discretion of the treating physician. Patients were prospectively followed for clinical outcomes by record review and phone follow-up. We created a multivariable logistic regression model to assess associations between the individual elements of the Wells’ PE scores. We enrolled 1,834 patients with suspected PE and a non-high pretest probability, with a mean Wells’ PE score of 1.8 (SD 1.8). 63.1% were female, 36.9% were male. 55.9% were younger than 50 years old, 44.1% were 50 or older. 58.9% were Caucasian, 30.2% were African American, 7.9% were Hispanic, 1% were Asian, and 2% were other ethnicities. 28.4% were tachycardic, 7.1% had active cancer, and 10% had recent immobilization or surgery in the past 4 weeks. 9.4% had a prior history of VTE. Overall 5.5% (101/1834) were diagnosed with PE. An additional 7 patients were diagnosed with subsegmental PE. The individual components of the Wells’ Score for PE are listed below in Table 1. In this large patient cohort evaluated for PE, PE being the #1 or equally likely diagnosis, prior history of VTE, and recent immobilization or surgery in the previous 4 weeks had the greatest predictive value for subsequent diagnosis of PE. Signs and symptoms of a DVT, malignancy, heart rate greater than 100 bpm, and hemoptysis were less predictive of PE in analysis. Amongst the Wells’ score for PE criteria, it is physician’s gestalt that best predicts diagnosis of PE.Table 1Individual Components of the Wells' Score for PE with associated adjusted odds ratio and p-valueWells’ Score ComponentAdjusted OR (95% CI)p-valuePE is the #1 diagnosis or equally likely3.97 (2.52-6.25)<0.0001Previous DVT or PE3.40 (1.97-5.88)<0.0001Immobilization or surgery in the previous 4 weeks2.18 (1.23-3.84)0.0074Clinical signs and symptoms of DVT1.71 (0.84-3.47)0.14Malignancy (on treatment, treatement in last 6 months, or palliative)1.19 (0.59-2.41)0.63Heart rate greater than 100 bpm1.18 (0.72-1.93)0.50Hemoptysis0.57 (0.10-3.24)0.52 Open table in a new tab

Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and Are Seldom Superior

We determine how often studies that evaluate the performance of an aid for decisionmaking, be it a simple laboratory or imaging test or a complex multielement decision instrument, compare the aid's performance to independent, unaided physician judgment. This was a cross-sectional survey of all Original Research and Brief Research Report articles in Annals of EmergencyMedicine from 1998 to 2015. We included all articles that evaluated the performance of an aid for decisionmaking in assisting a physician with a decision about testing, treatment, diagnosis, or disposition. Two authors independently characterized the intent and purpose of each aid for decisionmaking, determined whether each study had a comparison to unaided physician judgment within the article or in a separate article, and recorded the result of that comparison. One hundred seventy-one (8.3%) of 2,060 research articles studied the performance characteristics of an aid for decisionmaking, 48 of which were formal clinical decision instruments. Forty of the 171 studies retrospectively analyzed existing databases and therefore could not assess physician judgment. Investigators compared the aid for decisionmaking to physician judgment in 11% (15/131) of the prospective studies, including 15% (6/41) of studies that evaluated a formal clinical decision instrument. For 9 articles that had no comparison to physician judgment, we found 6 unique external publications that compared that aid to physician clinical judgment. The decision aid was superior to clinical judgment in 2 of the 21 studies that contained a comparison. Physician judgment is infrequently assessed when the performance of an aid for decisionmaking is evaluated, and, when reported, the decision aid seldom outperformed physician judgment.

Negative D-dimer testing excludes pulmonary embolism in non-high risk patients in the emergency department.

