The application of North American CT scan criteria to an Australian population with minor head injury

Objective: To determine potential changes in the number of CT head scans performed if the New Orleans Criteria (NOC) or Canadian CT Head Rule (CCTR) was applied to an Australian emergency department population of minor head injured (MHI) patients. Methods: A retrospective chart review was conducted in an adult metropolitan teaching hospital in Brisbane. All patients presenting over a 3‐month period with a GCS Score of 15 following an MHI and had a CT head scan performed were selected for analysis. Using clinically significant CT abnormalities and neurological intervention as the outcome measures, the NOC and CCTR were applied to determine if CT scanning was considered necessary. Results: Of the 240 patients reviewed, 230 had a normal CT scan and 10 had clinically significant CT abnormalities. One patient with CT abnormality required neurosurgical intervention. Application of the NOC would have resulted in a 3.8% (95% CI 1.7–7.0%) reduction in CT scans performed without missing any patients with CT abnormalities or requiring neurological intervention. Application of the CCTR using both high and low risk factors would have resulted in a 46.7% (95% CI 40.2–53.2%) reduction in CT scans performed without missing the patient requiring neurological intervention, but would not have detected two patients with clinically significant CT abnormalities. Conclusion: Neither the NOC nor the CCRT appear suitable for significantly reducing the number of normal CT head scans performed without missing clinically significant CT abnormalities when applied to our current clinical practice.     

Traumatic Brain Injury in Patients Receiving Direct Oral Anticoagulants

BackgroundEmergency departments (EDs) are faced with a growing number of patients with traumatic brain injury (TBI) using direct oral anticoagulants (DOACs). However, there remains uncertainty about the bleeding risk, rate of hematoma expansion, and the efficacy of reversal strategies in these patients.ObjectiveThis study aims to identify the risk of traumatic hemorrhagic complications in patients with TBI using DOACs.MethodsIn this retrospective study we included patients with TBI. All TBI patients were using DOACs, attended one of the three EDs of our hospital between January 2016 and October 2019, and received a computed tomography (CT) scan of the brain. The primary outcome was any traumatic intracranial hemorrhage on CT. Secondary outcomes were the use of reversal agents, secondary neurological deterioration, a neurosurgical intervention within 30 days after the injury, length of stay (LOS), Glasgow Outcome Scale (GOS) at discharge, and mortality.ResultsOf the included patients (N = 316), 24 patients (7.6%, 95% confidence interval [CI] 4.2–9.8) presented with a traumatic intracranial hematoma (ICH). Seven patients (2.2%, 95% CI 0.6–3.8) received a reversal agent and 1 patient (0.3%, 95% CI ?0.3–0.9) underwent a neurosurgical intervention. Of the 24 patients with a traumatic ICH, progression of the lesion was seen in 6 patients (1.9%, 95% CI 0.4–3.4). The mean LOS was 6.5 days (95% CI 3.0–10.1) and the mean GOS at discharge was 4 (95% CI 3.6–4.6). Death occurred in 1 patient (0.3%, 95% CI ?0.3–0.9) suffering from an ICH.ConclusionBased on the present findings it can be postulated that TBI patients using DOACs have a low risk for ICH. Hematoma progression occurred, however, in a substantial number of patients. Considering the retrospective nature of the present study, future prospective trials are needed to confirm this finding.     

