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The Rational Clinical Examination |

Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma?  The Rational Clinical Examination Systematic Review

Joshua S. Easter, MD, MSc1,2; Jason S. Haukoos, MD, MSc3,9; William P. Meehan, MD4,5; Victor Novack, MD, PhD6,7; Jonathan A. Edlow, MD8
[+] Author Affiliations
1Department of Emergency Medicine, Richmond Emergency Physicians, Bon Secours St Mary’s Hospital, Richmond, Virginia
2Department of Emergency Medicine, University of Virginia, Charlottesville
3Department of Emergency Medicine, Denver Health, University of Colorado, Denver
4The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
5Brain Injury Center, Boston Children’s Hospital, Boston, Massachusetts
6Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
7Faculty of Health Sciences, Ben Gurion University of the Negev, Israel
8Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
9Department of Epidemiology, Colorado School of Public Health, Aurora
JAMA. 2015;314(24):2672-2681. doi:10.1001/jama.2015.16316.
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Published online

Importance  Adults with apparently minor head trauma (Glasgow Coma Scale [GCS] scores ≥13 who appear well on examination) may have severe intracranial injuries requiring prompt intervention. Findings from clinical examination can aid in determining which adults with minor trauma have severe intracranial injuries visible on computed tomography (CT).

Objective  To assess systematically the accuracy of symptoms and signs in adults with minor head trauma in order to identify those with severe intracranial injuries.

Data Sources  We performed a systematic search of MEDLINE (1966-2015) and the Cochrane Library to identify studies assessing the diagnosis of intracranial injuries.

Study Selection  Studies were included that measured the performance of findings for identifying intracranial injury with a reference standard of neuroimaging or follow-up evaluation. Fourteen studies (range, 431-7955 patients) met inclusion criteria with patients having GCS scores between 13 and 15 and 50% or more older than 18 years.

Data Extraction and Synthesis  Three authors independently performed critical appraisal and data extraction.

Results  The prevalence of severe intracranial injury (requiring prompt intervention) among the 23 079 patients with minor head trauma was 7.1% (95% CI, 6.8%-7.4%) and the prevalence of injuries leading to death or requiring neurosurgical intervention was 0.9% (95% CI, 0.78%-1.0%). The presence of physical examination findings suggestive of skull fracture (likelihood ratio [LR], 16; 95% CI, 3.1-59; specificity, 99%), GCS score of 13 (LR, 4.9; 95% CI, 2.8-8.5; specificity, 97%), 2 or more vomiting episodes (LR, 3.6; 95% CI, 3.1-4.1; specificity, 92%), any decline in GCS score (LR range, 3.4-16; specificity range, 91%-99%;), and pedestrians struck by motor vehicles (LR range, 3.0-4.3; specificity range, 96%-97%) were associated with severe intracranial injury on CT. Among patients with apparent minor head trauma, the absence of any of the features of the Canadian CT Head Rule (≥65 years; ≥2 vomiting episodes, amnesia >30 minutes, pedestrian struck, ejected from vehicle, fall >1 m, suspected skull fracture, or GCS score <15 at 2 hours) had an LR of 0.04 (95% CI, 0-0.65), lowering the probability of severe injury to 0.31% (95% CI, 0%-4.7%). The absence of all the New Orleans Criteria findings (>60 years, intoxication, headache, vomiting, amnesia, seizure, or trauma above the clavicle) had an LR of 0.08 (95% CI, 0.01-0.84), lowering the probability of severe intracranial injury to 0.61% (95% CI, 0.08%-6.0%).

Conclusions and Relevance  Combinations of history and physical examination features in clinical decision rules can identify patients with minor head trauma at low risk of severe intracranial injuries. Certain findings, including signs of skull fracture, GCS score of 13, 2 or more vomiting episodes, decrease in GCS score, and pedestrians struck by motor vehicles, may help identify patients at increased risk of severe intracranial injuries.

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Figure 1.
Signs of Basilar Skull Fracture
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Figure 2.
Subdural Hemorrhage on Head–Computed Tomographic Scan

Single slice of noncontrast computed axial tomographic scan of the head showing a small acute hematoma (arrows) without any mass effect in the middle cranial foss on the patient’s right side.

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Figure 3.
Evaluation of Patients With Potential Head Traumaa

aThese recommendations are intended to provide general support for decision making and should not replace clinical judgment. CT indicates computed tomography; GCS, Glasgow Coma Scale.

bDangerous mechanisms is a pedestrian struck by a vehicle, an occupant ejected for a motor vehicle, or a fall from elevation of more than 1 m or 5 stairs.

cThe decision to discharge, observe or order a CT scan depends on the setting, clinician’s judgement about the likelihood of injury, patient preference, number of features present, and the particular features present.

dThe Canadian CT Head Rule includes age 65 years or older, dangerous mechanism, vomiting more than once, amnesia for more than 30 minutes, GCS score of less than 15 at 2 hours, or a skull fracture.

eThe New Orleans Criteria includes older than 60 years, intoxication, headache, any vomiting, seizure, amnesia, visible trauma above the clavicle.

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