Head Rule Research Articles

Accuracy of Canadian CT head rule in predicting positive findings on CT of the head of patients after mild head injury in a large trauma centre in Saudi Arabia.

Investigation of unjustified computed tomography (CT) scan in patients with minor head injury is lacking in Saudi Arabia. The purpose of the study was to evaluate the compliance and effectiveness of the Canadian computed tomography head rule (CCHR) in our emergency department (ED) and trauma centre and also to reduce the number of unjustified CT studies of the head in the centre. A retrospective study of 368 ED patients with minor head injury was conducted. Patients who underwent CT scan between July 2010 and June 2011 were selected from the ED head trauma registry by systematic randomisation. The CCHR was retrospectively applied on the patients' charts to calculate the prevalence of unjustified head CT scans. A separate survey was conducted to evaluate three emergency physicians' level of awareness about the CCHR and their ability to determine the necessity of CT scans with various clinical scenarios of head injury. The prevalence of unjustified CT scans as per the CCHR was 61.8% (95% confidence interval (CI) 56.5-66.9%). Approximately 5% of the sample had positive CT findings with 95% CI 2.9-7.6%. The CCHR correctly identified 12 cases with positive CT findings with 66.67% sensitivity. Only 24 (6.7%) had Glasgow coma scale scores less than 15 (13/14). The Glasgow coma scale correctly identified only two cases with positive CT findings with 11.11% sensitivity. The percentage of skull fracture (0.9% vs 5%, P=0.030) was significantly lower in patients with unjustified CT scans than in patients with clinically justified CT scans. There was fair to substantial agreement between the ED physicians and the CCHR (κ=35-61%). Two ED physicians identified all cases of justified CT scan with 100% sensitivity (95% CI 71.51-100%). The level of education regarding the CCHR was found to be optimal among emergency physicians using a case-based scenario survey. The CCHR was found to have a poor compliance potential in the busy ED of our trauma centre and the prevalence of unjustified cranial CT scans remained high.

Head CT scan in Iranian minor head injury patients: evaluating current decision rules.

The objective of this study is to select one of the seven available clinical decision rules for minor head injury, for managing Iranian patients. This was a prospective cohort study evaluating medium- or high-risk minor head injury patients presenting to the Emergency Department. Patients with minor head trauma who were eligible for brain imaging based on seven available clinical decision rules (National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS)-II, Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS), New Orleans, American College of Emergency Physicians (ACEP) Guideline, Scandinavian, and Canadian computed tomography (CT) head rule) were selected. Subjects were underwent a non-contrast axial spiral head CT scan. The outcome was defined as abnormal and normal head CT scan. Univariate analysis and stepwise linear regression were applied to show the best combination of risk factors for detecting CT scan abnormalities. Five hundred patients with minor head trauma were underwent brain CT scan. The following criteria were derived by stepwise linear regression: Glasgow Coma Scale (GCS) less than 15, confusion, signs of basal skull fracture, drug history of warfarin, vomiting more than once, loss of consciousness, focal neurologic deficit, and age over 65 years. This model has 86.15 % (75.33-93.45 %) sensitivity and 46.44 % (46.67-51.25 %) specificity in detecting minor head injury patients with CT scan abnormalities (95 % confidence interval). Of seven decision rules, only the Canadian CT Head Rule possesses seven of the eight high-risk factors associated with abnormal head CT results which were identified by this study. This study underlines the Canadian CT Head Rule's utility in Iranian minor head injury patients. Our study encourages researchers to evaluate available guidelines in different communities.

