Minimal Head Injury Research Articles

Preliminary Evaluation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries with Glial Fibrillary Acidic Protein.

Glial fibrillary acidic protein (GFAP) has become the most promising biomarker for detecting traumatic abnormalities on head computed tomography (CT) in patients with traumatic brain injury (TBI), but most studies have not addressed the potential added value of combining the biomarker with clinical variables that confer risk for intracranial injuries. The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults were the first clinical decision rules in the field with an incorporated biomarker, the S100 astroglial calcium-binding protein B (S100B), which is used in the Mild (Low Risk) group defined by the guidelines. Our aim was to evaluate the performance of the guidelines when S100B was substituted with GFAP. The sample (N = 296) was recruited from the Tampere University Hospital's emergency department between November 2015 and November 2016, and there were 49 patients with available GFAP results who were stratified in the Mild (Low Risk) group (thus patients undergoing biomarker triaging). A previously reported cutoff of plasma GFAP ≥140 pg/mL was used. Within the Mild (Low Risk) group (n = 49), GFAP sensitivity (with 95% confidence intervals in parentheses) for detecting traumatic CT abnormalities was 1.0 (0.40-1.00), specificity 0.34 (0.19-0.53), the negative predictive value (NPV) 1.0 (0.68-1.00), and the positive predictive value (PPV) 0.16 (0.05-0.37). The sensitivity and specificity of the modified guidelines with GFAP, when applied to all imaged patients (n = 197) in the whole sample, were 0.94 (0.77-0.99) and 0.20 (0.15-0.28), respectively. NPV was 0.94 (0.80-0.99) and PPV 0.18 (0.13-0.25). In the Mild (Low Risk) group, none of the patients with GFAP results below 140 pg/mL had traumatic abnormalities on their head CT. These findings were derived from a small patient subgroup. Future researchers should replicate these findings in larger samples and assess whether GFAP has added or comparable value to S100B in acute TBI management.

Validation of the scandinavian guidelines for initial management of minor and moderate head trauma in children

BackgroundHead trauma in children is common, with a low rate of clinically important traumatic brain injury. CT scan is the reference standard for diagnosis of traumatic brain injury, of which the increasing use is alarming because of the risk of induction of lethal malignancies. Recently, the Scandinavian Neurotrauma Committee derived new guidelines for the initial management of minor and moderate head trauma. Our aim was to validate these guidelines.MethodsWe applied the guidelines to a population consisting of children with mild and moderate head trauma, enrolled in the study: “Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study” by Kuppermann et al. (Lancet 374(9696):1160–1170, https://doi.org/10.1016/S0140-6736(09)61558-0, 2009). We calculated the negative predictive values of the guidelines to assess their ability to distinguish children without clinically-important traumatic brain injuries and traumatic brain injuries on CT scans, for whom CT could be omitted.ResultsWe analysed a population of 43,025 children. For clinically-important brain injuries among children with minimal head injuries, the negative predictive value was 99.8% and the rate was 0.15%. For traumatic findings on CT, the negative predictive value was 96.9%. Traumatic finding on CT was detected in 3.1% of children with minimal head injuries who underwent a CT examination, which accounts for 0.45% of all children in this group.ConclusionChildren with minimal head injuries can be safely discharged with oral and written instructions. Use of the SNC-G will potentially reduce the use of CT.

Prospective Validation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults.

The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults (Scandinavian guidelines) are the first to incorporate serum measurement of the S100 astroglial calcium-binding protein B (S100B) to emergency department (ED) triage of patients with head injury (HI). This prospective validation study was conducted in the ED of the Tampere University Hospital, Finland, between November 2015 and November 2016. All consecutive adult patients with HI presenting to the ED within 24 h from injury were eligible for inclusion. Venous blood for S100B sampling was drawn from all patients, and the result was available at the ED. Computed tomography (CT) scans of the head were performed according to the on-call physician's evaluation. Only the samples collected within 6 h after injury were used. A one-week follow-up was conducted to identify possible HI-related complications. A total of 295 patients (median age, 67.0 years, range, 18-100; women, 48.8%) were enrolled. Of those, 196 (66.4%) underwent scanning. Acute traumatic lesions were detected on 31 (15.8%) of the scans. Two of the CT-positive patients were scanned without a guidelines-based indication. These lesions did not require any specific treatment or repeated imaging. The guidelines-based sensitivity was 0.94 (95% confidence interval [CI], 0.77-0.99) and specificity 0.19 (95% CI, 0.13-0.26) for predicting traumatic intracranial CT abnormalities. The positive and negative predictive value for positive head CT was 0.18 (95% CI, 0.12-0.25) and 0.94 (95% CI, 0.78-0.99), respectively. In the mild-low risk group, no false negative S100B values were recorded. Thirteen patients (4.4%) were re-admitted to the ED, and two patients (0.7%) died one week after the primary HI. The deaths were unrelated to the injury. None of these adverse events were directly caused by a primarily undiagnosed intracranial injury. The Scandinavian guidelines incorporated with S100B are a valid means of screening clinically significant acute traumatic lesions after HI and have the potential to reduce unnecessary CT scanning.

