CT for Minor Head Injury

CT for Minor Head Injury in Adults

Minor head injury is a common reason for patients visiting the emergency department. Most patients to do not have a cause leading to a severe injury such as bleeding in the brain or skull fracture that would require use of a CT scan to diagnose. There are excellent evidence-based guidelines to determine which type of patients need a CT scan based on a careful taking of the medical history and physical examination, but the majority will not. As CT scans expose patients to ionizing radiation, they should only be used on patients at risk. This approach is a Choosing Wisely recommendation and has been endorsed by the American College of Emergency Physicians in conjunction with the Centers for Disease Control and Prevention, which have published guidelines recommending adherence to clinical decision rules when determining if a patient requires head CT imaging for these presentations. Within the Michigan Emergency Department Improvement Collaborative, we measure clinical performance against the standard of the Canadian CT Head Rule, which has consistently performed well in multiple settings and contexts.

MEDIC Adult Minor Head Injury Toolkit

MEDIC Adult Minor Head Injury Toolkit Implementation Guide

Canadian CT Head Rule

MEDIC Reference Card for the Canadian CT Head Rule

MEDIC Supplement for the Canadian CT Head Rule

MEDIC Adult Head Injury Flow Diagram

Adult Minor Head Injury Roundtable – April 2021

 

1. Dr. Sanford Vieder, Beaumont Hospital - Farmington Hills

2. Dr. Seth Krupp, Henry Ford Hospital - Detroit

3. How to engage APPs

4. Creating a physician scorecard

5. Competing head injury rules question

6. Conclusion & Final Remarks

Key References

  • Davey K, et al. Application of the Canadian Computed Tomography Head Rule to Patients with Minimal Head Injury. Annals of Emergency Medicine. 2018;72(4), pp.342-350
  • Nishijima DK, et al. Immediate and Delayed Traumatic Intracranial Hemorrhage in Patients with Head Trauma and Preinjury Warfarin or Clopidrogel Use. Annals of Emergency Medicine. 2012;59(6), pp.460-468
  • Probst MA, et al. Prevalence of Intracranial Injury in Adult Patients with Blunt Head Trauma with and without Anticoagulant or Antiplatelet Use. Annals of Emergency Medicine. 2020;75(3), pp.354-364
  • Ro RS, et al. Comparison of Clinical Performance of Cranial Computed Tomography Rules in Patients with Minor Head Injury: A Multicenter Prospective Study. Academic Emergency Medicine. 2011;18(6), pp.597-604.
  • Smits S, et al. External Validation of the Canadian CT Head Rule and the New Orleans Criteria for CT Scanning in Patients with Minor Head Injury. JAMA. 2005;294(12), pp.1519-1525
  • Stiell IG, et al. The Canadian CT Head Rule for Patients with Minor Head Injury. The Lancet. 2001;357(9266), pp.1391-1396

Reduction of CT use in Children with Minor Traumatic Head Injury

Minor head injuries are a frequent cause for emergency department visitation by children and CT scans are often used unnecessarily as a diagnostic tool to exclude serious intracranial injuries. However, the use of CT scanning exposes children to dangerous radiation, increases risk due to requirements for sedation medication in young children and adds unnecessary expense when children have very low risk for serious intracranial injury. Strong medical evidence now endorsed by the American Academy of Pediatrics, American College of Emergency Physicians and the national Choosing Wisely campaign is now available that offers detailed guidance to emergency physicians’ decision making to better direct use of CT scans in children with head injuries. Physician members of MEDIC are now able to easily access their personal and institutional rates of CT scanning in children meeting criteria for minor head injury through the MEDIC data platform. They can also directly review cases for which CT scans were done to review patient records to monitor their own performance. The MEDIC collaborative has adopted both collaborative wide as well as institutional targets for reduction in overuse of CT scanning for children with minor traumatic brain injury who meet select criteria.

MEDIC Pediatric Minor Head Injury Toolkit

PECARN Pediatric Minor Head Injury CT Guidelines

MEDIC Reference Card for the PECARN Pediatric Minor Head Injury CT Guidelines

MEDIC Supplement for the PECARN CT Head Guidelines

MEDIC Pediatric Head Injury Ages <2 Flow Diagram

MEDIC Pediatric Head Injury Ages 2-17 Flow Diagram

Pediatric Minor Head Injury Roundtable – April 2021

 

1. Welcome & Introduction

2. Dr. Lee Benjamin, St. Joseph Mercy Hospital – Ann Arbor

3. Dr. Helena Wang-Flores, Michigan Medicine

4. Final Remarks & Conclusion

 
 

Key References

  • Badawy, M. K., et al. Prevalence of Brain Injuries and Recurrence of Seizures in Children with Posttraumatic Seizures. Academic Emergency Medicine. 2017;24(5):595-605. 
  • Ballard DW, et al. Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries. Annals of Emergency Medicine. 2019;73(5):440-451.
  • Dayan PS, et al. Association of Traumatic Brain Injuries With Vomiting in Children With Blunt Head Trauma. Annals of Emergency Medicine. 2014;63(6):657-665.
  • Dayan PS, et al. Headache in Traumatic Brain Injuries From Blunt Head Trauma. Pediatrics. 2015;135(3):504-512.
  • Dayan PS, et al. Risk of Traumatic Brain Injuries in Children Younger than 24 Months With Isolated Scalp Hematomas. Annals of Emergency Medicine. 2014;64(2):153-162.
  • Hess EP, et al. Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma. JAMA Network Open. 2018;1(5).
  • Kuppermann N, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet. 2009;374(9696):1160-1170.
  • Lee LK, et al. Isolated Loss of Consciousness in Children With Minor Blunt Head Trauma. JAMA Pediatrics. 2014;168(9):837.
  • Nigrovic LE, et al. Prevalence of Clinically Important Traumatic Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms. Arch Pediatr Adolesc Med. 2012;166(4):356–361.
  • Varano P, et al. Acute outcomes of isolated cerebral contusions in children with Glasgow Coma Scale scores of 14 to 15 after blunt head trauma. Journal of Trauma and Acute Care Surgery. 2015;78(5):1039-1043.