52 Articles: Head CT in Minor Trauma

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:

Haydel et al., NEJM 2000.  Indications for Computed Tomography in Patients with Minor Head Injury.

Main Points:

1. This two-phase prospective trial sought to “derive and validate a set of clinical criteria that could be used to identify patients with minor head trauma in whom a head CT (HCT) could be foregone.”

2. “Minor head trauma” was defined as: loss of consciousness in a patient presenting with GCS 15, intact cranial nerves, and normal strength and sensation in all extremities.

3.  The presence of at least one of the following: Headache, vomiting, age >60 years old, drug/alcohol intoxication, short-term memory deficit, evidence of trauma above the clavicles, or post-traumatic seizure, was found to be 100% sensitive for subsequently positive HCT (presence of cerebral contusion, subdural or epidural hematoma, depressed skull fracture, or subarachnoid or intraparenchymal hemorrhage).

Background:

Since the advent of CT in the 1970s, many studies have sought to determine the most efficient and best use of this powerful tool for minor head trauma.  Early studies of HCT on patients with GCS 13-15 showed 17-20% incidence of positive findings and recommended HCT for all, but subsequent studies have shown positive HCT findings in GCS 15 patients to be as low as 6-9%.  Historically in the USA, ~66% of annual head trauma is “minor,” ~10% of this group will have positive HCTs, and ~1% will require neurosurgery.  This begs the question: is there a subset of minor head trauma patients for whom HCT adds little or no value?  Could we save time, money, and risk of complications for all participants if we could identify these patients based on clinical presentation? 

Method:

The study occurred at a large urban Level 1 trauma center from 1997 to 1999, and was split into two phases.  Phase 1 enrolled 520 consecutive patients with minor head trauma who were over 3 years old, presenting <24 hours since the trauma, getting a HCT already, and had “minor head trauma,” defined as a loss of consciousness in a patient with a GCS of 15, normal cranial nerves, and normal strength and sensation in all extremities.  No patients who did not lose consciousness or who declined HCT were included, and the CT scan was considered “positive” if it showed a cerebral contusion, subdural or epidural hematoma, subarachnoid, depressed skull fracture, or intraparenchymal hemorrhage.

Seven clinical variables from Phase 1 were found to correlate with positive HCT findings, and their predictive value was prospectively assessed in Phase 2, which enrolled 909 patients with the same inclusion criteria as Phase 1.  Importantly, the Phase 2 patients still received normal trauma care, with HCTs ordered at the discretion of the providers whether or not any of the Phase 1 variables were present; the researchers were simply validating the Phase 1 criteria again.

Results:

●        Phase 1 (520 patients)

○        36 patients (6.9%) had positive HCTs

○        Predictive Variables: Headache, vomiting, age >60, post-traumatic seizure, short-term memory deficit, drug/alcohol intoxication, and evidence of trauma above the clavicles. Of note, "short-term memory deficit + drug/alcohol intoxication + evidence of trauma above the clavicles” were the strongest predictors: If they had scanned ONLY the patients who had all 3 of these combined, the number of scans would have decreased 31%, and sensitivity would still have been 94%

●        Phase 2 (909 patients)

○        57 patients (6.3%) had positive HCTs

○        All patients with positive findings had at least 1 of the seven Phase 1 variables (sensitivity 100% [95% CI 95-100], specificity 25%, NPV 100%)

○        All 212 patients (23.3%) with ZERO Phase 1 variables had negative HCTs (20-26%, 95% CI; NPV 100%)

●        Of 93 patients from both Phases who had positive HCTs (total % → % obs, % surgery):

○        Cerebral Contusion: 47% →  100%, 0% 

○        SDH: 38% → 94%, 6%

○        SAH: 14% → 100%, 0%

○        Epidural: 10% → 78%, 22%

○        Depressed Skull Fracture: 11% → 80%, 20%

Discussion:

●        Historically, lots of head trauma (66%) is minor, with few (~10%) of these patients having positive HCTs, and even fewer (~1%) requiring neurosurgery.  So there is fat to trim.

●        In this study alone, if the criteria derived in Phase 1 had been applied to the Phase 2 patients (ie, “do not scan if zero variables are present”), the number of HCTs would have decreased by 22% with no additional missed findings. This certainly has broader implications when considering the trajectory of our healthcare spending as a percentage of GDP…. which is essentially like the SpaceX Falcon 9 rocket, which has 9 liquid oxygen engines and can generate 1.5 million pounds of thrust at sea level.

