Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury. Los estudios centrados en traumatismos craneoencefálicos leves en pacientes intoxicados documentan prevalencias discrepantes de lesión intracraneal. No está claro si los factores típicamente asociados con lesión intracraneal en las reglas de decisión clínica publicadas para la realización de una tomografía computarizada (TC) son de ayuda para diferenciar a los pacientes con y sin lesiones intracraneales, ya que la intoxicación puede enmascarar hallazgos particulares de la lesión intracraneal, como la cefalea, y minimizar otros signos del traumatismo craneoencefálico como la alteración del nivel de conciencia. Este estudio tiene el objetivo de estimar la prevalencia de lesión intracraneal tras un traumatismo craneoencefálico leve (puntuación de la Escala del Coma de Glasgow ≥14) en pacientes intoxicados y valorar el rendimiento de las reglas de decisión clínica establecidas en esta población. Estudio de cohorte prospectivo consecutivo de los adultos intoxicados que acudieron al servicio de urgencias tras un traumatismo craneoencefálico leve. Se incluyeron aquellos hallazgos de la historia clínica y la exploración física de la Canadian CT Head Rule, el National Emergency X-Radiography Utilization Study (NEXUS) y los New Orleans Criteria. A todos los pacientes se les realizó una TC craneal. Se incluyeron 283 pacientes, con una mediana de 40 años (RIC 28 a 48 años) y una mediana de concentración de alcoholemia de 195 mmol/L (RIC 154 a 256 mmol/L). Doscientos treinta y ocho de los 283 (84%) fueron hombres, y 225 (80%) tuvieron una puntuación en la escala de Glasgow de 15. Se identificaron lesiones clínicamente importantes (ej: lesiones que requirieron ingreso en el hospital o seguimiento neuroquirúrgico) en 23 pacientes (8%; IC 95% = 5% a 12%) y uno requirió intervención neuroquirúrgica (0,4%, IC95% = 0% a 2%). La pérdida de conciencia y la cefalea se asociaron con lesión intracraneal clínicamente importante en la TC. La Canadian CT Head Rule tuvo una sensibilidad del 70% (IC 95% = 47% a 87%) y los NEXUS criteria tuvieron una sensibilidad del 83% (IC 95% = 61% a 95%) para la lesión intracraneal clínicamente importante en los pacientes intoxicados. En este estudio, la prevalencia de la lesión clínicamente importante en pacientes intoxicados con traumatismo craneoencefálico leve fue significativa. Mientras la presencia de hallazgos comunes asociados con la lesión intracraneal en pacientes no intoxicados podría incrementar la sospecha clínica para la lesión intracraneal en pacientes intoxicados, la Canadian CT Head Rule y los NEXUS criteria no tienen una adecuada sensibilidad para ser aplicados en pacientes intoxicados con un traumatismo craneoencefálico leve. CME Editor: Hal Thomas, MD Authors: Joshua S. Easter, MD, Jason S. Haukoos, MD, MSc, Jonathan Claud, MD, Lee Wilbur, MD, Michelle Tartalgia Hagstrom, MD, Stephen Cantrill, MD, Michael Mestek, MD, David Symonds, MD, and Katherine Bakes, MD Article Title: Traumatic Intracranial Injury in Intoxicated Patients with Minor Head Trauma If you wish to receive free CME credit for this activity, please refer to the website: http://www.wileyhealthlearning.com. Accreditation and Designation Statement: Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Educational Objectives After completing this exercise the participant will be able to explain the relative roles of the various components of the diagnostic assessment for small bowel obstructions in adults. Activity Disclosures No commercial support has been accepted related to the development or publication of this activity. Faculty Disclosures: CME editor – Hal Thomas, MD: No relevant financial relationships to disclose. Authors – Joshua S. Easter, MD, Jason S. Haukoos, MD, MSc, Jonathan Claud, MD, Lee Wilbur, MD, Michelle Tartalgia Hagstrom, MD, Stephen Cantrill, MD, Michael Mestek, MD, David Symonds, MD, and Katherine Bakes, MD This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Academic Emergency Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Academic Emergency Medicine is double-blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review. Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. No relevant financial relationships exist for any individual in control of the content and therefore there were no conflicts to resolve. Instructions on Receiving Free CME Credit For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board. This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication. Follow these steps to earn credit: This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months. A recent systematic review reported a median prevalence of 7.2% for intracranial injury in adults with minor head injury.1 Review of the National Hospital Ambulatory Medical Care Survey (NHAMCS) revealed that 44% of emergency department (ED) patients with minor head injury undergo head computerized tomography (CT), the criterion standard for diagnosing intracranial injury.2 The risk of intracranial injury among intoxicated patients with minor head injury remains unclear. Prior studies report disparate prevalences of intracranial injury among intoxicated