The useful points this week were, as it happened, all on the topic of minor head injuries. When I was working in A&E, I used to struggle with the decision of which head injury patients should be scanned and which could be safely left. The New Orleans or Canadian rules, both for patients with minor head injuries and high initial GCS scores, could have helped me:
New Orleans criteria (for patients with an initial GCS of 15): Scan if headache, vomiting, >60, intoxication at the time of trauma or evaluation, persistent anterograde amnesia, trauma above the clavicle (huh? Unless my anatomy is a great deal worse even than I thought, surely all head injuries are trauma above the clavicle, by definition?), or seizure.
Canadian criteria (for patients with initial GCS 13 – 15):
GCS <15 two hours after injury
Suspected open skull fracture
Signs of basal skull fracture
Two or more episodes of vomiting
Unable to remember anything that happened for at least 30 mins before the trauma
This rule is more specific than the New Orleans rule, so can prevent more unnecessary CTs.
For both of them, I’m dubious about the criterion to scan everyone with minor head injury over a particular age, which I can’t see working too well in a primary care setting (or a secondary care setting, for that matter), and I’m interested that anticoagulation therapy isn’t included as a risk factor on either list. Either way, they both seem to list the kind of things I’d already consider a reason for referring a patient (other than the age criteria), so, mainly, this is reassuring for me in that I’m probably not missing any CTs that I should be doing in these circumstances.
And finally, from Minerva, a useful addendum to this for minor head injuries in children – an extremely large study in Pediatrics (almost 18 000 children presenting to A&E departments) showed that the risk of a late diagnosis of severe intracranial bleeding following minor head injury in children was zero in children who showed no deterioration in level of consciousness and 0.03% in children who did. As a doctor and as a parent, I find this good to know.