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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

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Open Access 01-12-2012 | Original research

Evaluation of the Scandinavian guidelines for head injuries based on a consecutive series with computed tomography from a Norwegian university hospital

Authors: Ingrid Haavde Strand, Ole Solheim, Kent Gøran Moen, Anne Vik

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2012

Abstract

Background

This study prospectively assesses clinical characteristics and management of consecutive minimal, mild and moderate head injury patients referred for CT scans. Compliance with the Scandinavian head injury guidelines and possible reasons for non-compliance is explored.

Methods

From January 16^th 2006 to January 15^th 2007, 1325 computed tomography (CT) examinations due to minimal, mild or moderate head injury according to the Head Injury Severity Scale (HISS) were carried out at our University Hospital. When ordering a CT scan due to head trauma, physicians were asked to fill out a questionnaire.

Results

Guideline compliance was impossible to assess in 49.5% of all cases. This was due to non-assessable or missing key variables necessary in the decision making algorithm. One or more key variables for HISS classification were not assessable in 34.4% as it was unknown whether there had been loss of consciousness (LOC), duration of LOC was unknown or it was impossible to assess amnesia or focal neurologic deficits. Definite compliance with both CT and admittance recommendations in guidelines was seen in only 31.2%. In 54.2% of patients with minimal head injuries who underwent CT scans, imaging was not necessary according to guidelines. 59.1% of all patients were admitted to hospital, however only 23.7% of these were admitted because of the head-injury alone. Age < 4 years, possible medical cause of injuries, severe headache/nausea or vomiting and the presence of non-traumatic CT findings were independently associated with non-assessable compliance with Scandinavian guidelines. Suspicion of influence of alcohol was inversely associated to non-compliance.

Conclusions

Despite the prospective study design, guideline compliance was not assessable in nearly half of the patients. Patients with isolated head injuries and available and obtainable complete clinical information necessary for guideline-based decision making are not dominating in a head injury population.

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Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, McKnight RD, Verbeek R, Brison R, Cass D, Eisenhauer ME, Greenberg G, Worthington J: The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001, 357: 1391-1396. 10.1016/S0140-6736(00)04561-X.CrossRefPubMed

Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM: Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000, 343: 100-105. 10.1056/NEJM200007133430204.CrossRefPubMed

Servadei F, Teasdale G, Merry G: Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma. 2001, 18: 657-664. 10.1089/089771501750357609.CrossRefPubMed

Vos PE, Battistin L, Birbamer G, Gerstenbrand F, Potapov A, Prevec T, Stepan Ch A, Traubner P, Twijnstra A, Vecsei L, von Wild K: EFNS guideline on mild traumatic brain injury: report of an EFNS task force. Eur J Neurol. 2002, 9: 207-219. 10.1046/j.1468-1331.2002.00407.x.CrossRefPubMed

Ingebrigtsen T, Romner B, Kock-Jensen C: Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma. 2000, 48: 760-766. 10.1097/00005373-200004000-00029.CrossRefPubMed

Harnan SE, Pickering A, Pandor A, Goodacre SW: Clinical decision rules for adults with minor head injury: a systematic review. J Trauma. 2011, 71: 245-251. 10.1097/TA.0b013e31820d090f.CrossRefPubMed

Heskestad B, Baardsen R, Helseth E, Ingebrigtsen T: Guideline compliance in management of minimal, mild, and moderate head injury: high frequency of noncompliance among individual physicians despite strong guideline support from clinical leaders. J Trauma. 2008, 65: 1309-1313. 10.1097/TA.0b013e31815e40cd.CrossRefPubMed

Harad FT, Kerstein MD: Inadequacy of bedside clinical indicators in identifying significant intracranial injury in trauma patients. J Trauma. 1992, 32: 359-361. 10.1097/00005373-199203000-00014. discussion 361-353CrossRefPubMed

Mooney JS, Yates A, Sellar L, Shipway T, Roberts C, Parris R, Hassan Z, Thomas M, Smith M, Lecky F: Emergency head injury imaging: implementing NICE 2007 in a tertiary neurosciences centre and a busy district general hospital. Emerg Med J. 2011, 28: 778-782. 10.1136/emj.2009.083360.CrossRefPubMed

10.

Soreide K, Reite A: Evaluating compliance to the Scandinavian guidelines on mild head injury. J Trauma. 2009, 67: 217-218. 10.1097/TA.0b013e3181a720b8.CrossRefPubMed

11.

Stein SC, Spettell C: The Head Injury Severity Scale (HISS): a practical classification of closed-head injury. Brain Inj. 1995, 9: 437-444. 10.3109/02699059509008203.CrossRefPubMed

12.

Harr ME, Heskestad B, Ingebrigtsen T, Romner B, Ronning P, Helseth E: Alcohol consumption, blood alcohol concentration level and guideline compliance in hospital referred patients with minimal, mild and moderate head injuries. Scand J Trauma Resusc Emerg Med. 2011, 19: 25-10.1186/1757-7241-19-25.PubMedCentralCrossRefPubMed

13.