patients. Several investigators have identified intoxication as an independent predictor of intracranial injury on CT.3-5 In contrast, more recent studies identified similar prevalences of intracranial injury in intoxicated patients compared to nonintoxicated patients selected for CT.6, 7 None of these studies focused exclusively on intoxicated patients, with only 6% to 35% of their study cohorts consisting of intoxicated patients. The true prevalence of intracranial injury among intoxicated patients remains unclear. Physicians are often guided by clinical decision rules to help determine the need for CT acquisition following minor head injury.3, 6, 8 However, the effect of alcohol intoxication on the performance of these rules is unclear. Studies of the New Orleans Criteria, Canadian CT Head Rule, and National Emergency X-Radiography Utilization Study (NEXUS) have included intoxicated patients as part of their derivation cohorts, suggesting the rules can be applied to patients with intoxication (Appendix 1).3, 6, 8 However, the performance of these rules in the intoxicated population was not assessed. Guidelines differ in their recommendations regarding the role of intoxication in the decision to acquire a head CT following minor head injury. The American College of Emergency Physicians clinical policy and Neurotraumatology Committee of the World Federation of Neurosurgical Societies include alcohol intoxication as an indication for CT acquisition after minor head injury with loss of consciousness or amnesia.9, 10 The National Institute for Health and Clinical Excellence (NICE) and the Eastern Association for the Surgery of Trauma (EAST) do not include intoxication as an indication for CT acquisition.11, 12 Given that 35% to 50% of patients with minor head injury are intoxicated, it is crucial to determine the prevalence of traumatic intracranial injury in this population and to assess the ability of existing clinical decision rules to identify intoxicated patients with intracranial injuries.13, 14 We hypothesized that the prevalence of clinically important intracranial injury in intoxicated patients would be similar to the prevalence reported in prior studies of nonintoxicated patients. We also hypothesized that existing clinical decision rules would successfully identify intoxicated patients with intracranial injury, as many of the historical and physical examination features included in the rules are present in intoxication as well as in patients with intracranial injuries. This was a prospective cohort study. The institutional review board approved this study with a waiver of informed consent. The study was performed over 1 year at Denver Health Medical Center in Denver, Colorado. Denver Health Medical Center is a 477-bed urban, Level 1 trauma center for the city and county of Denver, as well as a trauma referral center for the Rocky Mountain region. It has approximately 55,000 annual ED visits with 2,500 annual major trauma visits. We enrolled consecutive adults (≥18 years of age) presenting to the ED with intoxication and minor head injury, as defined by a Glasgow Coma Scale (GCS) score ≥14 and trauma to the head. As many patients were unable to provide accurate histories due to intoxication, objective evidence of injury to the head, defined by any evidence of injury above the eyebrows anteriorly or atlantoaxial line posteriorly, was required for inclusion to ensure patients had truly experienced head injury. In addition, all patients had alcohol concentrations measured via blood or breathalyzer and were excluded if their alcohol concentrations were <80 mmol/L, corresponding to the legal driving limit for intoxication. Patients were also excluded from the study if they: 1) had evidence of acute penetrating head injury; 2) were pregnant; 3) were transferred from outside facilities and already had received head CTs; 4) had GCS scores ≤13 on initial presentation; or 5) were in the custody of police, as this population is considered a protected population by our review board. The initial treating physicians identified patients with head injury and any suspicion for intoxication. As part of the study protocol, these patients had their blood drawn or breathalyzer administered to confirm intoxication. Urine pregnancy tests were obtained on all female patients with child-bearing potential; pregnant patients were excluded from the study. A noncontrast head CT was then obtained on each enrolled subject. This acquisition of head CTs was standard of care in the ED for all intoxicated patients with objective evidence of trauma to the head. Subsequent treatment and disposition decisions for each patient were at the discretion of the emergency physician (EP), with consultation from the trauma surgeon or neurosurgeon when appropriate. Prior to obtaining CT scans, EPs identified the presence of predictor variables and prospectively recorded them on a standardized, closed response data collection instrument. Physicians recorded the presenting signs and symptoms, including loss of consciousness, nausea, vomiting, amnesia, headache, seizure, and mechanism of injury (assault, fall, pedestrian struck, motor vehicle