II. General
- Image all moderate and severe head injuries
- Head CT indicated in only select Mild Head Injury
- Recommendations listed here are for adults
III. Protocol: Canadian CT Head Rule (for Mild Head Injury)
- See Management of Mild Head Injury for definition
- Exclusion criteria (cases in which rules cannot be applied and in which head imaging is typically pursued)
- Neurologic deficit
- Seizure
- Oral Anticoagulant use or other Bleeding Diathesis
- Efficacy
- Test Sensitivity: Approaches 100%
- Test Specificity: 50% (significantly better Specificity than New Orleans or NEXUS rules)
- Reduces unnecessary Head CTs and increases diagnostic yield
- High risk indications for Head CT
- Glasgow Coma Scale <15 at 2 hours after injury
- Open or depressed Skull Fracture
- Vomiting (Two or more episodes)
- Age 65 years or over (other studies suggest age 60)
- Basal Skull Fracture signs
- Hemotympanum
- Periorbital Bruising (Raccoon's Eyes)
- Mastoid process Ecchymosis (Battle's Sign)
- Cerebrospinal Fluid Leakage from ear or nose
- Moderate risk indications for Head CT
- Pre-trauma Amnesia lasting longer than 30 minutes
- High risk mechanism of injury
- Pedestrian in Motor Vehicle Accident
- Passenger ejected from vehicle
- Fall from height over 3 feet or 5 stairs
- References
IV. Protocol: New Orleans Head CT Indications (for Mild Head Injury)
- Inclusion criteria
- Age over 18 years old
- Glasgow Coma Scale 15
- Blunt Head Trauma occurring within the prior 24 hours and resulting in loss of consciousness, Amnesia, or Disorientation
-
Head CT is NOT indicated if ALL of the following criteria ABSENT
- Headache
- Vomiting
- Age over 60 years old
- Drug Intoxication or Alcohol Intoxication
- Short Term Memory deficits (persistent Anterograde Amnesia)
- Physical evidence of Trauma above the clavicles
- Seizure
- References
V. Protocol: Additional Head CT Indications (from other studies)
- Drug or Alcohol Intoxication
- Physical findings of Trauma above clavicle
- Seizure
- Focal neurologic deficit
- Oral Anticoagulant (e.g. Warfarin, Plavix) use or other Coagulopathy
- Even Minor Head Injury on oral Anticoagulants is associated with a significant risk of bleeding
- Often without typical red flag findings
- Nishijima (2012) Ann Emerg Med 59(6): 460-8 [PubMed]
- Warfarin is associated with delayed Intracranial Bleeding in 6% of patients at 24 hours
- Bleeding may be delayed as long as 1 week after Head Injury (esp. with supratherapeutic INR )
- Menditto (2012) Ann Emerg Med 59(6): 451-5 [PubMed]
- Even Minor Head Injury on oral Anticoagulants is associated with a significant risk of bleeding