Traumatic intracranial injury in intoxicated patients with minor head trauma

Overuse of computed tomography for mild head injury: A systematic review and meta-analysis

BACKGROUND

Computed tomography (CT) scan is a common imaging technique used to evaluate the severity of a head injury. The overuse of diagnostic interventions in the health system is a growing concern worldwide. Objectives: The aim of this systematic review is to investigate the rate of CT scan overuse in cases of mild head injury.

METHODS

Eligibility criteria: We encompassed observational studies-either designed as cohort, case-control, or cross-sectional investigations-that reported on CT scan overuse rates for mild head injuries. Studies had to be published in peer-reviewed, English-language sources and provide full content access Information sources: Web of Sciences, Scopus, Medline via PubMed, the Cochrane Library and Embase were searched from inception until April 1, 2023. Studies were included if reporting the overuse of CT scans for mild head injuries using validated criteria. Risk of bias: We used the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool to evaluate the risk bias assessment of included studies. Two independent reviewers evaluated the eligibility of studies, extracted data, and assessed study quality by using the Newcastle-Ottawa Scale. Synthesis of results: Overuse estimates were calculated using a random-effects model. Subgroup analyses were performed to investigate any sources of heterogeneity. Point rate of overuse of CT scans for mild head injuries was the main outcome measured as percentage point estimates with corresponding 95% CIs.

RESULTS

Included studies: Of the 913 potentially relevant studies identified, eight studies were selected for the final analysis. Synthesis of results: The pooled rate of CT scan overuse in patients with mild head injury was found to be 27% [95% CI: 16-43; I2 = 99%]. The rate of CT scan overuse in mild head injury cases varied depending on the criteria used. The rate of CT scan overuse was 37% [95% CI: 32-42; I2 = 0%] with the Glasgow Coma Scale (GCS), 30% [95% CI: 16-49; I2 = 99%] with the Canadian computed tomography head rule, and 10% [95% CI: 8-14; I2 = 0%] with the Pediatric Emergency Care Applied Research Network criterion (PERCAN). Based on subgroup analyses, the rate of CT scan overuse in mild head injury cases was observed to be 30% with the Canadian computed tomography head rule criterion, 43% with the National Institute for Health and Clinical Excellence criterion, and 18% with the New Orleans criterion.

CONCLUSION

Limitations of evidence: The restricted number of included studies may impact generalizability. High heterogeneity was observed, leading to subgroup analyses based on age, assessment criteria, and study region. Absent data on overuse causes hinders drawing conclusions on contributing factors. Furthermore, this study solely addressed overuse rates, not associated harm or benefits. Interpretation: The overuse of CT scans in mild head injury patients is concerning, as it can result in unnecessary radiation exposure and higher healthcare costs. Clinicians and policymakers should prioritize the implementation of guidelines to reduce unnecessary radiation exposure, healthcare costs, and potential harm to patients.

TRIAL REGISTRATION

The study protocol of this review was registered in PROSPERO under the identification code CRD42023416080. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023416080.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury: Approved by ACEP Board of Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses Association (April 5, 2023)

This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.

Saturday Night Fever: Interpersonal Violence as a Reason for Presentation in a University Emergency Department

(1) Presentations to a trauma emergency department following a violent confrontation account for a relevant proportion of the overall population. To date, violence (against women) in the domestic setting has been studied in particular. However, representative demographic and preclinical/clinical data outside of this specific subgroup on interpersonal violence are limited; (2) Patient admission records were searched for the occurrence of violent acts between 1 January and 31 December 2019. A total of 290 patients out of over 9000 patients were retrospectively included in the "violence group" (VG). A "typical" traumatologic cohort (presentation due to, among other things, sport-related trauma, falls, or traffic accidents) who had presented during the same period served as comparison group. Then, differences in the type of presentation (pedestrian, ambulance, or trauma room), time of presentation (day of week, time of day), diagnostic (imaging) and therapeutic (wound care, surgery, inpatient admission) measures performed, and discharge diagnosis were examined; (3) A large proportion of the VG were male, and half of the patients were under the influence of alcohol. Significantly more patients in the VG presented via the ambulance service or trauma room and during the weekend and the night. Computed tomography was performed significantly more often in the VG. Surgical wound care in the VG was required significantly more often, with injuries to the head being the most common; (4) The VG represents a relevant cost factor for the healthcare system. Because of the frequent head injuries with concomitant alcohol intoxication, all mental status abnormalities should be attributed to brain injury rather than alcohol intoxication until proven otherwise, to ensure the best possible clinical outcome.