collision, or other). Finally, any signs of trauma to the head were documented, including laceration, hematoma, abrasion, ecchymosis, and signs of or were present in the ED to ensure and of The was a clinically important intracranial injury, and the was an injury requiring neurosurgical Clinically important injuries were defined the criteria by their of and included injuries that would hospital admission or neurosurgical such as hematoma, 1 in or traumatic Patients to the hospital for of injuries were not considered to have clinically important intracranial injuries. Medical and prior studies were reviewed to ensure that only acute injuries were as clinically important intracranial injuries. injury in need for neurosurgical intervention was defined by a need for intracranial or within 1 after the injury. the presence of intracranial injury on CT. were each to the clinical and the other All the of the intracranial injuries on CT were resolved the two The of need for neurosurgical intervention was review of the medical by the was to ED data and at the time of the review. All data were and transferred All were performed College for all variables and the prevalence of acute intracranial injury were and reported with 95% confidence data are as with and data as with 95% was to estimate No a were for was to estimate for the prevalence of acute intracranial injury. We a prevalence of and the study to have a 95% confidence limit for this estimate of for the 95% As such, requiring a of in this study. the study period, consecutive patients with evidence of minor head injury and intoxication, with 283 of inclusion The median age was 40 years (IQR = 28 to 48 and 238 of 283 (84%) were the 283 patients, 95% CI = 6% to had acute intracranial injuries, with 23 (8%; 95% CI = 5% to 12%) of these considered clinically The clinically important intracranial injuries were as 10 of 23 one one and one was the two for the presence of intracranial injuries with on all a of (95% CI = to Neurosurgical intervention was required in one patient 95% CI = 0% to a year male, was over the head with a and had and in the ED had a GCS score of mental after admission to the A head CT a in the of was to the for and After a hospital was transferred to a with (Glasgow Scale score of Several factors were associated with clinically important intracranial injury in intoxicated patients loss of consciousness and headache were more common in with clinically important intracranial injuries compared to those without clinically important injuries loss of consciousness = 95% CI = to and headache = 95% CI = to was no in of injury, alcohol or initial GCS nausea, vomiting, and were also not the two While signs of were not associated with clinically important intracranial injury, were associated with any intracranial injury on when injuries such as were patients with intracranial injuries for CT by the Canadian CT Head Rule and NEXUS criteria the 23 intoxicated patients with clinically important intracranial injuries, 95% CI = 5% to not have any of the NEXUS and 95% CI = to not have any of the Canadian CT Head Rule in of 83% (95% CI = 61% to 95%) and 70% (95% CI = 47% to 87%) for these the patients by the NEXUS two had with one on one had with on initial and one had the patients by the Canadian CT Head Rule, had with one on two had with one on initial and one had None of the patients without any of the for CT by these rules required neurosurgical As intoxication and signs of trauma above the were inclusion criteria for our study, all patients the New Orleans Criteria, for which these are To our this is the study to designed to prospectively determine the prevalence of traumatic clinically important intracranial injury in a cohort of exclusively intoxicated patients presenting after minor head injury. We identified an prevalence of clinically important intracranial injury, compared to the 5% by in a review of focusing on intoxicated patients. to in study the true is this In our study, all patients presenting with intoxication and head injury underwent in the study patients only underwent CT at the discretion of the treating not intoxication to an of the prevalence of injury, as a of patients with intoxication in their study had intracranial injuries. In contrast, measured intoxication in all patients. The prevalence in our study was the prevalence of for any intracranial injury reported in a recent review of intoxicated trauma patients head This study was by its and In the New Orleans Criteria, the study of was similar to in that CT was performed on consecutive patients, in a prevalence of for traumatic intracranial injury in intoxicated patients. While the in their study was only included intoxicated patients. In addition, these intoxicated patients all had reported loss of consciousness or amnesia, as defined by their criteria for Given that these variables are to assess in intoxicated patients, that our provide a more estimate of the prevalence of traumatic intracranial injury in intoxicated patients presenting to the ED after minor head injury. The prevalence of clinically important intracranial injury that identified in intoxicated was similar to