○        The study quotes one estimate that a 10% reduction in the number of HCTs in minor head trauma patients would save >$20,000,000 per year

●        This was the first study to derive predictors that were 100% sensitive for positive HCTs, but it is important to note a few caveats:

○        The 95% Confidence Interval of “95-100%” for the sensitivity of their variables indicates that when generalized to the great big world, there is a chance that these predictors will no longer be perfect

○        “Positive CT findings” obviously does not necessarily equate with morbidity or mortality.  Whether we should try to find CT findings or those lesions that require intervention is a broader, and more controversial, topic.  This study simply sought to attain 100% sensitivity for HCT findings with a high degree of confidence.  They provide no information on the clinical significance of these findings as far as mortality or functional outcome.

●        Bottom line: Holding the clinical significance of lesions and a discussion on the sensitivity of HCT aside, discharging patients home after minor head trauma with a negative HCT and a normal neurological exam is generally supported in the literature.  If the variables these investigators are promoting help to identify patients who are exceedingly unlikely to benefit from receiving a HCT, and it saves everyone money, time and some risk of complications, then let’s consider it the next time someone comes in after being struck in the face by a feather.

Level of Evidence:

Based on the ACEP grading system for therapeutic questions this study was graded a level I.

Reviewers:

Resident Reviewer: Dr. Anatoly Kazakin
Faculty Reviewer: Dr. Matt Siket

Source Article:

Haydel et al. Indications for Computed Tomography in Patients with Minor Head Injury. N Engl J Med.  2000 July;343(2);100-105.

ED Throughput and #POCUS for Ectopic/IUP

Here’s the next study that was reviewed by Dr Tom Jelic at the latest EDE 3 Online Journal Club. It is a study by Wilson and his colleagues in California. They looked at the difference in ED length of stay when the pelvic ultrasound was done in radiology vs. when it was done by the emergency physician. See below for further discussion on the topic.

 

There are quite a number of studies (Burgher, Blaivas, Rodgerson) that have looked at the effect of POCUS on throughput vs. elective ultrasound in the past. The extra 2 hours for the elective ultrasound is pretty standard.

Let’s flesh out pelvic ultrasound a bit more and look at some barriers.

The first barrier is having an endocavitary probe. There are a number of EDs in Canada that have run into resistance in trying to get this probe. This include some academic EDs and even one entire province. The details vary from place to place, but in the end, these attempts at blockage have one common feature. They are bogus.

Another perceived barrier is time. In light of the study by Wilson, this is paradoxical. It takes no more than 2 minutes to perform a pelvic POCUS. This was shown in this study a few years ago. Yet the perception among some emergency physicians is that it is more time-consuming than that. If you spend the 2 minutes doing the scan, you will save about 2 hours on the patient’s ED length of stay, because in most cases, the patient will not require an elective ultrasound during that visit.

In some EDs, as in the emergency department in Sudbury, the endocavitary probe is kept locked up as part of the cleaning process. Although it sounds like a big barrier to its use, it shouldn’t be. In our ED, the probe is properly cleaned by a ward aide. It is then locked in a cabinet in close proximity to that part of our ED where we are most likely to use it. When we need it, we just request that the ward aide bring the probe to the patient’s room. Practically speaking, the most efficient way to get that done and still maintain flow is to request the probe, then go see another patient, then go back and do the scan. In most cases, you can then discharge the patient home.

Új és időszerű „verziót” kapott a Surviving Sepsis irányelvA…



Új és időszerű „verziót” kapott a Surviving Sepsis irányelv


A SSG legutóbbi teljes kiadása 2012-ben volt, azóta a Process, Promise és Arise vizsgálatok miatt szükségessé vált a kötelező Early Goal Directed Therapy (EGDT) eltávolítása, ezért 2015-ben rövid frissítéssel bekerült helyette vagy inkább mellé az echokardiográfia és a dinamikus folyadék reszponzivitás használata.


