A Head’s Up about Head Trauma


    A Head’s Up about Head Trauma

    The World Cup is on! Every four years, the beautiful game moves the big stage where we get to see the sport played at its finest. We also get to see the slide tackles, the dives and, more concerning, the head injuries…even if voluntary (see above). Let’s take this moment to review traumatic brain injury (TBI) and some imaging decision tools in head trauma that you can use on your next shift.

    The definition of TBI, based of GCS and clinical risk factors, has traditionally been inconsistent amongst researchers and somewhat contested. Historically, a patient presenting with blunt head trauma and a GCS of 13-15 were categorized as “mild/minor TBI, (mTBI).” I know what you’re thinking, GCS 13 doesn’t sound so minor. A study in the Journal of Neurotrauma, found rates of intracranial injury similar to moderate TBI. It’s important to know, thought, some of our favorite decision tools – Canadian CT Head Injury/Trauma Rule and Nexus II Rule – go with inclusion criteria of GCS 13-15. ACEP Clinical Practice Guidelines updated in 2008 included GCS 14-15 as minor.

    Using clinical signs/symptoms, you can risk stratify your mTBI to help guide your decision to pursue a CT Head of your head injured patient. The best validated studies have evolved into the clinical decision tools we should be apply to appropriate patients:

    Canadian CT Head Injury/Trauma Rule

    Sensitivity: 99%

    Specificity: 47%

    Inclusion: GCS 13-15, Age ≥ 16 y/o, no AC or coagulopathy, no skull fracture

    Exclusion: Age <16, AC, seizure after injury

    New Orleans/Charity Head Trauma/Injury Rule

    Sensitivity: 99%

    Specificity: 33%

    Inclusion: GCS of 15, age >18

    Take a moment to read ACEP Clinical Policy from 2008.

    Inclusion: non-penetrating trauma to the head, presentation to ED within 24 hours of injury, GCS 14-15 on initial eval, age ≥ 16

    Exclusion: penetrating trauma, patients with multisystem trauma, GCS < 14 on initial ED eval, age <16

    GAME ON!

    • Servadei, Franco, Graham Teasdale, and Glen Merry. “Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management.” Journal of neurotrauma 18.7 (2001): 657-664.
    • Jagoda, Andy S., et al. “Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting.” Journal of Emergency Nursing 35.2 (2009): e5-e40.
    • Stiell, Ian G., et al. “Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury.” Jama 294.12 (2005): 1511-1518.
    • Borg, Jorgen, et al. “Diagnostic procedures in mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.” Journal of rehabilitation medicine 36.0 (2004): 61-75.
    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Bag Mask Ventilation During Intubation

      A few days ago NEJM published the results of an investigation with profound implications for our specialty.  A group of intensivists and anesthesiologists conducted a multicenter, randomized trial conducted in seven ICUs to study theRead more

    • Gastric Emptying for Acute Poisonings

      At the request of department leadership, we will be revisiting methods of gastric decontamination for today’s pearl.  Two methods in particular. Ipecac-induced emesis and gastric lavage are two procedures that we read about in medicalRead more

    • Pacemakers Review pt. 3

      Today we will review complications associated w/ implanted pacemakers that you may encounter in the ED and thus ought to be familiar with. Generally, complications can be divided into two categories: early vs. late EarlyRead more

    • Pacemakers Review Pt. 2

      Cardiac pacing as an intervention can be conceptualized as addressing problems in electrophysiological conduction and/or.  So, for example, if there is a disruption in the electrical continuity between the atrium and the ventricle, a pacerRead more

    • Pacemakers Review Pt. 1

      The pursuit of mastery over cardiovascular emergencies demands a rough familiarity with implanted devices which includes why they get implanted in the first place (indications), how they work, how they malfunction, and how they affectRead more

    • In honor of a rosh review question that I got wrong, lets review Lyme disease!   Lyme disease is caused by the spirochete Boriella burgdorferi, transmitted to humans through tick bites from ixodes ticks. Location:Read more


      Your patient has an SBO and has repeated bilious emesis on the side. The surgery team is in the OR and they ask if you can place the nasogastric tube (NGT). Lets review proper NGTRead more

    • No, that’s not an olive. That’s Pyloric Stenosis!

      Inspired by what appears to have been a very interesting day in the Peds ED, lets review a rare but interesting pediatric entity: PYLORIC STENOSIS Background: MC in Males (5:1) & firstborn children (30%) UsuallyRead more