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Lucchi S, Giua G, Bettinelli A, Farabola M, Sina C, Mangiagalli E, Resta F, Righini A, Leonardi M. Ruolo della tomografia computerizzata cerebrale nel trauma lieve. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/197140099500800308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sulla base della revisione delle richieste di Tomografia Computerizzata Cerebrale (TC) inoltrate dal Pronto Soccorso al Servizio di Neuroradiologia dell'Ospedale Maggiore Policlinico di Milano, si è osservata una percentuale di casi di trauma cranico pari al 41% degli esami richiesti. È stato quindi effettuato lo studio retrospettivo di 300 casi di trauma cranico indagati con esame TC nel corso di un trimestre, il 92% dei quali è risultato negativo per complicanze intracraniche post-traumatiche. Tenuto conto di un'obiettività neurologica negativa al momento dell'ammissione in Pronto Soccorso, il 79% dei casi è stato ascritto alla categoria di trauma cranico lieve. Per essi si è rivelata una positività per lesioni intracraniche post-traumatiche del 2%, mentre si è osservato che un'obiettività neurologica positiva è associata alla presenza di lesioni intracraniche con una frequenza del 17%. Si è osservata una maggiore positività per complicanze intracraniche nei pazienti di età superiore ai 50 anni, nei casi di incidente stradale, nei casi di trauma in sede parietale e nei casi di amnesia e episodi di vomito successivi all'evento traumatico. Non si è invece riscontrata una maggiore associazione con lesioni intracraniche nei casi di trauma commotivo rispetto ai casi di trauma non commotivo. Gli autori, sulla base della esperienza presentata in questa sede e della revisione della letteratura in merito, propongono alcune linee guida per la gestione dei pazienti affetti da trauma cranico lieve.
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Affiliation(s)
- S. Lucchi
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
| | - G. Giua
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
| | - A. Bettinelli
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
| | - M. Farabola
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
| | - C. Sina
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
| | - E. Mangiagalli
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
| | - F. Resta
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
| | - A. Righini
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
| | - M. Leonardi
- Servizio di Neuroradiologia, IRCCS — Ospedale Maggiore Policlinico; Milano
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Stiell IG, Clement CM, Grimshaw JM, Brison RJ, Rowe BH, Lee JS, Shah A, Brehaut J, Holroyd BR, Schull MJ, McKnight RD, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, Macphail I, Ross S, Perry JJ, Ip U, Lesiuk H, Bennett C, Wells GA. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ 2010; 182:1527-32. [PMID: 20732978 DOI: 10.1503/cmaj.091974] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The Canadian CT Head Rule was developed to allow physicians to be more selective when ordering computed tomography (CT) imaging for patients with minor head injury. We sought to evaluate the effectiveness of implementing this validated decision rule at multiple emergency departments. METHODS We conducted a matched-pair cluster-randomized trial that compared the outcomes of 4531 patients with minor head injury during two 12-month periods (before and after) at hospital emergency departments in Canada, six of which were randomly allocated as intervention sites and six as control sites. At the intervention sites, active strategies, including education, changes to policy and real-time reminders on radiologic requisitions were used to implement the Canadian CT Head Rule. The main outcome measure was referral for CT scan of the head. RESULTS Baseline characteristics of patients were similar when comparing control to intervention sites. At the intervention sites, the proportion of patients referred for CT imaging increased from the "before" period (62.8%) to the "after" period (76.2%) (difference +13.3%, 95% CI 9.7%-17.0%). At the control sites, the proportion of CT imaging usage also increased, from 67.5% to 74.1% (difference +6.7%, 95% CI 2.6%-10.8%). The change in mean imaging rates from the "before" period to the "after" period for intervention versus control hospitals was not significant (p = 0.16). There were no missed brain injuries or adverse outcomes. INTERPRETATION Our knowledge-translation-based trial of the Canadian CT Head Rule did not reduce rates of CT imaging in Canadian emergency departments. Future studies should identify strategies to deal with barriers to implementation of this decision rule and explore more effective approaches to knowledge translation. (ClinicalTrials.gov trial register no. NCT00993252).
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ont.
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Maguire JL, Boutis K, Uleryk EM, Laupacis A, Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics 2009; 124:e145-54. [PMID: 19564261 DOI: 10.1542/peds.2009-0075] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty. OBJECTIVE To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury. METHODS Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used. RESULTS A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (>or=11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required <or=56% to undergo CT). Four of the 8 rules were applicable to children with minor head injury (Glasgow coma score >or=13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance. CONCLUSIONS Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.
