Head trauma: When to CT adults and kids in EDNZ guidelines

Anna WaterfieldED RMO

June 2014

Alternative guidelines Canadian CT head rules Stiell IG et al, Ann

Emerg Med 2001

New Orleans Haydel et al, NEJM 2000

NEXUS II Mower et al, J Trauma, 2005

PECARN Lancet 2009

Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation, ACC evidence-based best practice guideline summary, March 2007, updated 2013

NZ Guidelines NZ Guidelines Group, ACC funded Includes pre-/post-hospital care Clinically significant: ‘need for

intervention/care/support’

Classification:Severity of TBI GCS

Mild 13-15

Moderate 9-12

Severe 3-8

Traumatic Brain Injury

Acute brain injury for external force with one or more of: Confusion or disorientation Loss of consciousness Post-traumatic amnesia Focal neurological signs Seizure Intracranial lesion

When to CT adultsAny TBI TBI + LOC/anterograde

amnesia

GCS<13/GCS 13-14 2h post-injury

Age >65

Any deterioration in GCS Coagulopathy

Suspected open/depressed/basal #

High risk MOI e.g. pedestrian vs car, ejected from vehicle, fall > 1m / 5 stairs

Seizure (unless recovery is prompt and complete)

Focal neurology

>1 vomit

Retrograde amnesia >30min

. “The decision to CT scan should be applied regardless of the influence of intoxication”

When to CT kids0-16 years <2 years – additional risk

factors

Post-injury adverse features e.g. focal neurology/seizure (except immediate seizure)

Occipital/temporal/parietal soft tissue injury – swelling/haematoma

GCS<13 or any decrease

Skull #

NAI

Fall >1m or >5 stairs (less if younger)

Lethargic/irritable

Repeat CT in adults/kids? New severe/increasing headache or

persistent vomiting

New agitation/abnormal behaviour >30 min 1 point drop in GCS >2 GCS points drop New/evolving neurology

First CT NAD + GCS<15 after 24h

Summary All guidelines similar Instinct Resources incl. seniors/specialists Beware:

◦Iatrogenic anticoagulation◦Infants◦Insidious deterioration◦Intoxication