264 Application of the Canadian Computed Tomography Head Rule to a Very Low Risk Minor Head Injury Population

264 Application of the Canadian Computed Tomography Head Rule to a Very Low Risk Minor Head Injury Population

Redefining Overuse to Include Costs: A Decision Analysis for Computed Tomography in Minor Head Injury

A study was conducted to (1) determine the testing threshold for head computed tomography (CT) in minor head injury in the emergency department using decision analysis with and without costs included in the analysis, (2) to determine which variables have significant impact on the testing threshold, and (3) to compare this calculated testing threshold to the pretest risk estimate previously reported when the Canadian CT Head Rule (CCHR) was applied. It was hypothesized that the CCHR might not identify all patients above the testing threshold. A decision analytic model was constructed using commercially available software and data from published literature. Outcomes were assigned values on the basis of quality-adjusted life-years (QALYs) and cost. Two testing thresholds were calculated, the first based only on the effectiveness of either strategy, the second on the overall net monetary benefit. Two-way sensitivity analyses were performed to determine which variables most affected the testing threshold. When only effectiveness (QALYs) was considered, the testing threshold for obtaining head CT was 0.039%. This threshold increased to 0.421% when the net monetary benefit was considered in lieu of QALYs. Age, probability of lesion on CT requiring neurosurgery, and cost of CT were the main drivers of the model. If only effectiveness is considered, current clinical decision rules might not provide a sufficient degree of certainty to ensure identification of all patients for whom the benefits of CT outweigh its risks. However, inclusion of cost in the analysis increases the testing threshold by an order of magnitude and well outside the range of uncertainty of current clinical decision rules. These results suggest that the term overuse should be redefined to include the provision of medical services with no benefits or for which harms including cost outweigh benefits.

Comparison of quantitative EEG to current clinical decision rules for head CT use in acute mild traumatic brain injury in the ED

Study objectiveWe compared the performance of a handheld quantitative electroencephalogram (QEEG) acquisition device to New Orleans Criteria (NOC), Canadian CT Head Rule (CCHR), and National Emergency X-Radiography Utilization Study II (NEXUS II) Rule in predicting intracranial lesions on head computed tomography (CT) in acute mild traumatic brain injury in the emergency department (ED). MethodsPatients between 18 and 80 years of age who presented to the ED with acute blunt head trauma were enrolled in this prospective observational study at 2 urban academic EDs in Detroit, MI. Data were collected for 10 minutes from frontal leads to determine a QEEG discriminant score that could maximally classify intracranial lesions on head CT. ResultsOne hundred fifty-two patients were enrolled from July 2012 to February 2013. A total 17.1% had acute traumatic intracranial lesions on head CT. Quantitative electroencephalogram discriminant score of greater than or equal to 31 was found to be a good cutoff (area under receiver operating characteristic curve = 0.84; 95% confidence interval [CI], 0.76-0.93) to classify patients with positive head CT. The sensitivity of QEEG discriminant score was 92.3 (95% CI, 73.4-98.6), whereas the specificity was 57.1 (95% CI, 48.0-65.8). The sensitivity and specificity of the decision rules were as follows: NOC 96.1 (95% CI, 78.4-99.7) and 15.8 (95% CI, 10.1-23.6); CCHR 46.1 (95% CI, 27.1-66.2) and 86.5 (95% CI, 78.9-91.7); NEXUS II 96.1 (95% CI, 78.4-99.7) and 31.7 (95% CI, 23.9-40.7). ConclusionAt a sensitivity of greater than 90%, QEEG discriminant score had better specificity than NOC and NEXUS II. Only CCHR had better specificity than QEEG discriminant score but at the cost of low (<50%) sensitivity.

