EBQ:Indications for computed tomography in patients with minor head injury

Complete Journal Club Article
Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM.. "Indications for Computed Tomography in Patients with Minor Head Injury". N Engl J Med. 2000. 343(2):100-105.
PubMed Full text

Clinical Question

Can clinical criteria reliably identify which patients with minor head injury (GCS 15) require CT scanning?

Conclusion

  • Seven clinical criteria (the New Orleans Criteria) are 100% sensitive for identifying clinically significant intracranial findings on CT in patients with minor head injury
  • Patients with GCS 15 and none of the 7 criteria do not require CT scanning

Major Points

  • The New Orleans Criteria include: headache, vomiting, age >60, drug/alcohol intoxication, persistent anterograde amnesia, visible trauma above the clavicles, and seizure
  • The rule achieved 100% sensitivity for clinically significant findings but had only 25% specificity
  • Application of the rule would have reduced CT use by 22% in the study population
  • The rule is designed for GCS 15 patients only and should not be applied to patients with GCS <15
  • Subsequently compared with the Canadian CT Head Rule in validation studies

Study Design

  • Prospective, single-center cohort study with derivation and validation phases
  • Charity Hospital, New Orleans
  • Derivation: N = 520; Validation: N = 909
  • Study period: March 1996 - March 1997 (derivation), October 1997 to February 1999 (validation)
  • Primary Outcome: sensitivity for positive CT findings requiring neurosurgical intervention or prolonged observation

Population

Inclusion Criteria

  • Age >3 years
  • GCS 15
  • Loss of consciousness after blunt head trauma

Exclusion Criteria

  • Penetrating head injury
  • GCS <15
  • No loss of consciousness
  • Trivial mechanism (ground-level fall without head strike)

Interventions

  • No therapeutic intervention; clinical decision rule derivation and validation study
  • All patients received CT head regardless of clinical criteria (to establish reference standard)
  • 7 clinical variables assessed by treating physicians prior to CT

Outcomes

Primary Outcome

  • Sensitivity of the New Orleans Criteria for positive CT: 100% (95% CI 95-100%)
  • Specificity: 25%

Secondary Outcomes

  • CT positive rate: 6.9%
  • Neurosurgical intervention rate: 0.6%
  • If applied, the rule would have reduced CT use by 22%

Criticisms

  • Single-center study limits generalizability
  • Low specificity (25%) means the rule still results in many unnecessary CT scans
  • Only includes patients with loss of consciousness, which may be difficult to confirm
  • Comparison studies with the Canadian CT Head Rule suggest the Canadian rule has better specificity
  • Does not address patients on anticoagulants, which is an increasingly important population
  • The rule was derived in an urban, largely uninsured population

Funding

  • None reported

See Also

References

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