Defining “therapeutically inconsequential” head computed tomographic findings in patients with blunt head trauma - 25/08/11

Doi : 10.1016/j.annemergmed.2004.02.032

Clare Atzema, MD, William R. Mower, MD, PhD ^⁎ , Jerome R. Hoffman, MA, MD, James F. Holmes, MD, Anthony J. Killian, RN, Jennifer A. Oman, MD, Andrew H. Shen, MD, Stephen D. Greenwood, BSc
From the Emergency Medicine Center, University of California–Los Angeles School of Medicine, Los Angeles, CA (Atzema, Mower, Hoffman, Shen, Greenwood); the Division of Emergency Medicine, University of California–Davis Medical Center, Davis, CA (Holmes); the Department of Emergency Medicine, Cooper Hospital/University Medical Center, Camden, CA (Killian); and the Department of Emergency Medicine, University of California–Irvine Medical Center, Irvine, CA (Oman) USA

Address for reprints: William R. Mower, MD, PhD, University of California–Los Angeles School of Medicine, Emergency Medicine Center, 924 Westwood Boulevard, Los Angeles, CA 90024; 310-794-0582, fax 310-794-0599

For the National Emergency X-Radiography Utilization Study (NEXUS) II Group

Abstract

Study objective

Many injuries detected by computed tomographic (CT) imaging of blunt head trauma patients are considered “therapeutically inconsequential.” We estimate the prevalence of these findings and determine how frequently affected patients had “important neurosurgical outcomes,” defined as either a directed intervention or a poor Glasgow Outcome Scale score.

Methods

We prospectively enrolled all blunt head trauma patients undergoing emergency head CT imaging at 18 centers participating in the National Emergency X-radiography Utilization Study II (NEXUS). From these cases, we identified all patients whose official CT reading met predefined criteria for “therapeutically inconsequential” injuries. We obtained detailed follow-up information on all such patients at 6 sites, including the need for neurosurgical intervention and Glasgow Outcome Scale scores. Among patients having “important neurosurgical outcomes,” we assessed the frequency of 2 potential clinical identifiers: altered mental status and coagulopathy.

Results

“Therapeutically inconsequential” head CT findings were present in 155 of 8,374 subjects (1.85%; 95% confidence interval 1.57% to 2.16%). Sites participating in the follow-up study enrolled 81 of these patients, of whom 10 (12%) had “important neurosurgical outcomes.” Follow-up information was available for 9 patients, all of whom had abnormal mental status at CT scanning. Coagulopathy was also present in 5 of 7 patients for whom coagulation status was known.

Conclusion

“Therapeutically inconsequential” findings are identified in less than 2% of blunt head trauma patients who undergo CT scanning. A small proportion of these patients have an “important neurosurgical outcome,” but it appears that such patients may be identified clinically by the presence of abnormal mental status or coagulopathy.

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Plan

Introduction

Materials and methods

Setting

Selection of participants

Data collection and processing

	Author contributions: CA, WRM, and JRH participated in project development and analysis. CA, WRM, JRH, JFH, AJK, JAO, AHS, and SDG were responsible for data collection. CA participated in initial drafting of the manuscript. WRM, JRH, JFH, AJK, JAO, AHS, and SDG drafted the manuscript. WRM takes responsibility for the paper as a whole.
	Supported in part by grant RO1 HS09699 from the Agency for Healthcare Research and Quality (AHRQ).