Repetitions which are not repetitions: the non-redundant nature of tautological compounds

In English morphological literature, the term ‘tautological compound’ has been typically used to refer to two distinct – but closely related – phenomena: (1) compounds composed of a hyponym and a superordinate term (such as oak tree); and/or (2) compounds based upon two synonymous units (such as subject matter). Such combinations are one of the quirkiest – and least researched – phenomena of English compounding. Their oddity can be attributed to two main factors. First, as their name, ‘tautological compound’ implies, at face value such combinations can be considered as prime examples of the redundancy of language. Second, they do not follow normal compound-forming rules in the sense that both constituents can function as the semantic head (as opposed to ‘normal’ English compounds, which follow the Right-Hand Head Rule).Perhaps it is the quirkiness of tautological compounds that accounts for the fact that not much has been said about them in traditional accounts of compounding, which typically relegate them to a marginal area of the English language. However, there is more to tautological compounds than meets the eye. What the present study wishes to demonstrate is that the term ‘tautological compound’ is a misnomer, as such combinations are far from being tautological or redundant in their meaning. Accordingly, the article first clarifies the notion of tautological compound, and then aims to give an account of the various roles that such combinations play in language, thereby demonstrating their non-tautological and non-redundant nature – in order to assign this much-neglected category to its proper, well-deserved place within English word formation.

Theory of planned behaviour can help understand processes underlying the use of two emergency medicine diagnostic imaging rules.

BackgroundClinical decision rules (CDRs) can be an effective tool for knowledge translation in emergency medicine, but their implementation is often a challenge. This study examined whether the Theory of Planned Behaviour (TPB) could help explain the inconsistent results between the successful Canadian C-Spine Rule (CCR) implementation study and unsuccessful Canadian CT Head Rule (CCHR) implementation study. Both rules are aimed at improving the accuracy and efficiency of emergency department radiography use in clinical contexts that exhibit enormous inefficiency at the present time. The rules were prospectively derived and validated using the same methodology demonstrating high sensitivity and reliability. The rules subsequently underwent parallel implementations at 12 Canadian hospitals, yet only the CCR was observed to significantly reduce radiography ordering rates, while the CCHR failed to have any significant impact at all. The drastically different results are unlikely to be the result of differences in implementation strategies or the decision rules.MethodsPhysicians at the 12 participating Canadian hospitals were randomized to CCR or CCHR TPB surveys that were administered during the baseline phases of the implementation studies, before any intervention had taken place. The collected baseline survey data were linked to concurrent baseline physician and patient-specific imaging data, and subsequently analyzed using mixed effects linear and logistic models.ResultsA total of 223 of the 378 eligible physicians randomized to a TPB survey completed their assigned baseline survey (CCR: 122 of 181; CCHR: 101 of 197). Attitudes were significantly associated with intention in both settings (CCR: ß = 0.40; CCHR: ß = 0.30), as were subjective norms (CCR: ß = 0.26; CCHR: ß = 0.73). Intention was significantly associated with actual image ordering for CCR (OR = 1.79), but not CCHR.ConclusionsThe TPB can be used to better understand processes underlying use of CDRs. TPB constructs were significantly associated with intention to perform both imaging behaviours, but intention was only associated with actual behaviour for CCR, suggesting that constructs outside of the TPB framework may need to be considered when seeking to understand use of CDRs.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0088-x) contains supplementary material, which is available to authorized users.

Comparison of the Canadian CT head rule and the new orleans criteria in patients with minor head injury.

AimThe aim of the study was to compare the New Orleans Criteria and the New Orleans Criteria according to their diagnostic performance in patients with mild head injury.MethodsThe study was designed and conducted prospectively after obtaining ethics committee approval. Data was collected prospectively for patients presenting to the ED with Minor Head Injury. After clinical assessment, a standard CT scan of the head was performed in patients having at least one of the risk factors stated in one of the two clinical decision rules.Patients with positive traumatic head injury according to BT results defined as Group 1 and those who had no intracranial injury defined as Group 2. Statistical analysis was performed with SPSS 11.00 for Windows. ROC analyze was performed to determine the effectiveness of detecting intracranial injury with both decision rules. p < 0.05 was considered statistically significant.Results175 patients enrolled the study. Male to female ratio was 1.5. The mean age of the patients was 45 ± 21,3 in group 1 and 49 ± 20,6 in group 2. The most common mechanism of trauma was falling. The sensitivity and specificity of CCHR were respectively 76.4% and 41.7%, whereas sensitivity and specificity of NOC were 88.2% and 6.9%.ConclusionThe CCHR has higher specificity, PPV and NPV for important clinical outcomes than does the NOC.

