Repeat Head CT? Not Necessary for Patients with a Negative Initial Head CT on Anticoagulation or Antiplatelet Therapy Suffering Low-Altitude Falls

2017 ◽  
Vol 83 (5) ◽  
pp. 429-435 ◽  
Author(s):  
Zachary M. Bauman ◽  
John M. Ruggero ◽  
Sunny Squindo ◽  
Chris Mceachin ◽  
Michelle Jaskot ◽  
...  
Keyword(s):  
Head Trauma ◽  
Intracranial Hemorrhage ◽  
Trauma Center ◽  
Statistical Significance ◽  
Close Monitoring ◽  
Trauma Centers ◽  
Head Ct ◽  
Level Ii ◽  
Low Altitude ◽  
Related Mortality

Anticoagulation and antiplatelet (ACAP) medications are increasingly prescribed to patients at high risk for falls. Many trauma centers have developed protocols for obtaining repeat head CT (HCT) for patients with low-altitude falls on ACAP therapy. We assess the need for routine scheduled repeat HCT in this population. Prospective, observational analysis of all low-altitude fall (<6 feet) patients on ACAP therapy evaluated at a Level II trauma center. All low-altitude fall patients with visible or suspected head trauma received an initial HCT. Patients were admitted and repeat HCT was obtained 12 hours later or earlier if acute neurologic decline developed. Chisquared, Fischer exact, t, and Wilcoxon rank-sum tests were used. Statistical significance was defined as P < 0.05. Total of 1501 patients enrolled suffering low-altitude falls with initial HCT. Among them 1379(91.2%) were negative and 122(8.1%) were initially positive for intracranial hemorrhage. Mean age was 79.9 ± 11.4 years, 61 per cent were female and 85 per cent had visible head trauma at presentation. One hundred ninety-nine were excluded secondary to not receiving repeat HCT. Of the 1180 patients with normal initial HCT who underwent repeat HCT, only 7 (0.51%) had delayed intracranial hemorrhage. None of these patients required surgery, major changes in medical management or suffered head trauma–related mortality; 69 per cent were taking aspirin (acetylsalicylic acid, ASA), 19 per cent warfarin, 17 per cent clopidogrel, 6 per cent other anticoagulants, and 11 per cent were on combination therapy. Repeat HCT for patients on any ACAP therapy after low-altitude fall with a negative initial HCT is not necessary. Thorough neurologic examination and close monitoring is as effective as obtaining a repeat HCT.

scholarly journals ADHERENCE TO THE PECARN PEDIATRIC HEAD INJURY RULE IN TWO CANADIAN EMERGENCY SETTINGS

2018 ◽  
Vol 23 (suppl_1) ◽  
pp. e9-e10
Author(s):  
Martin Gariepy ◽  
Jocelyn Gravel ◽  
Stéphane Turcotte ◽  
France Légaré ◽  
Edward Melnick ◽  
...  
Keyword(s):  
Head Injury ◽  
Head Trauma ◽  
Trauma Center ◽  
Retrospective Chart Review ◽  
Pediatric Emergency ◽  
General Level ◽  
Related Complication ◽  
Head Ct ◽  
Level Ii ◽  
Risk Of Cancer

Abstract BACKGROUND Head computerized tomography (CT) increases the risk of cancer in children and should be carefully prescribed to paediatric patients with head injury. The Pediatric Emergency Care Applied Network (PECARN) validated a rule to identify children at risk of a clinically important traumatic brain injury (TBI) needing a head CT. OBJECTIVES The objective was to evaluate adherence to the PECARN rule as a function of CT overuse (defined as a prescribed CT when not recommended by the rule) and underuse rates (no CT performed when recommended) in two Canadian emergency departments (EDs). DESIGN/METHODS We conducted a retrospective chart review of children under 17 years of age seen in 2016 in a paediatric Level I (site 1) and a general Level II (site 2) trauma center. We reviewed charts to determine the appropriateness of head CT use according to the PECARN rule in a random subset of children presenting with a head trauma. Mandatory inclusion criteria were (1) that the head trauma occurred in the 24 hours prior to arrival to the ED, (2) a GCS over 13 and (3) and at least one sign or symptom of minor TBI. Patients with a special condition that could have influenced the decision to order a head CT were automatically excluded. When a patient did not receive a head CT when recommended by the rule, we reviewed medical records to determine if the patient has returned to the ED after his discharge within the next 30 days. RESULTS 1546 eligible patients younger than 17 years consulted during the study period. Of the 203 randomly selected cases per setting, 16 (7.9%) and 24 (12%) respectively from sites 1 and 2 had a head CT performed. For the younger group (< 2), both overuse and underuse rates were below 3%. For the older group, overuse rates were higher in site 2 (9.3% (95%CI:4.8–17%) vs. 1.2% (95%CI:0.2–6.5%) (P=.03)) and there was no difference in underuse rates (22% (95%CI:6.3–55%) vs 39% (95%CI:18–65%) (P=.65)). For children who did not receive a head CT when recommended, none returned to the ED for a related complication. CONCLUSION Overall, even if there may be slightly more overuse of head CTs in the Level II trauma center, results showed an excellent agreement with the PECARN rule when CT was not recommended. However, results also showed a deviation when CT was recommended, where a higher portion of patients than expected did not receive a head CT. Reasons to explain this behaviour will need further exploration.