Utility and effectiveness of the Scandinavian guidelines to exclude computerized tomography scanning in mild traumatic brain injury - a prospective cohort study

BackgroundIn 2013 the Scandinavian Neurotrauma Committee (SNC) published updated guidelines for the initial management of minimal, mild and moderate traumatic head injuries (MTHI) that included serum analysis of protein S100B as a marker for brain tissue damage. This study reviews the effectiveness of the new guidelines in a clinical setting.MethodsFor all patients admitted to Akershus University Hospital (AHUS) from June 30th 2014 to December 15th 2014 with MTHI a separate form was filled in recording the time, indication and result of any S100B sampling and/or head computer tomography (CT) examinations. Data from these forms were compared to information derived from the electronic patient records for patients with MTHI and related diagnoses and data from the laboratory for all patients that had undergone the S100B analysis within the same period.ResultsFive hundred seventy-five patients were identified with MTHI, S100B sampling was indicated for 223 (38.8%) patients and carried out for 188 (84.3%) of these patients. 69 (36.7%) of the patients had a negative S100B test, but a head CT scan was still performed in 31 cases despite the negative S100B test. In total the guidelines were followed for 362 of 575 patients (63.0%). 180 (31.3%) of the MTHI cases were discharged without further observation or CT examinations, including 38 (21.1%) as a direct result of S100B testing. No re-admissions or missed initial traumatic brain injuries were observed.ConclusionThe implementation of the updated SNC guidelines resulted in direct discharge of more than one third of the MTHI cases without further observation or CT examinations. One in five of these discharges was a direct result of S100B testing. However, compliance to the guidelines were poor and the guidelines were only followed in 40%. While this study showed benefits of implementing SNC guidelines to reduce the number of CT scans, additional training is needed for optimal use.

Traumatic Minor Intracranial Hemorrhage: Management by Non-neurosurgeon Consultants in a Regional Trauma Center is Safe and Effective.

There is debate concerning the need for specialist neurosurgical transfer of patients presenting to Level II trauma centers with a minimal head injury (Glasgow Coma Scale ≥13) and a small non-progressive intracranial bleeding (ICB). A retrospective chart analysis was performed assessing the outcomes of adult patients presenting with a minor traumatic ICB on initial CT scan (minimal subarachnoid hemorrhage; small-width subdural hematoma without shift; punctate cerebral contusion). Patients with extradural hematomas and those patients on antiplatelet or anticoagulant therapy were excluded from the protocol. Overall 291 cases were assessed (mean age 69.9years) with 75% of cases presenting after a fall. There was deterioration of neurological status in 11 patients (3.8%) with 8 hospital transfers and 5 with an abnormal neurological examination (NE). Two patients with an abnormal INR and a worsening head CT were transferred without neurosurgical intervention. Of the 8 transferred cases there were 2 deaths (both >90years of age with multiple comorbidities) with one craniotomy performed for a subdural hematoma (with full recovery). Three patients meeting transfer criteria were not transferred with one death (patient >90years of age with severe dementia). The remaining 2 patients were discharged with normal neurological outcomes. Patients with a minimal traumatic brain injury and a non-progressive minor ICB may be safely managed in a Level II trauma center by an acute care consultant with neurosurgical consultation but without the need for neurosurgical transfer. Retrospective analysis: Level IV.

External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children

BackgroundClinical decision rules (CDRs) aid in the management of children with traumatic brain injury (TBI). Recently, the Scandinavian Neurotrauma Committee (SNC) has published practical, evidence-based guidelines for children with Glasgow Coma Scale (GCS) scores of 9–15. This study aims to validate these guidelines and to compare them with other CDRs.MethodsA large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, we compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13–15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT.ResultsThe SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1–100.0; 32/32), 97.8% (94.5–99.4; 179/183) and 95% (95% CI 91.6–97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs.ConclusionThe SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI.

