This action might not be possible to undo. Are you sure you want to continue?
MARIA THERESA M. NAVARRO, MD. Quirino Memorial Medical Center
ages 1 to >60 years old. 38 (39. Positive scans identified as those having one or more of the following abnormal findings: subdural hematoma.INDICATIONS FOR COMPUTED TOMOGRAPHY IN EVALUATING MINOR HEAD TRAUMA PATIENTS OF QUIRINO MEMORIAL MEDICAL CENTER: A PROSPECTIVE STUDY ABSTRACT Purpose: This study aims to identify the clinical criteria that can be used as indications in performing cranial CT scans in minor head trauma patients. Clinical findings were also enumerated. Other abnormal findings such as scalp hematoma / soft tissue swelling. and 3) these minor head trauma patients who underwent cranial CT scans. but with normal brain were classified under negative CT scans. 2) time frame between injury to consult at ER is within 24 hours. respectively. who were seen at the emergency surgery unit of Quirino Memorial Medical Center were included in the study. and probable intrasinus hemorrhage. Results: For a period of 10 months (January 2008 to October 2008). with normal findings on a brief neurologic examination were classified to have minor head trauma. Data was gathered using checklist forms and official CT scan results. subarachnoid hemorrhage. and skull fracture. parenchymal hematoma.7%. cerebral contusion. -2- . Materials and Methodology: A purposive sampling technique was utilized in obtaining the population. Patients with Glasgow coma scale of 13-15. and CT scan may not be done if all of these clinical findings are absent. brought to the emergency room.7% and 32. The sensitivity and specificity of having at least one of the criteria set by NOC predicting the presence of a clinically significant abnormal cranial CT scans were 94. epidural hematoma. ages 1 to 83 years old. with the following inclusion criteria: 1) male and female minor head trauma patients. Positive and negative CT scans were determined.4%) had negative cranial CT scans.6%) had positive cranial CT scans and 58 (60. Conclusion: The clinical findings set by NOC can be used as indications for doing cranial CT scan in minor head trauma patients. a total of ninety six (96 ) patients. Of the 96 patients.
-3- . definite amnesia. most of its patients are indigents or belong to the low income earners. or at least the discounted price. 3) defines the nature of intracerebral hemorrhage . inefficient use of the CT scan adds significantly to healthcare costs and burden to the patients. 2) very sensitive for acute hemorrhage. 4) defines anatomical location. many researchers tried to develop clinical decision rules. efficient use of CT in evaluating minor head trauma patients should be done. Osterwell says that doing a CT or not is the main concern of clinicians when a patient with minor head injury comes in the emergency room 2. and 2) Canadian CT Head Rule (CCHR)6. and the two most well studied and validated decision rules are: 1) the New Orleans Criteria (NOC)3. 1 It has several advantages such as: 1) it is noninvasive and rapid . Since Quirino Memorial Medical Center is a government hospital.5. one will spent too much time and money chasing after too few serious cases. If we scan all of these patients. Hence. with minor head injury defined as GCS score of 13 to 15. who are most likely unable to pay the full amount of the procedure. To help the clinicians in identifying patients who are at risk of developing intracranial damage following minor head injuries.4. and 5) identify the presence of fractures. except for patients with only minor head trauma who are neurologically intact and not intoxicated with drugs or alcohol. Because of these. and it is warranted. wherein minor head injury is defined as loss of consciousness after head trauma with normal neurologic examination and Glasgow Coma Scale (GCS) score of 15. It will also save time and effort for the clinicians in the immediate management of their patients.INTRODUCTION CT scanning of the head is the criterion standard for patients with acute closed head injuries. If we don’t scan there might be a risk of missing an intracranial bleed. loss of consciousness. CT scanning will be costly for this group of people.
to determine the sensitivity and specificity of the clinical criteria set by the NOC in predicting clinically significant cranial CT scans of minor head trauma patients. to identify the cranial CT findings of minor head trauma patients encountered in Quirino Memorial Medical. Specifically. with the following inclusion criteria: 1) male and female minor head trauma patients. This study then aims to identify the clinical criteria that can be used as indications in performing cranial CT scans in minor head trauma patients of Quirino Memorial Medical Center. but it would identify all cases requiring neurological intervention. to describe the profile of minor head trauma patients who fulfilled the set criteria. it aims to: 1. the CCHR has a lower sensitivity than NOC for neurocranial traumatic CT findings. however. For patients with minor head injury and GCS score of 13 to 15. and 3) these minor head trauma patients who -4- . ages 1 to >60 years old. 3. A purposive sampling technique was utilized in obtaining the population. 2) time frame between injury to consult at ER is within 24 hours. 2.or witnessed disorientation from trauma. studies have shown that some clinical findings which the rule consider unimportant underwent neurosurgical intervention or had poor neurologic outcomes2. These two clinical decision rules have been compared and results showed that NOC and CCHR appear equally sensitive in predicting the need for neurosurgical intervention following minor head injury 7. brought to the emergency room. MATERIALS AND METHODOLOGY The research design is a prospective study using the descriptive survey method conducted from January 2008 to October 2008 at the emergency room of Quirino Memorial Medical Center. CCHR can significantly reduce CT use.
