Variation in ED Use of Computed Tomography for Patients With Minor Head Injury☆,☆☆,★,★★
Section snippets
INTRODUCTION
An estimated 800,000 cases of head injury are seen annually in US EDs.1 Some of these patients die or suffer serious morbidity requiring months of hospitalization and rehabilitation. Many others, however, are classified as having a “minimal” or “minor” head injury. “Minimal” head injury patients have not suffered loss of consciousness or amnesia and rarely require admission to hospital. “Minor” head injury is defined by a history of loss of consciousness or amnesia and Glasgow Coma Scale (GCS)2
MATERIALS AND METHODS
This retrospective health records survey was conducted at seven hospitals in British Columbia and Ontario. These institutions were chosen because they represent typical, busy teaching hospital EDs (35,000 to 65,000 annual visits) in a variety of communities. All departments are staffed by full-time, certified emergency physicians, although many of the patients are seen by residents under the supervision of the emergency physicians. The survey was designed to encompass all eligible adult
RESULTS
During the 12-month review period, 1,699 patients with minor head injury were seen at the seven study hospitals (Table 1). Among all patients, 72% had sustained loss of consciousness, 54% demonstrated amnesia, and most (81%) had a GCS score of 15. Although 72% of all cases arrived at hospital by ambulance, 71% were discharged directly from the ED. Overall, 105 patients (6.2%) had sustained acute brain injury demonstrated on CT although only 9 (.5%) had suffered an epidural hematoma. Demographic
DISCUSSION
This study revealed that although minor head injury is a common ED department problem, the actual prevalence of acute brain injury in this study was low (6.2% of cases) and the prevalence of epidural hematoma was very low (.5%). Although the study physicians were already very selective in ordering CT head scans (30.7% of cases), the yield of CT scans was low, with 79.8% being negative for any acute brain injury. There was a large and significant variation in the ordering rate among the study
Acknowledgements
We thank the following research assistants for their help with the study: Tracy Maciura, Marikay Bailey, Brenda Kearns, Lori Greenberg, Cathy Metcalfe, Patti Barber, Karen Code, Linda O'Brien, Raman Johal, TJ Gill, and Sharon Baker. We also thank Fiona Daigle, My-Linh Tran, and Di Wang for data management; Geri Wells for graphics; Silvia Visentin for assistance with the manuscript; and Dr Annette O'Connor and Dr Graham Nichol for their review of the manuscript.
References (74)
- et al.
Assessment of coma and impaired consciousness: A practical scale
Lancet
(1974) The role of neuroimaging in minor head injury
Ann Emerg Med
(1991)- et al.
Minor head injury: A proposed strategy for emergency management
Ann Emerg Med
(1993) - et al.
Management of low-risk head injuries in an entire area: Results of an 18-month survey
Surg Neurol
(1993) - et al.
Derivation of a decision rule for the use of radiography in acute knee injuries
Ann Emerg Med
(1995) - et al.
Meta-analysis in clinical trials
Control Clin Trials
(1986) Radiographic decision-making by the emergency physician
Emerg Med Clin North Am
(1985)- et al.
Is routine computed tomography scanning too expensive for mild head injury?
Ann Emerg Med
(1991) - et al.
Intracranial injury following minor head trauma
Am J Emerg Med
(1992) - et al.
A prospective study to identify high-yield criteria associated with acute intracranial computed tomography findings in head-injured patients
Am J Emerg Med
(1993)
Practical selection criteria for noncontrast cranial computed tomography in patients with head trauma
Ann Emerg Med
Predictors of intracranial injury in patients with mild head trauma
Ann Emerg Med
Delayed diagnosis of subdural hematoma following normal computed tomography scan
Ann Emerg Med
Skull fracture as a factor of increased risk in minor head injuries: Indication for a broader use of cerebral computed tomography scanning
Surg Neurol
The role of neuroimaging in the initial management of patients with minor head injury
Ann Emerg Med
Imaging after head trauma
Emerg Med Clin N Am
A prospective evaluation of radiologic criteria for head injury patients in a community emergency department
Am J Emerg Med
Minor head trauma: Is computed tomography always necessary?
Ann Emerg Med
A study to develop clinical decision rules for the use of radiography in acute ankle injuries
Ann Emerg Med
Cost-effectiveness analysis of the Ottawa ankle rules
Ann Emerg Med
National Hospital Ambulatory Medical Care Survey: 1992 Emergency department summary
Advance Data
The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries
J Trauma
Minor, moderate and severe head injury
Neurosurg Rev
Misdiagnosis and delayed diagnosis in traumatic intracranial haematoma
Br Med J
Extradural haematoma: Effect of delayed treatment
Br Med J
Traumatic acute subdural hematoma: Major mortality reduction in comatose patients treated within four hours
N Engl J Med
The National Traumatic Coma Data Bank: Part 2. Patients who talk and deteriorate: Implications for treatment
J Neurosurg
Analysis of management in thirty-three closed head injury patients who “talked and deteriorated.”
Neurosurg Rev
The utility and futility of radiographic skull examination for trauma
N Engl J Med
Skull x-ray examinations after head trauma
N Engl J Med
National Hospital Ambulatory Medical Care Survey 1992
Minor head injury
Ann Emerg Med
Neurosurgical complications after apparently minor head injury: Assessment of risk in a series of 610 patients
J Neurosurg
Risks of acute traumatic intracranial haematoma in children and adults: Implications for managing head injuries
Br Med J
Can patients with minor head injuries be safely discharged home?
Arch Surg
Use of radiography in acute ankle injuries: Physicians’ attitudes and practice
Can Med Assoc J
Use of radiography in acute knee injures: Need for clinical decision rules
Acad Emerg Med
Cited by (0)
- ☆
From the Division of Emergency Medicine,* the Department of Medicine,‡ the Ottawa Civic Hospital Loeb Medical Research Institute,§ and the Division of Neurosurgery,∥ University of Ottawa, Ottawa; the Department of Emergency Medicine, Queens University, Kingston;¶ the Division of Emergency Medicine, University of Western Ontario, London;# and the Division of Emergency Medicine, University of Toronto, Toronto,** Ontario; and the Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia,‡‡ Canada.
- ☆☆
Supported by grant GR-13304 from the Medical Research Council of Canada. Drs Stiell and Laupacis are Career Scientists of the Medical Research Council of Canada.
- ★
Reprint no.47/1/82465
- ★★
Address for reprints: Ian G Stiell, MD Clinical Epidemiology Unit Ottawa Civic Hospital Loeb Research Institute 1053 Carling Avenue Ottawa, Ontario Canada K1Y 4E9