Stein SC, Fabbri A, Servadei F, Glick HA: A critical comparison of clinical decision instruments for computed tomographic scanning in mild closed traumatic brain injury in adolescents and adults. Ann Emerg Med. 2009, 53: 180-188. 10.1016/j.annemergmed.2008.01.002.CrossRefPubMed

14.

Pandor A, Goodacre S, Harnan S, Holmes M, Pickering A, Fitzgerald P, Rees A, Stevenson M: Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess. 2011, 15: 1-202.CrossRefPubMed

15.

Livingston DH, Loder PA, Hunt CD: Minimal head injury: is admission necessary?. Am Surg. 1991, 57: 14-17.PubMed

16.

Livingston DH, Loder PA, Koziol J, Hunt CD: The use of CT scanning to triage patients requiring admission following minimal head injury. J Trauma. 1991, 31: 483-487. 10.1097/00005373-199104000-00006. discussion 487-489CrossRefPubMed

17.

Shackford SR, Wald SL, Ross SE, Cogbill TH, Hoyt DB, Morris JA, Mucha PA, Pachter HL, Sugerman HJ, O'Malley K: The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma. 1992, 33: 385-394. 10.1097/00005373-199209000-00009.CrossRefPubMed

18.

Stein SC, Ross SE: Mild head injury: a plea for routine early CT scanning. J Trauma. 1992, 33: 11-13. 10.1097/00005373-199207000-00003.CrossRefPubMed

19.

Feuerman T, Wackym PA, Gade GF, Becker DP: Value of skull radiography, head computed tomographic scanning, and admission for observation in cases of minor head injury. Neurosurgery. 1988, 22: 449-453. 10.1227/00006123-198803000-00001.CrossRefPubMed

20.

Mohanty SK, Thompson W, Rakower S: Are CT scans for head injury patients always necessary?. J Trauma. 1991, 31: 801-804. 10.1097/00005373-199106000-00010. discussion 804-805CrossRefPubMed

21.

Ingebrigtsen T, Romner B: Management of minor head injuries in hospitals in Norway. Acta Neurol Scand. 1997, 95: 51-55.CrossRefPubMed

22.

Stiell IG, Wells GA, Vandemheen K, Laupacis A, Brison R, Eisenhauer MA, Greenberg GH, MacPhail I, McKnight RD, Reardon M, Verbeek R, Worthington J, Lesiuk H: Variation in ED use of computed tomography for patients with minor head injury. Ann Emerg Med. 1997, 30: 14-22. 10.1016/S0196-0644(97)70104-5.CrossRefPubMed

23.

af Geijerstam JL, Oredsson S, Britton M: Medical outcome after immediate computed tomography or admission for observation in patients with mild head injury: randomised controlled trial. BMJ. 2006, 333: 465-10.1136/bmj.38918.669317.4F.CrossRefPubMed

24.

Holmes MW, Goodacre S, Stevenson MD, Pandor A, Pickering A: The cost-effectiveness of diagnostic management strategies for adults with minor head injury. Injury. 2012, 43: 1423-1431. 10.1016/j.injury.2011.07.017.CrossRefPubMed

25.

Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, Nederkoorn PJ, Hofman PA, Twijnstra A, Tanghe HL, Hunink MG: 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: 1519-1525. 10.1001/jama.294.12.1519.CrossRefPubMed

26.

Smits M, Dippel DW, Steyerberg EW, de Haan GG, Dekker HM, Vos PE, Kool DR, Nederkoorn PJ, Hofman PA, Twijnstra A, Tanghe HL, Hunink MG: Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med. 2007, 146: 397-405.CrossRefPubMed

27.

Stiell IG, Clement CM, Grimshaw JM, Brison RJ, Rowe BH, Lee JS, Shah A, Brehaut J, Holroyd BR, Schull MJ, McKnight RD, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, Macphail I, Ross S, Perry JJ, Ip U, Lesiuk H, Bennett C, Wells GA: A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ. 2010, 182: 1527-1532. 10.1503/cmaj.091974.PubMedCentralCrossRefPubMed

28.

Fong C, Chong W, Villaneuva E, Segal AY: Implementation of a guideline for computed tomography head imaging in head injury: a prospective study. EMA. 2008, 20: 410-419.PubMed

29.

Rohacek M, Albrecht M, Kleim B, Zimmermann H, Exadaktylos A: Reasons for ordering computed tomography scans of the head in patients with minor brain injury. Injury. 2012, 43: 1415-1418. 10.1016/j.injury.2012.01.001.CrossRefPubMed

Title: Evaluation of the Scandinavian guidelines for head injuries based on a consecutive series with computed tomography from a Norwegian university hospital
Authors: Ingrid Haavde Strand
Ole Solheim
Kent Gøran Moen
Anne Vik
Publication date: 01-12-2012
Publisher: BioMed Central
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine / Issue 1/2012
Electronic ISSN: 1757-7241
DOI: https://doi.org/10.1186/1757-7241-20-62

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Evaluation of the Scandinavian guidelines for head injuries based on a consecutive series with computed tomography from a Norwegian university hospital

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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