Clinical Characteristics Predict the Yield of Head Computed Tomography Scans among Intoxicated Trauma Patients: Implications for the Initial Work-up

Background and Aims:

Alcohol intoxication may confound the clinical assessment of the trauma patient. Head computed tomography (h-CT) is the standard imaging technique to rule out intracranial injury in most intoxicated trauma patients. The objective of this study was to determine whether certain clinical findings (computed clinical score [CCS]) could predict the h-CT yield, admission, and neurosurgical consultation (NSC) among intoxicated trauma patients.

Materials and Methods:

This is a 4-year retrospective cohort study (2013–2017) of trauma patients who presented to our level 1 trauma center emergency department with alcohol intoxication. For each patient, a computed clinical score (CCS) was generated based on the following findings: age ≥50 years, Glasgow Coma Scale <13, evidence of trauma above the clavicles, amnesia, loss of consciousness, headache, vomiting, and seizures. The primary endpoints were NSC, admission, and acute h-CT finding. Univariate and multivariate regressions were used to compare predictors of the primary endpoints.

Results:

We identified 437 intoxicated trauma patients (median age: 35 years [interquartile range: 25–50]; 71.9% men; median blood alcohol content: 207.8 mg/dL). One hundred and twenty-four (30.4%) patients had acute findings on h-CT, 351 (80.3%) were admitted, and 112 (25.6%) received NSC. On multivariate analysis, CCS was the only predictor of acute h-CT (odds ratio [OR] =1.6; 95% confidence interval [CI]: 1.3–2.0; P < 0.0001) and the best predictor of admission (OR = 1.6; 95% CI: 1.3–1.9; P < 0.0001) and NSC (OR = 1.8; 95% CI: 1.5–2.3; P < 0.0001).

Conclusions:

One-third of intoxicated trauma patients have acute findings on h-CT. While the CCS was the best predictor of acute h-CT findings, hospital admission, and NSC, h-CT scanning should continue to be a standard of care.

Characterizing the type and location of intracranial abnormalities in mild traumatic brain injury

OBJECTIVEThe incidence of intracranial abnormalities after mild traumatic brain injury (TBI) varies widely across studies. This study describes the characteristics of intracranial abnormalities (acute/preexisting) in a large representative sample of head-injured patients who underwent CT imaging in an emergency department.METHODSCT scans were systematically analyzed/coded in the TBI Common Data Elements framework. Logistic regression modeling was used to quantify risk factors for traumatic intracranial abnormalities in patients with mild TBIs. This cohort included all patients who were treated at the emergency department of the Tampere University Hospital (between 2010 and 2012) and who had undergone head CT imaging after suffering a suspected TBI (n = 3023), including 2766 with mild TBI and a reference group with moderate to severe TBI.RESULTSThe most common traumatic lesions seen on CT scans obtained in patients with mild TBIs and those with moderate to severe TBIs were subdural hematomas, subarachnoid hemorrhages, and contusions. Every sixth patient (16.1%) with mild TBI had an intracranial lesion compared with 5 of 6 patients (85.6%) in the group with moderate to severe TBI. The distribution of different types of acute traumatic lesions was similar among mild and moderate/severe TBI groups. Preexisting brain lesions were a more common CT finding among patients with mild TBIs than those with moderate to severe TBIs. Having a past traumatic lesion was associated with increased risk for an acute traumatic lesion but neurodegenerative and ischemic lesions were not. A lower Glasgow Coma Scale score, male sex, older age, falls, and chronic alcohol abuse were associated with higher risk of acute intracranial lesion in patients with mild TBI.CONCLUSIONSThese findings underscore the heterogeneity of neuropathology associated with the mild TBI classification. Preexisting brain lesions are common in patients with mild TBI, and the incidence of preexisting lesions increases with age. Acute traumatic lesions are fairly common in patients with mild TBI; every sixth patient had a positive CT scan. Older adults (especially men) who fall represent a susceptible group for acute CT-positive TBI.