Identification of Ethanol-intoxicated Patients with Minor Head TVauma Requiring Computed Tomography Scans

Objective: To determine whether clinical parameters and neurologic scores can be used to guide the decision to obtain computed tomography (CT) head scans for ethanol-intoxicated patients with presumed-minor head injuries.
Methods: In a prospective cohort analysis, 107 consecutive adult patients who presented to a county emergency department (ED) with serum ethanol levels >80 mg/dL and minor head trauma were studied. Commonly used clinical variables were determined for each patient. Each patient also underwent an abbreviated neurologic scoring examination and a Glasgow coma scale (GCS) score evaluation at the time of presentation and one hour later, after which a cranial CT scan was done. For purposes of analysis, patients with and patients without intracerebral injuries visible on CT scans of the head were compared.
Results: Nine of 107 patients (8.4%; 95% confidence interval [CI] = 3.9–15.4%) had CT scans that were positive for intracerebral injury. Two patients (1.9%; 95% CI = 0.2–6.6%) needed craniotomy. Five patients had hemotympanum and two patients had bilateral periorbital ecchy-mosis, but CT scans were negative for intracerebral injury in these patients. There was no statistically significant difference between the patients with and without CT scan abnormalities, based on the clinical variables, the GCS scores, or the abbreviated neurologic scoring examinations at presentation or at one hour.
Conclusion: The prevalence of intracerebral injury in CT scans of ethanol-intoxicated patients with minor head injuries was 8.4%. Commonly used clinical parameters and neurologic scores at presentation and one hour later were unable to predict which patients would have intracerebral injuries as evidenced by CT scans. Our low (1.9%) neurosurgical intervention rate supports the need to develop a selective approach to CT scanning in this population.     

Computerized tomography of the brain for elderly patients presenting to the emergency department with acute confusion

Objective: Confusion is a common reason for presentation of elderly patients to the ED. There are many potential causes of confusion, which include acute neurological events. Computerized tomography (CT) scans are often routinely ordered to investigate confusion, despite the recommendation of guidelines against routine use. The aim of the present study was to determine the usefulness of CT brain scans in a prospective cohort of confused elderly patients presenting to an ED. Methods: The progress notes of 106 consecutive patients over 70 years of age who had a CT brain scan for a presentation of acute confusion were reviewed for indications for the scan and the presence of neurological examination findings. Official radiology reports of CT brain scans were assessed for the presence of abnormalities. Results: Of the 106 patients, 12 (11%, 95% CI 5.29–17.35) had no documented neurological examination. Fifteen patients (14%, 95% CI 7.51–20.79) had acute abnormalities on CT scan, one of whom had two abnormalities. There were ten acute ischaemic strokes, four cerebral haemorrhages and two meningiomas. Thirteen of the patients with positive CT findings (93%, 95% CI 80.7–105.96) had new findings on neurological examination. The only patient with no neurological findings with a positive CT scan had had a fall. A history of a fall or the presence of neurological findings on examination was predictive of a positive CT scan (odds ratio 17.07, 95% CI 2.15–135.35). Conclusion: The results add further support to guidelines that suggest that CT scans of the brain for confused elderly patients should only be performed for those with acute neurological findings, head trauma or a fall.     

Can the “important brain injury criteria” predict neurosurgical intervention in mild traumatic brain injury? A validation study

BackgroundThere is variability in the management of patients presenting to the emergency department (ED) with mild traumatic brain injury (MTBI) and abnormal findings on their initial head computed tomography (CT). The main objective of this study was to validate the value of the Important Brain Injury (IBI) criteria, introduced by the Canadian CT-Head Rule, in predicting the need for surgical intervention. The secondary objective was to identify independent predictors for neurosurgical intervention.MethodsThis is a post hoc analysis of a prospective cohort of adult patients presenting to the ED of one tertiary care, academic center, between 2008 and 2012, with MTBI and an abnormal initial head CT. Neurosurgical intervention was at the discretion of the treating physician. The sensitivity and specificity of the IBI criteria were calculated with 95% confidence intervals (CI95%). A multivariate logistic regression model was used to identify independent predictors for neurosurgical intervention with the direct entry method.ResultsA total of 678 patients (male = 65.9%, mean age = 62.5 years) were included, of whom 114 (16.8%) required neurosurgical intervention. All patients requiring neurosurgical intervention met IBI criteria on their initial head CT (sensitivity of 100% [CI95% 96.8–100]). However, 368 (65.2%) patients with findings of IBI did not require neurosurgical intervention (specificity of 34.8% [CI95% 30.8–38.8]). Age over 65 was independently associated with neurosurgical intervention in the IBI population.ConclusionThe IBI criteria for MTBI identified all patients who required neurosurgical intervention; however its specificity is low.     

