Criteria for minor head injury:
(1) initial Glasgow coma score 13 to 15 (I believe this is as determined by the physician in the Emergency Department)
(2) one or more of the following:
(2a) witnessed loss of consciousness
(2b) definite amnesia
(2c) witnessed disorientation
Exclusion criteria:
(1) age < 16 years of age
(2) current anticoagulation therapy
(3) bleeding disorder
(4) Glasgow coma score < 13
(5) obvious open-skull fracture
The endpoints were either a need for neurological intervention and/or clinically important brain injury detected on CT scan.
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Endpoint
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Criteria
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Need for neurological intervention
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death within 7 days from head injury; need for craniotomy, elevation of skull fracture, intracranial pressure monitoring, or intubation due to head injury within 7 days of injury.
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Clinically important brain injury
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any acute brain injury found on CT scan which would require hospitalization and/or neurological followup.
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Rule: A CT scan is done if one or more medium and/or high risk factors are present.
Medium risk (for brain injury identified on CT scan)
(1) amnesia for events before impact > 30 minutes
(2) dangerous mechanism
where:
• A dangerous mechanism includes (1) pedestrian struck by motor vehicle, (2) occupant ejected from motor vehicle, (3) fall from a height > 3 feet, or (4) fall down stairs > 5 steps
High risk (for need of neurological intervention):
(1) GCS score < 15 at 2 hours after injury
(2) suspected open or depressed skull fracture
(3) any sign of basal skull fracture
(4) >= 2 vomiting episodes
(5) age >= 65 years
where:
• Signs of basal skull fracture includes (1) hemotympanum, (2) "raccoon" eyes, (3) CSF otorrhea or rhinorrhea, or (4) Battle's sign
• raccoon eyes = periorbital ecchymosis
• Battle's sign = discoloration in the line of the posterior auricular artery, with ecchymosis first appearing near the tip of the mastoid process
Performance:
• Using both high and medium risk criteria to detect clinically important brain injury: sensitivity 98.4%, specificity 49.6%, proportion of patients with CT ordered 54.3%.
• Using the high risk criteria to identifying patients requiring neurological intervention: sensitivity 100%, specificity 68.7%, proportion of patients with CT ordered 32.2%.