and with GCS score of <13 were excluded. cerebral contusion. but with normal brain. -5- . patients with co morbidity ( i. specificity. subarachnoid hemorrhage. Official CT scan results Patients were separated into two groups: those who had at least one of the seven findings. without intravenous contrast. 2. Glasgow coma scale for every sample patient was validated by the Surgery resident-on-duty. Patients with Glasgow coma scale of 13-15. Negative scans were identified as those who have scalp hematoma / soft tissue swelling. and those who had none. The sensitivity. Checklist attached to the CT scan request forms were provided at the Surgery Unit. These forms were filled-up prior to the performance of the CT scan procedure to avoid bias in their physical examination. with a 5 mm slice thickness infratentorially. with 95 percent confidence intervals. Data was gathered using the following tools: 1. and was recorded. diabetes mellitus. stroke. The radiology resident-on-duty did the initial reading of the cranial CT scans in brain and bone window settings.e. parenchymal hematoma. etc). verified by the radiology consultant-on-duty.underwent cranial CT scans. Positive and negative CT scans were determined. and skull fracture. Postgraduate interns and/or clerks entered the data on the checklist. and probable intrasinus hemorrhage. at the region of the skull base and 10 mm slice thickness supratentorially. The frequency of positive CT scans was determined for each group and then entered in a two-by-two table. with normal findings on a brief neurologic examination were classified to have minor head trauma. epidural hematoma. (see Appendix I). were calculated. and negative predictive value of the criteria. Included patients underwent cranial CT scans using a single slice spiral CT scan unit. with positive scans identified as those having one or more of the following: subdural hematoma. Patient’s with onset of injury more than 24 hours before seen at the emergency room.
4%) 4 ( 15. visible trauma above clavicles.8%) 40 19-59 (41. The top three clinical findings which resulted to a positive CT scan result were headache (15.6%).7% are male.1 %) 64 Overall (66.4%) (39.8%) 46 (32. short-term memory loss.2% ) 0 (17.2%) N = 96 (51%) ( 9. 66.3%). Characteristics of Minor Head Trauma Patients Seen At The ER of QMMC AGE in years M 21 1 – 18 (21.3% are female ( see Table 1). while fall (62.6 %) 7 (62.1%) 49 (0%) 9 (42.8%) is the most common cause for pediatric patients. headache. were included in the study. and age above 60 years old. vomiting. and presence of visible trauma above the clavicles (55. The overall most common cause of head injury is vehicular accident (51%) and for each group of patients.2 %) 32 (7.5%) 31 (4. who were seen at the emergency surgery unit of Quirino Memorial Medical.3%) (4. Table 1.7%) (33.3%) 4 (47.4%) 3 (22.9%) 7 (67. vehicular accident is the most common cause in adults (67. and 33. vomiting (31.8) 38 (6.9%) 6 (44.6%) (57. ninety six (96 ) patients.4%).8%) 8 SEX F 22 Total 43 NATURE OF TRAUMA Vehicular accident 14 Mauling 2 Fall 27 Table 2 shows the following pertinent clinical findings and risk factors which are as follows: alcohol intake. Among the 96 minor head trauma patients. ages 1 to 83 years old.8 %). -6- .8%) 3 >60 (3. especially in the lower age group. posttraumatic seizure.RESULTS For a period of 10 months (January 2008 to October 2008).