Performance of the Pediatric Glasgow Coma Scale in Children with Blunt Head Trauma

Objectives: To compare the accuracy of a pediatric Glasgow Coma Scale (GCS) score in preverbal children with blunt head trauma with the standard GCS score in older children. Methods: The authors prospectively enrolled children younger than 18 years with blunt head trauma. Patients were divided into cohorts of those 2 years and younger and those older than 2 years. The authors assigned a pediatric GCS score to the younger cohort and the standard GCS score to the older cohort. Outcomes were 1) traumatic brain injury (TBI) on computed tomography (CT) scan or 2) TBI in need of acute intervention. The authors created and compared receiver operating characteristic (ROC) curves between the age cohorts for the association of GCS scores and TBI. Results: The authors enrolled 2,043 children, and 327 were 2 years and younger. Among these 327, 15 (7.7%; 95% confidence interval [CI] = 4.4% to 12.4%) of 194 who underwent imaging with CT had TBI visible and nine (2.8%; 95% CI = 1.3% to 5.2%) had TBI needing acute intervention. In children older than 2 years, 83 (7.7%; 95% CI = 6.2% to 9.5%) of the 1,077 who underwent imaging with CT had TBI visible and 96 (5.6%; 95% CI = 4.6% to 6.8%) had TBI needing acute intervention. For the pediatric GCS in children 2 years and younger, the area under the ROC curve was 0.72 (95% CI = 0.56 to 0.87) for TBI on CT scan and 0.97 (95% CI = 0.94 to 1.00) for TBI needing acute intervention. For the standard GCS in older children, the area under the ROC curve was 0.82 (95% CI = 0.76 to 0.87) for TBI on CT scan and 0.87 (95% CI = 0.83 to 0.92) for TBI needing acute intervention. Conclusions: This pediatric GCS for children 2 years and younger compares favorably with the standard GCS in the evaluation of children with blunt head trauma. The pediatric GCS is particularly accurate in evaluating preverbal children with blunt head trauma with regard to the need for acute intervention.     

Cranial Computed Tomography Utilization for Suspected Ventriculoperitoneal Shunt Malfunction in a Pediatric Emergency Department

Background

Computed tomography (CT) scan, the largest medical source of ionizing radiation in the United States, is used to test for failure of ventricular peritoneal shunts.

Study Objectives

To quantify the exposure to cranial CT scans in pediatric patients presenting with symptoms of shunt malfunction, and to measure the association of signs and symptoms with clinical shunt malfunction and the need for neurosurgical intervention within 30 days of presentation.

Method

This was a quality improvement study evaluating a pathway used by providers in a tertiary care pediatric emergency department with 85,000 patient visits per year, by retrospective chart review of 223 patient visits for suspected shunt malfunction. We determined the median CT scan per patient per year and the association of signs and symptoms on the pathway with radiological signs of shunt failure and neurosurgical intervention within 30 days of scan.

Results

The median exposure was 2.6 (interquartile range 1.44–4.63) scans per patient per year. Among 11 signs and symptoms, none was associated with radiologic shunt failure. Neurosurgical intervention within 30 days was positively associated with bulging fontanelle (adjusted odds ratio [AOR] 11.78; 95% confidence interval [CI] 1.67–83.0) and behavioral change (AOR 3.01; 95% CI 1.14–7.93), and negatively associated with seizure (AOR 0.13; 95% CI 0.02–0.79) and fever (AOR 0.15; 95% CI 0.04–0.55).

Conclusions

Patients with ventricular peritoneal shunts underwent many cranial CT scans each year. None of the signs or symptoms included on the clinical pathway was predictive of changes on CT scan.     