Is Repeated Head Computed Tomography Necessary for Traumatic Intracranial Hemorrhage?

2005 ◽  
Vol 71 (9) ◽  
pp. 701-704 ◽  
Author(s):  
Rob Schuster ◽  
Kenneth Waxman
Keyword(s):  
Risk Factors ◽  
Computed Tomography ◽  
Multivariate Analysis ◽  
Intracranial Hemorrhage ◽  
Trauma Center ◽  
Head Ct ◽  
Neurologic Status ◽  
Level Ii ◽  
Traumatic Intracranial Hemorrhage ◽  
Head Computed Tomography

This study was performed to determine the need for repeat head computed tomography (CT) in patients with blunt traumatic intracranial hemorrhage (ICH) who were initially treated nonoperatively and to determine which factors predicted observation failure or success. A total of 1,462 patients were admitted to our level II trauma center for treatment of head injury. Seventeen per cent (255/1,462) were diagnosed with ICH on initial head CT. Craniotomy was initially performed in 15.7 per cent (40/255) of patients with ICH. Two hundred sixteen patients with ICH were initially observed. Ninety-seven per cent (179/184) of observed patients with ICH and repeat head CT never underwent a craniotomy, 2.7 per cent (5/184) of patients with ICH initially observed underwent craniotomy after repeat head CT, and four patients (80%) had deteriorating neurologic status. Multivariate analysis revealed the following significant admission risk factors were associated with a need for repeat head CT indicating the need for craniotomy: treatment with anti-coagulation and/or antiplatelet medications, elevated prothrombin time (PT), and age greater than 70 years. In patients with blunt traumatic intracranial hemorrhage initially observed, there is little utility of repeated head CT in the absence of deteriorating neurologic status. The only admission risk factors for a repeat CT indicating the need for craniotomy were advanced age and coagulopathy.

Safety and efficacy of early thromboembolism chemoprophylaxis after intracranial hemorrhage from traumatic brain injury

2013 ◽  
Vol 119 (6) ◽  
pp. 1576-1582 ◽  
Author(s):  
Ali Farooqui ◽  
Bradley Hiser ◽  
Stephen L. Barnes ◽  
N. Scott Litofsky
Keyword(s):  
Traumatic Brain Injury ◽  
Pulmonary Embolism ◽  
Brain Injury ◽  
Intracranial Hemorrhage ◽  
Statistical Significance ◽  
Thromboembolic Disease ◽  
Safety And Efficacy ◽  
Head Ct ◽  
Routine Administration ◽  
Significant Difference