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Affiliation(s)
- Jonathon L Maguire
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team (PORT, Hospital for Sick Children, Toronto, Ontario, Canada
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Saboori M, Ahmadi J, Farajzadegan Z. Indications for brain CT scan in patients with minor head injury. Clin Neurol Neurosurg 2007; 109:399-405. [PMID: 17350162 DOI: 10.1016/j.clineuro.2007.01.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2006] [Revised: 01/26/2007] [Accepted: 01/26/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Minor head injury is the most common type of head injury. Despite of high incidence and numerous studies performed, there is much controversy about correct evaluation of these patients. The aim of this study was to find clinical signs and symptoms which help to predict the indications for brain CT scan following minor head injury. METHODS A series of 682 consecutive patients who had been attended at two university hospitals (Alzahra and Kashani) with minor head injury (GCS=15) were prospectively enrolled in this cohort study. In all cases clinical signs and symptoms were collected and a cranial computerized tomography (CT) scan was obtained. The relationship between the occurrence of clinical findings and appearance of intracranial posttraumatic lesions on cranial CT was analyzed by chi-square tests and statistic logistic regression methods, with 95% confidence intervals. RESULTS Of 682 patients, 46 (6.7%) presented brain injuries on CT scan. All patients with abnormal CT scans had at least one of the following factors (risk factors): posttraumatic amnesia, loss of consciousness, posttraumatic seizure, headache, vomiting, focal neurological deficit, skull fracture, coagulopathy or antecedent of treatment with anticoagulants and patient age older than 60 years. No abnormal CT scans were found among patients without any of those risk factors on admission. Vomiting, skull fracture and age greater than 60 years were risk factors significantly correlated to an abnormal cranial CT after head injury. The presence of several risk factors in a patient increased the probability of posttraumatic lesion on CT scan. CONCLUSION Some clinical risk factors can be used as a guide to predict the probability of abnormal CT following minor head injury.
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Affiliation(s)
- Masih Saboori
- Department of Neurosurgery, Medical School, Medical University of Isfahan, Isfahan, Iran.
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Perry JJ, Stiell IG. Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head. Injury 2006; 37:1157-65. [PMID: 17078955 DOI: 10.1016/j.injury.2006.07.028] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 07/12/2006] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic injuries to the ankle/foot, knee, cervical spine, and head are very commonly seen in emergency and accident departments around the world. There has been much interest in the development of clinical decision rules to help guide the investigations of these patients in a standardised and cost-effective manner. METHODS In this article we reviewed the impact of the Ottawa ankle rules, Ottawa knee rules, Canadian C-spine rule and the Canadian CT head rule. RESULTS The studies conducted have confirmed that the use of well developed clinical decision rules results in less radiography, less time spent in the emergency department and does not decrease patient satisfaction or result in misdiagnosis. CONCLUSIONS Emergency physicians around the world should adopt the use of clinical decision rules for ankle/foot, knee, cervical spine and minor head injuries. With relatively simple implementation strategies, care can be standardized and costs reduced while providing excellent clinical care.
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Affiliation(s)
- Jeffrey J Perry
- Clinical Epidemiology Program, The Ottawa Hospital, University of Ottawa, Canada.
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Dunning J, Batchelor J, Stratford-Smith P, Teece S, Browne J, Sharpin C, Mackway-Jones K. A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child 2004; 89:653-9. [PMID: 15210499 PMCID: PMC1719991 DOI: 10.1136/adc.2003.027722] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Previous studies have presented conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in children with minor head injury. AIMS To perform a meta-analysis of the literature in order to assess the significance of these factors and intracranial haemorrhage (ICH) in the paediatric population. METHODS The literature was searched using Medline, Embase, Experts, and the grey literature. Reference lists of major guidelines were crosschecked. Control or nested case-control studies of children with head injury who had skull radiography, recording of common symptoms and signs, and head computed tomography (CT) were selected. OUTCOME VARIABLE CT presence or absence of ICH. RESULTS Sixteen papers were identified as satisfying criteria for inclusion in the meta-analysis, although not every paper contained data on every correlate. Available evidence gave pooled patient numbers from 1136 to 22 420. Skull fracture gave a relative risk ratio of 6.13 (95% CI 3.35 to 11.2), headache 1.02 (95% CI 0.62 to 1.69), vomiting 0.88 (95% CI 0.67 to 1.15), focal neurology 9.43 (2.89 to 30.8), seizures 2.82 (95% CI 0.89 to 9.00), LOC 2.23 (95% CI 1.20 to 4.16), and Glasgow Coma Scale (GCS) <15 of 5.51 (95% CI 1.59 to 19.0). CONCLUSIONS There was a statistically significant correlation between intracranial haemorrhage and skull fracture, focal neurology, loss of consciousness, and GCS abnormality. Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. More information is required about the current predictor variables so that more refined guidelines can be developed. Further research is currently underway by three large study groups.