Risk factors indicating the need for cranial CT scans in elderly patients with head trauma: an Austrian trial and comparison with the Canadian CT Head Rule

This study presents newly defined risk factors for detecting clinically important brain injury requiring neurosurgical intervention and intensive care, and compares it with the Canadian CT Head Rule (CCHR). This prospective cohort study was conducted in a single Austrian Level-I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department with witnessed loss of consciousness, disorientation, or amnesia, and a Glasgow Coma Scale (GCS) score of 13-15. The studied population consisted of a large number of elderly patients living in Vienna. The aim of the study was to investigate risk factors that help to predict the need for immediate cranial CT in patients with mild head trauma. Among the 12,786 enrolled patients, 1307 received a cranial CT scan. Four hundred eighty-nine patients (37.4%) with a mean age of 63.9 ± 22.8 years had evidence of an acute traumatic intracranial lesion on CT. Three patients (< 0.1%) were admitted to the intensive care unit for neurological observation and received oropharyngeal intubation. Seventeen patients (0.1%) underwent neurosurgical intervention. In 818 patients (62.6%), no evidence of an acute trauma-related lesion was found on CT. Data analysis showed that the presence of at least 1 of the following factors can predict the necessity of cranial CT: amnesia, GCS score, age > 65 years, loss of consciousness, nausea or vomiting, hypocoagulation, dementia or a history of ischemic stroke, anisocoria, skull fracture, and development of a focal neurological deficit. Patients requiring neurosurgical intervention were detected with a sensitivity of 90% and a specificity of 67% by using the authors' analysis. In contrast, the use of the CCHR in these patients detected the need for neurosurgical intervention with a sensitivity of only 80% and a specificity of 72%. The use of the suggested parameters proved to be superior in the detection of high-risk patients who sustained a mild head trauma compared with the CCHR rules. Further validation of these results in a multicenter setting is needed. Clinical trial registration no.: NCT00451789 ( ClinicalTrials.gov .).

Facial Fractures of the Upper Craniofacial Skeleton Predict Mortality and Occult Intracranial Injury After Blunt Trauma

The aim of this article was to assess how regional facial fracture patterns predict mortality and occult intracranial injury after blunt trauma. Retrospective chart review was performed for blunt-mechanism craniofacial fracture patients who presented to an urban trauma center from 1998 to 2010. Fractures were confirmed by author review of computed tomographic imaging and then grouped into 1 of 5 patterns of regional involvement representing all possible permutations of facial-third injury. Mortality and the presence of occult intracranial injury, defined as those occurring in patients at low risk at presentation for head injury by Canadian CT Head Rule criteria, were evaluated. Relative risk estimates were obtained using multivariable regression. Of 4540 patients identified, 338 (7.4%) died, and 171 (8.1%) had intracranial injury despite normal Glasgow Coma Scale at presentation. Cumulative mortality reached 18.8% for isolated upper face fractures, compared with 6.9% and 4.0% for middle and lower face fractures (P < 0.001), respectively. Upper face fractures were independently associated with 4.06-, 3.46-, and 3.59-fold increased risk of death for the following fracture patterns: isolated upper, combined upper, panfacial, respectively (P < 0.001). Patients who were at low risk for head injury remained 4 to 6 times more likely to suffer an occult intracranial injury if they had involvement of the upper face. The association between facial fractures, intracranial injury, and death varies by regional involvement, with increasing insult in those with upper face fractures. Cognizance of the increased risk for intracranial injury in patients with upper face fractures may supplement existing triage tools and should increase suspicion for underlying or impending neuropathology, regardless of clinical picture at presentation.

Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury.