Utility of INR For Prediction of Delayed Intracranial Hemorrhage Among Warfarin Users with Head Injury

BackgroundIncidence of delayed intracranial hemorrhage (DICH) in patients on warfarin has been controversial. No previous literature has reported the utility of international normalized ratio (INR) in predicting traumatic DICH.ObjectivesUtilizing INR to risk stratify head trauma patients who may be managed without repeat imaging.MethodsThis was a retrospective study at a Level II trauma center. All patients on warfarin with head injuries from March 2014 to December 31, 2017 were included. Each patient underwent an initial head computed tomography scan (HCT) and subsequent repeat HCT 12 h after. Patients presenting > 12 h after head injury received only one HCT. Two blinded neuroradiologists reviewed each case of DICH. Statistical analysis evaluated Glasgow Coma Scale (GCS), Injury Severity Score (ISS), heart rate, systolic blood pressure (SBP), age, and platelet count.ResultsThere were 395 patients who qualified for the protocol; 238 were female. Average age was 79 years. Seventy-seven percent of patients underwent repeat HCT. Five resulted in DICH (INR 2.6–3.0), three of which might have been present on initial HCT; incidence rate of 0.51–1.27%. One patient required neurosurgical intervention. Among 80 patients with INR < 2, no DICH was identified, resulting in high sensitivity, but with a wide confidence interval; sensitivity of 100% (95% confidence interval [CI] 47.8–100), specificity 21% (95% CI 16.6–28.9). Correlation of factors: ISS (p = 0.039), GCS (p = 0.978), HR (p = 0.601), SBP (p = 0.198), age (p = 0.014), and platelets (p = 0.281).ConclusionNo patient with INR < 2 suffered DICH, suggesting that warfarin users presenting with INR < 2 may be managed without repeat HCT. For INR > 2, patients age and injury severity can be used for shared decision-making to discharge home with standard head injury precautions and no repeat HCT.     

Use of a complete neurological examination to screen for significant intracranial abnormalities in minor head injury

Indications for head computed tomography (CT) scans are unclear in patients with nonpenetrating head injury and Glasgow Coma Scale (GCS) scores of 15. We performed a prospective study to determine if significant intracranial injury could be excluded in patients with GCS-15 and a normal complete neurological examination. A prospective trial of clinically sober adult patients with GCS = 15 on emergency department (ED) presentation after closed head injury with loss of consciousness or amnesia was conducted from May 1996 through April 1997. All subjects underwent a standardized neurological examination including mental status evaluation, and assessment of motor, sensory, cerebellar and reflex function before CT scan. During the study period, 58 patients met inclusion criteria. Fifty-five patients (95%) had normal CT scans and 23 (42%) had focal neurological abnormalities. Three patients (5%) had CT scan findings of acute intracranial injury, two of whom had normal neurological examinations. One patient had an acute subdural hematoma requiring emergent surgical decompression; the other had both an epidural hematoma and pneumocephalus that did not require surgery. Significant brain injury and need for CT scanning cannot be excluded in patients with minor head injury despite a GCS = 15 and normal complete neurological examination on presentation.     

A Decision Instrument to Identify Isolated Traumatic Subdural Hematomas at Low Risk of Neurologic Deterioration,Surgical Intervention,or Radiographic Worsening

Objectives

Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low risk for neurologic decline, neurosurgical intervention, or radiographic worsening.

Methods

Retrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and computed tomography (CT)‐documented isolated SDH presenting to a university‐affiliated, urban, 100,000‐annual‐visit ED from 2009 to 2015. Demographic, historical, and physical examination variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT, and neurologic decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model.

Results

A total of 644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. A total 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors—SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS < 14, and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1%, and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5%, and negative likelihood ratio was 0.127.

Conclusion

Subdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers.     

Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage

ObjectivesMild traumatic brain injury (mTBI) is defined as Glasgow Coma Score (GCS) of 14 or 15. Despite good outcomes, patients are commonly transferred to trauma centers for observation and/or neurosurgical consultation. The aim of this study is to assess the value of redefining mTBI with novel radiographic criteria to determine the appropriateness of interhospital transfer for neurosurgical evaluation.MethodsA retrospective study of patients with blunt head injury with GCS 13–15 and CT head from Jan 2014–Dec 2016 was performed. A novel criteria of head CT findings was created at our institution to classify mTBI. Outcomes included neurosurgical intervention and transfer cost.ResultsA total of 2120 patients were identified with 1442 (68.0%) meeting CT criteria for mTBI and 678 (32.0%) classified high risk. Two (0.14%) patients with mTBI required neurosurgical intervention compared with 143 (21.28%) high risk TBI (p < 0.0001). Mean age (55.8 years), and anticoagulation (2.6% vs 2.8%) or antiplatelet use (2.1% vs 3.0%) was similar between groups (p > 0.05). Of patients with mTBI, 689 were transferred without receiving neurosurgical intervention. Given an average EMS transfer cost of $700 for ground and $5800 for air, we estimate an unnecessary transfer cost of $733,600.ConclusionDefining mTBI with the described novel criteria clearly identifies patients who can be safely managed without transfer for neurosurgical consultation. These unnecessary transfers represent a substantial financial and resource burden to the trauma system and inconvenience to patients.     

ED utilization of computed tomography in a poisoned population

The objective of this prospective, analytic study was to identify predictors and describe the demographic and clinical correlates of head computed tomography (CT) evaluation in patients with poisoning or drug overdose and altered mental status. Forty-three patients that were evaluated by head CT and 109 that were not evaluated by head CT were entered into the study at a poison control center. None of the 43 scanned patients had any acute findings on head CT. A logistic regression model yielded 4 predictors that were statistically associated with the ordering of a head CT scan: Glasgow Coma Scale (GCS) < or = 8 (odds ratio [OR]: 2.3; 95% confidence interval [CI] 1.03-5.7); age > or = 41 years (OR 5.3; 95% CI 2.2-13); use of drugs or abuse by history (OR 2.8; 95% CI 1.04-7.6); and witnessed seizure activity (OR 4.8; 95% CI 1.3-17.9). We also tested 2 additional models to identify predictors of hospital admission, 1 with and 1 without CT scan included as a covariate. In the first model, only GCS 相似文献   

A Comparison of Five Simplified Scales to the Out-of-hospital Glasgow Coma Scale for the Prediction of Traumatic Brain Injury Outcomes

Background: The 15-point Glasgow Coma Scale (GCS) frequently is used in the initial evaluation of traumatic brain injury (TBI) in out-of-hospital settings. We hypothesized that the GCS might be unnecessarily complex for out-of-hospital use.
Objectives: To assess whether a simpler scoring system might demonstrate similar accuracy in the prediction of TBI outcomes.
Methods: We performed a retrospective analysis of a trauma registry consisting of patients evaluated at our Level 1 trauma center from 1990 to 2002. The ability of out-of-hospital GCS scores to predict four clinically relevant TBI outcomes (emergency intubation, neurosurgical intervention, brain injury, and mortality) by using areas under receiver operating characteristic curves (AUROCs) was calculated. The same analyses for five simplified scales were performed, and compared with the predictive accuracies of the total GCS score.
Results: In this evaluation of 7,233 trauma patients over a 12-year period of time, the AUROCs for the total GCS score were 0.83 (95% confidence interval [CI] = 0.81 to 0.84) for emergency intubation, 0.86 (95% CI = 0.85 to 0.88) for neurosurgical intervention, 0.83 (95% CI = 0.82 to 0.84) for brain injury, and 0.89 (95% CI = 0.88 to 0.90) for mortality. The five simplified scales approached the performance of the total GCS score for all clinical outcomes.
Conclusions: In the evaluation of injured patients, five simplified neurological scales approached the performance of the total GCS score for the prediction of four clinically relevant TBI outcomes.     

Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study

Introduction

Pre-injury antithrombotic therapy might influence the outcome of subjects with head injuries and positive computed tomography (CT) scans. We aimed to determine the potential risk of pre-injury antiplatelet drug use on short- and long-term outcome of head injured subjects admitted to emergency departments (EDs) in Italy for extended observation.

Methods

A total of 1,558 adult subjects with mild, moderate and severe head injury admitted to Italian EDs were studied. In multivariable logistic regression analyses, the short-term outcome was assessed by an evaluation of head CT scan at 6 to 24 hours after trauma and the long-term outcome by the Glasgow outcome scale (GOS) at six months.

Results

Head CT scan comparisons showed that 201 subjects (12.9%) worsened. The risk of worsening was increased two fold by the use of antiplatelet drugs (106, 19.7% treated versus 95, 9.3% untreated; relative risk (RR) 2.09, 95% CI 1.63 to 2.71). The risk was particularly high in subjects on clopidogrel (RR 5.76, 95% CI 3.88 to 8.54), independent of the association with aspirin. By logistic regression, 5 of 14 items were independently associated with worsening (Glasgow coma scale (GCS), Marshall category, antiplatelet therapy, intraventricular hemorrhage, number of lesions). After six months, only 4 of 14 items were predictors of unfavorable outcome (GOS 1 to 3) (GCS score, Marshall category, age in decades, intracerebral hemorrhage/contusion). The risk increased by 50% in the group treated with antiplatelet therapy (RR 1.58, 95% CI 1.28 to 1.95; P < 0.001).

Conclusions

Antithrombotic therapy (in particular clopidogrel) is a risk factor for both short-term and long-term unfavorable outcome in subjects with head injury, increasing the risk of progression and death, permanent vegetative state and severe disability.     

Failure of the Miller Criteria to Predict Significant Intracranial Injury in Patients with a Glasgow Coma Scale Score of 14 after Minor Head Trauma

Objective: To determine the utility of the Miller criteria (presence of headache, nausea, vomiting, and signs of depressed skull fracture) for predicting the need for CT in patients with minor head trauma and a Glasgow Coma Scale score (GCS) of 14.
Methods: The study was a prospective, consecutive series of all patients undergoing head CT scans with a GCS of 14 following head trauma. A data sheet was completed for all patients prior to obtaining a head CT scan.
Results: 264 patients were entered into the study and 35 patients were found to have traumatic abnormalities on head CT scan. The use of the Miller criteria to select those patients who would require head CT scan would have resulted in missing 17 of the 35 abnormal scans, including 2 patients who required neurosurgical intervention. These 2 patients were markedly intoxicated upon presentation.
Conclusion: The use of the Miller criteria as the only criteria for screening patients with a GCS of 14 after minor head trauma who require a head CT scan is not recommended. While the authors have identified ethanol intoxication as one confounding factor, further refinement of this risk-stratification tool is required.     

Use of Neuroimaging for Children With Seizure in General and Pediatric Emergency Departments

