Acute traumatic brain injury and the use of head computed tomography scans in the emergency department

Abstract

Introduction

The use of CT head scanning for traumatic brain injury (TBI) is a vital diagnostic tool, guided by risk stratification tools. This study aims to review the use of CT head scans and adherence to guidelines for TBI in two New Zealand emergency departments (EDs).

Methods

Retrospective observational study of patients referred for head CT from EDs to exclude a significant intracranial injury between 1st September 2018 and 31st August 2019. Clinical data were collected regarding presenting patterns, identification of injuries on CT scan and adherence to National Institute of Clinical Excellence (NICE) CT head guidelines.

Results

Out of 425 included cases, 41 (10%) patients had an intracranial injury seen on their CT head scan. Patients who reported loss (32% vs 20%, p < 0.05) or possible loss of consciousness (34% vs 22%, p < 0.05) and had a Glasgow Coma Score (GCS) <13 (17% vs 8%, p < 0.05) or focal neurology (10% vs 3%, p < 0.05) were more likely to have an intracranial injury on CT. Interestingly, 17 (41%) patients with CT diagnosed injuries had a GCS 15 and no focal neurology. NICE guidelines were adhered to in 364 (86%) of CT requests. In the 14% of cases that did not meet guideline criteria, all CT head scans were negative.

Conclusion

CT head scans are a valuable tool in TBI, and guidelines successfully identify those with significant intracranial injuries. However, the rate of significant injury for the total population requiring head CT remains low, with over 90% of head CTs in the population normal, despite high guideline compliance, perhaps identifying a role for novel objective tests in ED guidelines internationally.

Keywords

Traumatic brain injury computed tomography head scan guideline adherence computed tomography head use clinical guidelines

Get full access to this article

View all access options for this article.

References

Seidel

Bissell

Vatturi

, et al. Retrospective analysis of emergency computed tomography imaging utilization at an academic centre: an analysis of clinical indications and outcomes. Can Assoc Radiol J 2019; 70(1): 13–22. DOI: 10.1016/j.carj.2018.10.004.

Feigin

Theadom

Barker-Collo

, et al. Incidence of traumatic brain injury in New Zealand: a population-based study. Lancet Neurol 2013; 12(1): 53–64. DOI: 10.1016/S1474-4422(12)70262-4.

King

Hume

Hardaker

, et al. Traumatic brain injuries in New Zealand: National insurance (Accident Compensation Corporation) claims from 2012 to 2016. J Neurol Sci 2019; 399: 61–68. DOI: 10.1016/j.jns.2019.01.049.

DeAngelis

Lou

, et al. Head CT for minor head injury presenting to the emergency department in the Era of choosing wisely. West J Emerg Med 2017; 18(5): 821–829. DOI: 10.5811/westjem.2017.6.33685.

Bazarian

Biberthaler

Welch

, et al. Serum GFAP and UCH-L1 for prediction of absence of intracranial injuries on head CT (ALERT-TBI): a multicentre observational study. Lancet Neurol 2018; 17(9): 782–789. DOI: 10.1016/S1474-4422(18)30231-X.

Xiao

Lateef

. The use of CT scanners in the emergency department. Austin Emerg Med 2015; 1(1): 1003.

Baloescu

. Diagnostic imaging in emergency medicine: how much is too much? Ann Emerg Med 2018; 72(6): 637–643. DOI: 10.1016/j.annemergmed.2018.06.034.

Kelly

A-M

Kerr

Kelly

A-M

. Are too many head CT scans ordered in emergency departments? Emerg Med Australasia 2000; 12: 50–54.

Brenner

Hall

Phil

. Computed tomography - an increasing source of radiation exposure. New Engl J Med 2007; 357: 2277–2284.

10.

Fayngersh

Passero

. Estimating radiation risk from computed tomography scanning. Lung 2009; 187(3): 143–148. DOI: 10.1007/s00408-009-9143-9.

11.

Lagerstedt

Egea-Guerrero

Bustamante

, et al. H-FABP: a new biomarker to differentiate between CT-positive and CT-negative patients with mild traumatic brain injury. PLoS One 2017; 12(4): e0175572. DOI: 10.1371/journal.pone.0175572.

12.

Stiell

Clement

Rowe

, et al. Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury. JAMA 2005; 294(12): 1511–1518. DOI: 10.1001/jama.294.12.1511.

13.

National Institute for Health and Care Excellence . ‘Head injury’, NICE clinical guideline 176. London: National Clinical Guideline, https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-pdf-498950893 (2014, accessed 21 July 2020).

14.

Australasian College of Emergency Medicine . Tests, treatments and procedures health professionals and consumers should question. Aotearoa, New Zealand: Choosing Wisely, https://choosingwisely.org.nz/wp-content/uploads/2016/12/CMC0003-Australian-College-for-Emergency-Medicine-1.pdf (2019, accessed 21 July 2020).

15.

Howkins

Ngoma

Sattar

, et al. Emergency department use of NICE guidelines for CT imaging in head trauma: an audit cycle. Clin Radiol 2017; 72: S15. DOI: 10.1016/j.crad.2017.06.017.

16.

Cnossen

Scholten

Lingsma

, et al. Adherence to guidelines in adult patients with traumatic brain injury: a living systematic review. J Neurotrauma 2021; 38: 1072–1085. DOI: 10.1089/neu.2015.4121.

17.

Foks

van den Brand

Lingsma

, et al. External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands. BMJ 2018; 362: k3527. DOI: 10.1136/bmj.k3527.

18.

Pozzato

Meares

Kifley

, et al. Challenges in the acute identification of mild traumatic brain injuries: results from an emergency department surveillance study. BMJ Open 2020; 10(2): e034494. DOI: 10.1136/bmjopen-2019-034494.

19.

Marincowitz

Lecky

Allgar

, et al. Development of a clinical decision rule for the early safe discharge of patients with mild traumatic brain injury and findings on computed tomography brain scan: a retrospective cohort study. J Neurotrauma 2020; 37(2): 324–333. DOI: 10.1089/neu.2019.6652.

20.

Amyot

Arciniegas

Brazaitis

, et al. A review of the effectiveness of neuroimaging modalities for the detection of traumatic brain injury. J Neurotrauma 2015; 32(22): 1693–1721. DOI: 10.1089/neu.2013.3306.

21.

Calcagnile

Undén

. Clinical validation of S100B use in management of mild head injury. BMC Emerg Med 2012; 12: 13. DOI: 10.1186/1471-227X-12-13.

22.

Undén

Calcagnile

Undén

, et al. Validation of the Scandinavian guidelines for initial management of minimal, mild and moderate traumatic brain injury in adults. BMC Med 2015; 13(1): 292. DOI: 10.1186/s12916-015-0533-y.

23.

Kaji

Schriger

Green

. Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann Emerg Med 2014; 64(3): 292–298.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.41 MB