Személyes vélemény következik:Először 2012-ben olvastam az SSGt. Először voltam intenzív osztályon és érdekes, hasznos irányelvnek tűnt. Kicsit jobban elmélyedve és az idő múlásával azonban a következő komoly problémáim voltak vele:

  1. Túl széles körül. A szepszis kezelése mellett olyan dolgokról tartalmazott ajánlásokat, mint az ARDS lélegeztetés, táplálás, trombózis profilaxis vagy a stressz ulcus profilaxis. Ebből a szempontból ez volt az „Intenzíves” irányelv.
  2. Nem követte a klnikumban és best practice-ben bekövetkező változásokat. Már 2012-ben sem volt „trendi” szeptikus sokkot szigorú EGDT alapján kezelni, ha lehetett mindenki hemodinamikai monitort használt és józan paraszti észt. Nem véletlenül. Már akkor nyilvánvaló volt, hogy a lényeg a korai folyadék, hemokultúra, antibiotikum a sürgősségin, majd később „gondolkodós” folyadék-vazopresszor terápia az ITOn. Ebből a szempontból „Sürgősségis” irányelv volt, ahol még ugye nem áll rendelkezésre hemodinamikai monitor.
  3. A vazopresszorokról és szteroidokat illető ajánlása homályos volt, amit mindenki máshogy értelmezett.

Lássuk, mennyiben változott ez 2016-ban. Fontos megjegyezni, hogy a konkrét ajánlásokon kívül, ami meglehetősen riasztó olvasmány, van egy külön megjelent „magyarázat” is, ami nem az evidenciák felsorolása, hanem kontextusába helyezi, értelmezi a javaslatokat. Ez is bele lesz szőve a következő összegzésbe.

Folyadék terápia

Milyen folyadék?

  • Egyértelműen krisztalloidok javasoltak (erős javaslat, közepes evidencia), ez lehet 0.9% NaCl és balanszírozott oldat is. Albumin gyenge javaslatként került be, ha nagy mennyiségű krisztalloidra van szükség.

  • Adagolás?
  • A „kemény” ajánlás, hogy folyadék bolus formájában, kb 30ml\kg javasolt, viszont a már említett „magyarázatban” hasznos ábrát találunk.
  • Ha a betegünk nem szorul oxigénra, nem szívelégtelen és nem dializált vesebeteg, bátran adhatunk neki 2 liter folyadékot. Ha ezek valamelyik fennáll, akkora korai intubációt és\vagy óvatos adagolást javasol az oxigenizáció és szöveti perfúzió gyakori megfigyelésével.
  • Nincs többé EGDT és 6 órás célok, ki-ki válogathat helyette kedvenc reszuszcitációs céljaiból: BP, HR, UO, ScVO2, CVP, PPV, Laktát, Echo egyéb dinamikus folyadékreszponzivitás markerek.

  • Vazopresszorok

    • A „kemény” ajánlásban, nincs érdemi változás. Első választás noradrenalin, amihez nagy dózis esetén vazopresszint vagy adrenalint lehet adni. Vesedózisú dopamin továbbra sem javasolt. Továbbra is javasolt Dobutamin szervhipoperfúzió jelei esetén, ha a folyadék és noradrenalin nem használ.
    • A „magyarázatban” található folyamatábrában kicsit konkrétabban fogalmaz.Ha 90mcg\min (70 kilóra 1.3mcg\kg\min) nem elegendő a 65-ös MAP fenntartására, akkor először adjunk Vasopressint, ha ez sem elégséges akkor kezdjünk szteroid terápiát és ha még így sem megy akkor adrenalint.
    • Valahogy még a végére a phenylephrine is odakerült miért…???

    És a „saláta ajánlások”

    • Antibiotikum: Továbbra is 7-10 napig javasolt antibiotikum adása, viszont bekerült, hogy bizonyos esetekben (effektív source control, uroszepszis) rövidebb is elég lehet. Itt külön megemlítik a prokalcitonin használatát erre a célra.Az antibiotikumokat tekintve, néhány magától értetődő javaslat kimaradt (pl. ha virális eredetűnek gondoljunk, adjunk antivirális szert), bekerült viszont a szöveges részben a béta laktámok folyamatos adagolása a kezdeti bolus után.
    • Transzfúzió: eddig 7-9 g\dl volt, most 7 felett, ha csak nincs súlyos hipoxémia, myokardiális iszkémia vagy akut vérzés. EPO és koagulopátia kezelésében nincs változás.
    • Szteroidok: nincs változás, ld. fentebb 
    • Továbbra is szerepelnek benne ilyen-olyan lélegeztetési javaslatok.
    • A vesepótló kezelésekkel kapcsolatban, nem javasolja a filtráció megkezdését csak oliguria vagy magas kreatinin alapján, csak „kemény” indikációk után.
    • Táplálás: minimiális változás, hogy nem javasolt a hasi reziduális volumen rutin monitorozása, csak akiknél látjuk, hogy nem tolerálják a táplálást. Használjunk prokinetikumokat és NJ szondát ha kell.

