When should a Head CT be performed for an adult patient with minor head trauma and a GCS of 15?

by
Micelle J. Haydel, MD
Assistant Clinical Professor
Section of Emergency Medicine
Louisiana State University Health Science Center at New Orleans

Computed Tomography is the test of choice to evaluate patients with head injury, although "who to scan" has been controversial since the introduction of CT in the early 1970s. Adult patients with minor head injury and a normal GCS of 15 have a 6-9% rate of intracranial injury on CT, and less than one percent required neurosurgical intervention.1-3 Several authors have proposed bedside clinical criteria that identified 96-98% of patients with minor head injury that have intracranial injury,2-5 but because of potential morbidity, many physicians are not willing to "miss" any patients with an abnormal scan.6

We conducted a study that derived and validated a set of clinical criteria to identify patients with minor head injury who could be evaluated safely without obtaining a screening CT.7 We found that in the absence of headache, emesis, age over 60, drug or alcohol intoxication, convulsion, trauma visible above the clavicles, and short-term memory deficits (mnemonic:HEADCTS) a CT is not needed. Application of our proposed guideline would have reduced the need for CT by 22% without missing any patients with intracranial injury on CT. Because our results were 100% sensitive and preliminary validations at other centers have reported similar results, I use the criteria in our emergency department. Our sample did not include a sufficient number of patients on anticoagulants to validate the concern of CT use in anti-coagulated patients. Based on concerns raised by other studies,8 I continue to liberally scan patients on anticoagulants.

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References

1. Jeret JS, Mandell M, Anziska B, et al. Clinical predictors of abnormality disclosed by computed tomography after mild head trauma [see comments]. Neurosurgery 1993; 32:9-15; discussion 15-6.
2. Miller E, Derlet R, Kinser D. Minor Head Trauma: Is tomography always necessary. Annals of Emergency Medicine 1996; 27:290-294.
3. Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. J Emerg Med 1997; 15:453-7.
4. Nagy KKea. Use of Head CT after Minimal Trauma. Journal of Trauma 1999; 46:268-.
5. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357:1391-6.
6. Graham ID, Stiell IG, Laupacis A, O'Connor AM, Wells GA. Emergency physicians' attitudes toward and use of clinical decision rules for radiography. Acad Emerg Med 1998; 5:134-40.
7. Haydel MJ PC, Mills TJ, Luber S, Blaudeau E, DeBlieux PMC. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000; 343:100-5.
8. Li J, Brown J, Levine M. Mild head injury, anticoagulants, and risk of intracranial injury. Lancet 2001; 357:771-2.