Object Patients with traumatic brain injury (TBI) are at risk for development of thromboembolic disease. The use of chemoprophylaxis in this patient group has not fully been characterized. The authors hypothesize that early chemoprophylaxis in patients with TBI is safe and efficacious. Methods In May 2009, a protocol was instituted for patients with TBI where chemoprophylaxis for thromboembolic disease (either 30 mg of Lovenox twice daily or 5000 U of heparin 3 times a day) was initiated 24 hours after an intracranial hemorrhage (ICH) was demonstrated as stable on head CT image. Two cohorts were evaluated: Cohort A included patients from May 2008 through April 2009 who had no routine administration of chemoprophylaxis, and Cohort B included patients from May 2009 through May 2010 after the protocol was instituted. The groups were compared, with the major outcomes being deep venous thrombosis (DVT), pulmonary embolism, and increase in size of ICH. Results Of the 312 patients with TBI who were seen during the study course, 236 patients met criteria for inclusion in the study: 107 patients in Cohort A and 129 patients in Cohort B. The DVT rate was 6 occurrences (5.61%) in Cohort A and 0 occurrences (0%) in Cohort B, which was a statistically significant difference (p = 0.0080). Pulmonary embolism was found in 4 patients (3.74%) in Cohort A and 1 patient (0.78%) in Cohort B, a difference that did not reach statistical significance (p = 0.18). Three instances (2.8%) in Cohort A and 1 instance (0.7%) in Cohort B of increased ICH occurred after starting anticoagulation for chemoprophylaxis; this was not statistically different (p = 0.33). Conclusions Use of chemoprophylaxis in TBI 24 hours after stable head CT is safe and decreases the rate of DVT formation.

Analysis of Hospital Ability to Provide Trauma Services: A Comparison between Teaching and Community Hospitals

1991 ◽  
Vol 6 (4) ◽  
pp. 455-458 ◽  
Author(s):  
Keith W. Neely ◽  
Robert L. Norton ◽  
Ed Bartkus ◽  
John A. Schiver
Keyword(s):  
Trauma Care ◽  
Trauma Center ◽  
Trauma System ◽  
Teaching Hospitals ◽  
Trauma Centers ◽  
Ct Scanner ◽  
Community Hospitals ◽  
Availability Analysis ◽  
Level Ii ◽  
American College Of Surgeons

AbstractHypothesis:Teaching hospitals (TH) can maintain the American College of Surgeons Committee on Trauma (ACSCOT) criteria for Level II trauma care more consistently than can community hospitals (CH).Methods:A retrospective analysis of 2,091 trauma system patients was done to determine if TH in an urban area are better able to meet the criteria for Level II trauma care than are CH. During the study period, a voluntary trauma plan existed among five hospitals; two TH and three CH. A hospital could accept patients that met trauma system entry criteria as long as, at that moment, it could provide the resources specified by ACSCOT. Hospitals were required to report their current resources accurately. A centralized communications center maintained a computerized, inter-hospital link which continuously monitored the availability of all participating hospitals. Trauma system protocols required paramedics to transport system patients to the closest available trauma hospital that had all the required resources available. Nine of the required ACSCOT Level II trauma center criteria were monitored for each institution emergency department (ED); trauma surgeon (TS); operating room (OR); angiogaphy (ANG); anesthesiologist (ANE); intensive care unit (ICU); on-call surgeon (OCS); neurosurgeon (NS); and CT scanner (CT) available at the time of each trauma system entry.Results:With the exception of OR, TH generally maintained the required staff and services more successfully than did CH. Further, less day to night variation in the available resources occurred at the TH. Specifically, ANE, ICU, TS, NS and CT were available more often both day and night, at TH than CH. However, OR was less available at TH than CH during both day and night (p<.01).Conclusions:In this community, TH provided a greater availability of trauma services than did CH. This study supports the designation of TH as trauma centers. A similar availability analysis can be performed in other communities to help guide trauma center designation.

Impact of adding Level II and III trauma centers on volume and disease severity at a nearby Level I trauma center

2014 ◽  
Vol 77 (5) ◽  
pp. 764-768 ◽  
Author(s):  
Brendan G. Carr ◽  
Juliet Geiger ◽  
Nathan McWilliams ◽  
Patrick M. Reilly ◽  
Douglas J. Wiebe
Keyword(s):  
Disease Severity ◽  
Trauma Center ◽  
Trauma Centers ◽  
Level Ii ◽  
Level I

Impact of Trauma Center Designation on Outcomes: Is There a Difference Between Level I and Level II Trauma Centers?