Application of the Canadian Computed Tomography Head Rule to Patients With Minimal Head Injury

Two clinical decision rules, the Canadian CT Head Rule and the New Orleans Criteria, set the standard to guide clinicians in determining which patients with minor head trauma need computed tomography (CT) imaging. Both rules were derived with patients with minor head injury who had had a loss of consciousness or witnessed disorientation. No evidence exists for evaluating patients and need for CT imaging with minimal head injury; that is, patients who had a head injury but no loss of consciousness or disorientation and therefore would have been excluded from the Canadian CT Head Rule and New Orleans Criteria trials. We evaluate the Canadian CT Head Rule in patients with head injury without loss of consciousness or witnessed disorientation (minimal head injury). We studied a prospective convenience sample of patients with minimal head injury who received head CTs as part of their evaluations in the emergency department (ED). Participants were enrolled after head CT was ordered, but before the physician received the imaging results. Physicians were surveyed on their clinical reasoning for ordering imaging in this low-risk cohort of patients. Physicians surveyed consisted of ED attending physicians and senior-level emergency medicine residents. Final patient disposition was recorded when it became available. Patients with positive CT findings had their medical records reviewed for specific disposition, admission length of stay, ICU stay, and any operative or procedural interventions. Two hundred forty patients with minimal head injury were enrolled. Five patients (2.1%) had head CTs that were positive for intracranial hemorrhage. All instances of intracranial hemorrhage occurred in patients who were at high or moderate risk by the Canadian CT Head Rule (2 high risk [age], 3 moderate risk [mechanism]). No patient with intracranial hemorrhage went to the ICU or underwent any intervention; the average hospital length of stay was 1.25 days. The Canadian CT Head Rule was 100% sensitive (95% confidence interval 40% to 100%) and 29% specific (95% confidence interval 23% to 35%) for the presence of intracranial hemorrhage. Physicians listed their own reassurance (24.6%), patient reassurance (24.2%), patient expectation (14.6%), and reduction of legal liability (11.7%) as the rationale for ordering head CT in patients with minimal head injury. Shared decisionmaking was used in 51% of cases. Risk of intracranial hemorrhage in patients with minimal head injury was very low, and even in patients found to have an intracranial hemorrhage, none had any serious adverse outcome (eg, death, intubation, prolonged hospitalization, surgical procedure). The Canadian CT Head Rule was 100% sensitive in this small cohort of patients with minimal head injury. Among our study cohort, which specifically included only patients who had CT scanning, applying the Canadian CT Head Rule may have reduced the need for CT, potentially saving costs and resources. However, because many patients with minimal head injury who present to the ED may not have CTs, it is unclear what effect the broad application of this rule would have on overall CT use. Providers' rationale for obtaining CT was multifactorial. These represent barriers that may need to be overcome before physicians are comfortable changing CT ordering patterns in this group of head injury patients.

Eliminating unnecessary routine head CT scanning in neurologically intact mild traumatic brain injury patients: implementation and evaluation of a new protocol.

OBJECTIVE The utility of routine repeat head CT (HCT) scans in the management of minimal head injury (MHI) patients with an intracranial hemorrhage (ICH) has been questioned in multiple studies. All these studies analyzed this by obtaining a repeat HCT study, and none examined the effects of eliminating these routine HCT studies in neurologically intact patients. The authors' institution implemented a new "Neurologic Observation without Repeat HCT" (NORH) protocol with no repeat HCT scanning for patients admitted for MHI and ICH whose neurological status was maintained or improved to a Glasgow Coma Scale score of 15 at 24 hours after admission. This purpose of this study was to assess the outcomes and safety of this novel protocol. METHODS Records of patients who sustained blunt trauma MHI and an ICH and/or skull fracture on initial HCT between January 1, 2009, and December 31, 2012, were retrieved from the trauma registry of a Level I trauma center. The authors analyzed 95 patients in whom the NORH protocol was followed. Outcome measures included death, emergency department readmission, neurosurgical intervention, delayed repeat HCT, and length of stay. RESULTS The NORH protocol was followed for 95 patients; 83% of the patients were male, the average age was 38 ± 16.0 years old, and the most common cause of trauma was assault (35%). Of the 95 patients in whom the NORH protocol was followed, 8 (8%) had a delayed repeat HCT study (> 24 hours) after admission, but none resulted in neurosurgical intervention because of progression of ICH. The average length of stay was 4 ± 7.2 days. None of the patients were readmitted to the hospital. CONCLUSIONS Implementation of the NORH protocol (eliminating routine follow-up HCT) resulted in very low rates of delayed neurological deterioration, no late neurosurgical interventions resulting from ICH progression, very few emergency department revisits, and no readmissions. For a select group of MHI patients with ICH, the NORH protocol is safe and effective, and can reduce radiation exposure and costs.

