Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

Abstract

Objectives 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. Methods 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. Results 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. Conclusions 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.

Imaging of Frequent Emergency Department Users with Alcohol Use Disorders

“…Although the retrospective design of our study does not allow us to make direct conclusions about the decisions involved in ordering imaging studies, the yield of acute radiologic findings is considerably higher than the aforementioned observational studies and comparable to large-scale trials that have prospectively applied the Canadian CT Head Rule and the New Orleans Criteria in cases of minor head trauma (3,17). This may suggest that our clinicians may have adopted a practice of observing these patients in lieu of early imaging.…”

“…The presence of alcohol intoxication in patients presenting to the emergency department (ED) can limit the quality of the medical history and physical examination, thereby hindering their ability to guide the need for imaging and other diagnostic studies (1–3). As a result, physicians in the ED may be more liberal with the use of computed tomography (CT) imaging in patients with diminished levels of awareness, behavioral disturbances, or with evidence of injury – particularly when a description of the mechanism is unobtainable secondary to an alcohol-induced altered level of consciousness (4).…”

Schädel-Hirn-Trauma des Erwachsenen

“…Die Überlagerung der Intoxikationseffekte mit den potenziellen klinischen Zeichen eines SHT stellt in der Notaufnahme oftmals eine differenzialdiagnostische Schwierigkeit dar. Es konnte gezeigt werden, dass auch objektive Algorithmen zur CCT-Indikationsstellung eine deutlich geringere Sensitivität aufweisen bei intoxikierten Patienten [29]. Die S2-Leitlinie empfiehlt daher bei diesen Patienten eine großzügige Entscheidung zur CCT-Bildgebung [13].…”

Clinical characteristics predict the yield of head computed tomography scans among intoxicated trauma patients: Implications for the initial work-up

“…While h-CT decision guidelines that utilize clinical presentation provide valuable information for patients presenting to the ED without an obvious mechanism of injury (fall or motor vehicle accident) and are alert and orientated, they may have limited applicability to the intoxicated trauma patient. [ 10 11 12 ] Past estimates of h-CT yield among intoxicated trauma patients range to over 40%; however, there is a paucity of clinical tools that predict h-CT yield among this population. [ 1 13 14 ] There also remains the question of triaging (i.e., determining who should be scanned first) when patient flow through CT scanners becomes congested.…”