Glial Fibrillary Acidic Protein (GFAP) Outperforms S100 Calcium-Binding Protein B (S100B) and Ubiquitin C-Terminal Hydrolase L1 (UCH-L1) as Predictor for Positive Computed Tomography of the Head in Trauma Subjects

OBJECTIVE

Traumatic brain injuries (TBIs) are largely underdiagnosed and may have persistent refractory consequences. Current assessments for acute TBI are limited to physical examination and imaging. Biomarkers such as glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase L1 (UCH-L1), and S100 calcium-binding protein B (S100B) have shown predictive value as indicators of TBI and potential screening tools.

METHODS

In total, 37 controls and 118 unique trauma subjects who received a clinically ordered head computed tomography (CT) in the emergency department of a level 1 trauma center were evaluated. Blood samples collected at 0-8 hours (initial) and 12-32 hours (delayed) postinjury were analyzed for GFAP, UCH-L1, and S100B concentrations. These were then compared in CT-negative and CT-positive subjects.

RESULTS

Median GFAP, UCH-L1, and S100B concentrations were greater in CT-positive subjects at both timepoints compared with CT-negative subjects. In addition, median UCH-L1 and S100B concentrations were lower at the delayed timepoint, whereas median GFAP concentrations were increased. As predictors of a positive CT of the head, GFAP outperformed UCH-L1 and S100B at both timepoints (initial: 0.89 sensitivity, 0.62 specificity; delayed: 0.94 sensitivity, 0.67 specificity). GFAP alone also outperformed all possible combinations of biomarkers.

CONCLUSIONS

GFAP, UCH-L1, and S100B demonstrated utility for rapid prediction of a CT-positive TBI within 0-8 hours of injury. GFAP exhibited the greatest predictive power at 12-32 hours. Furthermore, these results suggest that GFAP alone has greater utility for predicting a positive CT of the head than UCH-L1, S100B, or any combination of the 3.

Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication

STUDY OBJECTIVE

Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication.

METHODS

This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations.

RESULTS

We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0.

CONCLUSION

Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness.

Imaging of frequent emergency department users with alcohol use disorders

BACKGROUND

Patients with altered level of consciousness secondary to alcohol use disorders (AUDs) often undergo imaging in the emergency department (ED), although the frequency and yield of this practice over time are unknown.

STUDY OBJECTIVES

We describe the use of imaging, the associated ionizing radiation exposure, cumulative costs, and identified acute and chronic injuries and abnormalities among frequent users of the ED with AUDs.

METHODS

This is a retrospective case series of individuals identified through an administrative database having 10 or more annual ED visits in 2 consecutive years who were prospectively followed for a third year. International Classification of Diseases, 9(th) Revision, Clinical Modification and Current Procedural Terminology codes were used to select individuals with alcohol-related diagnoses, track imaging procedures, and calculate cost. Diagnoses, imaging results, and radiation exposure per computed tomography (CT) study were abstracted from the medical record.

RESULTS

Fifty-one individuals met inclusion criteria and had a total of 1648 imaging studies over the 3-year period. Subjects had a median of 5 (interquartile range [IQR] 2-10) CT scans, 20 (IQR 10-33) radiographs, 28.3 mSv (IQR 8.97-61.71) ionizing radiation, 0.2% (IQR 0.07-0.4) attributable risk of cancer, and $2979 (IQR 1560-5440) in charges using a national rate. The incidence of acute fracture or intracranial head injury was 55%, and 39% of the cohort had a history of moderate or severe traumatic brain injury.

CONCLUSION

The remarkable use of imaging and occurrence of injury among these highly vulnerable and frequently encountered individuals compels further study to refine clinical practices through the development of evidence-based, effective interventions.