Awareness and use of the Canadian computed tomography head rule for mild head injury patients among Chinese emergency physicians

Computed tomography (CT) scan has been an increasingly essential diagnostic tool for emergency physicians (EPs) to triage emergency patients. Canadian computed tomography Head Rule (CCHR) had been established and widely used to spare patients with mild head injury from unnecessary radiation. However, the awareness of CCHR and its actual utilization among Chinese EPs were unknown. This survey was to investigate the awareness and use of CCHR and their associated characteristics among Chinese EPs. Questionnaire was randomly sent to EPs from different Chinese hospitals. Surveyed EPs were asked how well they know about the CCHR and how often they use the CCHR to guide head CT use. Association between the awareness and utilization of CCHR and the physicians' characteristics were analyzed using repeated-measures logistic regression. About 41.7% of the total 247 responders noted they "very familiar" or "somewhat familiar" with CCHR while the utilization rate was 24.7%. With respect to the most important underlying barriers for the use of CCHR, approximate half (48.5%) cited "fear of malpractice" as the leading cause. "Received specific training regarding radiation dose of CT" was the significant predicting factor both for the awareness (OR 5.87; 95% CI, 3.08-11.21) and the use (OR 6.10, 95% CI, 2.91-12.80) of CCHR. Fear of malpractice and lack of radiation risk knowledge were two main barriers to apply CCHR in the request of CT for patients with mild head injury. Furthermore, EPs with specific training about radiation risk of CT were more likely to know and use of CCHR.

Understanding the Canadian adult CT head rule trial: use of the theoretical domains framework for process evaluation

BackgroundThe Canadian CT Head Rule was prospectively derived and validated to assist clinicians with diagnostic decision-making regarding the use of computed tomography (CT) in adult patients with minor head injury. A recent intervention trial failed to demonstrate a decrease in the rate of head CTs following implementation of the rule in Canadian emergency departments. Yet, the same intervention, which included a one-hour educational session and reminders at the point of requisition, was successful in reducing cervical spine imaging rates in the same emergency departments. The reason for the varied effect of the intervention across these two behaviours is unclear. There is an increasing appreciation for the use of theory to conduct process evaluations to better understand how strategies are linked with outcomes in implementation trials. The Theoretical Domains Framework (TDF) has been used to explore health professional behaviour and to design behaviour change interventions but, to date, has not been used to guide a theory-based process evaluation. In this proof of concept study, we explored whether the TDF could be used to guide a retrospective process evaluation to better understand emergency physicians’ responses to the interventions employed in the Canadian CT Head Rule trial.MethodsA semi-structured interview guide, based on the 12 domains from the TDF, was used to conduct telephone interviews with project leads and physician participants from the intervention sites in the Canadian CT Head Rule trial. Two reviewers independently coded the anonymised interview transcripts using the TDF as a coding framework. Relevant domains were identified by: the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour.ResultsEight physicians from four of the intervention sites in the Canadian CT Head Rule trial participated in the interviews. Barriers likely to assist with understanding physicians’ responses to the intervention in the trial were identified in six of the theoretical domains: beliefs about consequences; beliefs about capabilities; behavioural regulation; memory, attention and decision processes; environmental context and resources; and social influences. Despite knowledge that the Canadian CT Head Rule was highly sensitive and reliable for identifying clinically important brain injuries and strong beliefs about the benefits for using the rule, a number of barriers were identified that may have prevented physicians from consistently applying the rule.ConclusionThis proof of concept study demonstrates the use of the TDF as a guiding framework to design a retrospective theory-based process evaluation. There is a need for further development and testing of methods for using the TDF to guide theory-based process evaluations running alongside behaviour change intervention trials.