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Affiliation(s)
- J Dunning
- Emergency Medicine Research Group (EmeRGe), Manchester Royal Infirmary, UK.
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7
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Abstract
INTRODUCTION AND OBJECTIVES Despite of the high incidence of minor head injury, there is still controversy and disparity of criteria regarding its management. The lack of consensual protocols and clinical guidelines can lead to deficiencies in the attention to these patients and to inadequate use of resources. The objective of this study has been to describe the present situation of the management of this entity in the neurosurgical departments of the Spanish public hospitals, and to compare it with other European countries. MATERIAL AND METHODS A 57-item questionnaire regarding different aspects of minor head injury was designed and distributed to the 66 neurosurgical departments of the Spanish National Health System between December 1999 and February 2000. RESULTS A 83.3% of responses were obtained. More than 92,000 patients per year are assisted at the Spanish third-level hospitals (general hospitals) after suffering a minor head injury. In-hospital on duty neurosurgeons are not available in 49.1% of the Spanish neurosurgical departments. Only in 7.3% of the centres the neurosurgeon is the first physician that assists these patients. However, in 52.7% of the hospitals neurosurgical evaluation is required if the patient refers transient loss of consciousness. A GCS score of 13 is still included in the group of minor head injuries in 29.1% of the centres. Although 89.1% of the surveyed neurosurgical departments considered as satisfactory the attention they provide to these patients, 85.5% think that it would be convenient to elaborate clinical guidelines. Cranial x-ray is considered a useful diagnostic tool by only 38.2% of the centres, however, 89.1% of them still use it as a routine. CT-scan is systematically indicated in all patients after suffering a mild head trauma only in 5.5% of the centres, although it is completely available in 74.5% of them. The study of economical costs shows that choosing cranial CT as screening tool in these patients would mean a 40.6% reduction in costs compared to a management based on x-ray plus in-hospital observation. CONCLUSIONS This study shows the inter-hospital variability of minor head injury management in Spain. Clinical guidelines are considered as positive and necessary. Although the Spanish situation is similar to that in other European countries, following the tendency toward a broader cranial CT utilisation, would improve diagnosis profitability and economical efficiency. The results of this study may contribute to the creation of consensual protocols and clinical guidelines in our country that help in daily practice decision-making optimising assistance quality.
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Affiliation(s)
- M Brell
- Servicio de Neurocirugía, Hospital Clínic, Barcelona, España
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Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med 2001; 38:160-9. [PMID: 11468612 DOI: 10.1067/mem.2001.116796] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Head injuries are among the most common types of trauma seen in North American emergency departments, with an estimated 1 million cases seen annually. "Minor" head injury (sometimes known as "mild") is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, that is, with a Glasgow Coma Scale score of 13 to 15. Although most patients with minor head injury can be discharged without sequelae after a period of observation, in a small proportion, their neurologic condition deteriorates and requires neurosurgical intervention for intracranial hematoma. The objective of the Canadian CT Head Rule Study is to develop an accurate and reliable decision rule for the use of computed tomography (CT) in patients with minor head injury. Such a decision rule would allow physicians to be more selective in their use of CT without compromising care of patients with minor head injury. This paper describes in detail the rationale, objectives, and methodology for Phase I of the study in which the decision rule was derived. [Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A, for the Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. August 2001;38:160-169.]