The purpose of this study was to assess the ability of d-dimer testing to obviate the need for cross-sectional imaging for patients at "non-high risk" for pulmonary embolism (PE). This is a retrospective study of emergency department patients at an academic medical center who underwent cross-sectional imaging (MRA or CTA) to evaluate for PE from 2008 to 2013. The primary outcome was the NPV of d-dimer testing when used in conjunction with clinical decision instruments (CDIs = Wells', Revised Geneva, and Simplified Revised Geneva Scores). The reference standard for PE status included image test results and a 6-month chart review follow-up for venous thromboembolism as a proxy for false negative imaging. Secondary analyses included ROC curves for each CDI and calculation of PE prevalence in each risk stratum. Of 459 patients, 41 (8.9%) had PE. None of the 76 patients (16.6%) with negative d-dimer results had PE. Thus, d-dimer testing had 100% sensitivity and NPV, and there were no differences in CDI performance. Similarly, when evaluated independently of d-dimer results, no CDI outperformed the others (areas under the ROC curves ranged 0.53-0.55). There was a significantly higher PE prevalence in the high versus "non-high risk" groups when stratified by the Wells' Score (p=0.03). Negative d-dimer testing excluded PE in our retrospective cohort. Each CDI had similar NPVs, whether analyzed in conjunction with or independently of d-dimer results. Our results confirm that PE can be safely excluded in patients with "non-high risk" CDI scores and a negative d-dimer.

Knowledge Translation and Barriers to Imaging Optimization in the Emergency Department: A Research Agenda.

Researchers have attempted to optimize imaging utilization by describing which clinical variables are more predictive of acute disease and, conversely, what combination of variables can obviate the need for imaging. These results are then used to develop evidence-based clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the validation of these results in subsequent studies, with some demonstrating improved outcomes, their actual use is often limited. This article outlines a research agenda to promote the dissemination and implementation (also known as knowledge translation) of evidence-based interventions for emergency department (ED) imaging, i.e., clinical pathways, clinical decision instruments, and clinical practice guidelines. We convened a multidisciplinary group of stakeholders and held online and telephone discussions over a 6-month period culminating in an in-person meeting at the 2015 Academic Emergency Medicine consensus conference. We identified the following four overarching research questions: 1) what determinants (barriers and facilitators) influence emergency physicians' use of evidence-based interventions when ordering imaging in the ED; 2) what implementation strategies at the institutional level can improve the use of evidence-based interventions for ED imaging; 3) what interventions at the health care policy level can facilitate the adoption of evidence-based interventions for ED imaging; and 4) how can health information technology, including electronic health records, clinical decision support, and health information exchanges, be used to increase awareness, use, and adherence to evidence-based interventions for ED imaging? Advancing research that addresses these questions will provide valuable information as to how we can use evidence-based interventions to optimize imaging utilization and ultimately improve patient care.

New clinical decision instruments can and should reduce radiation exposure.

In this Perspective linked to Rodriguez and colleagues, Emmanuel Lagarde discusses the importance of decision instruments that can help physicians avoid subjecting patients to radiation exposure from unnecessary CT scans.

A conceptual model of emergency physician decision making for head computed tomography in mild head injury

The use of computed tomographic scanning in blunt head trauma has increased dramatically in recent years without an accompanying rise in the prevalence of injury or hospital admission for serious conditions. Because computed tomography is neither harmless nor inexpensive, researchers have attempted to optimize utilization, largely through research that describes which clinical variables predict intracranial injury, and use this information to develop clinical decision instruments. Although such techniques may be useful when the benefits and harms of each strategy (neuroimaging vs observation) are quantifiable and amenable to comparison, the exact magnitude of these benefits and harms remains unknown in this clinical scenario. We believe that most clinical decision instrument development efforts are misguided insofar as they ignore critical, nonclinical factors influencing the decision to image. In this article, we propose a conceptual model to illustrate how clinical and nonclinical factors influence emergency physicians making this decision. We posit that elements unrelated to standard clinical factors, such as personality of the physician, fear of litigation and of missed diagnoses, patient expectations, and compensation method, may have equal or greater impact on actual decision making than traditional clinical factors. We believe that 3 particular factors deserve special consideration for further research: fear of error/malpractice, financial incentives, and patient engagement. Acknowledgement and study of these factors will be essential if we are to understand how emergency physicians truly make these decisions and how test-ordering behavior can be modified.