BackgroundSeizure is a common reason for children to visit the emergency department (ED). Pediatric and general EDs may obtain computed tomography (CT) scans of the head for seizure at different rates.ObjectiveTo compare rates of head CT for pediatric seizure between general and pediatric EDs.MethodsThis was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey for patients <21 years of age presenting to an ED with a chief complaint or diagnosis of seizure between 2006 to 2017. Of these patients, we compared head CT use between general and pediatric EDs among patients with fever, trauma, and co-diagnosis of epilepsy using univariable risk differences and in a multivariable logistic regression model.ResultsMore than 5 (5.4) million (78.8%) and 1.5 million (21.2%) pediatric patients with seizure presented to general and pediatric EDs, respectively. Of those, 22.4% (1.21 million) and 13.2% (192,357) underwent CT scans of the head, respectively, a risk difference of 9.2% (95% confidence interval [CI] 2.3–16.1). General EDs obtained CT scans of the head more often in patients with epilepsy (risk difference 17.9% [95% CI 4.0–31.9]), without fever (12.2% [95% CI 3.1–21.4]), and without trauma (10.6% [95% CI 4.4–16.8]). Presenting to a general ED, being afebrile, or having trauma were associated with head CT with adjusted odds ratios of 1.7 (95% CI 1.0–3.2), 4.9 (95% CI 2.6–9.2), and 2.0 (95% CI 1.2–3.4), respectively. Age, gender, and epilepsy were not associated with head CT among all patients with seizure.ConclusionsChildren with seizure are more likely to undergo CT scans of the head at general EDs compared with pediatric EDs.     

Elder Patients with Closed Head Trauma: A Comparison with Nonelder Patients

Abstract. Objective: Little is known about the circumstances surrounding closed head trauma (CHT) in elders, and how they differ from nonelders. The study objective was to compare the 2 populations for outcome (positive cranial CT scan depicting traumatic injury, or the need for neurosurgery), mechanism of injury, and the value of the neurologic examination to predict a CT scan positive for traumatic injury or the need for neurosurgical intervention. Methods: A retrospective study was conducted by collecting a case series of patients with blunt head trauma who underwent CT scanning, and comparing elder (aged s60 years) with nonelder patients. The setting was the ED of a university-affiliated Level-1 trauma center. Results: Twenty percent of the elders and 13% of the nonelders had CT scans positive for traumatic injury, which conferred a risk ratio of 1.58 (95% CI 1.21–2.05). Older women were more at risk for the need for neurosurgery than were younger ones (3.1 vs 0.3%, RR 10.66, 95% CI 1.26–90.46). Among the elders, falls were the dominant mechanism of closed head trauma, followed by motor vehicle collisions (MVCs), then being struck as a pedestrian. In the nonelders, MVCs, falls, and assaults were the most important mechanisms of injury. A focally abnormal neurologic examination imparted an increased risk for both a CT scan positive for traumatic injury (elder 4.39, 95% CI 2.91–6.62; nonelder 7.75, 95% CI 5.53–10.72) and the need for neurosurgery (elder 35.68, 95% CI 4.58–275.89; nonelder 142.58, 95% CI 19.11–1064.22) in both age groups. Conclusions : Significant differences exist between elder and nonelder victims of CHT with respect to mechanisms of trauma and outcomes (CT scan positive for traumatic injury, or the need for neurosurgery).     

Utility of an Initial D-dimer Assay in Screening for Traumatic or Spontaneous Intracranial Hemorrhage

OBJECTIVE: To evaluate the sensitivity of a D-dimer assay as a screening tool for possible traumatic or spontaneous intracranial hemorrhage. If adequately sensitive, the D-dimer assay may potentially permit omission of a more expensive computed tomography (CT) scan of the head when such hemorrhage is clinically suspected. METHODS: Prospective, consecutive, blinded study of patients (age > 16 years) requiring a CT scan of the head for suspected intracranial hemorrhage over a five-month period at a university, Level I trauma center. All study patients had a serum D-dimer assay obtained prior to their CT scans. Sensitivity and specificity, with 95% confidence intervals (95% CIs), of the enzyme-linked immunosorbent assay (ELISA) D-dimer assay for the detection of intracranial hemorrhage were calculated. RESULTS: Of the 319 patients entered in the study, 25 (7.8%) had a CT scan positive for intracranial hemorrhage. Patients with intracranial hemorrhage were more likely to have a positive D-dimer assay (chi-square = 13.075, p < 0.001). The D-dimer assay had 21 true-positive and four false-negative tests, resulting in a sensitivity of 84.0% (95% CI = 63.7% to 95.5%) and a specificity of 55.8% (95% CI = 55.5% to 55.9%). The four false-negative cases included one small intraparenchymal hemorrhage, one small subarachnoid hemorrhage, one moderate-sized intraparenchymal hemorrhage with mid-line shift, and one large subdural hematoma requiring emergent surgery. CONCLUSIONS: Due to the catastrophic nature of missing an intracranial hemorrhage in the emergency department, the D-dimer assay is not adequately sensitive or predictive to use as a screening tool to allow routine omission of head CT scanning.     