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Affiliation(s)
- I G Stiell
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Ontario, Canada K1Y 4E9
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Servadei F, Teasdale G, Merry G. Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma 2001; 18:657-64. [PMID: 11497092 DOI: 10.1089/089771501750357609] [Citation(s) in RCA: 183] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The lack of a common, widely acceptable criterion for the definition of trivial, minor, or mild head injury has led to confusion and difficulty in comparing findings in published series. This review proposes that acute head-injured patients previously described as minor, mild, or trivial are defined as "mild head injury," and that further groups are recognized and classified as "low-risk mild head injury," "medium risk mild head injury," or "high-risk mild head injury." Low-risk mild injury patients are those with a Glasgow Coma Score (GCS) of 15 and without a history of loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring surgical evacuation is definitively less than 0.1:100. These patients can be sent home with written recommendations. Medium risk mild injury patients have a GCS of 15 and one or more of the following symptoms: loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring surgical evacuation is in the range of 1-3:100. Where there is one computed tomography (CT) scanner available in an area for 100,000 people or less, a CT scan should be obtained for such patients. If CT scanning is not so readily available, adults should have a skull x-ray and, if this shows a fracture, should be moved to the "high-risk" category and undergo CT scanning. High-risk mild head injury patients are those with an admission GCS of 14 or 15, with a skull fracture and/or neurological deficits. The risk of intracranial hematoma requiring surgical evacuation is in the range 6-10:100. If a CT scan is available for 500,000 people or less, this examination must be obtained. Patients with one of the following risk factors--coagulopathy, drug or alcohol consumption, previous neurosurgical procedures, pretrauma epilepsy, or age over 60 years--are included in the high-risk group independent of the clinical presentation.
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Affiliation(s)
- F Servadei
- WHO Neurotrauma Collaborating Center, Ospedale Bufalini, Cesena, Italy.
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Gómez P, Lobato R, Lagares A, Alén J. Trauma craneal leve en adultos. Revisión de la literatura. Neurocirugia (Astur) 2000. [DOI: 10.1016/s1130-1473(00)70949-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Coloma Valverde G, Granado Peña J, Avendaño P, Medina Ruiz J. Lesiones intracraneales múltiples en paciente con trauma craneal leve. Neurocirugia (Astur) 2000. [DOI: 10.1016/s1130-1473(00)70750-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Feickert HJ, Drommer S, Heyer R. Severe head injury in children: impact of risk factors on outcome. THE JOURNAL OF TRAUMA 1999; 47:33-8. [PMID: 10421183 DOI: 10.1097/00005373-199907000-00008] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Outcome after severe head injury has been shown in some studies to be more favorable in children than in adults. Mortality rates reported range between 20% and 40% for children. Only contradicting data are available regarding the impact of trauma modalities on long-term outcome, or the relative influence of head fractures, intracranial hemorrhages, and brain edema on survival or neurologic sequelae in children. METHODS A retrospective study in a tertiary care facility of long-term outcome of children after severe head injury, and analysis of risk factors for poor outcome. All children up to 16 years of age with severe head injury (Glasgow Coma Scale [GCS] score < or = 8), which have been treated in the pediatric intensive care unit from 1977 until 1994 in a single institution. RESULTS A total of 150 children with severe head injury (GCS score < or = 8) were treated, 92 of them (61.3%) had traffic-related injuries. The median age was 6.6 years (SD +/- 3.6). There were 96 boys (64%) and 54 girls (36%). Sixty-five children (43.3%) had skull fractures, 87 patients (58.0%) developed an intracranial hemorrhage, and 79 patients (52.7%) developed a diffuse brain swelling/edema visible in computed tomographic scans within 72 hours after trauma. Of 150 children treated, 33 died (22%). In most cases, death was related to the development of secondary brain edema. Fifty-nine children (39.3%) had severe neurologic impairments at the time of discharge. The most significant risk factors for adverse outcome, shown by multivariate analysis, were primary areflexia and secondary brain edema. The risk for development of brain edema and poor prognosis was well predicted by the GCS score. CONCLUSION The overall death rate in this study of children with severe head injury was low (22%) compared with other studies. However, the incidence of severe neurologic impairment at discharge remained high. The major risks for death or neurologic impairment were primary areflexia and the development of secondary brain swelling/edema, indicated by a low GCS score.