What Is the Incidence of Intracranial Bleeding in Patients with Mild Traumatic Brain Injury? A Retrospective Study in 3088 Canadian CT Head Rule Patients

Objective. Only limited data exists in terms of the incidence of intracranial bleeding (ICB) in patients with mild traumatic brain injury (MTBI). Methods. We retrospectively identified 3088 patients (mean age 41 range (7–99) years) presenting with isolated MTBI and GCS 14-15 at our Emergency Department who had undergone cranial CT (CCT) between 2002 and 2011. Indication for CCT was according to the “Canadian CT head rules.” Patients with ICB were either submitted for neurosurgical treatment or kept under surveillance for at least 24 hours. Pearson's correlation coefficient was used to correlate the incidence of ICB with age, gender, or intake of coumarins, platelet aggregation inhibitors, or heparins. Results. 149 patients (4.8%) had ICB on CCT. No patient with ICB died or deteriorated neurologically. The incidence of ICB increased with age and intake of anticoagulants without clinically relevant correlation (R = 0.11; P < 0.001; R = −0.06; P < 0.001). Conclusion. Our data show an incidence of 4.8% for ICB after MTBI. However, neurological deterioration after MTBI seems to be rare, and the need for neurosurgical intervention is only required in selected cases. The general need for CCT in patients after MTBI is therefore questionable, and clinical surveillance may be sufficient when CCT is not available.

CT Overuse for Mild Traumatic Brain Injury

Multiple, validated, evidence-based guidelines exist to inform the appropriate use of computed tomography (CT) to differentiate mild traumatic brain injury (MTBI) from clinically important brain injury and to prevent the overuse of CT. Yet, CT use is growing rapidly, potentially exposing patients to unnecessary ionizing radiation risk and costs. A study was conducted to quantify the overuse of CT in MTBI on the basis of current guideline recommendations. A retrospective analysis of secondary data from a prospective observational study was undertaken at an urban, Level I emergency department (ED) with more than 90,000 visits per year. For adult patients with minor head injury receiving CT imaging at the discretion of the treating physician, the proportion of cases meeting criteria for CT on the basis of the Canadian CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clinical Policy, New Orleans Criteria (NOC), and National Institute for Health and Clinical Excellence (NICE) guidelines was reported. All 346 patients enrolled in the original study were included in the analysis. The proportion of cases meeting criteria for CT for each of the guidelines was: CCHR 64.7% (95% confidence interval [CI], 0.60-0.70), ACEP 74.3% (95% CI, 0.70-0.79), NICE 86.7% (95% CI, 0.83-0.90), and NOC 90.5% (95% CI, 0.87-0.94). The odds ratio of the guidelines for predicting positive head CT findings were also reported. Some 10%-35% of CTs obtained in the ED for MTBI were not recommended according to the guidelines. Successful implementation of existing guidelines could decrease CT use in MTBI by up to 35%, leading to a significant reduction in radiation-induced cancers and health care costs.

