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Blunt Head Trauma Algorithm

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Head CT Rules

Nexus II (J Trauma 2005;59:954–959)

  • Criteria highly associated with intra-cranial injury:
    • Evidence of significant skull fracture
    • Scalp hematoma
    • Neurologic deficit
    • Altered level of alertness
    • Abnormal behavior
    • Coagulopathy
    • Persistent vomiting
    • Age 65 years or more

  • Evidence:
    • Clinically significant injuries: Sens 98.3; NPV 99.1%; Specificty-13.7%
    • Expected miss rate: approximately 1.7% of cases with “clinically important” intracranial injuries
  • Use: Identify patients that are low risk that don’t need further imaging, not useful in deciding who does need imaging

ACEP Clinical Policy (Ann Emerg Med. 2008;52:714-748)

  • A head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present (Level A Recommendation):
    • Headache
    • Vomiting
    • Age greater than 60 years
    • Drug or alcohol intoxication
    • Deficits in short-term memory
    • Physical evidence of trauma above the clavicle
    • Posttraumatic seizure
    • GCS score less than 15
    • Focal neurologic deficit
    • Coagulopathy
  • A head CT should be considered in head trauma patients with no LOC or posttraumatic amnesia if there is (Level B Recommendation):
    • Focal neurologic deficit
    • Vomiting, severe headache
    • Age 65 years or greater
    • Physical signs of a basilar skull fracture
    • GCS score less than 15
    • Coagulopathy
    • Dangerous mechanism of injury*
      • * Dangerous mechanism of injury includes ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs.
Blunt Head Trauma Algorithm
Blunt Head Trauma Algorithm

Other Head CT Rules (For Your Consideration)

Canadian (Lancet. 2001;357:1391-6)

  • Clinically important brain injury Sens 98%, Specificity 50%
  • Neurosurgical intervention Sens 100%, Specificity 68%
  • Complicated algorithm, extensive inclusion criteria for study, difficult to use in practice
  • Inclusion Criteria:
    • LOC, amnesia, disorientation
    • GCS >13
    • Age >16
    • No penetrating skull injury
    • Not pregnant
    • No focal deficit
    • No coagulopathy
    • No seizure
    • No unstable vital signs

New Orleans (NEJM 2000;343(2):100)

  • Too sensitive and non-specific (Sens 100%, Spec 24%)
  • Limitations: limited applicability, wide confidence intervals, has not been validated, used any injury as outcome measure
  • Imaging obtained for any patient with trauma above clavicles → decreases specificity
  • Inclusion criteria
    • Age >3yo
    • +LOC
    • Normal neuro exam
    • GCS 15

Delayed Bleed Risk

Delayed bleed Evidence

  • Immediate intracranial hemorrhage (Blunt Head Trauma + Anticoagulation)
    • ICH is a real entity with occurrence of 10-15%
    • Any patient with head trauma on warfarin or clopidogrel should get an initial Head CT scan
  • Delayed intracranial hemorrhage (Blunt Head Trauma + Anticoagulation + CT neg)
    • Delayed ICH is also a real entity
    • Increased risk in elderly and INR >3
    • Observation option: admit for 24 h observation and repeat CT?
    • Discharge option: Low risk, reliable, family present and able to return for any subtle changes

INR Reversal

  • FFP
    • 15cc/kg begins working immediately
    • Use if PCC not readily available
  • Vitamin K
    • INR > 10 → Vit K 2.5-5mg po
    • Serious/Life threat bleed → 10mg IV over 30 min (prevents anaphylactoid reaction)
    • Begins working at 4 hours, full effect at 24h
  • Prothrombin Complex Concentrate (PCC, KCentra)
    • Concentrated clotting factors affected by warfarin (factors II, VII, IX and X)
    • Use: Any serious or life threatening bleed
    • VS FFP: PCC has a smaller volume, higher concentration of factors, complete reversal, only one dose in 24h, no need for thawing
    • PCC in the ER (Circulation. 2013;128:360)
      • Lower Adverse event: FFP:19.5% patients and PCC: 9.7%
      • PCC: faster time to reversal (5.7 to 11.8 hours) and about half as much blood transfused vs FFP
      • No increase in blood clots/DVT/PE
Pre Treatment INR2-44-6>6
Dose of 4-PCC (U/kg)253550
Max Dose25003500500
KCentra (4-Factor PCC) Dosing (FDA)

Guidelines for the Management of Supratherapeutic INR
Guidelines for the Management of Supratherapeutic INR

Read More About :

Journal Club: Delayed Bleed Risk in BHT

Study 1 (Ann Emerg Med 2012;59(6):460)

  • Immediate bleed higher with Clopidogrel:
    • Clopidogrel 12.0%; vs Warfarin 5.1%; (relative risk 2.3)
  • Delayed bleed only seen in Warfarin:
    • Warfarin: 0.6% (4 of 687 pts) vs Clopidogrel: 0% (0 of 243pts)
    • Patients with delayed bleeds on warfarin, all had a GCS of 15 and 50% died

Study 2 (Ann Emerg Med 2012;59:451)

  • Prospective case series of patients with BHT on warfarin with normal initial CT
  • 6% (5 pts) delayed bleed risk on repeat CT, only 1 had neuro changes
  • 2% returned with bleeds even after the 24 hour observation period and two negative head CTs.
  • The relative risk of delayed hemorrhage with an initial INR > 3.0 was 14 (RR = 14)

Special Populations

  • Loss of Consciousness
    • Increased prevalence of injury but not present as an independent predictor when control for other variables
    • Do not use as indicator for CT imaging
  • Seizure
    • Not associated with increased prevalence of injury
    • Infrequently seen, difficult to assess if truly had a seizure vs syncope
  • Intoxication
    • Decreased prevalence of injury → likely because of over-imaging intoxicated patients
    • Need to improve risk stratification
  • Elderly
    • High prevalence of occult head injury and delayed bleeds
    • Does not require high mechanism of injury (usually GLF) and increased use of anticoagulants
    • Have low threshold for CT, admission, correction of coagulopathy and re-imaging
  • Normal CT
    • Altered Mental Status on presentation → concern for Diffuse Axonal Injury (DAI)
    • Coagulopathy → Observation for delayed intracranial hemorrhage vs Discharge home with strict return precautions

Concussion

Diagnosis

  • Symptoms: somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and/or emotional symptoms (e.g. lability)
  • Physical signs (e.g. loss of consciousness (LOC), amnesia)
  • Behavioral changes (e.g. irritability)
  • Cognitive impairment (e.g. slowed reaction times)
  • Sleep disturbance (e.g. insomnia)

On-field evaluation

  • Concussion assessment using SCAT3, SAC or other assessment tool
  • Serial monitoring and NO Return To Play (RTP) on same day

Treatment

  • Physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and RTP
  • Graduated RTP (Return To Play) protocol
    • 6 step program, each step lasting 24h → RTP in 7 days
    • Must be symptoms free 24h to go to next step
  • Second impact syndrome.
    • Diffuse cerebral edema if the patient experiences a second concussion while still symptomatic from the first concussion → increased ICP → coma/death.
    • Rare: 1.5 deaths/yr
  • Post-concussion syndrome: persistence of symptoms > 3 months

Gradual RTP (Return To Play) Steps

No activity
Light aerobic exercise
Sport-specific exercise
Non-contact training drills
Full-contact practice
Return to play

References

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