and pneumocephalus (0.3%).7%).7%).3%).1%). Findings Scan (n=38). and 22 (17.2%).76 0.3) 5 (8.7) Seizure 1 (1) 0 1 (1.8) 21 (55.4 0. scalp hematoma/ subgaleal hematoma(17.4) Loss Age > 60 7 (7. non-hemorrhagic hemorrhagic contusion or contusion(3. epidural hemorrhage(0.e.96 0 1.2%). For findings considered as negative. no Scan (n=58).2%) had soft tissue swelling of the scalp.9%) is the most common. Other positive findings are : intrasinus hemorrhage(20. contusion (3. Figure 1.3) 2 (5.6) 2 (3.4) Intake Headache 14 (14.8) Vomiting 31 (32.8) 8 (13. i. brain is normal with no evidence of soft tissue swelling.9) Above Clavicles Short-term Memory 3 (3) 1 (2.3) 12 (31.Table 2 Clinical Findings and CT Results of Minor Head Trauma Patients at the ER of QMMC Positive CT Negative CT Total (n=96).61 Figure 1 describes the positive CT findings of the patients and results show that skull fracture (21. Cranial CT Findings of Minor Head Trauma Patients Seen At The ER of QMMC * -7- . no no (%) (%) (%) Alcohol 2 (2) 0 2 (3.4%) patients were found to have normal examination. parenchymal subarachnoid hemorrhage(2.1 0. 30 (23. or subgaleal hematoma.3) 22 (37. signed out as scalp hematoma. subdural hemorrhage(6.9%).6) years Likelihood Ratio 0 1.6) 6 (15.3%) had haziness of the sinuses.6) 19 (32. which were signed out as either secondary to sinusitis and/or hemorrhage but with normal brain. but with normal brain. 26 (20.7) Visible Trauma 43 (44.
30 25 20 15 10 5 0 CT Findings Normal Intrasinus hemorrhage vs.99% and 32. Table 3. 36 had positive CT scan results. The values for sensitivity. and 39 had negative CT scan results. and specificity of the criteria for patients with GCS 13-15. were 94.46%).7% (95% CI 81% . and 19 presented with negative CT scans ( Table 3).4%. Association Between The Nine Clinical Findings and CT Results In 96 Patients With Minor Head Injury -8- .7% (95% CI 21% . Sinusitis Scalp hematoma / subgaleal hematoma Skull Fracture Subarachnoid hemorrhage Hemorrhagic contusion / Parechymal contusion Subdural hemorrhage Epidural hematoma Pneumocephalus Nonhemorrhagic Contusion * Some of the patients had at least one of the above cranial CT findings Seventy-five patients (75) had pertinent clinical findings/risk factors. Twenty one (21) patients did not have any of the clinical findings/risk factors. respectively. with the probability that the absence of any of the clinical findings will result to a negative CT scan (negative predictive value) of 90. but 2 presented with a positive CT scan.
GCS score less than 15 at two hours or more after injury.8. more than 30 minutes of amnesia of events prior to the injury. headache.6% vs. These studies were compared. suspected open or depressed skull fracture. with CCHR having a higher specificity than NOC (50. the researcher decided to apply NOC instead to its set of population but with the inclusion of patients with GCS 13-15. several sets of criteria were developed and two of the most studied “head rules” are the Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC). two or more episodes of vomiting. physical evidence of trauma above the clavicles. Also. and results showed that both have 100% sensitivity.001)7. and vomiting while CCHR uses the following criteria6: basal skull fracture. age 65 years or older. drug or alcohol intoxication. p < . age more than 60 years old. NOC uses the following criteria4: short-term memory loss. and dangerous mechanism. seizure.7%. -9- . since CCHR has a tendency to disregard some clinical findings which can be significantly important and miss intracranial injuries.Positive Cranial CT Scans With Clinical Findings Without Clinical Findings Total 36 2 Negative Cranial CT Scans 39 19 Total 75 21 38 58 96 DISCUSSION In an attempt to minimize the unnecessary use of cranial CT scans in minor head trauma patients. 12.
In Stein and Ross study. close to 9 . Moreover. with likelihood ratios of 1. the present study showed that headache.7% and 32. However. 0. and 1. and physical evidence of trauma above clavicles were significantly associated with positive CT scan results. 12 Nine out of 19 patients who had intracranial hematomas (47. findings of skull fracture as the most common clinically significant abnormal finding.000 cases of mild head trauma patients in Southern Brazil 9.96. fall is the most common cause of trauma. The sensitivity and specificity of the clinical findings set be NOC and CCHR in determining positive cranial CT were 94.7%. although it is not well documented. drug or alcohol intoxication. Vehicular accident is also the leading cause of head trauma in youth and middle age people according to a research done in Taiwan 10. requiring neurosurgical follow-up or referral are comparable to the other series of studies that described CT findings in mild head trauma. For the pediatric age group. and visible trauma above the clavicles were noted to be significantly associated.Table 2 showed that head trauma is more common in males than in females especially in the adult group (19-59 years old) and vehicular accident is the most common cause of head trauma. In the study of Bordignon and Arruda only one case of intracranial hematoma was associated with skull fracture.4 respectively.6%) cases of intracranial hematoma have skull fractures13.3%) were noted to have associated skull fractures.10 - . 7 out of 11 (63.1. vomiting. Compared with the study done by Haydel et al. vomiting was also one of the major clinical findings / risk factor in another study11. Difference in findings maybe attributed to the difference in the type and nature of trauma experienced by the patients or the difference in size of samples. motorcycle accidents were mostly the type of vehicular accident that QMMC encountered at the ER.9. These findings were likewise shown by Bordignon and Arruda when they described the CT findings of 2. respectively. For the lesion types. wherein short-term memory loss.
