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.
