II. General

  1. Image all moderate and severe head injuries
  2. Head CT indicated in only select Mild Head Injury
  3. Recommendations listed here are for adults

III. Protocol: Canadian CT Head Rule (for Mild Head Injury)

  1. See Management of Mild Head Injury for definition
  2. Exclusion criteria (cases in which rules cannot be applied and in which head imaging is typically pursued)
    1. Neurologic deficit
    2. Seizure
    3. Oral Anticoagulant use or other Bleeding Diathesis
  3. Efficacy
    1. Test Sensitivity: Approaches 100%
    2. Test Specificity: 50% (significantly better Specificity than New Orleans or NEXUS rules)
    3. Reduces unnecessary Head CTs and increases diagnostic yield
      1. Sharp (2017) Ann Emerg Med 71(1):54-63 +PMID:28739290 [PubMed]
  4. High risk indications for Head CT
    1. Glasgow Coma Scale <15 at 2 hours after injury
    2. Open or depressed Skull Fracture
    3. Vomiting (Two or more episodes)
    4. Age 65 years or over (other studies suggest age 60)
    5. Basal Skull Fracture signs
      1. Hemotympanum
      2. Periorbital Bruising (Raccoon's Eyes)
      3. Mastoid process Ecchymosis (Battle's Sign)
      4. Cerebrospinal Fluid Leakage from ear or nose
  5. Moderate risk indications for Head CT
    1. Pre-trauma Amnesia lasting longer than 30 minutes
    2. High risk mechanism of injury
      1. Pedestrian in Motor Vehicle Accident
      2. Passenger ejected from vehicle
      3. Fall from height over 3 feet or 5 stairs
  6. References
    1. Stiell (2001) Lancet 357:1394 [PubMed]

IV. Protocol: New Orleans Head CT Indications (for Mild Head Injury)

  1. Inclusion criteria
    1. Age over 18 years old
    2. Glasgow Coma Scale 15
    3. Blunt Head Trauma occurring within the prior 24 hours and resulting in loss of consciousness, Amnesia, or Disorientation
  2. Head CT is NOT indicated if ALL of the following criteria ABSENT
    1. Headache
    2. Vomiting
    3. Age over 60 years old
    4. Drug Intoxication or Alcohol Intoxication
    5. Short Term Memory deficits (persistent Anterograde Amnesia)
    6. Physical evidence of Trauma above the clavicles
    7. Seizure
  3. References
    1. Haydel (2000) N Engl J Med 343: 100-105 [PubMed]

V. Protocol: Additional Head CT Indications (from other studies)

  1. Drug or Alcohol Intoxication
  2. Physical findings of Trauma above clavicle
  3. Seizure
  4. Focal neurologic deficit
  5. Oral Anticoagulant (e.g. Warfarin, Plavix) use or other Coagulopathy
    1. Even Minor Head Injury on oral Anticoagulants is associated with a significant risk of bleeding
      1. Often without typical red flag findings
      2. Nishijima (2012) Ann Emerg Med 59(6): 460-8 [PubMed]
    2. Warfarin is associated with delayed Intracranial Bleeding in 6% of patients at 24 hours
      1. Bleeding may be delayed as long as 1 week after Head Injury (esp. with supratherapeutic INR )
      2. Menditto (2012) Ann Emerg Med 59(6): 451-5 [PubMed]

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