Canadian Computed Tomography Head Rule and Its Impact on Singaporean Practice

Introduction We aim to determine the usefulness of the Canadian Computed Tomography (CT) Head Rule in patients who present with minor and minimal head injury to the emergency department. Methods Clinical information was retrospectively collected and the need for CT head was evaluated. The primary outcome measure was the requirement for neurological intervention. The secondary outcome measure was brain injury requiring admission or neurological follow-up. Results A total of 1127 cases were reviewed. About 6.3% had clinically important brain injury; and 1.2% required neurological intervention. The high-risk factors were 45.2% sensitive (95% confidence interval [CI]=27.8-63.7%) and 76.2% specific (95% CI=73.5-78.7%) for predicting need for neurological intervention. All seven risk factors were 73.2% sensitive (95% CI=61.2-82.7%) and 69.8% specific (95% CI=66.9-72.5%) for predicting clinically important brain injury. Overall, the rule had a positive predictive value of 14.0 (95% CI=10.7-18.1) and negative predictive value of 97.5 (95% CI=96.0-98.4). Conclusions In this retrospective validation of the Canadian CT Head Rule in the Singaporean context, we conclude that the lower sensitivity of the rule could be attributed to local neurosurgical practice, lack of application of the rule among clinicians and inclusion of patients with minimal head injury. Practically, the high NPV will mean that patients who do not fulfill the rule can be safely discharged with head injury advice, without the need for a scan. The judicious use of CT head can achieve savings for our health-care system. (Hong Kong j.emerg.med. 2015;22:359-363)

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

Intracranial Bleeds after Minor and Minimal Head Injury in Patients on Warfarin

BackgroundThere is little evidence to guide physicians on management of patients who sustain head injuries while on warfarin. ObjectivesOur objective was to determine the rate of intracranial bleeding in anticoagulated patients with minor and minimal head injuries and the association with clinical features and international normalized ratio (INR). MethodsWe conducted a historical cohort study of adult patients, taking warfarin, at two tertiary care emergency departments over 2 years with minor (Glasgow Coma Score 13–15, with loss of consciousness, amnesia, or confusion) or minimal (Glasgow Coma Score 15 without loss of consciousness, amnesia, or confusion) head injuries. Patients with penetrating injuries, INR < 1.5, or a new focal neurological deficit were excluded. Our outcome, intracranial bleeding, was determined by the radiologist’s final computed tomography (CT) report for imaging performed within 2 weeks. ResultsThere were 176 patients enrolled, of which 157 (89.2%) had CT and 28 (15.9%) had intracranial bleeding. Comparing patients with and without intracranial bleeding found no significant differences in INR, and loss of consciousness was associated with higher rate of intracranial bleeding. The rate of intracranial bleeding in the minor and minimal head injury groups was 21.9% and 4.8%, respectively. ConclusionsThe rate of intracranial bleeding in patients on warfarin is considerable. Loss of consciousness is associated with high rates of intracranial bleeding. This study supports a low threshold for ordering CT scans for anticoagulated patients with head injuries.

Neurologic outcome of minimal head injury patients managed with or without a routine repeat head computed tomography

Previous studies proposed that routine repeat head computed tomography (RHCT) is of little value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). As of 2003, routine RHCT in these MHI patients was ordered at the discretion of the attending physician. The goal of this study was to compare the neurologic outcomes of MHI patients with an intracranial bleed and a normal NE who were managed with or without a routine RHCT. A retrospective chart review of adult patients with MHI presenting to a Level I trauma center from August 2003 to December 2008 was performed. Demographics, injury severity, and HCT findings were collected for patients managed with or without a routine RHCT. Outcome measures included delayed neurologic deterioration, neurosurgical interventions, Glasgow Outcome Scale, and hospital length of stay (LOS). A total of 321 MHI patients with an intracranial bleed had a normal NE 24 hours after presentation. There were no significant differences in demographics, arrival Glasgow Coma Scale score, or injury severity between the 142 (44%) patients managed with RHCT and the 179 (56%) managed without RHCT. No patient had a neurologic deterioration or required a neurosurgical intervention, regardless of initial management. There was no significant difference in the neurologic outcomes, mortality, or discharge dispositions between both groups. Patients managed without an RHCT had significantly shorter LOS (2.2 ± 2.3 days vs. 4.3 ± 6.0 days; p < 0.001) compared with those with RHCT. Our study is the first to compare early neurologic outcomes of MHI patients with or without a routine RHCT. Patients managed without an RHCT had similar neurologic outcomes and shorter hospital LOS. Our data suggest that initial HCT followed by serial NEs (not routine RHCT) should be the standard of care in this patient population.