207 A “Top Five” List for Emergency Medicine: A Pilot to Improve the Value of Emergency Care

Study Objectives: Overuse of health care services is a major contributor to rising health care costs. As part of an institutional affordability initiative, we created an emergency medicine (EM) “top 5” list consisting of tests, treatments, and disposition decisions that are of little value to patients. Each item had to be evidence-based, amenable to standardization, and actionable. Methods: Design: Three-phase consensus and survey process. Setting and Participants: An integrated delivery system with 2 academic and 4 community EDs. The technical expert panel included ED leadership and content experts in imaging, admissions and transfers. The provider survey was administered to all physicians, physician assistants and nurse practitioners who practice in the 6 EDs (N=286). Measurement: In phase I, the technical expert panel used a modified Delphi process with 2 rounds of surveys to rank a list of low-value clinical actions. The initial list was generated by TEP brainstorming and email solicitation of providers. Technical expert panel members ranked each item on 3 domains: contribution to cost, benefit to patients, and actionability by emergency medicine providers. In phase II, all providers were surveyed to assess distinct dimensions of each item using 2 5-point Likert scales: (a) potential benefit or harm to the patient and (b) actionable by the provider. In phase III, the technical expert panel voted for a final “Top Five” list based on survey results and discussion. Pearson correlation was used to assess inter-domain correlation. Results: The initial solicitation yielded 64 low-value clinical actions. The phase I ranking process narrowed this to 7 lab tests, 3 medications, 4 imaging studies and 3 disposition decisions, which were included in an provider survey that had a 78% response rate. All 17 items had a median score of “very” or “somewhat” beneficial and actionable. For all items, there was significant positive correlation between scores on benefit and actionability (ρ = 0.19-0.37, P-value = 0.09-0.001). Composite scores were similar when stratified by provider type (attending/resident versus nurse practitioners/physician assistants), setting (academic versus community), and experience (1-2 years, 3-9y versus >10y). In phase III, 1 action received unanimous technical expert panel support, 5 received majority support, and 12 received at least 1 vote. The final “Top Five” list included: 1) Don't order CT of the cervical spine for patients after trauma who do not meet the NEXUS or Canadian C-Spine Rule, 2) Don't order CT to diagnose pulmonary embolism without first risk stratifying, 3) Don't order MRI of the lumbar spine for patients with low back pain without “red flags,” 4) Don't order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule, 5) Don't order coagulation studies for patients without hemorrhage or suspected coagulopathy. Conclusion: We identified, through a consensus process, clinical actions that were of low value and within provider control. While organized emergency medicine is absent from the 17 medical specialties involved in the “Choosing Wisely” campaign, our project has piloted a methodology that emergency medicine providers can use to identify actionable targets of overuse.

Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study

The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury. This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value. We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15. For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

Continuing Professional Development: Diagnosis and management of minor head injury in the UK

Overview Head injury accounts for a large amount of emergency services work in the UK. This article summarizes the findings of studies undertaken for the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme examining the available evidence regarding the diagnostic management of minor head injuries. These studies included a review of current practice in the management of minor head injured patients (GCS 13–15) by way of a survey of UK emergency departments. We also performed a systematic review of the head injury literature to identify the most accurate clinical decision rule for adults (Canadian CT Head Rule) and children (Paediatric Emergency Care and Research Network) and commented on the applicability of these in the UK population. This review helped to identify the most significant clinical findings that increase the likelihood of intracranial and neurosurgical injury, following minor head injury in adults, children and infants. Finally, we have highlighted where these findings may be relevant to UK paramedic practice, in particular in influencing the decision to transfer patients to the emergency department. Learning Outcomes After completing this module you will: • Have an understanding of the significant clinical characteristics following head injury • Understand potential pathological problems following head injury • Be able to assess the relevant clinical features of all patients following head injury • Be familiar with key clinical decision rules for patients with head injury • Be able to provide the appropriate pre-hospital management for all head injured patients.

Neurological Injury and Anesthetic Neurotoxicity Following Neonatal Cardiac Surgery: Does the Head Rule the Heart Or the Heart Rule the head?

The improvements in care of children with heart disease have resulted in a major decrease in mortality and increased attention to adverse events and quality of survival. There is important neurological morbidity in children with congenital heart disease. Some problems such as stroke or seizure may be immediately apparent, but others, such as learning disability and motor delay emerge over time. The etiology is multifactorial and includes genetic, procedural and social causes. Only some factors are modifiable. Over the last decade, evidence has been presented that anesthetic drugs may be a potential cause of CNS morbidity. Neonates and infants may be particularly vulnerable to this. The purpose of this article is to describe the multiple known causes of neurodevelopmental impairment in children with heart disease, including anesthetic agents, and to explore the relationship between congenital heart disease and its treatment in this regard.

Canadian CT Head Rule Is Superior to New Orleans Criteria in Minor Head Injury

In a prospective cohort study, the authors compared sensitivity and specificity of the Canadian CT Head Rule and the New Orleans Criteria (JW Emerg Med