A Critical Comparison of Clinical Decision Instruments for Computed Tomographic Scanning in Mild Closed Traumatic Brain Injury in Adolescents and Adults

A number of clinical decision aids have been introduced to limit unnecessary computed tomographic scans in patients with mild traumatic brain injury. These aids differ in the risk factors they use to recommend a scan. We compare the instruments according to their sensitivity and specificity and recommend ones based on incremental benefit of correctly classifying patients as having surgical, nonsurgical, or no intracranial lesions. We performed a secondary analysis of prospectively collected database from 7,955 patients aged 10 years or older with mild traumatic brain injury to compare sensitivity and specificity of 6 common clinical decision strategies: the Canadian CT Head Rule, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the New Orleans, the National Emergency X-Radiography Utilization Study II (NEXUS-II), the National Institute of Clinical Excellence guideline, and the Scandinavian Neurotrauma Committee guideline. Excluded from the database were patients for whom the history of trauma was unclear, the initial Glasgow Coma Scale score was less than 14, the injury was penetrating, vital signs were unstable, or who refused diagnostic tests. Patients revisiting the emergency department within 7 days were counted only once. The percentage of scans that would have been required by applying each of the 6 aids were Canadian CT head rule (high risk only) 53%, Canadian (medium & high risk) 56%, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies 56%, New Orleans 69%, NEXUS-II 56%, National Institute of Clinical Excellence 71%, and the Scandinavian 50%. The 6 decision aids' sensitivities for surgical hematomas could not be distinguished statistically (P>.05). Sensitivity was 100% (95% confidence interval [CI] 96% to 100%) for NEXUS-II, 98.1% (95% CI 93% to 100%) for National Institute of Clinical Excellence, and 99.1% (95% CI 94% to 100%) for the other 4 clinical decision instruments. Sensitivity for any intracranial lesion ranged from 95.7% (95% CI 93% to 97%) (Scandinavian) to 100% (95% CI 98% to 100%) (National Institute of Clinical Excellence). In contrast, specificities varied between 30.9% (95% CI 30% to 32%) (National Institute of Clinical Excellence) and 52.9% (95% CI 52% to 54) (Scandinavian). NEXUS-II and the Scandinavian clinical decision aids displayed the best combination of sensitivity and specificity in this patient population. However, we cannot demonstrate that the higher sensitivity of NEXUS-II for surgical hematomas is statistically significant. Therefore, choosing which of the 2 clinical decision instruments to use must be based on decisionmakers' attitudes toward risk.

Clinical Decision Instruments for CT Scan in Minor Head Trauma

Previous studies have presented conflicting results regarding the predictive value of various clinical symptoms and signs for performing computed tomography (CT) scan in minor head injury. Moreover, despite the presence in the literature of several similar publications regarding whether or not CT should be employed at the time of presentation of minor head injured patients, data regarding delayed CT are limited. The objective of this study was to determine whether high-risk criteria represent a significant indication for initial CT scan in patients with minor head trauma, and whether or not analysis using delayed CT scan is necessary in patients with high-risk criteria before being discharged. Patients presenting to the Emergency Department with minor head trauma between September 1, 2003 and September 1, 2004 were evaluated prospectively. After being divided into two main groups, low- and high-risk, four separate sub-groups based on age were established. Initial spiral CT examination was done within 3 h of trauma on all patients in addition to a delayed control CT scan in those with high-risk criteria between 16 and 24 h after trauma. The difference between the high- and low-risk groups in terms of abnormal CT findings was statistically significant ( p < 0.0005). Among high-risk patients there was a significant difference between patients with a Glasgow Coma Scale (GCS) score of 13 or 14 and those with a GCS score of 15 ( p < 0.0005). The relationship between vomiting and abnormal CT scan was significant (odds ratio 4.61, 95% confidence interval 2.20–9.64, p = 0.0001), and the relationship between abnormal CT scan and suspected skull fracture was also significant (odds ratio 3.46, 95% confidence interval 1.52–7.91, p = 0.0032). No significant correlations between other high-risk criteria and abnormal CT scan were determined. The difference between initial and delayed CT scans in patients with high-risk criteria was not significant ( p = 0.161). Low-risk patients with a GCS score of 15 may be discharged without initial CT scan being performed. Initial CT scan absolutely must be performed, however, on patients with GCS ≤ 15 in the event of vomiting or suspected skull fracture, even if isolated. Even though the difference between initial and delayed CT scans in patients with high-risk criteria is not significant, it is our opinion that it is still prudent for delayed CT scan to be performed, particularly on patients whose GCS score does not rise to 15, or decreases.

Clinical Decision Instruments for CT Scanning in Minor Head Injury

Clinical Decision Instruments for CT Scanning in Minor Head Injury