CT Head Decision Rules for GCS 13 to 15

GCS </= 8

These patients and those with declining GCS score should undergo endotracheal intubation as part of resuscitation. All require neurosurgical consult and most patients die.

GCS 9 - 12

Major head injury. These patients should be promptly referred to a trauma center where neurosurgical consult is available. A lot will have residual neurological deficit. Surgery is still often required.

GCS 13 - 15

Minor head injury. Most do “OK”, but many have deficits. Loss of consciousness or memory defecit is not necessarily found in traumatic brain injury.

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Canadian CT Head Rules [1]

CT of the head is only required for patients with a history of mild head injury within the previous 24 hours and any one of the following risk factors for neurological intervention: (also consider Additional Head CT Indications below). This decision rule is limited by including only patients with loss of consciousness and anterograde amnesia. It also excluded those with abnormal neurologic findings, those on anticoagulants and those with seizures. There has been extensive external validation.

1. High Risk (for neurological intervention)

· GCS < 15 at two hours after injury.

· Suspected open or depressed skull fracture. This is a clinical rather than X-ray diagnosis.

· Any sign of basal skull fracture (hemotympanum, "raccoon" eyes, cerebrospinal fluid otorrhea/rhinorrhea, Battle's sign).

· Vomiting 2 or more episodes.

· Age > 65.

2. Medium Risk (for brain injury on CT)

· Amnesia before impact > 30 minutes

· Dangerous Mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or 5 stairs).

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Consider Additional Head CT Indications from Other Studies

These factors take into consideration criteria included and excluded in the Canadian CT Head Rules. They also include findings identified by other decision rules such as the CHIP prediction rule developed in the Netherlands. Additional factors (identified as *) are included recognizing the increased climate of medicolegal risk in the USA as compared to Canada.

1. Drug or alcohol intoxication or inappropriate mental status*

2. Physical findings of trauma above clavicle

3. Seizure (even if seizure disorder resulted in head trauma*)

4. Coagulopathy. Includes all patients on warfarin regardless of INR [5]*

5. Focal neurologic deficit

6. Graze wound from high velocity missile (bullet)*

7. Any vomiting*

8. Persistent deficit of short-term memory

9. Persistent anterograde amnesia

10. GCS <15

11. Any GCS deterioration

12. Age > 60 (ACEP guidelines)

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CT in Head Injury Patients (CHIP Prediction Rules) [6]

This prediction rule developed in the Netherlands includes those patients with blunt injury to the head who have a normal or minimally altered level of consciousness on presentation in the emergency department, that is, a Glasgow Coma Scale (GCS) score of 13 to 15, and a maximum loss of consciousness of 15 minutes, posttraumatic amnesia for 60 minutes, or both. External validation remains to be done in different populations.

1. A CT is indicated in the presence of 1 major criterion

· Pedestrian or cyclist versus vehicle

· Ejected from vehicle

· Vomiting

· Posttraumatic amnesia 4 hr or more

· Clinical signs of skull fracture

· GCS score <15

· GCS deterioration 2 points or more (1 h after presentation)

· Use of anticoagulant therapy

· Posttraumatic seizure

· Age 60 years or more

2. A CT is indicated in the presence of at least 2 minor criteria

· Fall from any elevation

· Persistent anterograde amnesia

· Posttraumatic amnesia of 2 to 4 hours

· Contusion of the skull

· Neurologic deficit

· Loss of consciousness

· GCS deterioration of 1 point (1 hour after presentation)

· Age 40 to 60 years

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References

1. Stiell IG, Wells GA, Vandemheen K, et al: The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357:1391‑6.

2. Additional Web reference: www.fpnotebook.com/NEU245.htm

3. Hebert ME. [Audio program]. Audio Digest Emergency Medicine 2004; 21(5).

4. Klauer KM. Traumatic head, neck and spine injuries [Audio program]. Audio Digest Emergency Medicine 2007; 24(20). Available at: www.audio-digest.com (Accessed Jan 3, 2008)

5. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma 2006; 60(3): 553-557.

6. Smits M, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: The CHIP prediction rule. Ann Int Med 2007; 146: 397-405.

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