Outcome of patients after air medical transport for management of nontraumatic acute intracranial bleeding

INTRODUCTION: Patients with acute, intracranial bleeding (ICB), particularly from intracranial aneurysms, are believed to be at high risk for rebleeding or neurologic deterioration if subjected to noise, motion, or stress, but are transported by helicopter with increasing frequency. This study was undertaken to examine the characteristics, safety, and outcomes of air transport for patients with acute subarachnoid hemorrhage (SAH) or other forms of acute ICB in an air medical system. METHODS: Charts of all patients with spontaneous, acute ICB who were transported by air from 1986 through 1989 were reviewed. Age, gender, time of transport, transport management measures, pre- and post-transport Glasgow Coma Scale (GCS) score, intensive care unit (ICU) and hospital days, operations, and mortality were compiled for all patients and analyzed. RESULTS: Eighty-seven patients ranging in age from 2 to 83 years (mean: 47.5 +/- 18.5 years) met entry criteria. The source of bleeding was cerebral aneurysm in 37 patients; intraparenchymal hemorrhage in 29; an unidentified vascular source in 11; and arteriovenous malformation (AVM) in 10. Mean GCS score measured in 69 patients before and after transport was 10.5 +/- 4.5 Glasgow Coma Scale score did not change during transport in 61 patients (88%), improved in three (4%), and deteriorated in five (7%). Fifty-nine patients (69%) underwent operations, 36 (41%) within 24 hours of arrival. Mean ICU stay was 14 days (95% CI: 12-15); mean hospital stay was 36 days (95% CI: 27-45 days). Overall mortality was 25% (95% CI: 16-34 days). A GCS score of 3 to 8 at time of transport was associated with both increased hospital length of stay and higher mortality. Patients transported within eight hours of symptom onset had lower GCS scores, but outcome measures were not significantly different from those transported later. CONCLUSIONS: Emergency air medical transfer of patients with acute ICB for definitive neurosurgical care appears to be both safe and effective, and facilitates early definitive diagnosis and operative intervention.     

Fiabilidad interobservador de la escala del coma de Glasgow en pacientes críticos con enfermedad neurológica o neuroquirúrgica

IntroductionThe Glasgow coma scale (GCS) is a common tool used for neurological assessment of critically ill patients. Despite its widespread use, the GCS has some limitations, as sometimes different observers may value differently the same response.ObjectiveTo evaluate the interobserver agreement, among intensive care nurses with a minimum of 3 years experience, both in the overall estimate of GCS and for each of its components.MethodsProspective observational study including 110 neurological and/or neurosurgical patients conducted in a critical care unit of 18 beds, from October 2010 until December 2012. Registered variables: Demographic characteristics, reason for admission, overall GCS and its components. The neurological evaluation was conducted by a minimum of 3 nurses. One of them applied an algorithm and consensual assessment technique and all, independently, valued response to stimuli. Interobserver agreement was measured using the intraclass correlation coefficient (ICC) for a confidence interval (CI) of 95%. The study was approved by the Ethics Committee for Clinical Trails.ResultsThe intraclass correlation coefficient (confident interval) for scale was: Overall GCS: 0.989 (0.985-0.992); ocular response: 0.981 (0.974-0.986); verbal response: 0.971 (0.960-0.979); motor response: 0.987 (0.982-0.991).ConclusionIn our cohort of patients we observed a high level of consistency in the application of both the GCS as in each of its components.