    Összefoglalva

    Az irányelv időszerű frissítést kapott, az elmúlt évek releváns eredményeit mind tartalmazza.Nincs többé EGDT, helyette – helyesen – nem újabb protokollt gyártottak, hanem ki-ki tapasztalata, a beteg és elérhetőség alapján megválaszthatja legmegfelelőbb módszert a folyadék-vazopresszor terápia vezetésére. Szimpatikus viszont, hogy a „magyarázat” jó és praktikus kiindulópont ebben a kérdésben, viszont nem tették kötelezővé.

    (Csak halkan jegyzem meg, hogy továbbra is fölöslegesnek tűnik tengernyi saláta javaslat, melyek csak igen lazán kapcsolódnak a témához.)


    http://journals.lww.com/ccmjournal/Abstract/publishahead/Surviving_Sepsis_Campaign___International.96723.aspx

    Magyarázat:

    http://link.springer.com/article/10.1007/s00134-017-4681-8

    Another Failure Of Shotgun Style Diagnostic Testing: The Trauma Incidentaloma

    When our patients present with a problem, there is a time honored and well-defined sequence to help us come to a final diagnosis.

    • Take a detailed history
    • Examine the patient
    • Order pertinent diagnostic tests, if indicated
    • Then think about it a while

    The first two items are a chip shot, and the trauma professional can gain a lot of information by spending a relatively short period of time doing these. And many times the diagnosis can be made without any further action.

    However, diagnostic testing of all kinds has become so prevalent and easy to obtain that we rely on it a bit too much. And sometimes, we order it up in lieu of a thorough history and exam. If the clinician skimps on those steps, it’s much more difficult to narrow the list of differential diagnoses to a manageable number.

    So what happens then? They use diagnostic tests as a crutch. Instead of being able to select a few focused tests to answer the questions, they essentially put an order sheet on the wall, fire off a shotgun, and order everything that’s been hit by the pellets.

    Lots of tests, so they will definitely find the answer, right? Nope! There are two major problems here. First, the so-called signal to noise ratio is very low. There are so many results, that it is easy to overlook a pertinent positive among all the negatives.

    But more significantly, there is always the possibility that there will be more than one positive. One of them might actually be the answer you were seeking. But what about the others? There are the trauma incidentalomas. Some may be truly positive, but there is always the possibility of a false positive. These are the most treacherous, because many trauma professionals then feel obligated to “do something about it.”

    As we have found from multiple screening tests like PSA, PAP smear, and mammography, a significant number of patients may be harmed trying to further investigate what turns out to be nothing at all (artifact), or something completely benign. This includes not only harm from complications or unnecessary procedures, but months of anxiety the patient may suffer while the clinicians figure out what that thing inside them really is.

    There are only a few studies on trauma incidentalomas available. One reviewed a series of almost 600 head CT scans in patients with TBI and found unexpected findings on 85%. About 90% were obviously benign. Unfortunately, it was not possible to follow these patients to find out how many of the remaining lesions turned out to be benign as well. But I would wager that most did.

    Bottom line: I shouldn’t even have to say this, but do a good history and physical exam! If you need diagnostic studies, order only the one(s) that have the potential to make your final diagnosis. Don’t shotgun it. One very helpful tool is a well-designed practice guideline for commonly encountered clinical scenarios. This will limit the number of “other” findings you have to deal with. And finally, did I say to do a good history and physical exam?

    Related posts:

    Reference: Incidental cranial CT findings in head injury patients in a Nigerian tertiary hospital. J Emerg Trauma Shock 8(2):77-82, 2015.

    Source: http://thetraumapro.com/2017/01/19/another-failure-of-shotgun-style-diagnostic-testing-the-trauma-incidentaloma/