2012 ◽  
Vol 215 (3) ◽  
pp. 372-378 ◽  
Author(s):  
Laurent G. Glance ◽  
Turner M. Osler ◽  
Dana B. Mukamel ◽  
Andrew W. Dick
Keyword(s):  
Trauma Center ◽  
Trauma Centers ◽  
Level Ii ◽  
Level I

scholarly journals Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries

2020 ◽  
Vol 5 (1) ◽  
pp. e000520
Author(s):  
Scott M Alter ◽  
Benjamin A Mazer ◽  
Joshua J Solano ◽  
Richard D Shih ◽  
Mary J Hughes ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Head Trauma ◽  
Intracranial Hemorrhage ◽  
Injury Severity ◽  
Head Injuries ◽  
Antiplatelet Agents ◽  
High Rate ◽  
Head Ct ◽  
Severity Scores ◽  
Blunt Head Trauma

BackgroundAntiplatelet agents are increasingly used in cardiovascular treatment. Limited research has been performed into risks of acute and delayed traumatic intracranial hemorrhage (ICH) in these patients who sustain head injuries. Our goal was to assess the overall odds and identify factors associated with ICH in patients on antiplatelet therapy.MethodsA retrospective observational study was conducted at two level I trauma centers. Adult patients with head injuries on antiplatelet agents were enrolled from the hospitals’ trauma registries. Acute ICH was diagnosed by head CT. Observation and repeat CT to evaluate for delayed ICH was performed at clinicians’ discretion. Patients were stratified by antiplatelet type and analyzed by ICH outcome.ResultsOf 327 patients on antiplatelets who presented with blunt head trauma, 133 (40.7%) had acute ICH. Three (0.9%) had delayed ICH on repeat CT, were asymptomatic and did not require neurosurgical intervention. One with delayed ICH was on clopidogrel and two were on both clopidogrel and aspirin. Patients with delayed ICH compared with no ICH were older (94 vs 74 years) with higher injury severity scores (15.7 vs 4.4) and trended towards lower platelet counts (141 vs 216). Patients on aspirin had a higher acute ICH rate compared with patients on P2Y12 inhibitors (48% vs 30%, 18% difference, 95% CI 4 to 33; OR 2.18, 95% CI 1.15 to 4.13). No other group comparison had significant differences in ICH rate.ConclusionsPatients on antiplatelet agents with head trauma have a high rate of ICH. Routine head CT is recommended. Patients infrequently developed delayed ICH. Routine repeat CT imaging does not appear to be necessary for all patients.Level of evidenceLevel III, prognostic.

scholarly journals Primary admission and secondary transfer of trauma patients to Dutch level I and level II trauma centers: predictors and outcomes

2021 ◽  
Author(s):  
Claire R. L. van den Driessche ◽  
Charlie A. Sewalt ◽  
Jan C. van Ditshuizen ◽  
Lisa Stocker ◽  
Michiel H. J. Verhofstad ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Hospital Mortality ◽  
Trauma Center ◽  
Regression Models ◽  
Trauma Patients ◽  
Trauma Centers ◽  
Logistic Regression Models ◽  
Level Ii ◽  
Secondary Transfer ◽  
Level I

Abstract Purpose The importance and impact of determining which trauma patients need to be transferred between hospitals, especially considering prehospital triage systems, is evident. The objective of this study was to investigate the association between mortality and primary admission and secondary transfer of patients to level I and II trauma centers, and to identify predictors of primary and secondary admission to a designated level I trauma center. Methods Data from the Dutch Trauma Registry South West (DTR SW) was obtained. Patients ≥ 18 years who were admitted to a level I or level II trauma center were included. Patients with isolated burn injuries were excluded. In-hospital mortality was compared between patients that were primarily admitted to a level I trauma center, patients that were transferred to a level I trauma center, and patients that were primarily admitted to level II trauma centers. Logistic regression models were used to adjust for potential confounders. A subgroup analysis was done including major trauma (MT) patients (ISS > 15). Predictors determining whether patients were primarily admitted to level I or level II trauma centers or transferred to a level I trauma center were identified using logistic regression models. Results A total of 17,035 patients were included. Patients admitted primarily to a level I center, did not differ significantly in mortality from patients admitted primarily to level II trauma centers (Odds Ratio (OR): 0.73; 95% confidence interval (CI) 0.51–1.06) and patients transferred to level I centers (OR: 0.99; 95%CI 0.57–1.71). Subgroup analyses confirmed these findings for MT patients. Adjusted logistic regression analyses showed that age (OR: 0.96; 95%CI 0.94–0.97), GCS (OR: 0.81; 95%CI 0.77–0.86), AIS head (OR: 2.30; 95%CI 2.07–2.55), AIS neck (OR: 1.74; 95%CI 1.27–2.45) and AIS spine (OR: 3.22; 95%CI 2.87–3.61) are associated with increased odds of transfers to a level I trauma center. Conclusions This retrospective study showed no differences in in-hospital mortality between general trauma patients admitted primarily and secondarily to level I trauma centers. The most prominent predictors regarding transfer of trauma patients were age and neurotrauma. These findings could have practical implications regarding the triage protocols currently used.