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Affiliation(s)
- H J Feickert
- Medizinische Hochschule Hannover, Kinderklinik, Germany
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13
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Stiell IG, Wells GA, Vandemheen K, Laupacis A, Brison R, Eisenhauer MA, Greenberg GH, MacPhail I, McKnight RD, Reardon M, Verbeek R, Worthington J, Lesiuk H. Variation in ED use of computed tomography for patients with minor head injury. Ann Emerg Med 1997; 30:14-22. [PMID: 9209219 DOI: 10.1016/s0196-0644(97)70104-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE To determine the frequency of utilization, yield for brain injury, incidence of missed injury, and variation in the use of computed tomography (CT) for ED patients with minor head injury. METHODS This retrospective health records survey was conducted over a 12-month period in the EDs at seven Canadian teaching institutions. Included in this review were adult patients who sustained acute minor head injury, defined as witnessed loss of consciousness or amnesia and a Glasgow Coma Scale score of 13 or greater. Data were collected by research assistants who were trained to select cases and abstract data in a standardized fashion according to a resource manual. Subsequently, patient eligibility was reviewed by the study coordinator and principal investigator. RESULTS Of the 1,699 patients seen, 521 (30.7%) were referred for CT, and 418 (79.8%) of these scans were negative for any type of brain injury. Overall, 105 (6.2%) of these patients sustained acute brain injury, including 9 (.5%) with an epidural hematoma Cochran's Q test for homogeneity demonstrated significant variation between the seven centers for rate of ordering CT (P < .0001), from a low of 15.9% to a high of 70.4%. All five cases of "missed" hematoma occurred at the institutions with the highest and third highest rates of CT use. After controlling for possible differences in case severity and patient characteristics at each hospital, logistic regression analysis revealed that five of seven hospitals were significantly associated with the use of CT (respected odds ratios [OR], .4, .5, .5, 3.2, and 4.7). Three of the centers (two with the highest ordering rates) showed significant heterogeneity in the ordering of CT among their attending staff physicians, from a low of 6.5% to a high of 80.0%. CONCLUSION There was considerable variation among institutions and individual physicians in the ordering of CT for patients with minor head injury. Although emergency physicians were selective when ordering CT, the yield of radiography was very low at all hospitals. None of the cases of "missed" intracranial hematoma came from the lowest ordering institutions, indicating that patients may be managed safely with a selective approach to CT use. These findings suggest great potential for more standardized and efficient use of CT of the head, possibly through the use of a clinical decision rule.
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Affiliation(s)
- I G Stiell
- Department of Medicine, Ottawa Civic Hospital, Loeb Medical Research Institute, Canada
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14
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Cranshaw J, Hughes G, Clancy M. Computerised tomography and acute traumatic head injury: time for change? J Accid Emerg Med 1996; 13:80-5. [PMID: 8653255 PMCID: PMC1342641 DOI: 10.1136/emj.13.2.80] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The aim was to reconsider the "Guidelines for initial management of head injury in adults"--particularly with respect to the indications for computerised tomographic (CT) scanning--suggested by "a group of neurosurgeons" over a decade ago and still followed in some accident and emergency (A&E) departments. These recommendations are placed in the context of more recent research and the increased number of A&E departments with on-site rapid access to a CT scanner but without a resident neurosurgical facility. A case can be made for an updated policy with more liberal indications for CT scanning of acutely head injured adults in peripheral A&E departments. However, calculating the cost-efficiency of more frequent use of what is now a common but relatively expensive resource would remain a challenge.
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Affiliation(s)
- J Cranshaw
- Department of Accident and Emergency Medicine, Bristol Royal Infirmary, United Kingdom
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Keskil IS, Baykaner MK, Ceviker N, Kaymaz M. Assessment of mortality associated with mild head injury in the pediatric age group. Childs Nerv Syst 1995; 11:467-73. [PMID: 7585684 DOI: 10.1007/bf00334967] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Reducing mortality among accident and trauma patients requires careful attention to monitoring those regarded as being at low risk. We hospitalized almost 1600 head-injured patients in the period between 1979 and 1992 at the Neurosurgery Department of Gazi University Medical School, Ankara, Turkey. These patients were selected from among the numerous patients admitted to our emergency unit and treated with the same protocol in the same department. Among the hospitalized children, there were three patients defined as having a mild head injury on the basis of Glasgow Coma Scale scores of 15 who later had unfavorable outcomes. Clinical signs that might identify potentially endangered patients with mild injury were gathered; these included the presence of post-traumatic amnesia, somnolence, irritability, anisocoria, local evidence of trauma to the head, associated injuries, history of altered consciousness, and skull fracture. The study was designed to identify features by which patients who are in real danger can be distinguished among the many with trivial trauma that we face every day. We did not find any identifying clinical features and concluded that computed tomographic scanning is the only reliable answer. This will reduce avoidable mortality and morbidity by identifying the patients who are at higher risk than is at first evident.
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Affiliation(s)
- I S Keskil
- Department of Neurosurgery, Gazi University Medical School, Bşevler, Ankara, Turkey
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Protocolo de asistencia inmediata a los traumatismos de cráneo en los Hospitales de la Comunidad Valenciana. Neurocirugia (Astur) 1995. [DOI: 10.1016/s1130-1473(95)70763-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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