Olympic boxing is associated with elevated levels of the neuronal protein tau in plasma

Objectives: The aim of this study was to investigate if olympic (amateur) boxing is associated with elevation of brain injury biomarkers in peripheral blood compared to controls.Materials and methods: Thirty olympic boxers competing in at least 47 bouts were compared to 25 controls. Blood was collected from the controls at one occasion and from the boxers within 1–6 days after a bout and after a rest period of at least 14 days. Tau concentration in plasma was determined using a novel single molecule ELISA assay and S-100B, glial fibrillary acidic protein, brain-derived neurotrophic factor and amyloid β 1–42 were determined using standard immunoassays.Results: None of the boxers had been knocked-out during the bout. Plasma-tau was significantly increased in the boxers after a bout compared to controls (mean ± SD, 2.46 ± 5.10 vs. 0.79 ± 0.961 ng L−1, p = 0.038). The other brain injury markers did not differ between the groups. Plasma-tau decreased significantly in the boxers after a resting period compared to after a bout (p = 0.030).Conclusions: Olympic boxing is associated with elevation of tau in plasma. The repetitive minimal head injury in boxing may lead to axonal injuries that can be diagnosed with a blood test.

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

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.

New guidelines for the initial management of head injury

The majority of patients presenting with mild head trauma will have no intracranial pathology and can be safely discharged home. It is estimated that 10% to 15% of these patients will have clinically significant findings on computed tomography imaging and up to 1% may require neurosurgical intervention. The revised Scandinavian Head Trauma Guidelines provide an evidence- and consensus-based algorithm to assist physicians in determining which patients presenting with minimal, mild or moderate blunt head injury are at higher risk for intracranial pathology and thus require neuroimaging and hospital admission. Striking a balance between health care costs and risk of morbidity remains an ongoing challenge and we will present our concerns with this useful, but conservative management algorithm.

Skandinaviske retningslinjer for akutt håndtering av voksne pasienter med minimal, lett eller moderat hodeskade

BACKGROUND In 2000, the Scandinavian Neurotrauma Committee (SNC) published evidence-based guidelines for the management of minimal, mild or moderate head injuries. Since then, considerable new evidence has emerged on the clinical use of these guidelines and on the radiation risks associated with computer tomographic (CT) examinations. The SNC has recently published updated Scandinavian guidelines. Here we present the Norwegian version of the updated guidelines with emphasis on the professional recommendations and the reasons the new guidelines were necessary, plus comments from the Norwegian authors.MATERIALS AND METHODS A task force appointed by the SNC compiled recommendations based on a systematic, evidence-based review. These recommendations were revised through consensus in the SNC and through consultation with relevant clinical experts.RESULTS A blood test of the brain injury biomarker S100B is for the first time recommended as an initial diagnostic measure for mild head injury patients with low risk. Of these patients, CT examination is only recommended for those who show a pathologically elevated S100B. CT examination is still the recommended routine for moderate head injury patients and for mild head injury patients with medium to high risk. An updated information sheet on head injuries has also been compiled for patients and their relatives.CONCLUSION The SNC recommends the implementation of these guidelines in Norway.