Pediatric Trauma System Evaluation before and after Level II Verification

2019 ◽  
Vol 85 (11) ◽  
pp. 1281-1287
Author(s):  
Michael D. Dixon ◽  
Scott Engum
Keyword(s):  
Native American ◽  
Trauma Center ◽  
Injury Severity ◽  
Life Support ◽  
Pediatric Trauma ◽  
Trauma System ◽  
Trauma Centers ◽  
Level Ii ◽  
Level I ◽  
Pediatric Trauma Center

ACS-verified trauma centers show higher survival and improved mortality rates in states with ACS-verified Level I pediatric trauma centers. However, few significant changes are appreciated in the first two years after verification. Minimal research exists examining verification of ACS Level II pediatric trauma centers. We analyzed ACS Level II pediatric trauma verification at our institution. In 2014, Sanford Medical Center Fargo became the only Level II pediatric trauma center in North Dakota, as well as the only center between Spokane and Minneapolis. A retrospective review of the institution's pre-existing trauma database one year pre- and postverification was performed. Patients aged <18 years were included in the study ( P < 0.05). Patient number increased by 23 per cent, from 167 to 205 patients. A statistically significant increase occured in the three to six year old age group ( P = 0.0002); motorized recreational vehicle ( P = 0.028), violent ( P = 0.009), and other ( P = 0.0374) mechanism of injury categories; ambulance ( P = 0.0124), fixed wing ( P = 0.0028), and personal-owned vehicle ( P = 0.0112) modes of transportation. Decreased public injuries ( P = 0.0071) and advanced life support ambulance transportation ( P = 0.0397). The study showed a nonstatistically significant increase in mean Injury Severity Score (from 6.3 to 7) and Native American trauma (from 14 to 20 per cent). Whereas prolonged ACS Level I pediatric trauma center verification was found to benefit patients, minimal data exist on ACS Level II verification. Our findings are consistent with current Level I ACS pediatric trauma center data. Future benefits will require continued analysis because our Level II pediatric trauma center continues to mature and affect our rural and large Native American community.

scholarly journals Evaluation of Concomitant Orbital Floor Fractures in Patients with Head Trauma Using Conventional Head CT Scan: A Retrospective Study at a Level II Trauma Center

2019 ◽  
Vol 8 (11) ◽  
pp. 1852 ◽  
Author(s):  
Li-Kuo Huang ◽  
Hsi-Feng Tu ◽  
Liang-De Jiang ◽  
Ying-Yuan Chen ◽  
Chih-Yuan Fu
Keyword(s):  
Head Trauma ◽  
Predictive Value ◽  
Orbital Floor ◽  
Trauma Patients ◽  
Head Ct ◽  
High Attenuation ◽  
Ct Findings ◽  
Level Ii ◽  
Orbital Floor Fractures ◽  
High Negative Predictive Value

Background: Patients with head trauma may have concomitant orbital floor fractures (OFFs). The objective of our study was to determine the specific CT findings and investigate the diagnostic performance of head CT in detecting OFFs. Methods: We analyzed 3534 head trauma patients undergoing simultaneous head and facial CT over a 3-year period. The clinical data and specific head CT findings between patients with and without OFFs were compared. Results: In our cohort, 198 patients (5.6%) had OFFs visible on CT. On head CT, orbital floor discontinuity, gas bubbles entrapped between floor fragments, inferior extraconal emphysema, and maxillary hemosinus (MHS) were more commonly observed among patients with OFFs (p < 0.001). The absence of MHS had a high negative predictive value (99.7%) for excluding OFFs. Among the different types of MHS, the pattern showing high-attenuation opacity mixed with mottled gas had the highest positive predictive value (69.5%) for OFFs and was the only independent predictor of OFFs after adjusting for the other CT variables in all patients with MHS. Conclusion: Head CT may serve as a first-line screening tool to detect OFFs in head trauma patients. Hence, unnecessary facial CT and additional radiation exposure may be reduced.

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