Head CT after minimal, mild and moderate traumatic brain injury: Audit of clinical practice
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Introduction: Traumatic brain injury (TBI), commonly classified as minimal, mild, moderate and severe, is one of the most common presentations in an Emergency Department (ED). Majority of TBIs are classified as minimal and mild, where 8-15% of the patients have a neurocranial injury (NI), and less than 1% requires neurosurgery. Guidelines have been developed in order to aid in the management of TBI patients, where the Scandinavian (SNC) guidelines for the management of TBI patients is standard practice at the Oslo Emergency Department (OED). However, it is evident in the literature that it is difficult to identify the small portion of patients at risk, which often leads to unnecessary head CTs. Further, recent studies describe a shift in the age and injury mechanism in the TBI population; we hypothesize that this trend is also reflected in the TBI population at OED. The aim of this study is two-fold; firstly, we will review the TBI population at OED as a cohort. To do this we will assess the frequency of TBI patients, describe patient characteristics, and the number of patients with NI. Secondly, we will assess compliance with the SNC guidelines at the OED. Methods: Data was collected retrospectively of all consecutive head CTs preformed due to TBI at OED, between Jan-June 2016. It was gathered from the CT referral forms and radiology reports. Patient demographics as well as GCS-score, injury mechanism, anticoagulants, SNC guideline defined risk factors, symptoms and frequency of positive CT findings (NI) was retrieved. Guideline compliance regarding CT use was assessed, where compliant implied correct use of CT, and where no indication for a CT was found implied non-compliance. Result: 2000 head CTs were performed during the study period, median age was 54 years and falls was the dominating trauma mechanism (69.4%). A positive head CT was described in 5.5% of the patients, where 0.25% required neurosurgical intervention. GCS-score of 14-15 and confirmed loss of consciousness was associated with a positive head CT (p<0.05). Compliance with the guidelines was seen in 88.2% whilst 11.8% resulted in non-compliance; correct application of the SNC guidelines would result in 13.4% reduction of head CTs. Conclusion: Analysis of the TBI population at the OED confirmed the shift of an increase in age and falls being the most important trauma mechanism for minimal, mild and moderate TBI. Although guideline compliance rate was adequate, the high numbers of head CTs preformed is rather alarming. The lack of clinical risk factors present in the patients with a positive head CT highlights the need for constant revision of guidelines in this heterogeneous TBI population.
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