Evaluation of the Scandinavian guidelines for head injuries based on a consecutive series with computed tomography from a Norwegian university hospital

BackgroundThis study prospectively assesses clinical characteristics and management of consecutive minimal, mild and moderate head injury patients referred for CT scans. Compliance with the Scandinavian head injury guidelines and possible reasons for non-compliance is explored.MethodsFrom January 16th 2006 to January 15th 2007, 1325 computed tomography (CT) examinations due to minimal, mild or moderate head injury according to the Head Injury Severity Scale (HISS) were carried out at our University Hospital. When ordering a CT scan due to head trauma, physicians were asked to fill out a questionnaire.ResultsGuideline compliance was impossible to assess in 49.5% of all cases. This was due to non-assessable or missing key variables necessary in the decision making algorithm. One or more key variables for HISS classification were not assessable in 34.4% as it was unknown whether there had been loss of consciousness (LOC), duration of LOC was unknown or it was impossible to assess amnesia or focal neurologic deficits. Definite compliance with both CT and admittance recommendations in guidelines was seen in only 31.2%. In 54.2% of patients with minimal head injuries who underwent CT scans, imaging was not necessary according to guidelines. 59.1% of all patients were admitted to hospital, however only 23.7% of these were admitted because of the head-injury alone. Age < 4 years, possible medical cause of injuries, severe headache/nausea or vomiting and the presence of non-traumatic CT findings were independently associated with non-assessable compliance with Scandinavian guidelines. Suspicion of influence of alcohol was inversely associated to non-compliance.ConclusionsDespite the prospective study design, guideline compliance was not assessable in nearly half of the patients. Patients with isolated head injuries and available and obtainable complete clinical information necessary for guideline-based decision making are not dominating in a head injury population.

An observational study of compliance with the Scandinavian guidelines for management of minimal, mild and moderate head injury

BackgroundThe Scandinavian guidelines for management of minimal, mild and moderate head injuries were developed to provide safe and cost effective assessment of head injured patients. In a previous study conducted one year after publication and implementation of the guidelines (2003), we showed low compliance, involving over-triage with computed tomography (CT) and hospital admissions. The aim of the present study was to investigate guideline compliance after an educational intervention.MethodsWe evaluated guideline compliance in the management of head injured patients referred to the University Hospital of Stavanger, Norway. The findings from the previous study in 2003 were communicated to the hospitals physicians, and a feed-back loop training program for guideline implementation was conducted. All patients managed during the months January through June in the years 2005, 2007 and 2009 were then identified with an electronic search in the hospitals patient administrative database, and the patient files were reviewed. Patients were classified according to the Head Injury Severity Scale, and the management was classified as compliant or not with the guideline.ResultsThe 1 180 patients were 759 (64%) males and 421 (36%) females with a mean age of 31.5 (range 0-97) years. Over all, 738 (63%) patients were managed in accordance with the guidelines and 442 (37%) were not. Compliance was not significantly different between minimal (56%) and mild (59%) injuries, while most moderate (93%) injuries were managed in accordance with the guidelines (p < 0.05). Noncompliance was caused by overtriage in 362 cases (30%) and undertriage in 80 (7%). Guideline compliance was 54% in 2005, 71% in 2007, and 64% in 2009.ConclusionsThis study shows higher guideline compliance after an educational intervention involving feed-back on performance. A substantial number of patients are exposed to over-triage, involving unnecessary radiation from CT examinations, and unnecessary costs from hospital admissions.

Utility of repeat head computed tomography in patients with an abnormal neurologic examination after minimal head injury

Utility of repeat head computed tomography in patients with an abnormal neurologic examination after minimal head injury

Utility of Repeat Head Computed Tomography in Patients With an Abnormal Neurologic Examination After Minimal Head Injury

Previous studies proposed that repeat head computed tomography (RHCT) is of no value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). The goal of our study was to investigate the value of RHCT in patients with MHI with an abnormal NE. A retrospective chart review of adult patients presenting to a Level I trauma center from July 2002 to December 2006 with MHI was performed. Demographics, injury severity, and HCT findings were collected. Patients with an abnormal NE at the time of RHCT were divided into three subgroups: acute deterioration NE (AD-NE), persistently abnormal NE (PA-NE), and unknown NE (U-NE). Changes in the management and outcomes after RHCT were compared. One hundred seven patients had a MHI with an abnormal NE. Of those, seven (6.5%) had a change in management after RHCT. At the time of RHCT, 68 patients (63%) had a PA-NE, 21 AD-NE, and 18 U-NE. Six patients (29%) with AD-NE, 1 patient (6%) with an U-NE, and no patients with PA-NE required changes in management after RHCT. Compared with a RHCT, NE had higher positive and negative predictive values in determining the need for management changes. Of all patients with MHI with an abnormal NE at the time of RHCT, 63% had a PA-NE. Although a RHCT is beneficial to patients with an acutely deteriorating or U-NE, it appears to be of little value in patients with a PA-NE. Compared with RHCT, serial NE may be a stronger predictor for the need for intervention in patients with MHI.