detailed account of the type of trauma maybe done in order to correlate it with the clinical and CT findings. since there was a discrepancy in the clinical findings and CT scan result. the following recommendations were derived: 1) research regarding the external validation of other CT rules. maybe done in the future. Closed head trauma: Differential Diagnoses and Work-up. As observed. and nonhemorrhagic contusion). despite of this the author may confidently conclude that the criteria set by NOC can be used as indications for doing cranial CT scan in minor head trauma patients. and CT scan may not be done if all of these criteria are absent. . Other studies made by Khan 14. 3) and lastly. two major limitations were identified: 1) the population or sample under observation is relatively low such that determining the sensitivity and specificity of NOC and CCHR separately cannot be done. 2) strict compliance in the proper filling-up of forms by the clinicians and the researcher must make sure that proper physical examination has been done to maintain accuracy of findings. in our study. there is a great possibility of inaccurate data reporting. 2 of the patients who did not have any of the clinical findings and with Glasgow coma scale of 15 had significant positive CT findings (fracture. such as the recently developed CT in Head Injury Patients (CHIP)16. or participation of other hospitals could be done to gather enough sample size. For this case. Hence.the values of CCHR and NOC 5. However. the clinician might have missed or failed to report pertinent data and thus created a discrepancy in our results. Saboori15 also derived at the same conclusion. although it is not included in the scope of this study. but the author suggests a longer time frame.11 - . and REFERENCES 1 Rangel-Castillo. Leonardo. However. Results should have shown that those patients who did not have any of the clinical criteria should also have a negative CT scan. and 2) as mentioned.
33: 11-13. Vandemheen K. 2002. Ahmadi J. Clinical decision instruments for CT scanning in minor head injury. et al. 2007. 2 3 4 5 6 7 8 9 10 11 12 Osterwell. Herbert M. Ann Intern Med. Medpage Today. 2007. Nazir R. Features of head injury in a developing country Taiwan (1977-1987). Steill IG. JAMA 2005. Schackford SR. Pak J Radiol. Feb. Arruda WO. Rowe BH. Indications for computed tomography in patients with minor head injury. CT scan findings in mild head trauma. 2001. Clement CM. Stein SC. June 15. CT scan in minor head injury: a guide for rural doctors. 63(1). Indications for brain CT scan in patients with minor head injury. 1990. et al. 12(4): 2-9. 294: 1551-3. 2001. Latip A. 357:1391-96. Ross SE. Lui TN. et al. et al. American Family Physician. 2000. 33:385-394. Haydel MJ. Steill IG. et al. The Canadian CT Head Rule for patients with minor head injury. Journal of Clinical Neuroscience. et al. The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. Alias A. 11(8):835-839. J Trauma. Mild head injury: plea for routine early CT scanning.eMedicine. and Ariff AR. 394: 1511-8. Clin Neurol Neurosurgery. Steyerberg EW. Arq Neuro-Psiquiatr. Hoff JR.. et al. 343: 100-5 Kirchner JT.12 - . 146:397-405 13 14 15 16 . Wells GA. September 28. 1992. 109(%): 399-405 Smits M. Dippel DWJ. J Trauma. 2005 Haydel MJ. Use of CT scan in assessing minor head trauma. Indications for computed tomography in patients with minor head injury. N Engl J Med. Ross SE. Computed tomography after minor head injury. Comparison of the Canadian CT Head Rule and New Orleans Criteria in patients with minor head injury. Saboori M. Chang CN. 60(20 Lee ST. JAMA 2005. Ebell MH. 2004. Wald SL. Criteria for head injury CTs go head to head. J Trauma. et al. Neil. 1992. Bordignon KC. 30:194-199. American Family Physician. 2006. Lancet 2001. 2008. Khan SF. Predicting intracranial findings on computed tomography in patients with minor head injury: The CHIP Prediction Rule.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.