reported prevalences of clinically important intracranial injuries in all patients, of intoxication status. of patients with minor head injury had clinically important intracranial injuries, of patients had clinically important intracranial injuries. of these studies only included patients with loss of consciousness, amnesia, or and therefore are to a risk population included in our study. study is to the prevalence of head injury in intoxicated and nonintoxicated on our in the of head injury, physicians should signs or of intracranial injury altered mental or to intoxication Prior studies the effect of intoxication on GCS score support this that alcohol intoxication not in in GCS is also the study to report factors associated with traumatic intracranial injury in intoxicated patients. The only other prior study that to identify such factors was performed over years and included only It not identify any factors associated with intracranial injury. our loss of consciousness and headache to be associated with traumatic intracranial injury in intoxicated patients, factors also to be associated with traumatic intracranial injury in nonintoxicated 6, our study that these factors should suspicion for intracranial injury in intoxicated patients, these their presence should head CT to the performance in prior studies in nonintoxicated patients, the Canadian CT Head and NEXUS criteria performed well in our cohort of intoxicated patients for clinically important intracranial injuries. As many physicians on these clinical decision rules for the need for CT acquisition in the of minor head injury, there may be a to these rules for intoxicated patients, in of for this population. each of the rules included intoxicated patients in their derivation only to 35% of their cohorts and not include independent performance of the rules for intoxicated 6, 8 We that the of the signs and of intoxication with intracranial injury would in intoxicated patients one of the criteria of the the rules would sensitivity for intracranial injury. identified patients with intracranial injuries not have any of the published criteria for injury in minor head injury. these injuries were each clinically neurosurgical The sensitivity for clinically important intracranial injury was similar for the NEXUS criteria and the Canadian CT Head Rule The New Orleans identified all patients with clinically important injuries, as intoxication is a criterion for this of the two of the New Orleans that were inclusion criteria for our study and signs of trauma above the a sensitivity of for clinically important intracranial injury. The of injuries in our study the need for when common clinical decision rules to intoxicated patients with head injury. of the New Orleans would successfully identify all intoxicated patients with clinically important injuries, would CT acquisition on all intoxicated patients with signs of trauma above the This would CT patients to potentially from studies should on clinical decision rules to identify intoxicated patients at risk for injury do not CT and also the performance of these rules to In the to injuries or obtaining CT on all intoxication patients in of alcohol such as our for those intoxicated patients with clinical for injury and for those patients to and of existing clinical decision patients and should have CTs obtained if are not or any in their We identified only one patient required neurosurgical it to identify clinical factors associated with this in intoxicated patients. We on clinically important injuries and that physicians would to identify these injuries, if do not neurosurgical We included only patients with alcohol intoxication. are many other that can intoxication and limit the diagnostic of the and physical It is unclear if intracranial injury is as in these This study provide with published clinical decision our inclusion criteria were We included all intoxicated patients, existing rules focused on patients with loss of consciousness, amnesia, or We that these factors would be in intoxicated patients. to all patients presenting with intoxication and as a our population from the derivation for the clinical decision to these in study a in the of the However, our interest was the and injuries. The should not have been by our inclusion In the it will be important to assess the of the rules in intoxicated patients. Finally, included only patients with evidence of trauma to the head. This was the only objective criterion to be a of head trauma in intoxicated patients. This may our population risk compared to patients presenting with of head injury no evidence of trauma to the head. Intoxicated patients with minor head injury are at risk for intracranial injury, with of intoxicated patients in our cohort clinically important intracranial injuries. The Canadian CT Head Rule and National Emergency X-Radiography Utilization Study criteria not have adequate sensitivity for clinically intracranial injuries in a cohort of intoxicated patients. Loss of consciousness or GCS score of Loss of consciousness, amnesia, or GCS score of Trauma above GCS score at mechanism

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